Riccardo Pizzolato

Comparison of Contrast-Enhanced Sonography with Unenhanced Sonography and Contrast-Enhanced CT in the Diagnosis of Malignancy in Complex Cystic Renal Masses

OBJECTIVE The objective of our study was to evaluate contrast-enhanced sonography in the diagnosis of malignancy in complex cystic renal masses. MATERIALS AND METHODS We analyzed a series of 40 cystic renal masses (diameter, 2-8 cm) with a complex pattern at contrast-enhanced CT in 40 consecutive subjects (18 men, 22 women; mean age +/- SD, 62 +/- 11 years). Each renal mass was scanned using sonography without contrast material and after IV injection of sulfur hexafluoride-filled microbubbles during the arterial (15-40 seconds) and venous (40-120 seconds from injection) phases. Two radiologists in consensus assessed onsite the enhancement patterns in the peripheral wall and intracystic septa and the evidence of solid endocystic components. Three blinded readers with 2, 6, and 10 years of experience in renal imaging performed a retrospective off-site interpretation of unenhanced sonography, contrast-enhanced sonography, and CT images and made a benign or malignant diagnosis according to refer ence diagnostic criteria for contrast-enhanced sonography and to the Bosniak classification for CT. RESULTS Final diagnoses comprised two multilocular cystic nephromas, two inflammatory and seven hemorrhagic cysts, and eight uncomplicated benign cysts and 21 cystic renal cell carcinomas. The overall diagnostic accuracy of contrast-enhanced sonography was better than unenhanced sonography and CT (contrast-enhanced sonography vs unenhanced sonography vs CT: reader 1, 83% vs 30% vs 75%; reader 2, 83% vs 30% vs 63%; reader 3, 80% vs 30% vs 70%; p < 0.05, McNemar test). CONCLUSION Contrast-enhanced sonography was found to be better than unenhanced sonography and CT in the diagnosis of malignancy in complex cystic renal masses.

The diagnostic value of small bowel wall vascularity after sulfur hexafluoride-filled microbubble injection in patients with Crohn's disease. Correlation with the therapeutic effectiveness of specific anti-inflammatory treatment

PURPOSE To assess the value of small bowel wall vascularity after microbubble contrast agent injection in evaluating the therapeutic effectiveness of specific anti-inflammatory treatment in patients with Crohns disease. MATERIALS AND METHODS Fifteen patients (7 male and 8 female; mean age+/-SD, 40 years+/-6) with a biopsy-proven diagnosis of Crohns disease--Crohns disease activity index (CDAI)>150 (n=12 patients) or <150 (n=3)--involving the terminal loop of the small bowel (wall thickness>5 mm) were included. In each patient the terminal loop was scanned by contrast-enhanced ultrasound (CEUS) after sulfur hexafluoride-filled microbubble injection before and after 6-month anti-inflammatory treatment. The vascularity of the terminal loop was quantified in gray-scale levels (0-255) by a manually drawn ROI encompassing the thickened bowel wall and it was correlated with CDAI. RESULT Before the beginning of the specific treatment all patients revealed diffuse transparietal contrast enhancement after microbubble injection, except for 3 patients who revealed contrast enhancement limited to the submucosa. In 13 patients the slope of the first ascending tract and the area under the enhancement curve were significantly lower after anti-inflammatory treatment (P<0.05; Wilcoxon test) with a significant correlation with the CDAI score (rho=0.85, P<0.05). In 2 patients no significant vascularity changes were found even though a mild reduction of CDAI score was identified (from 200 to 150 gray-scale levels). CONCLUSION CEUS is a useful method to assess the therapeutic effectiveness of specific medical anti-inflammatory treatment in patients with Crohns disease.

Effect of Observer Experience in the Differentiation Between Benign and Malignant Liver Tumors After Ultrasound Contrast Agent Injection

Objective. The purpose of this study was to assess the impact of the observer level of experience on the diagnostic performance of contrast‐enhanced ultrasound imaging (CEUS) for differentiation between benign and malignant liver tumors. Methods. From a computerized search, we retrospectively identified 286 biopsy‐proven liver tumors (105 hepatocellular carcinomas, 48 metastases, 7 intra‐hepatic cholangiocarcinomas, 33 liver hemangiomas, and 93 nonhemangiomatous benign lesions) in 235 patients (140 male and 95 female; mean age ± SD, 56 ± 11 years) who underwent CEUS after sulfur hexafluoride‐filled microbubble injection. The digital cine clips recorded during the arterial (10–35 seconds from injection), portal (50–120 seconds), and late (130–300 seconds) phases were analyzed by 6 independent observers without experience (group 1, observers 1–3) or with 2 to 10 years of experience in CEUS (group 2, observers 4–6). Specific training in the diagnostic and interpretative criteria was provided to the inexperienced observers. Each observer used a 5‐point scale to grade diagnostic confidence: 1, definitely benign; 2, probably benign; 3, indeterminate; 4, probably malignant; or 5, definitely malignant on the basis of the enhancement pattern during the arterial phase and enhancement degree during the portal and late phases compared with the liver (hypoenhancement indicating malignant and isoenhancement to hyperenhancement indicating benign). Results. The analysis of observer diagnostic confidence revealed higher intragroup (κ = 0.63–0.83) than intergroup (κ = 0.47–0.63) observer agreement. The experienced observers showed higher diagnostic performance in malignancy diagnosis than did inexperienced observers (overall accuracy: group 1, 63.3%–72.8%; group 2, 75.9%–93.1%; P < .05, χ2 test). Conclusions. The diagnostic performance of CEUS in liver tumor characterization was dependant on the observers level of experience.

Comparison between 64-row CT angiography and digital subtraction angiography in the study of lower extremities: personal experience

PurposeThis study was undertaken to evaluate the potential of 64-row multislice computed tomography (CT) versus digital subtraction angiography (DSA) in detecting significant lesions of lower-extremity inflow and runoff arteries.Materials and methodsFifty-three patients underwent 64-row multislice CT and DSA over a mean of 36 days. The vascular tree was divided into 33 segments. Three readers independently reviewed the axial CT scans and multiplanar oblique and two- and three-dimensional reconstructions (maximum intensity projection and volume rendering) images to assess degree of stenosis according to four categories: 1 (0%–49% stenosis); 2 (50%–99% stenosis); 3 (occluded); 4 (not evaluable). In all cases, DSA was performed by arterial catheterisation.ResultsIn 53 patients, 1,440 segments were evaluated (infrarenal aorta and 16 arterial segments for each leg; 42 bilateral studies, 11 unilateral studies). Compared with DSA, CT angiography yielded 97.2% sensitivity, 97% specificity, 92.5% positive predictive value, 98.9% negative predictive value, 97.1% diagnostic accuracy and 95.4% concordance on the degree of stenosis.ConclusionsSixty-four-row multislice CT proved to be helpful in detecting haemodynamically significant lesions in peripheral arterial occlusive disease and improved the results obtained with 4- and 16-slice multidetector CT. In addition, owing to the high spatial resolution and rigorous technique, no variations in the data obtained below the knee were detected, overcoming a limitation of earlier generations of CT scanners.RiassuntoObiettiviScopo del nostro lavoro è stato valutare le potenzialità dell’angio-tomografia computerizzata (TC) a 64 strati nella valutazione dell’arteriopatia ostruttiva degli arti inferiori (AOAI) vs l’angiografia digitale.Materiali e metodiCinquantatre pazienti sono stati sottoposti ad angio-TC a 64 strati e angiografia digitale in un intervallo medio di tempo di 36 giorni. L’albero vascolare è stato suddiviso in 33 segmenti. Tre radiologi hanno valutato le immagini assiali e le ricostruzioni multiplanari oblique e bi-tridimensionali (maximum intensity projection [MIP], volume rendering [VR]), e hanno classificato le lesioni in 4 gradi: 1=stenosi 0%–49%, 2=stenosi 50%–99%, 3=occlusione, 4=non valutabile. Gli esami di angiografia digitale sono stati eseguiti sempre mediante cateterismo arterioso.RisultatiNei 53 pazienti sono risultati valutabili 1440 segmenti (aorta sottorenale e 16 segmenti/arto; 42 studi bilaterali; 11 studi monolaterali). Nei confronti dell’angiografia, l’angio-TC ha dimostrato sensibilità=97,2%, specificità=97%, valore predittivo positivo=92,5%, valore predittivo negativo=98,9%, accuratezza diagnostica=97,1%, concordanza grado di stenosi=95,4%.ConclusioniL’angio-TC a 64 strati si è dimostrata affidabile nella valutazione delle lesioni steno-ostruttive dell’AOAI ed è stata in grado di migliorare ulteriormente i risultati ottenuti con TC a 4–16 strati. Inoltre, grazie all’elevata risoluzione spaziale e ad una tecnica rigorosa, non sono stati rilevate variazioni nei dati ottenuti al di sotto del ginocchio, superando un limite delle TC delle generazioni precedenti.

Predictors of Dysplastic Nodule Diagnosis in Patients With Liver Cirrhosis on Unenhanced and Gadobenate Dimeglumine–Enhanced MRI With Dynamic and Hepatobiliary Phase

OBJECTIVE The purpose of this article is to assess whether unenhanced and gadobenate dimeglumine-enhanced MRI with dynamic and hepatobiliary phase may predict the diagnosis of dysplastic nodules in patients with liver cirrhosis. MATERIALS AND METHODS We retrospectively analyzed 75 cirrhotic patients (47 men and 28 women; mean [± SD] age, 55 ± 12 years) with 82 hepatocellular nodules, including histology-proven dysplastic nodules (n = 25; diameter, 1-3 cm) and hepatocellular carcinomas (n = 57; diameter, 2-3 cm) scanned by MRI before and after gadobenate dimeglumine injection during hepatic arterial phase (HAP), portal venous phase (PVP), equilibrium phase, and hepatobiliary phase. Nodule T1 and T2 intensities before contrast agent injection and nodule HAP, PVP, equilibrium phase, and hepatobiliary phase intensities were compared with the adjacent liver. Univariate and multivariate logistic regression analysis was conducted to assess how the nodule could predict dysplastic nodule diagnosis. RESULTS Some imaging findings were independent predictors of dysplastic nodule diagnosis-namely, nodule T2 isohypointensity (odds ratio [OR], 12.28; 95% CI, 3.88-38.82), T1 isohyperintensity (OR, 26.74; 95% CI, 7.53-94.90), HAP isohypointensity (OR, 97.16; 95% CI, 20.06-470.49), PVP-equilibrium phase isohyperintensity (OR, 20.53; 95% CI, 5.36-78.62), and hepatobiliary phase isohyperintensity (OR, 119.6; 95% CI, 21.59-662.40). Nodule T2 and HAP isohypointensity (OR 31.47; 95% CI, 7.88-125.58), nodule T2 isohypointensity and hepatobiliary phase isohyperintensity (OR, 28.77; 95% CI, 7.79-106.19), nodule T1 isohyperintensity and HAP isohypointensity (OR, 17.22; 95% CI, 4.85-61.14), and nodule T1 and hepatobiliary phase isohyperintensity (OR, 19.39; 95% CI, 5.38-69.90) were also predictors of dysplastic nodule diagnosis. CONCLUSION The combination of nodule appearance on T2-weighted MRI and nodule enhancement after gadobenate dimeglumine injection may predict dysplastic nodule diagnosis in patients with liver cirrhosis.

Color Doppler Appearance of Penile Cavernosal-Spongiosal Communications in Patients with High-Flow Priapism

Background: Superselective embolization of the torn artery is currently considered the treatment of choice for patients with high-flow priapism. After embolization, however, the arterial-sinusoidal fistula is still patent in a significant percentage of patients, despite arteriographic evidence of occlusion. Purpose: To investigate the prevalence and flow characteristics of penile cavernosal-spongiosal communications (CSCs) in patients with high-flow priapism, and to establish whether the recognition of these vessels before and after angiographic embolization has a role in predicting the outcome of therapy. Material and Methods: Twelve consecutive patients with high-flow priapism underwent penile color Doppler ultrasound before and after angiographic embolization of the arterial-sinusoidal fistula. The prevalence of CSCs feeding the fistula was evaluated before and after embolization. Results: Before angiographic embolization, color Doppler ultrasound identified five CSCs in 3/12 patients. One CSC was proximal to the fistula, and 4/5 were distal. After angiographic embolization, the fistula was not completely closed in these patients, fed by the distal CSCs. However, spontaneous closure occurred within 1 month. The fistula was also fed by CSCs in another two patients in whom these vessels were not evident before embolization. In one case, the fistula closed spontaneously within 1 week, while in the other case the fistula remained patent, fed by other collateral vessels. Conclusion: The type of vessels that are involved in refilling the fistula after embolization is of concern for the outcome of the patients. In our series, the fistulas supplied only by CSCs closed spontaneously within 1 month. Watchful waiting should be preferred to repeated embolization to avoid the risk of unnecessary procedures.

Arterial enhancing-only nodules less than 2 cm in diameter in patients with liver cirrhosis: Predictors of hepatocellular carcinoma diagnosis on gadobenate dimeglumine-enhanced mr imaging

To assess whether gadobenate dimeglumine (Gd‐BOPTA)‐enhanced MR imaging could predict hepatocellular carcinoma (HCC) diagnosis in small arterial enhancing‐only nodules detected by contrast‐enhanced computed tomography (CT) in patients with liver cirrhosis.

US Anatomy of the Penis: Common Findings and Anatomical Variations

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. In fact, improved spatial resolution and increased color Doppler sensitivity provided by the latest generation of ultrasound equipment allow an excellent evaluation of normal and pathological penile structures. Ultrasound evaluation of the penis, however, requires a good knowledge of penile anatomy to identify subtle changes that can be appreciated in pathological conditions.

Prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta and lower limbs

PurposeThe aim of this study was to assess the prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta (AA-CTA) and lower limbs (LL-CTA).Materials and methodsThe images of 536 AA-CTA and LL-CTA examinations performed for suspected aortic and peripheral vascular disease in 500 patients were retrospectively reviewed. Two radiologists evaluated the 5-mm axial images independently using appropriate window settings for the area under investigation. Collateral findings were divided according to their clinical significance into significant, nonsignificant and meriting further investigation.ResultsNo collateral findings were identified in 97/500 patients (19.4%). In the remaining patients, 821 collateral findings were detected, of which 43 (5.24%) were classified as significant, 135 (16.44%) as meriting further investigation and 643 (78.32%) as nonsignificant. The findings indicative of the presence of a malignant lesion totalled 36 (4.5%).ConclusionsAA-CTA and LL-CTA demonstrate a nonnegligible prevalence of collateral findings, many of them major. It therefore appears that the evaluation should focus not only on the image reconstructions to identify vascular disease, but also on the native axial images to detect incidental findings.RiassuntoObiettivoScopo di questo studio è quello di valutare la prevalenza dei reperti collaterali extravascolari in corso di indagini di angio-TC dell’aorta addominale (AA-CTA) e degli arti inferiori (AI-CTA).Materiali e metodiSono state valutate retrospettivamente le immagini di 500 pazienti sottoposti ad AA-CTA e AI-CTA, per un totale di 536 esami, mediante apparecchiatura a 64 strati per sospetta patologia vascolare aortica e periferica. Due radiologi hanno valutato separatamente le immagini assiali a 5 mm utilizzando finestre di vista adeguate al distretto valutato. I reperti collaterali sono stati divisi a seconda della loro rilevanza clinica in significativi, non significativi e meritevoli di approfondimento.RisultatiSu 500 pazienti, solo in 97 non sono stati riscontrati reperti collaterali (19,4%); sono stati identificati 821 reperti accessori, dei quali 43 (5,24%) sono stati reputati significativi; 135 (16,44%) meritevoli di approfondimento e 643 (78,32%) non significativi. I reperti suggestivi per la presenza di una lesione neoplastica sono stati 36 (4,5%).ConclusioniGli esami di angio-TC addominali e degli arti inferiori presentano una prevalenza di reperti collaterali anche maggiori non trascurabile. Appare quindi necessario effettuare una valutazione dei reperti accessori sulle immagini assiali native, senza limitarsi alla sola valutazione delle ricostruzioni focalizzate alla valutazione vascolare.

Radiological-pathological correlation in intratumoural tissue components of solid lung tumours.

The aim of this paper is to describe the intratumoural tissue components of solid lung tumours evidenced by macroscopic and/or microscopic examination of the autopsic or surgical specimen and visible on computed tomography (CT) without and with contrast material administration. Seven intratumoural tissue components can be identified both at CT and at pathology: (1) solid component, (2) haemorrhagic component, (3) coagulation necrosis, (4) liquefactive necrosis, (5) parenchymal consolidation, (6) diffuse peripheral component and (7) fibrotic component. Necrotic and haemorrhagic components are typically observed in malignant lesions, whereas solid and fibrotic components may be seen both in solid lung malignancies and in benign lesions.RiassuntoLo scopo di questa presentazione è descrivere le componenti tissutali intratumorali presenti nei tumori polmonari solidi che risultino evidenti all’analisi macroscopica e/o microscopica del campione patologico, autoptico oppure chirurgico, e che siano identificabili anche all’indagine tomografia computerizzata (TC) eseguita mediante metodica diretta e dopo la somministrazione di mezzo di contrasto. Sette distinte componenti tissutali intratumorali sono identificabili sulle immagini TC e sul reperto patologico: 1) componente solida; 2) componente emorragica; 3) necrosi coagulativa; 4) necrosi colliquativa; 5) addensamento parenchimale; 6) componente periferica diffusa; 7) componente fibrotica. Le componenti a carattere necrotico ed emorragico vengono osservate tipicamente nelle neoplasie maligne, mentre le componenti solide ed a carattere fibrotico possono essere osservate sia nei processi polmonari solidi a carattere maligno sia nelle lesioni benigne.