Silvia Tresoldi

In Vivo Evaluation of the Chemical Composition of Urinary Stones Using Dual-Energy CT

OBJECTIVE The purpose of this article is to evaluate in vivo the chemical composition of urinary stones using dual-source and dual-energy CT, with crystallography as the reference standard. MATERIALS AND METHODS Forty patients (mean [± SD] age, 49 ± 17 years) with known or suspected nephrolithiasis underwent unenhanced abdominal CT for urinary tract evaluation using a dual-energy technique (tube voltages, 140 and 80 kVp). For each stone 5 mm or larger in diameter, we evaluated the site, diameter, CT density, surface (smooth vs rough), and stone composition. Patients were treated with extracorporeal shock wave lithotripsy (n = 34), percutaneous nephrolithotomy (n = 4), or therapeutic ureterorenoscopy (n = 2). Collected stones underwent crystallography, and the agreement with the results of dual-energy CT was calculated with the Cohen kappa coefficient. The correlation among stone composition, diameter, and CT density was estimated using the Kruskal-Wallis test. RESULTS Thirty-one patients had a single stone and nine had multiple stones, for a total of 49 stones. Forty-five stones were in the kidneys, and four were in the ureters; 23 had a smooth surface and 26 had a rough surface. The mean stone diameter was 12 ± 6 mm; mean CT density was 783 ± 274 HU. According to crystallography, stone composition was as follows: 33 were calcium oxalate, seven were cystine, four were uric acid, and five were of mixed composition. Dual-energy CT failed to identify four stones with mixed composition, resulting in substantial agreement between dual-energy CT and crystallography (Cohen κ = 0.684). Stone composition was not correlated with either stone diameter (p = 0.920) or stone CT density (p = 0.185). CONCLUSION CT showed excellent accuracy in classifying urinary stone chemical composition, except for uric acid-hydroxyapatite mixed stones.

Malignant Incidental Extracardiac Findings on Cardiac CT: Systematic Review and Meta-Analysis

OBJECTIVE The objective of our study was to systematically review the evidence on incidental extracardiac findings on cardiac CT with a focus on previously unknown malignancies. MATERIALS AND METHODS A systematic search was performed (PubMed, EMBASE, Cochrane databases) for studies reporting incidental extracardiac findings on cardiac CT. Among 1099 articles initially found, 15 studies met the inclusion criteria. The references of those articles were hand-searched and 14 additional studies were identified. After review of the full text, 10 articles were excluded. Nineteen studies including 15,877 patients (64% male) were analyzed. A three-level analysis was performed to determine the prevalence of patients with incidental extracardiac findings, the prevalence of patients with major incidental extracardiac findings, and the prevalence of patients with a proven cancer. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% CI were calculated. RESULTS The prevalence of both incidental extracardiac findings and major incidental extracardiac findings showed a high heterogeneity (I2>95%): The pooled prevalence was 44% (95% CI, 35-54%) and 16% (95% CI, 14-20%), respectively. No significant explanatory variables were found for using or not using contrast material, the size of the FOV, and study design (I2>85%). The pooled cancer prevalence for 10 studies including 5082 patients was 0.7% (95% CI, 0.5-1.0%), with an almost perfect homogeneity (I2<0.1%). Of 29 reported malignancies, 21 (72%) were lung cancers; three, thyroid cancers; two, breast cancers; two, liver cancers; and one, mediastinal lymphoma. CONCLUSION Although the prevalence of reported incidental extracardiac finding at cardiac CT was highly variable, a homogeneous prevalence of previously unknown malignancies was reported across the studies, for a pooled estimate of 0.7%; more than 70% of these previously unknown malignancies were lung cancers. Extracardiac findings on cardiac CT require careful evaluation and reporting.

MDCT of 220 consecutive patients with suspected acute pulmonary embolism: incidence of pulmonary embolism and of other acute or non-acute thoracic findings

Purpose . This study was undertaken to evaluate the incidence of pulmonary embolism (PE) and other clinically relevant thoracic findings discovered on contrast-enhanced multidetector computed tomography (MDCT) examination in patients with a suspicion of acute PEMaterials and methods . We retrospectively reviewed 220 reports of 40-row MDCT exams in consecutive patients (101 men, 119 women; mean age 55 years±18) suspected for acute PE. Presenting symptoms and risk factors were recorded. Image quality and incidence of PE and other clinically relevant thoracic findings were evaluatedResults . MDCT were diagnostic in 96.8% of patients. Nineteen patients (8.6%) were positive for PE. Signs and symptoms were present in 82.7% (182) and risk factors in 38.2% (84) of the population. Clinically relevant thoracic findings were detected in 45.9% (101) of the patients. Ten patients had PE and other thoracic findings. Half of the patients (110) had neither PE nor other clinically relevant thoracic findingsConclusions . Chest MDCT, with an excellent overall image quality, provided an explanation for the clinical presentation in about 50% of emergency department patients studied and was useful in detecting PE and other thoracic diseases with symptoms mimicking PE. However, half of the exams were negativeRiassuntoObiettivo . Scopo dello studio è valutare l’incidenza di embolia polmonare (EP) e di altri reperti toracici clinicamente rilevanti, in esami di tomografia computerizzata multi-detettore (TCMD) con mezzo di contrasto, in pazienti con sospetta embolia polmonare acutaMateriali e metodi . Abbiamo analizzato retrospettivamente i referti TC 40-strati di 220 pazienti consecutivi (101 maschi, 119 femmine; età media 55±18 anni) con sospetto di EP acuta. Sono stati raccolti sintomi e fattori di rischio. Abbiamo valutato la qualità delle immagini e l’incidenza di EP e di altri reperti toracici clinicamente rilevanti. Risultati. La TCMD è risultata diagnostica nel 96,8% dei pazienti. L’82,7% (n=182) dei pazienti aveva segni/sintomi, il 38,2% (n=84) fattori di rischio. All’8,6% dei pazienti (n=19) è stata fatta diagnosi di embolia polmonare, al 45,9% (n=101) sono stati identificati altri reperti toracici clinicamente rilevanti. Dieci pazienti avevano sia EP sia altri reperti toracici. Metà della popolazione (n=110) non aveva né EP né altri reperti toracici clinicamente rilevantiRisultati . La TCMD è risultata diagnostica nel 96,8% dei pazienti. L’82,7% (n=182) dei pazienti aveva segni/sintomi, il 38,2% (n=84) fattori di rischio. All’8,6% dei pazienti (n=19) è stata fatta diagnosi di embolia polmonare, al 45,9% (n=101) sono stati identificati altri reperti toracici clinicamente rilevanti. Dieci pazienti avevano sia EP sia altri reperti toracici. Metà della popolazione (n=110) non aveva né EP né altri reperti toracici clinicamente rilevantiConclusioni . La 40-TCMD del torace, grazie anche ad un’eccellente qualità dell’immagine, ha fornito una spiegazione alla presentazione clinica in circa metà dei pazienti studiati, risultando utile nell’identificazione dell’embolia polmonare e di altre patologie toraciche con sintomi simili. Tuttavia la metà degli esami è risultata negativa

Myocardial Fatty Foci in Adult Patients with Tuberous Sclerosis Complex: Association with Gene Mutation and Multiorgan Involvement

PURPOSE To estimate the association between myocardial fatty foci (MFF) on chest computed tomographic (CT) images and type of gene mutation or multiorgan involvement in patients with tuberous sclerosis complex (TSC). MATERIALS AND METHODS This retrospective case-control study was approved by the ethics committee, which waived the need for patient consent. Forty-eight patients with definite TSC (41 women; mean age, 35 years ± 11 [standard deviation]) and 96 age- and sex-matched patients without TSC who had undergone chest CT were evaluated. Two blinded readers independently scored MFF as low-attenuation areas within the myocardium. Patient history, gene mutation, and multiorgan involvement were obtained from clinical records. Cohen κ, Mann-Whitney U, χ(2) or Fisher exact, Kruskal-Wallis, and Spearman statistics were calculated. RESULTS One or more MFF was detected in 50% (24 of 48) of patients with TSC; however, no MFF was detected in control patients (P < .001). MFFs were oval (62%, 15 of 24) or linear (38%, nine of 24) and involved the left ventricle in 13 patients and both ventricles in 24 patients (mostly the apical or midleft ventricle); median size was 127 mm(2). After four patients with TSC and unknown mutational status (two with MFF) were excluded, MFF was detected in 53% (10 of 19) of patients with TSC1 mutation, 65% (11 of 17) of patients with TSC2 mutation, and 12% (one of eight) of patients with TSC but without an identified mutation (P = .044). MFF presence was associated with brain (P = .011) and multiorgan (P = .008) involvement. The number of MFF per patient correlated with the degree of multiorgan involvement (P = .014). With MFF considered predictive of TSC, 50% (24of 48) sensitivity, 100% (96 of 96) specificity, 100% (24 of 24) positive predictive value, and 80% (96 of 120) negative predictive value were obtained. CONCLUSION MFF was highly specific for TSC. MFF presence was associated with TSC gene mutations and with brain or multiorgan involvement; their number per patient was correlated with the degree of multiorgan involvement.

Liver metastases on serial contrast-enhanced multidetector computed tomography examinations: was the detection possible on previous examinations?

Objective: To verify the earliest detectability of liver metastases in patients who underwent serial multidetector computed tomography (MDCT) examinations. Methods: We selected 12 patients with known primary cancer who underwent 4 or more contrast-enhanced, 4-detector MDCTs. When metastases had been reported, an evaluation of the preceding MDCT was done to define whether the lesion was detectable, detectable only by minimal signs, undetectable, or detected but misdiagnosed as a benign lesion (MBL). Results: Eighty-eight lesions were analyzed. Evaluating the preceding examination, we defined detectable (n = 8), detectable only by minimal signs (n = 5), undetectable (n = 74), and MBL (n = 1). The group with minimal signs was composed of 4 small hypodense foci and 1 calcification. The MBL was a non-Hodgkin lesion first misdiagnosed as a hemangioma. Conclusion: Approximately 15% of liver metastases were prospectively missed, 9% of them being retrospectively detectable, 6% being retrospectively visible as minimal signs, whereas only 1% of liver metastases were misdiagnosed as a benign lesion.

Pulmonary Embolism in Oncologic Patients

Interest in diagnosis and treatment of pulmonary embolism (PE), a potentially fatal disease, is always high, especially among oncologic patients. In fact, not only tumors but also chemotherapy increases the risk to develop thromboembolic events in these particular patients. Moreover, nowadays, it frequently happens to detect incidental PE by imaging examinations performed for other purposes and, as oncologic patients are surely the ones who undergo the most of the diagnostic procedures, they are also the ones that more often are found to be affected by incidental, asymptomatic, pulmonary embolism.

Fractional flow reserve based on computed tomography: an overview

Computed tomography coronary angiography (CTCA) is a technique proved to provide high sensitivity and negative predictive value for the identification of anatomically significant coronary artery disease (CAD) when compared with invasive X-ray coronary angiography. While the CTCA limitation of a ionizing radiation dose delivered to patients is substantially overcome by recent technical innovations, a relevant limitation remains the only anatomical assessment of coronary stenoses in the absence of evaluation of their functional haemodynamic significance. This limitation is highly important for those stenosis graded as intermediate at the anatomical assessment. Recently, non-invasive methods based on computational fluid dynamics were developed to calculate vessel-specific fractional flow reserve (FFR) using data routinely acquired by CTCA [computed tomographic fractional flow reserve (CT-FFR)]. Here we summarize methods for CT-FFR and review the evidence available in the literature up to June 26, 2016, including 16 original articles and one meta-analysis. The perspective of CT-FFR may greatly impact on CAD diagnosis, prognostic evaluation, and treatment decision-making. The aim of this review is to describe technical characteristics and clinical applications of CT-FFR, also in comparison with catheter-based invasive FFR, in order to make a cost-benefit balance in terms of clinical management and patients health.

Imaging of Tuberous Sclerosis

AJR 2016; 206:W42 0361–803X/16/2062–W42

Bronchial artery hypertrophy is correlated with coronary artery disease

Background Bronchial arteries support the systemic pulmonary vasculature and physiologically communicate with pulmonary arteries and coronary arteries. While there is evidence supporting the link between pulmonary diseases and bronchial artery hypertrophy (BAH), few data on the correlation between coronary artery disease (CAD) and BAH have been published. Purpose To evaluate a possible association between BAH and CAD in patients without known pulmonary diseases undergoing computed tomography coronary angiography (CTCA). Material and Methods This retrospective study was approved by the local ethics committee. One hundred patients with varying degrees of CAD underwent CTCA. Patients were stratified into four groups as follows: group I, 25 patients without CAD or with non-significant CAD; group II, 25 untreated patients with significant CAD; group III, 25 stented patients; group IV, 25 patients with coronary artery bypass grafts. The number and diameter of bronchial arteries were recorded. Correlation between age, CAD, and BAH was estimated. Results One hundred and ninety-nine bronchial arteries were detected. Approximately 51% were hypertrophic (diameter, >1.5 mm) with a mean diameter of 1.7 ± 0.5 mm. Seventy-six patients showed no pulmonary alterations; 24 were found to have previously undiagnosed pulmonary findings, six of which were severe. Presence and degree of CAD correlated with patients’ mean age (60 in group I, 68 in group II, 65 in group III, 69 in group IV; P = 0.023), and mean bronchial artery transverse diameter (1.6 mm, 1.7 mm, 1.8 mm, and 2.0 mm, respectively; P = 0.009). The bronchial artery diameter was not associated with pulmonary findings (P = 0.390). Conclusion There is an association between CAD and BAH. In patients with no pulmonary alterations, BAH could be caused by undiagnosed underlying CAD.

Use of ultrasound malignancy score (TMS) in the management of thyroid nodules

Purpose The purpose of this study was to validate the role of the total malignancy score (TMS) in identifying thyroid nodules suspicious for malignancy through the sum of their ultrasound features. Methods The local ethical committee approved this prospective observational study. We examined 231 nodules in 231 consecutive patients (164 females and 67 males; age range, 20 to 87 years; median age, 59 years; interquartile range, 48 to 70 years) who underwent ultrasound followed by fine-needle aspiration cytology (FNAC). The nodules were further classified using the TMS, which considers ultrasound features (number, echogenicity, structure, halo, margins, Doppler signal, calcifications, and growth), and the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), which considers cytological features. Patients with non-negative nodules (TBSRTC categories III to VI) underwent histological analysis, repeated FNAC, or 2 years of regular ultrasound follow-up. The associations between the final diagnosis, each of the ultrasound features, and the TMS were estimated using the chi-square test, the Mann-Whitney U test, and multivariate logistic regression. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of the TMS. Results On ultrasound, 47% of the nodules (108 of 231) had a TMS <3, 18% (42 of 231) had a TMS of 3, and 35% (81 of 231) had a TMS >3. The FNAC results of 85% of the nodules (196 of 231) were benign, while 15% (35 of 231) had non-negative results. Hypoechogenicity, solid structure, the presence of microcalcifications, and the number of nodules were independent predictors of the final diagnosis, and the diagnostic accuracy of the TMS was good (area under the ROC curve, 0.82). Conclusion The TMS system is simple to use, reliable, easily reproducible, and closely reflects malignancy risk. Based on our results, FNAC could be limited to nodules with a TMS ≥3 without missing any cases of carcinoma.