Sara Savelli

Potential role of fetal cardiac evaluation with magnetic resonance imaging: preliminary experience

To report our experience with magnetic resonance imaging (MRI) in fetal heart evaluation.

Evaluation of normal brain development by prenatal MR imaging.

AbstractPurpose.The aim of this study was to describe the normal pattern of development and maturation of the foetal brain with respect to gestational age as assessed with magnetic resonance imaging (MRI) and to provide an overview of the possibilities of the technique.Materials and methods.Foetal cerebral MRI was performed on 56 pregnant women between 19 and 37 weeks of gestation. Half-Fourier single-shot turbo spin-echo (HASTE), true fast imaging with steady precession (FISP), T1-weighted fast low angle shot (FLASH) two-dimensional (2D) and diffusion-weighted (DW) sequences with apparent diffusion coefficient (ADC) were obtained. Biometric parameters and developmental areas of the cerebral cortex were correlated to gestational age by using the Spearman rank correlation test.Results.We found a negative correlation between the germinal matrix/biparietal diameter ratio and gestational age and a positive correlation between the germinal and cortical matrix when expressed as external intraocular diameter ratio (R=0.452, p=0.02). The cortical mantle was correlated with biometric parameters, such as the biparietal diameter and the frontooccipital diameter, and with gestational age. The interhemispheric fissure, the parietooccipital fissure and the sylvian fissure were detectable by the 22nd week. In the grey matter, the mean ADC values varied from 1.76×10-3 mm2/s (at week 19) to 0.89×10-3 mm2/s (at week 37), whereas in the white matter, the values varied from 2.03×10-3 mm2/s (at week 19) to 1.25×10-3 mm2/s (at week 37).Conclusions.MRI provides a reliable valuation of brain maturation during pregnancy.

Role of breast Magnetic Resonance Imaging (MRI) in patients with unilateral nipple discharge: preliminary study

PurposeThis study was performed to assess the role of magnetic resonance imaging (MRI) in patients with unilateral nipple discharge.Materials and methodsForty-four patients with bloody or serosanguineous nipple discharge and negative mammographic findings (35/44 cases) underwent MRI for evaluation of breast ducts. Ultrasonography, negative in 18 patients, identified 26 cases of ductal ectasia (12 simple, nine with solid intraductal echoes and wall thickening, five with inhomogeneous parenchyma). Galactography was negative in three patients and positive in nine. Nineteen patients were followed up by clinical examination, ultrasonography, and cytological evaluation of nipple discharge (6–12 months); three patients underwent excisional biopsy, ten core biopsy and 12 cytological biopsy (followed by excisional biopsy).ResultsMRI identified 25 enhancing lesions Breast Imaging Reporting and Data Systems (BI-RADS) 3 or 4) and confirmed the galactographic findings (ductal ectasia, intraluminal filling defects). Five papillomatoses appeared as patchy, homogeneous enhancing areas, 15 intraductal papillomas as areas with well-defined margins and type II time-intensity curves, and two atypical ductal hyperplasias as diffuse nodular enhancement. One micropapillary ductal carcinoma in situ (DCIS), one papillary carcinoma and one infiltrating ductal carcinoma (IDC) were visualised as two segmental areas of enhancement and one mass-like enhancement with poorly defined margins (BI-RADS 4). The follow-up was negative, showing no pathological enhancement (BI-RADS 1) in 12 patients and benign enhancement (BI-RADS 2) in seven.ConclusionsBreast MRI can be considered a valuable examination in the diagnosis of suspected ductal disease and an alternative to galactography when the latter cannot be used.RiassuntoObiettivoValutare il ruolo della risonanza magnetica (RM) in pazienti con secrezione monorifiziale dal capezzolo.Materiali e metodiQuarantaquattro pazienti con secrezione ematica/sieroematica dal capezzolo, mammografia negativa (35/44 casi) si sottoponevano allo studio dei dotti con RM. L’ecografia negativa in 18 casi, identificava ectasia duttale in 26: semplici in 12, con proliferazione solida intraduttale ed ispessimento parietale in 9 e con disomogeneità ghiandolare in 5; la galattografia negativa in 3 e positiva in 9. Diciannove pazienti effettuavano follow-up clinico, radiologico, citologico della secrezione (6–12 mesi), 3 biopsia chirurgica, 10 core-biopsy e 12 prelievo citologico (seguite da biopsia chirurgica).RisultatiRM identificava 25 aree di potenziamento classificate BI-RADS 3 o 4. Nelle pazienti sottoposte a galattografia, la RM riconosceva i reperti galattografici (ectasia o difetti di riempimento). Cinque papillomatosi duttali si identificavano come potenziamento lineare ed omogeneo; 15 papillomi: enhancement a margini netti e curva intensità-tempo di tipo II, 2 iperplasie duttali atipiche: potenziamento nodulare diffuso. Un carcinoma papillare, 1 CDIS con aspetto micropapillare e 1 CDI si evidenziavano come 2 aree di potenziamento segmentale e un’area di potenziamento nodulare a margini irregolari (BI-RADS4). Follow-up negativo in 12 pazienti senza potenziamento patologico (BI-RADS1) e in 7 con potenziamento benigno (BIRADS2).ConclusioniLa RM può essere considerata valida metodica diagnostica nello studio della sospetta patologia duttale con secrezione, in alternativa alla galattografia quando questa metodica non sia utilizzabile.

Role of fetal MRI in the diagnosis of cerebral ventriculomegaly assessed by ultrasonography

PurposeTo evaluate the additional diagnostic value of fetal MRI to evaluate cerebral ventriculomegaly assessed by ultrasonography (US) for the possibility to change the diagnosis, the counseling and the management of pregnancy.Materials and MethodsFrom february 2006 to october 2008, we studied 55 pregnant women by fetal MRI (mean age 28 years), 4 with twin pregnancy, for a total of 59 fetuses with mean gestational age of 27 weeks. The number of fetuses affected by ventriculomegaly assessed by US was 55. All fetuses had a US diagnosis of ventriculomegaly: 29 fetuses with isolated ventriculomegaly and 26 fetuses with ventriculomegaly associated with CNS (central nervous system) abnormalities (18) and with no CNS abnormalities (8).ResultsThe findings showed that the two techniques are substantially in agreement in defining the degree of VM, with the exception of some cases in which the disagreement could be attributed to the possible progression of the dilatation between the US and MRI examinations, which sway between two days and two weeks. We proved a low correlation between US and MRI in the evaluation of ventriculomegaly associated either with CNS or non-CNS anomalies: in fact while fetal MRI detected 26/55 (47,3%) VM associated with CNS anomalies, US demonstrated only 18/55(32,7%). Referring to VM associated with non-CNS anomalies, MRI diagnosed 10/55 cases (18,2%) compared to 8/55 fetuses (14,5%) showed by US.ConclusionsOur experience demonstrated that fetal MRI has an important role as adjunctive tool to sonography in the evaluation of cerebral ventriculomegaly for the additional informations given to parents and for the possibility to change the diagnosis, the counseling and the management of pregnancy.RiassuntoObiettivoLo scopo del nostro studio è valutare il ruolo della risonanza magnetica nell’inquadramento diagnostico delle ventricolomegalie per le conseguenze che un cambiamento della diagnosi può avere sul counselling materno, sul management della gravidanza e sulla pianificazione di eventuali interventi pre e postnatali, nell’ottica di una gestione multidisciplinare.Materiali e metodiNel periodo compreso fra febbraio 2006 ed ottobre 2008, abbiamo sottoposto a risonanza magnetica 55 donne in stato di gravidanza (età media 28 aa), 4 delle quali con gravidanze gemellari, per un totale di 59 feti di età gestazionale con età gestazionale media di 27 settimane. Il numero di feti interessati da ventricolomegalia secondo l’indicazione ecografica era di 55. Tutti i feti avevano diagnosi ecografica di ventricolomegalia: 29 feti con ventricolomegalia isolata e 26 feti con ventricolomegalia associata; in particolare in quest’ultimo gruppo 18 feti riportavano associazioni con anomalie del SNC ed 8 feti con anomalie di altri distretti.RisultatiÈ emerso così che le due metodiche sono sostanzialmente in accordo nel definire l’entità della ventricolomegalia, fatta eccezione per alcuni casi nei quali la discordanza potrebbe attribuirsi alla possibile progressione della dilatazione nell’arco di tempo intercorso fra ecografia e risonanza magnetica, variabile fra 2 giorni e 2 settimane. Minor grado di accordo è invece emerso dal confronto rispetto alla associazione delle ventricolomegalie con ulteriori anomalie sia del SNC fetale che di altri organi e apparati. Infatti la RM ha evidenziato 26/55 (47,3%) VM associate ad anomalie del SNC, versus 18/55 (32,7%) diagnosi di associazione con ulteriori anomalie encefaliche poste con l’ecografia; quanto alle associazioni con anomalie di altri distretti la RM ne ha posto diagnosi in 10/55 casi (18,2%) e l’ecografia in 8/55 feti (14,5%).ConclusioniIn base ai nostri risultati concludiamo che qualora si riscontri una ventricolomegalia vadano sempre informati i genitori circa il rischio di ulteriori anomalie associate e di conseguenti possibili ripercussioni sullo sviluppo psicomotorio del nascituro rispetto alla popolazione normale, consigliandone l’approfondimento diagnostico con i mezzi diagnostici disponibili.

Magnetic resonance imaging versus ultrasonography in fetal pathology.

PurposeThis paper describes our experience with magnetic resonance imaging (MRI) in the assessment of fetal anatomical structures and major fetal pathologies.Materials and methodsThe retrospective study included 128 pregnant women between the 22nd and 38th week of gestation. We used the following imaging protocol: T2-weighted single-shot fast spin-echo sequences for all foetuses and, in selected cases, gradient echo with steady-state free precession (SSFP), T1-weighted spoiled gradient echo [fast low-angle shot (FLASH)] with and without fat saturation, and T2 thick-slab sequences with multiplanar technique. In 32 cases, we performed diffusion-weighted sequences with apparent diffusion coefficient (ACD) maps on the brain, the kidneys and the lungs.ResultsWe achieved diagnostic-quality images in 125 of 128 patients; MR image quality was unsatisfactory in three cases only. In 16 cases with previous negative ultrasound (US) findings, MRI confirmed the US diagnosis. MRI confirmed the positive US diagnosis in 67 of 109 cases (61.5%); in 11 cases it changed the US diagnosis, and in 31/109 the examination was negative. In addition, MRI identified other anomalies not recognised during US examination.ConclusionsWith its ultrafast sequences, fetal MRI provides good detail of normal fetal anatomy and allows characterisation of suspected anomalies.RiassuntoObiettivoPresentare la nostra esperienza con la risonanza magnetica nella valutazione delle strutture anatomiche e delle patologie principali nel feto.Materiali e metodiLo studio retrospettivo include 128 donne in gravidanza tra la 22a e la 38a settimana di gestazione. Abbiamo utilizzato il seguente protocollo: per tutti i feti sequenze T2 pesate Single Shot Fast Spin Echo e in casi selezionati sequenze Gradient Echo con tecnica steady state free precession (SSFP), sequenze spoiled gradient echo T1 pesate (Fast Low Angle Shot, FLASH) con e senza saturazione del segnale del grasso e sequenze T2 thick slab acquisite con tecnica multiplanare. In 32 casi, abbiamo effettuato sequenze pesate per diffusione con il coefficiente di diffusione apparente (ADC) su cervello, reni e polmoni.RisultatiIn 125 pazienti su 128, l’esame ha mostrato una buona qualità; solo in 3 casi le immagini RM non sono risultate soddisfacenti. Nei 16 casi già negativi all’ecografia, l’RM ha confermato il risultato ecografico. L’RM ha confermato come positive 67 diagnosi ecografiche su 109 casi (61,5%); in 11 casi, invece, l’RM ha modificato la diagnosi ecografica ed in 31 pazienti l’esame è risultato negativo. Inoltre l’RM ha consentito di riconoscere ulteriori anomalie che non sono state diagnosticate durante l’esame ecografico.ConclusioniL’RM fetale, grazie alle sequenze ultra-fast, consente di visualizzare buoni dettagli dell’anatomia fetale e di caratterizzare sospette anomalie.

Diffusion-weighted MR imaging and apparent diffusion coefficient of the normal fetal lung: preliminary experience.

To assess if a correlation is present between apparent diffusion coefficient (ADC) values and normal lung maturation during gestation to define potential reference values as indicators of the lung development.

MRI and DWI: feasibility of DWI and ADC maps in the evaluation of placental changes during gestation.

To establish if a correlation exists between apparent diffusion coefficient (ADC) values, obtained by diffusion‐weighted imaging (DWI), and placental aging.

Breast MRI: Are T2 IR sequences useful in the evaluation of breast lesions?

AIM To evaluate the potential role of signal intensities calculated in T2 images as an adjunctive parameter in the analysis of mass-like enhancements classified as BIRADS (Breast Imaging Reporting and Data System) assessment categories 2, 3, 4 or 5 with the standard T1 criteria. MATERIALS AND METHODS After a retrospective review of 338-breast Magnetic Resonance Imaging (MRI) performed for the evaluation of a suspicious lesion we selected a group of 65 mass-like enhancements ranging from 5 to 20mm, classified as BIRADS assessment categories 2, 3, 4 or 5, histologically proved. In all cases we calculated the ratio between the signal intensity (SI) of the nodule and the pectoralis major muscle (LMSIR, lesion to muscle signal intensity ratio) with a multiROIs (region of interest) analysis on T2 images. A ROC analysis was performed to test the ability of the two diagnostic parameters separately considered (BIRADS and LMSIR) and combined in a new mono-dimensional variable obtained by a computerized discriminant function. RESULTS Histological examination assessed 34 malignant lesions (52.3%) and 31 benign lesions (47.7%). The evaluation of ROC curves gave the following results: BIRADS area under the curve (AUC) 0.913, S.E. 0.0368, LMSIR AUC 0.854, S.E. 0.0487, combined BIRADS-LMSIR AUC 0.965, S.E. 0.0191 with a definitive increase in the AUC between the overall ROC area and those of the two diagnostic modalities separately considered. DISCUSSION T2-weighted SI assessment with LMSIR measurement improves the diagnostic information content of standard breast MRI and can be considered a promising potential tool in the differential diagnosis of mass-like enhancements judged as borderline lesions (BIRADS 3 and 4).

Carotid body tumors: radioguided surgical approach

BackgroundCarotid body tumours (CBTs) are very rare lesions which should be treated as soon as possible even when benign since small tumour size permits easier removal and lower incidence of perioperative complications and recurrence. Malignant forms are rare and they can be identified by lymph node invasion and metastases in distant locations. The need of reliable and effective diagnostic modalities for both primary CBTs and its metastases or recurrence is evident.The present study reviews our experience and attempt to define the role of colour coded ultrasound (CCU) and Somatostatin receptor scintigraphy (SRS) with Indium-111-DTPA-pentetretide (Octreoscan®) using both planar and single photon emission tomography (SPECT) technique in the diagnosis and follow-up of these uncommon lesions within a multidisciplinary approach.MethodsFrom 1997 to 2008, 12 patients suffering from 16 CBTs (4 bilateral) were investigated by CCU and SRS-SPECT before and after surgery. All tumours were grouped according to Shamblins classification in order to assess the technical difficulties and morbidity of surgical resection on the ground of their size and relationship with the carotid arteries. Intraoperative radiocaptation by Octreoscan®) was also carried out in all cases to evaluate the radicality of surgery. All perioperative scans were evaluated by the same nuclear medicine physician.ResultsPreoperatively CCU showed CBTs (four were not palpable) with a sensitivity of 100%. Radioisotope imaging identified the CBTs as chemodectomas in 15 cases while no radioisotopic uptake was detected in 1 vagus nerve neurinoma. No evidence of metastasis or multicentricity were seen by total body radioisotopic scans. Combined data from CCU and SRS-SPECT allowed to determine tumour size in order to select 7 larger tumours which were submitted to selective preoperative embolization.Intraoperatively Octreoscan demonstrated microscopic tumour leftovers promptly removed in 1 case and an unresectable remnant at the base of the skull in another case.During follow-up CCI and radioisotope scans showed no recurrence in 14 cases and a slightly enlargement of the intracranial residual as detected during surgery in 1 patient.ConclusionCCU may allow an early and noninvasive detection of CBTs and hence safer operations. The combined use of CCU and SRS-SPECT provide useful data to identify those tumours and to evaluate their extent and carotid arteries infiltration. Radioisotope imaging is a sensitive modality to detect metastases and lymph node involvement that are markers of CBT malignancy. After surgery CCU and SRS-SPECT can be accurate modalities for surveillance for an early detection of CBTs recurrence.

Diagnostic utility of combined ultrasonography and mammography in the evaluation of women with mammographically dense breasts

PURPOSE To assess the diagnostic utility and additional cost of combined breast ultrasonography and mammography in the evaluation of asymptomatic women with mammographically dense breasts. MATERIALS AND METHODS Of 5108 asymptomatic women, who underwent mammography, 1754 had dense breasts (BI-RADS 3 or 4) and negative mammographic outcome. They were divided in 4 subgroups according to their age (<40 yrs; 40-49 yrs; 50-59 yrs; >59 yrs). Breast ultrasonography was performed immediately after mammography. Lesions detected at ultrasonography were examined cytologically/histologically. Mammograms from women, who were diagnosed carcinoma at ultrasonography, were reviewed by an external radiologist. Costs per diagnosed carcinoma and per examined woman were calculated on the basis of current regional charges. RESULTS Mammographies (5108) were performed, 67 cancers were detected (cancer detection rate 13.1‰): mammography identified 55 carcinomas and ultrasonography performed in women with dense breasts identified 12 cancers (17.9% of all cancers detected, overall cancer detection rate 6.8‰). Ultrasonography identified a benign condition in 1567 out of 1754 women (89.3%) (in 925 absence of focal lesions; 438 simple cysts; 56 ductal ectasia; 148 benign solid lesions); 97 complex cysts, 52 lesions that could not be differentiated as liquid or solid lesions, and 38 solid lesions suspicious for malignancy in the remaining 187 out of 1754 patients (10.7%). Cytology/histology confirmed carcinoma in 12 women (overall biopsy rate 26.2‰, benign biopsy rate 19.4‰). The additional costs were: € 6,123.45 per detected cancer, € 41.89 per examined woman. CONCLUSION Breast ultrasonography immediately after mammography in women with dense breasts is useful to avoid diagnostic delays and inconvenient medico-legal implications even though this procedure involves increased costs.