Riccardo Piccazzo

Diagnostic Accuracy of Chest Radiography for the Diagnosis of Tuberculosis (TB) and Its Role in the Detection of Latent TB Infection: a Systematic Review

In this systematic review we evaluate the role of chest radiography (CXR) in the diagnostic flow chart for tuberculosis (TB) infection, focusing on latent TB infection (LTBI) in patients requiring medical treatment with biological drugs. In recent findings, patients scheduled for immunomodulatory therapy with biologic drugs are a group at risk of TB reactivation and, in such patients, detection of LTBI is of great importance. CXR for diagnosis of pulmonary TB has good sensitivity, but poor specificity. Radiographic diagnosis of active disease can only be reliably made on the basis of temporal evolution of pulmonary lesions. In vivo tuberculin skin test and ex vivo interferon-γ release assays are designed to identify development of an adaptive immune response, but not necessarily LTBI. Computed tomography (CT) is able to distinguish active from inactive disease. CT is considered a complementary imaging modality to CXR in the screening procedure to detect past and LTBI infection in specific subgroups of patients who have increased risk for TB reactivation, including those scheduled for medical treatment with biological drugs.

Multimodality imaging of intraosseous ganglia of the wrist and their differential diagnosis

Intraosseous ganglion (IOG) is the most frequently occurring bone lesion within the carpus and is often an incidental finding on radiographs obtained for other reasons. Two types of IOG have been described: an “idiopathic” form (or type I), the pathogenesis of which has not been completely clarified, and a “penetrating” form (or type II), caused by the intrusion of juxtacortical material (often a ganglion cyst of the dorsal soft tissue) into the cancellous bone compartment. The differential diagnosis for IOG is wide-ranging and complex, including lesions of posttraumatic (posttraumatic cystlike defects), degenerative (subchondral degenerative cysts), inflammatory [cystic rheumatoid arthritis, chronic tophaceous gout (CTG)], neoplastic (benign primary bone tumours and synovial proliferative lesions), ischaemic (Kienböck’s disease or avascular osteonecrosis of the lunate) and metabolic (amyloidosis) origin. Multimodality imaging of IOGs is a useful diagnostic tool that provides complete morphological characterisation and differentiation from other intraosseous cystic abnormalities of the carpus. Thin-slice multidetector computed tomography (MDCT) can provide high-spatial-resolution images of the cortical and cancellous bone compartments, allowing detection of morphological findings helpful in characterising bone lesions, whereas magnetic resonance (MR) imaging can simultaneously visualise bone, articular surfaces, hyaline cartilage, fibrocartilage, capsules and ligaments, along with intra- and periarticular soft tissues.RiassuntoIl ganglio intraosseo (IOG) è la lesione ossea del carpo di più frequente riscontro e spesso rappresenta un reperto occasionale in esami radiografici eseguiti per altri motivi. I IOG vengono distinti in due forme: la forma idiopatica (o tipo I), la cui patogenesi non è stata ancora completamente chiarita, e quella penetrante (o tipo II), determinata dall’intrusione nel compartimento spongioso di materiale juxtacorticale, spesso rappresentato da un ganglio dei tessuti molli dorsali del carpo. La diagnosi differenziale dei IOG è ampia ed articolata, includendo lesioni di origine post-traumatica (difetti simil-cistici post-traumatici, PTCD), degenerativa (cisti subcondrali degenerative, SDC), infiammatoria (artrite reumatoide cistica e gotta cronica tofacea), neoplastica (tumori ossei primitivi e lesioni proliferative sinoviali benigne), ischemica (morbo di Kienbock od osteonecrosi avascolare del semilunare) e metabolica (amiloidosi). L’imaging integrato dei IOG è fondamentale per la loro completa caratterizzazione morfologica e per distinguerli dalle altre lesioni pseudocistiche intraspongiose che si possono sviluppare nelle ossa del carpo. La tomografia computerizzata multi-detettore (MDCT) consente di ottenere immagini ad elevata risoluzione spaziale dei compartimenti ossei corticale e spongioso, permettendo di rilevare elementi morfologici utili ad una precisa caratterizzazione delle lesioni ossee, mentre la risonanza magnetica (RM) offre il vantaggio di visualizzare simultaneamente la componente ossea, le superfici articolari, gli spessori condrali, le strutture fibrocartilaginee, capsulo-legamentose ed i tessuti molli intra- e peri-articolari.

Value of bimodal (18)F-choline-PET/MRI and trimodal (18)F-choline-PET/MRI/TRUS for the assessment of prostate cancer recurrence after radiation therapy and radical prostatectomy.

Abstract Between 27% and 53% of all patients who undergo radical prostatectomy (RP) or radiation therapy (RT) as the first-line treatment of prostate cancer (PCa) develop a biochemical recurrence. Imaging plays a pivotal role in restaging by helping to distinguish between local relapse and metastatic disease (i.e., lymph-node and skeletal metastases). At present, the most promising tools for assessing PCa patients with biochemical recurrence are multiparametric magnetic resonance imaging (mpMRI) and positron emission tomography (PET)/computed tomography (CT) with radio-labeled choline derivatives. The main advantage of mpMRI is its high diagnostic accuracy in detecting local recurrence, while choline-PET/CT is able to identify lymph-node metastases when they are not suspicious on morphological imaging. The most recent advances in the field of fusion imaging have shown that multimodal co-registration, synchronized navigation, and combined interpretation are more valuable than the individual; separate assessment offered by different diagnostic techniques. The objective of the present essay was to describe the value of bimodal choline-PET/mpMRI fusion imaging and trimodal choline-PET/mpMRI/transrectal ultrasound (TRUS) in the assessment of PCa recurrence after RP and RT. Bimodal choline-PET/mpMRI fusion imaging allows morphological, functional, and metabolic information to be combined, thereby overcoming the limitations of each separate imaging modality. In addition, trimodal real-time choline-PET/mpMRI/TRUS fusion imaging may be useful for the planning and real-time guidance of biopsy procedures in order to obtain histological confirmation of the local recurrence.

Advantages of percutaneous abdominal biopsy under PET-CT/ultrasound fusion imaging guidance: a pictorial essay

Positron emission tomography (PET) is a functional imaging technique that can investigate the metabolic characteristics of tissues. Currently, PET images are acquired and co-registered with a computed tomography (CT) scan (PET-CT), which is employed for correction of attenuation and anatomical localization. In spite of the high negative predictive value of PET, false-positive results may occur; indeed, Fluorine 18 (18F)-fluorodeoxyglucose (18F-FDG) uptake is not specific to cancer. As 18F-FDG uptake may also be seen in non-malignant infectious or inflammatory processes, FDG-avid lesions may necessitate biopsy to confirm or rule out malignancy. However, some PET-positive lesions may have little or no correlative ultrasound (US) and/or CT findings (i.e., low conspicuity on morphological imaging). Since it is not possible to perform biopsy under PET guidance alone, owing to intrinsic technical limitations, PET information has to be integrated into a CT- or US-guided biopsy procedure (multimodal US/PET-CT fusion imaging). The purpose of this pictorial essay is to describe the technique of multimodal imaging fusion between real-time US and PET/CT, and to provide an overview of the clinical settings in which this multimodal integration may be useful in guiding biopsy procedures in PET-positive abdominal lesions.

Multimodality fusion imaging in abdominal and pelvic malignancies: current applications and future perspectives

Abstract Medicine is evolving toward personalized care and this development entails the integration, amalgamation, and synchronized analysis of data from multiple sources. Multimodality fusion imaging refers to the simultaneous visualization of spatially aligned and juxtaposed medical images obtained by two or more image modalities. PET/MRI scanners and MMFI platforms are able to improve the diagnostic workflow in oncologic patients and provide exquisite images that aid physicians in the molecular profiling and characterization of tissues. Advanced navigation platforms involving real-time ultrasound are promising tools for guiding personalized and tailored mini-invasive interventional procedures on technically challenging targets. The main objective of the present essay was to describe the current applications and future perspectives of multimodality fusion imaging for both diagnostic and interventional purposes in the field of abdominal and pelvic malignancies. We also outlined the technical differences between fusion imaging achieved by means of simultaneous bimodal acquisition (i.e., integrated PET/MRI scanners), retrospective co-registration, and multimodality fusion imaging involving ultrafast or real-time imaging modalities.

Imaging studies of crystalline arthritides

Gout, calcium pyrophosphate dihydrate (CPPD) deposition disease, and calcium hydroxyapatite deposition disease (HADD) are the three most common crystal-induced arthropathies. Multimodality imaging may help in their diagnosis, and is useful for a precise and comprehensive assessment and grading of the related osteoarticular damage. Plain film radiography, due to its low cost and wide availability, is the first imaging technique to be used in crystal deposition diseases, providing well-known and specific findings for CPPD deposition disease and HADD, while it may undergrade the early osteoarticular lesions in gouty patients. Ultrasonography (US) is a radiation-free approach that accurately depicts crystal deposits in cartilage, peri- and intra-articular soft tissues, but it does not give a panoramic view of the affected joints. Cross-sectional imaging techniques can examine crystal deposits in the spine and axial joints. CT has the potential to distinguish monosodium urate (MSU) crystals from calcium containing crystals, due to their different attenuation values. MRI may demonstrate synovitis, erosions and bone marrow edema in gouty patients and it may differentiate tophi from other soft tissue nodules due to its high contrast resolution and power of tissue characterization.

Extraintestinal Findings in Crohn’s Disease Patients

Crohn’s disease is a chronic inflammatory bowel disease with a relapsing and remitting course that may affect any part of the gastrointestinal tract, often with multiple discontinuous involvements [1–3].

A Case of Spontaneous Rupture of the Renal Pelvis Initially Misdiagnosed as a Ruptured Aneurysm of the Abdominal Aorta

A 78-year-old man, affected by a known aneurysm of the sub-renal abdominal aorta, was admitted to our Emergency Department for the sudden onset of severe pain on the lower back and left flank. The first diagnostic hypothesis entertained was that of rupture of the aortic aneurysm, but his physical examination and laboratory data were not coherent with that condition, revealing blood pressure values of 175/90 mm Hg, hemoglobin concentration of 13.5 g/dL, and the presence of bilateral and symmetric femoral pulses. At physical examination, the abdomen was distended and tender to palpation, but without peritoneal signs. A contrast-enhanced computed tomography (CT) scan was performed, demonstrating a large hypodense collection in the left perirenal space and no CT signs of a ruptured aneurysm (Figure 1A). Urographic phase CT images demonstrated left hydroureteronephrosis and leakage of iodinated urine in the perirenal space with formation of a large urinoma (Figure 1B). Such findings suggested the diagnosis of obstructive uropathy complicated by spontaneous rupture of the collecting system. The site of leakage was identified in correspondence to the ureteropelvic junction (Figure 2). The cause of the obstructive uropathy was a histologically confirmed flat urothelial carcinoma in situ of the left superolateral bladder wall, surrounded