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Objectives To develop a structured reporting (SR) template for whole-body CT examinations of polytrauma patients, based on the consensus of a panel of emergency radiology experts from the Italian Society of Medical and Interventional Radiology. Methods A multi-round Delphi method was used to quantify inter-panelist agreement for all SR sections. Internal consistency for each section and quality analysis in terms of average inter-item correlation were evaluated by means of the Cronbach’s alpha (Cα) correlation coefficient. Results The final SR form included 118 items (6 in the “Patient Clinical Data” section, 4 in the “Clinical Evaluation” section, 9 in the “Imaging Protocol” section, and 99 in the “Report” section). The experts’ overall mean score and sum of scores were 4.77 (range 1–5) and 257.56 (range 206–270) in the first Delphi round, and 4.96 (range 4–5) and 208.44 (range 200–210) in the second round, respectively. In the second Delphi round, the experts’ overall mean score was higher than in the first round, and standard deviation was lower (3.11 in the second round vs 19.71 in the first round), reflecting a higher expert agreement in the second round. Moreover, Cα was higher in the second round than in the first round (0.97 vs 0.87). Conclusions Our SR template for whole-body CT examinations of polytrauma patients is based on a strong agreement among panel experts in emergency radiology and could improve communication between radiologists and the trauma team.

Background The aim is to find a correlation between texture features extracted from neuroendocrine (NET) lung cancer subtypes, both Ki-67 index and the presence of lymph-nodal mediastinal metastases detected while using different computer tomography (CT) scanners. Methods Sixty patients with a confirmed pulmonary NET histological diagnosis, a known Ki-67 status and metastases, were included. After subdivision of primary lesions in baseline acquisition and venous phase, 107 radiomic features of first and higher orders were extracted. Spearman’s correlation matrix with Ward’s hierarchical clustering was applied to confirm the absence of bias due to the database heterogeneity. Nonparametric tests were conducted to identify statistically significant features in the distinction between patient groups (Ki-67 20—Group 3, and presence of metastases). Results No bias arising from sample heterogeneity was found. Regarding Ki-67 groups statistical tests, seven statistically significant features (p value Conclusions Some radiomic features can be used as a valid and reproducible tool for predicting Ki-67 class and hence the subtype of lung NET in baseline and post-contrast enhanced CT images. In particular, in baseline examination three features can establish both tumour class and aggressiveness.

Objective This study was performed to evaluate the prognostic meaning of volumetric and semi-quantitative parameters measured using [18F]FDG PET/CT and somatostatin receptor (SSTR) imaging in patients with typical lung carcinoid (TC), and their relationship with proliferative index (Ki67). Methods We retrospectively reviewed 67 patients (38–94 years old, mean: 69.7) with diagnosis of TC who underwent [18F]FDG PET/CT and/or SSTR scintigraphy/SPECT with [111In]DTPA-Octreotide plus contrast-enhanced CT (CECT) at staging evaluation. All patients had Ki67 measured and a follow-up (FU) of at least 1 year. SSTR density (SSTRd) was calculated as the percentage difference of tumor/non-tumor ratio at 4 and 24 h post-injection. At PET/CT, metabolic activity was measured using SUVmax and SUVratio; volumetric parameters included MTV and TLG of the primary tumor, measured using the threshold SUV41%. ROC analysis, discriminant analysis and Kaplan–Meier curves (KM) were performed. Results 11 patients died during FU. Disease stage (localized versus advanced), SUVratio, SUVmax, Ki67, MTV and TLG were significantly higher in non-survivors than in survivors. ROC curves resulted statistically significant for Ki67, SUVratio, SUVmax, MTV and TLG. On multivariate analysis, stage of disease and TLG were significant independent predictors of overall survival (OS). In KM curves, the combination of disease stage and TLG identified four groups with significantly different outcomes (p In patients with advanced and localized disease, SSTRd proved to be the best imaging prognostic factor for progression and for disease-free survival (DFS), respectively. In localized disease, SSTRd 31.5% identified two subgroups of patients with significant different DFS distribution and in advanced disease, a high cutoff value (58.5%) was a significant predictor of adverse prognosis. Conclusion Volumetric and semi-quantitative parameters measured using [18F]FDG PET/CT and SSTR imaging combined with Ki67 may provide a reference for prognosis evaluation of patients with TC, to better stratify risk groups with the goal of developing individualized therapeutic strategies.

Urothelial tumours are the fourth most common cancer in the world and account for the majority of tumours involving the bladder. The symptom that often leads to diagnosis is the presence of haematuria. Diagnosis is made by cystoscopy, which is currently the gold standard in bladder cancer. Computed tomography (CT) performed with pre- and post-contrastographic phases is essential in order to assess the loco-regional and distant extension of disease. The diagnosis and staging of upper tract urothelial cancer (UTUC) are best done with computed tomography urography and flexible ureteroscopy (URS). In the acquisition protocol of this type of tumour, a urographic phase is mandatory, which allows for an accurate diagnostic assessment of the renal pelvis, ureter and bladder, especially in papillary forms. The use of multiple acquisition phases, especially in this type of patient who will have to perform follow-up CTs, leads to the problem of overexposure to ionising radiation, as well as the frequent administration of iodinated contrast medium. For this reason, in recent year, the focus has been put on advanced technologies such as dual-energy CT (DECT), that is a method that can offer some advantages for both radiologist and patient, in the diagnosis of cancer and, in particular, urinary tract disease.

Today there is a growing interest in the quantification of late gadolinium enhancement (LGE) in ischemic and non-ischemic cardiac pathologies. We build an automatic self-made free software FLORA (For Late gadOlinium enhanced aReas clAssification) for the recognition, classification and quantification of LGE areas that allows to improve the observer's performances and that homogenizes the evaluations between different operators.We have retrospectively selected 120 CMR exams: 40-ischemic with evident scar tissue on LGE sequences; 40-non-ischemic cardiomyopathy; 40-any myocardial alteration on CMR, especially on LGE sequences. FLORA's performance was compared to the radiologist's evaluation.FLORA identified both ischemic and non-ischemic myocardial lesions in almost all cases (80/80 and 79/80 for the double-Gaussian fit method and fixed-shift method, respectively, with sensitivity and specificity of 100%/98.8% and 55%/50%, respectively). The best results were obtained from the classification of ischemic myocardial damage, which was correctly identified in 85%-95% of cases. FLORA also increases the agreement between observers and allows a quantitative evaluation of transmurality.FLORA has proven to be an applicable tool that improves and facilitates the classification of LGE areas allowing their quantification.

Since the first report of the outbreak in Wuhan, China in December 2019, as of 1 September 2021, the World Health Organization has confirmed more than 239 million cases of the novel coronavirus (SARS-CoV-2) infectious disease named coronavirus disease 2019 (COVID-19), with more than 4.5 million deaths. Although SARS-CoV-2 mainly involves the respiratory tract, it is considered to be a systemic disease. Imaging plays a pivotal role in the diagnosis of all manifestations of COVID-19 disease, as well as its related complications. The figure of the radiologist is fundamental in the management and treatment of the patient. The authors try to provide a systematic approach based on an imaging review of major multi-organ manifestations of this infection.

Computed tomography-urography is currently the imaging modality of choice for the assessment of the whole urinary tract, giving the possibility to detect and characterize benign and malignant conditions. In particular, computed tomography-urography takes advantage from an improved visualization of the urinary collecting system due to acquisition of delayed scan obtained after excretion of intravenous contrast medium from the kidneys. Nevertheless, the remaining scans are of great help for identification, characterization, and staging of urological tumors. Considering the high number of diseases, urinary segment potentially involved and patients' features, scanning protocols of computed tomography-urography largely vary from one clinical case to another as well as selection and previous preparation of the patient. According to the supramentioned considerations, radiation exposure is also of particular concern. Italian radiologists were asked to express their opinions about computed tomography-urography performance and about its role in their daily practice through an online survey. This paper collects and summarizes the results.

Our primary purpose was to search for computed tomography (CT) radiomic features of gastrointestinal stromal tumors (GISTs) that could potentially correlate with the risk class according to the Miettinen classification. Subsequently, assess the existence of features with possible predictive value in differentiating responder from non-responder patients to first-line therapy with Imatinib.A retrospective study design was carried out using data from June 2009 to December 2020. We analyzed all the preoperative CTs of patients undergoing surgery for GISTs. We segmented non-contrast-enhanced CT (NCECT) and contrast-enhanced venous CT (CECT) images obtained either on three different CT scans (heterogeneous cohort) or on a single CT scan (homogeneous cohort). We then divided the patients into two groups according to Miettinen classification criteria and based on the predictive value of response to first-line therapy with Imatinib.We examined 54 patients with pathological confirmation of GISTs. For the heterogeneous cohort, we found a statistically significant relationship between 57 radiomic features for NCECT and 56 radiomic features for CECT using the Miettinen risk classification. In the homogeneous cohort, we found the same relationship between 8 features for the NCECT and 5 features for CECT, all included in the heterogeneous cohort. The various radiomic features are distributed with different values in the two risk stratification groups according to the Miettinen classification. We also found some features for groups predictive of response to first-line therapy with Imatinib.We found radiomic features that correlate with statistical significance for both the Miettinen risk classification and the molecular subtypes of response. All features found in the homogeneous study cohort were also found in the heterogeneous cohort. CT radiomic features may be useful in assessing the risk class and prognosis of GISTs.

Since its beginning in March 2020, the COVID-19 pandemic has claimed an exceptionally high number of victims and brought significant disruption to the personal and professional lives of millions of people worldwide. Among medical specialists, radiologists have found themselves at the forefront of the crisis due to the pivotal role of imaging in the diagnostic and interventional management of COVID-19 pneumonia and its complications. Because of the disruptive changes related to the COVID-19 outbreak, a proportion of radiologists have faced burnout to several degrees, resulting in detrimental effects on their working activities and overall wellbeing. This paper aims to provide an overview of the literature exploring the issue of radiologists’ burnout in the COVID-19 era.

Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien–Dindo grade 3–4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The “watch and wait” approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.

The treatment of primary and secondary lung neoplasms now sees the fundamental role of radiotherapy, associated with surgery and systemic therapies. The improvement in survival outcomes has also increased attention to the quality of life, treatment compliance and the management of side effects. The role of imaging is not only limited to recognizing the efficacy of treatment but also to identifying, as soon as possible, the uncommon effects, especially when more treatments, such as chemotherapy, immunotherapy and radiotherapy, are associated. Radiation recall pneumonitis is an uncommon treatment complication that should be correctly characterized, and it is essential to recognize the mechanisms of radiation recall pneumonitis pathogenesis and diagnostic features in order to promptly identify them and adopt the best therapeutic strategy, with the shortest possible withdrawal of the current oncological drug. In this setting, artificial intelligence could have a critical role, although a larger patient data set is required.

In modern clinical practice, there is an increasing dependence on imaging techniques in several settings, and especially during emergencies. Consequently, there has been an increase in the frequency of imaging examinations and thus also an increased risk of radiation exposure. In this context, a critical phase is a woman’s pregnancy management that requires a proper diagnostic assessment to reduce radiation risk to the fetus and mother. The risk is greatest during the first phases of pregnancy at the time of organogenesis. Therefore, the principles of radiation protection should guide the multidisciplinary team. Although diagnostic tools that do not employ ionizing radiation, such as ultrasound (US) and magnetic resonance imaging (MRI) should be preferred, in several settings as polytrauma, computed tomography (CT) nonetheless remains the examination to perform, beyond the fetus risk. In addition, protocol optimization, using dose-limiting protocols and avoiding multiple acquisitions, is a critical point that makes it possible to reduce risks. The purpose of this review is to provide a critical evaluation of emergency conditions, e.g., abdominal pain and trauma, considering the different diagnostic tools that should be used as study protocols in order to control the dose to the pregnant woman and fetus.

Researchers nowadays may take advantage of broad collections of medical data to develop personalized medicine solutions. Imaging bio-banks play a fundamental role, in this regard, by serving as organized repositories of medical images associated with imaging biomarkers. In this context, the NAVIGATOR Project aims to advance colorectal, prostate, and gastric oncology translational research by leveraging quantitative imaging and multi-omics analyses. As Project's core, an imaging bio-bank is being designed and implemented in a web-accessible Virtual Research Environment (VRE). The VRE serves to extract the imaging biomarkers and further process them within prediction algorithms. In our work, we present the realization of the data models for the three cancer use-cases of the Project. First, we carried out an extensive requirements analysis to fulfill the necessities of the clinical partners involved in the Project. Then, we designed three separate data models utilizing entity-relationship diagrams. We found diagrams' modeling for colorectal and prostate cancers to be more straightforward, while gastric cancer required a higher level of complexity. Future developments of this work would include designing a common data model following the Observational Medical Outcomes Partnership Standards. Indeed, a common data model would standardize the logical infrastructure of data models and make the bio-bank easily interoperable with other bio-banks.

Neuroendocrine neoplasms (NENs) are heterogeneous tumours with a common phenotype descended from the diffuse endocrine system. NENs are found nearly anywhere in the body but the most frequent location is the gastrointestinal tract. Gastrointestinal neuroendocrine neoplasms (GI-NENs) are rather uncommon, representing around 2% of all gastrointestinal tumours and 20–30% of all primary neoplasms of the small bowel. GI-NENs have various clinical manifestations due to the different substances they can produce; some of these tumours appear to be associated with familial syndromes, such as multiple endocrine neoplasm and neurofibromatosis type 1. The current WHO classification (2019) divides NENs into three major categories: well-differentiated NENs, poorly differentiated NENs, and mixed neuroendocrine-non-neuroendocrine neoplasms. The diagnosis, localization, and staging of GI-NENs include morphology and functional imaging, above all contrast-enhanced computed tomography (CECT), and in the field of nuclear medicine imaging, a key role is played by 68Ga-labelled-somatostatin analogues (68Ga-DOTA-peptides) positron emission tomography/computed tomography (PET/TC). In this review of recent literature, we described the objectives of morphological/functional imaging and potential future possibilities of prognostic imaging in the assessment of GI-NENs.

Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.

Purpose To understand how COVID-19 pandemic has changed radiology research in Italy. Methods A questionnaire (n = 19 questions) was sent to all members of the Italian Society of Radiology two months after the first Italian national lockdown was lifted. Results A total of 327 Italian radiologists took part in the survey (mean age: 49 ± 12 years). After national lockdown, the working-flow came back to normal in the vast majority of cases (285/327, 87.2%). Participants reported that a total of 462 radiological trials were recruiting patients at their institutions prior to COVID-19 outbreak, of which 332 (71.9%) were stopped during the emergency. On the other hand, 252 radiological trials have been started during the pandemic, of which 156 were non-COVID-19 trials (61.9%) and 96 were focused on COVID-19 patients (38.2%). The majority of radiologists surveyed (61.5%) do not conduct research. Of the radiologists who carried on research activities, participants reported a significant increase of the number of hours per week spent for research purposes during national lockdown (mean 4.5 ± 8.9 h during lockdown vs. 3.3 ± 6.8 h before lockdown; p = .046), followed by a significant drop after the lockdown was lifted (3.2 ± 6.5 h per week, p = .035). During national lockdown, 15.6% of participants started new review articles and completed old papers, 14.1% completed old works, and 8.9% started new review articles. Ninety-six surveyed radiologists (29.3%) declared to have submitted at least one article during COVID-19 emergency. Conclusion This study shows the need to support radiology research in challenging scenarios like COVID-19 emergency.

Purpose (1) To investigate correlations between different types of FAI and the ratio of acetabular volume (AV) to femoral head volume (FV) on MR arthrography. (2) To assess 2D/3D measurements in identifying different types of FAI by means of cut-off values of AV/FV ratio (AFR). Materials and methods Alpha angle, cranial acetabular version, acetabular depth, lateral center edge angle, AV, and FV of 52 hip MR arthrography were measured. ANOVA test correlated different types of FAI with AFR. ROC curves classified FAI by cut-off values of AFR. Accuracy of 2D/3D measurements was calculated. Results ANOVA test showed a significant difference of AFR (p value Conclusions 3D measurements were clearly more accurate than 2D measurements. Distinct cut-off values of AFR discriminated cam types from pincer types and identified pincer types in all cases. Cam and mixed types were not accurately recognized.

Background Currently, the technologies most commonly used to treat locally advanced pancreatic cancer are radiofrequency ablation (RFA), microwave ablation, and irreversible (IRE) or reversible electroporation combined with low doses of chemotherapeutic drugs. Aim To report an overview and updates on ablative techniques in pancreatic cancer. Methods Several electronic databases were searched. The search covered the years from January 2000 to January 2021. Moreover, the reference lists of the found papers were analysed for papers not indexed in the electronic databases. All titles and abstracts were analysed. Results We found 30 studies (14 studies for RFA, 3 for microwave therapy, 10 for IRE, and 3 for electrochemotherapy), comprising 1047 patients, which were analysed further. Two randomized trials were found for IRE. Percutaneous and laparotomy approaches were performed. In the assessed patients, the median maximal diameter of the lesions was in the range of 2.8 to 4.5 cm. All series included patients unfit for surgical treatment, but Martin et al assessed a subgroup of patients with borderline resectable tumours who underwent resection with margin attenuation with IRE. Most studies administered chemotherapy prior to ablative therapies. However, several studies suggest that the key determinant of improved survival is attributable to ablative treatment alone. Nevertheless, the authors suggested chemotherapy before local therapies for several reasons. This strategy may not only downstage a subgroup of patients to curative-intent surgery but also support to recognize patients with biologically unfavourable tumours who would likely not benefit from ablation treatments. Ablation therapies seem safe based on the 1047 patients assessed in this review. The mortality rate ranged from 1.8% to 2%. However, despite the low mortality, the reported rates of severe post procedural complications ranged from 0%-42%. Most reported complications have been self-limiting and manageable. Median overall survival varied between 6.0 and 33 mo. Regarding the technical success rate, assessed papers reported an estimated rate in the range of 85% to 100%. However, the authors reported early recurrence after treatment. A distinct consideration should be made on whether local treatments induce an immune response in the ablated area. Preclinical and clinical studies have shown that RFA is a promising mechanism for inducing antigen-presenting cell infiltration and enhancing the systemic antitumour T-cell immune response and tumour regression. Conclusion In the management of patients with pancreatic cancer, the possibility of a multimodal approach should be considered, and conceptually, the combination of RFA with immunotherapy represents a novel angle of attack against this tumour.

Clinico-radiological presentation of granulomatous prostatitis (GP) is quite similar to cancer, and differential diagnosis can be very challenging. The study aims to highlight GP features based on clinical findings and multiparametric magnetic resonance imaging (mpMRI) characteristics. We retrospectively reviewed eleven patients from a cohort undergoing targeted biopsy between August 2019 and August 2021. Retrospective data including serum prostate-specific antigen (PSA) levels, PSA density and mpMRI findings were collected. Histopathology revealed seven cases of non-specific GP and four cases of specific GP as a result of intravesical Bacillus Calmette–Guérin (BCG) instillation. All lesions showed low signal intensity in T2w images, restricted diffusivity with hyperintensity in Diffusion-Weighted Imaging (DWI) and low Apparent Diffusion Coefficient (ADC) values. In Dynamic Contrast-Enhanced (DCE) imaging, the enhancement was high-peak and persistent in the majority of cases, especially in BCG-GPs. Moreover, almost all those latter lesions showed avascular core and peripheral rim enhancement. All areas identified on mpMRI were assessed with high to very high suspicion to hold prostate cancer (PIRADS v2.1 scores 4–5). Despite recent advances in imaging modalities and serological investigations, it is currently still a challenge to identify granulomatous prostatitis. Histopathology remains the gold standard in disease diagnosis. However, a differential diagnosis should be considered in patients with prior treatment with BCG.

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department.This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis.The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively.CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

Thoracic imaging is fundamental in the diagnostic route of Coronavirus disease 2019 (COVID-19) especially in patients admitted to hospitals. In particular, chest computed tomography (CT) has a key role in identifying the typical features of the infection. Ground-glass opacities (GGO) are one of the main CT findings, but their presence is not specific for this viral pneumonia. In fact, GGO is a radiological sign of different pathologies with both acute and subacute/chronic clinical manifestations. In the evaluation of a subject with focal or diffuse GGO, the radiologist has to know the patient’s medical history to obtain a valid diagnostic hypothesis. The authors describe the various CT appearance of GGO, related to the onset of symptoms, focusing also on the ancillary signs that can help radiologist to obtain a correct and prompt diagnosis.

It is common for a cardiac mass to be discovered accidentally during an echocardiographic examination. Following the relief of a cardiac mass, being able to evaluate and characterize it using non-invasive imaging methods is critical. Echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (CMR), and positron emission tomography (PET) are the main imaging modalities used to evaluate cardiac masses. Although multimodal imaging often allows for a better assessment, CMR is the best technique for the non-invasive characterization of tissues, as the different MR sequences help in the diagnosis of cardiac masses. This article provides detailed descriptions of each CMR sequence employed in the evaluation of cardiac masses, underlining the potential information it can provide. The description in the individual sequences provides useful guidance to the radiologist in performing the examination.

Background: This paper offers an assessment of radiomics tools in the evaluation of intrahepatic cholangiocarcinoma. Methods: The PubMed database was searched for papers published in the English language no earlier than October 2022. Results: We found 236 studies, and 37 satisfied our research criteria. Several studies addressed multidisciplinary topics, especially diagnosis, prognosis, response to therapy, and prediction of staging (TNM) or pathomorphological patterns. In this review, we have covered diagnostic tools developed through machine learning, deep learning, and neural network for the recurrence and prediction of biological characteristics. The majority of the studies were retrospective. Conclusions: It is possible to conclude that many performing models have been developed to make differential diagnosis easier for radiologists to predict recurrence and genomic patterns. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.

(1) Purpose: The latest Breast Imaging Reporting and Data System (BI-RADS) lexicon for CEM introduced a new descriptor, enhancing asymmetries (EAs). The purpose of this study was to determine which types of lesions were correlated with EAs. (2) Methods: A total of 3359 CEM exams, executed at AOUC Careggi in Florence, Italy between 2019 and 2021 were retrospectively assessed by two radiologists. For each of the EAs found, the size, the enhancing conspicuity (degree of enhancement relative to background described as low, moderate, or high), whether there was a corresponding finding in the traditional radiology images (US or mammography), the biopsy results when performed including any follow-up exams, and the presence of background parenchymal enhancement (BPE) of the normal breast tissue (minimal, mild, moderate, marked) were described. (3) Results: A total of 64 women were included, 36 of them underwent CEM for a preoperative staging assessment, and 28 for a problem-solving examination. Among the 64 EAs, 19/64 (29.69%) resulted in being category B5 (B5) lesions, 5/64 (7.81%) as category B3 (B3) lesions, and 40/64(62.50%) were negative or benign either after biopsy or second-look exams or follow-up. We assessed that EAs with higher enhancing conspicuity correlated significantly with a higher risk of B5 lesions (p: 0.0071), especially bigger ones (p: 0.0274). Conclusions: EAs can relate both with benign and tumoral lesions, and they need to be assessed as the other CEM descriptors, with re-evaluation of low-energy images and second-look exams, particularly larger EAs with higher enhancing conspicuity.

Breast ultrasound (US) has undergone dramatic technological improvement through recent decades, moving from a low spatial resolution, grayscale-limited technique to a highly performing, multiparametric modality. In this review, we first focus on the spectrum of technical tools that have become commercially available, including new microvasculature imaging modalities, high-frequency transducers, extended field-of-view scanning, elastography, contrast-enhanced US, MicroPure, 3D US, automated US, S-Detect, nomograms, images fusion, and virtual navigation. In the subsequent section, we discuss the broadened current application of US in breast clinical scenarios, distinguishing among primary US, complementary US, and second-look US. Finally, we mention the still ongoing limitations and the challenging aspects of breast US.

Purpose The aims of our study are: (1) to estimate admission chest X-ray (CXR) accuracy during the descending phase of pandemic; (2) to identify specific CXR findings strictly associated with COVID-19 infection; and (3) to correlate lung involvement of admission CXR with patients’ outcome. Materials and methods We prospectively evaluated the admission CXR of 327 patients accessed to our institute during the Italian pandemic descending phase (April 2020). For each CXR were searched ground glass opacification (GGO), consolidation (CO), reticular-nodular opacities (RNO), nodules, excavations, pneumothorax, pleural effusion, vascular congestion and cardiac enlargement. For lung alterations was defined the predominance (upper or basal, focal or diffuse, central or peripheric, etc.). Then radiologists assessed whether CXRs were suggestive or not for COVID-19 infection. For COVID-19 patients, a prognostic score was applied and correlated with the patients’ outcome. Results CXR showed 83% of specificity and 60% of sensitivity. GGO, CO, RNO and a peripheric, diffuse and basal prevalence showed good correlation with COVID-19 diagnosis. A logistic regression analysis pointed out GGO and a basal or diffuse distribution as independent predictors of COVID-19 diagnosis. The prognostic score showed good correlation with the patients’ outcome. Conclusion In our study, admission CXR showed a fair specificity and a good correlation with patients’ outcome. GGO and others CXR findings showed a good correlation with COVID-19 diagnosis; besides GGO a diffuse or bibasal distribution resulted in independent variables highly suggestive for COVID-19 infection thus enabling radiologists to signal to clinicians radiologically suspect patients during the pandemic descending phase.

Aim: Prostate cancer represents the most common cancer afflicting men. It may be asymptomatic at the early stage. In this paper, we propose a methodology aimed to detect the prostate cancer grade by computing non-invasive shape-based radiomic features directly from magnetic resonance images. Materials and methods: We use a freely available dataset composed by coronal magnetic resonance images belonging to 112 patients. We represent magnetic resonance slices in terms of formal model, and we exploit model checking to check whether a set of properties (formulated with the support of pathologists and radiologists) is verified on the formal model. Each property is related to a different cancer grade with the aim to cover all the cancer grade groups. Results: An average specificity equal to 0.97 and an average sensitivity equal to 1 have been obtained with our methodology. Conclusion: The experimental analysis demonstrates the effectiveness of radiomics and formal verification for Gleason grade group detection from magnetic resonance.

Background CEDM has demonstrated a diagnostic performance similar to MRI and could have similar limitations in breast cancer (BC) detection. Purpose The aim of our study was to systematically analyze the characteristics of the lesions with the absence of enhancement with CEDMs, called false-negatives (FNs), in order to identify which clinical, radiological, histological and molecular parameters are associated with the absence of enhancement of known BCs with CEDMs, and which types of BC are most likely to cause FNs in CEDMs. We also tried to evaluate which parameters instead increased the probability of showing enhancement in the same context. Materials and methods Included in our study group were 348 women with 348 diagnosed BCs performing CEDM as preoperative staging. Two breast-imaging radiologists reviewed the CEDM exams. The absence of perceptible contrast enhancement at the index cancer site was indicative of an FN CEDM, whereas cases with appreciable enhancement were considered true positives (TPs). Dichotomic variables were analyzed with Fisher’s exact probability test or, when applicable, the chi-square test. Binary logistic regression was performed on variables shown to be significant by the univariate analysis in order to assess the relationship between predictors (independent variables) and TFNs (outcome). Results Enhancement was observed in 317 (91.1%) of the 348 BCs. From the 31 (8.9%) lesions which were FNs, we excluded 12 (38.7%) which showed an artifact generated by the post biopsy hematoma and 6 (19.4%) which were outside the CEDM field of vision. We thus obtained 13 (41.9%) BCs considered “True False Negatives” (TFNs), i.e. BCs which showed no enhancement despite being within the CEDM field of vision and failed to show post biopsy hematoma artifacts. We found that the TFNs frequently have a unifocal disease extension, diameter, Highlights • The variables associated with an increased risk of no enhancement were unifocal disease extension, non-classifiable molecular subtype, DCIS histotype, lesion dimensions

Background Radiological evaluation of dementia is expected to increase more and more in routine practice due to both the primary role of neuroimaging in the diagnostic pathway and the increasing incidence of the disease. Despite this, radiologists often do not follow a disease-oriented approach to image interpretation, for several reasons, leading to reports of limited value to clinicians. In our work, through an intersocietal consensus on the main mandatory knowledge about dementia, we proposed a disease-oriented protocol to optimize and standardize the acquisition/evaluation/interpretation and reporting of radiological images. Our main purpose is to provide a practical guideline for the radiologist to help increase the effectiveness of interdisciplinary dialogue and diagnostic accuracy in daily practice. Results We defined key clinical and imaging features of the dementias (A), recommended MRI protocol (B), proposed a disease-oriented imaging evaluation and interpretation (C) and report (D) with a glimpse to future avenues (E). The proposed radiological practice is to systematically evaluate and score atrophy, white matter changes, microbleeds, small vessel disease, consider the use of quantitative measures using commercial software tools critically, and adopt a structured disease-oriented report. Summary statement In the expanding field of cognitive disorders, the only effective assessment approach is the standardized disease-oriented one, which includes a multidisciplinary integration of the clinical picture, MRI, CSF and blood biomarkers and nuclear medicine.

Objectives: To compare second-look ultrasound (SL-ultrasound) with second-look digital breast tomosynthesis (SL-DBT) in the detection of additional lesions (ALs) with presurgical contrast-enhanced spectral mammography (CESM). Methods: We retrospectively included 121 women with 128 ALs from patients who underwent CESM for presurgical staging at our centre from September 2016 to December 2018. These ALs underwent SL-ultrasound and a retrospective review of DBT (SL-DBT) performed 1–3 weeks prior to CESM to evaluate the performance of each technique individually and in combination. ALs in CESM images were evaluated according to enhancement type (focus, mass, or non-mass), size (10 mm) and level of suspicion (BI-RADS 2, 3, 4 or 5). Our gold-standard was post-biopsy histology, post-surgical specimen or >24 month negative follow-up. McNemar’s test was used for the statistical analysis. Results: Out of the 128 ALs, an imaging correlate was found for 71 (55.5 %) with ultrasound, 79 (61.7%) with DBT, 53 (41.4 %) with DBT and ultrasound, and 97 (75.8%) with ultrasound and/or DBT. SL-DBT demonstrated a higher detection rate vs SL-ultrasound in non-mass enhancement (NME) pattern (p: 0.0325) and ductal carcinoma in situ histological type (p: 0.0081). Adding SL-DBT improved the performance vs SL-ultrasound alone in the overall sample (p: Conclusion: Combined second-look imaging (SL-DBT+ SL-ultrasound) for CESM ALs is superior to SL-DBT alone and SL-ultrasound alone. In B3 lesions, NME, and foci, the analysis of a larger sample could determine whether adding SL-ultrasound to SL-DBT is necessary or not. Advances in knowledge: Thanks to its high sensitivity, CESM is a useful tool in presurgical staging to detect the extent of the disease burden and identify ALs not detected with conventional imaging. Since CESM-guided biopsy systems are still scarcely available in clinical practice, it is necessary to look for other approaches to histologically characterize ALs detected with CESM. In our study, combined second-look imaging (SL-DBT + SL-ultrasound) showed better performance in terms of detectability of ALs, than either SL-DBT or SL-ultrasound alone, and allowed us to identify 91.2% of ALs that turned out to be malignant at final histology; for the remaining 8.8% it was still necessary to perform MRI or MRI-guided biopsy. However, this issue could be solved once CESM-guided biopsies spread in clinical practice. SL-DBT demonstrated a higher detection rate than SL-ultrasound in NME and ductal carcinoma in situ histology.

Inflammatory bowel disease (IBD) is the term used to identify a form of chronic inflammation of the gastrointestinal tract that primarily contemplates two major entities: ulcerative colitis (UC) and Crohn’s disease (CD). The classic signs are abdominal pain and diarrhoea that correlate with the localization of gastro-enteric disease, although in this pathology extraintestinal symptoms may coexist. The diagnosis of CD relies on a synergistic combination of clinical, laboratory (stool and biochemical), cross-sectional imaging evaluation, as well as endoscopic and histologic assessments. The purpose of this paper is to prove the role of imaging in the diagnosis and follow-up of patients with CD with particular focus on recent innovations of magnetic resonance enterography (MRE) as a pivotal diagnostic tool, analysing the MRE study protocol and imaging features during the various phases of disease activity and its complications.

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare type of primary liver malignancy. Among the risk factors, hepatitis B and hepatitis C virus infections, cirrhosis, and male gender are widely reported. The clinical appearance of cHCC-CCA is similar to that of HCC and iCCA and it is usually silent until advanced states, causing a delay of diagnosis. Diagnosis is mainly based on histology from biopsies or surgical specimens. Correct pre-surgical diagnosis during imaging studies is very problematic and is due to the heterogeneous characteristics of the lesion in imaging, with overlapping features of HCC and CCA. The predominant histological subtype within the lesion establishes the predominant imaging findings. Therefore, in this scenario, the radiological findings characteristic of HCC show an overlap with those of CCA. Since cHCC-CCAs are prevalent in patients at high risk of HCC and there is a risk that these may mimic HCC, it is currently difficult to see a non-invasive diagnosis of HCC. Surgery is the only curative treatment of HCC-CCA. The role of liver transplantation (LT) in the treatment of cHCC-CCA remains controversial, as is the role of ablative or systemic therapies in the treatment of this tumour. These lesions still remain challenging, both in diagnosis and in the treatment phase. Therefore, a pre-treatment imaging diagnosis is essential, as well as the identification of prognostic factors that could stratify the risk of recurrence and the most adequate therapy according to patient characteristics.

OBJECTIVES: To obtain information from radiology departments throughout Europe regarding the practice of emergency radiology METHODS: A survey which comprised of 24 questions was developed and made available online. The questionnaire was sent to 1097 chairs of radiology departments throughout Europe using the ESR database. All data were collected and analyzed using IBM SPSS Statistics software, version 20 (IBM). RESULTS: A total of 1097 radiologists were asked to participate, 109 responded to our survey. The response rate was 10%. From our survey, 71.6% of the hospitals had more than 500 beds. Ninety-eight percent of hospitals have an active teaching affiliation. In large trauma centers, emergency radiology was considered a dedicated section. Fifty-three percent of institutions have dedicated emergency radiology sections. Less than 30% had all imaging modalities available. Seventy-nine percent of institutions have 24/7 coverage by staff radiologists. Emergency radiologists interpret cross-sectional body imaging, US scans, and basic CT/MRI neuroimaging in more than 50% of responding institutions. Cardiac imaging examinations/procedures are usually performed by cardiologist in 53% of institutions, while non-cardiac vascular procedures are largely performed and interpreted by interventional radiologists. Most people consider the European Diploma in Emergency Radiology an essential tool to advance the education and the dissemination of information within the specialty of emergency radiology. CONCLUSION: Emergency radiologists have an active role in the emergency medical team. Indeed, based upon our survey, they have to interact with emergency physicians and surgeons in the management of critically ill patients. A broad skillset from ultrasonography and basic neuroimaging is required. KEY POINTS: • At most major trauma centers in Europe, emergency imaging is currently performed by all radiologists in specific units who are designated in the emergency department. • Radiologists in the emergency section at present have a broad skillset, which includes cross-sectional body imaging, ultrasonography, and basic neuroimaging of the brain and spine. • A dedicated curriculum that certifies a subspecialty in emergency radiology with a diploma offered by the European Society of Emergency Radiology demonstrates a great interest by the vast majority of the respondents.

A man in his 70s with acute abdominal pain underwent contrast-enhanced CT (CCT). At the top of the CCT scan, it was incidentally detected a mass in the right atrium (figure 1A,B). The patient suffered from atrial fibrillation. The transthoracic echocardiography confirmed the mass in the right atrium extending to superior vena cava. The patient refused transoesophageal echocardiography. Finally, cardiac magnetic resonance (CMR) was requested (figure 1C–I). The mass was 3×3.5×4.6 cm in size. Figure 1 CT images: basal phase (A) and venous contrast phase (B) CT. CMR four-chamber images (C and D). T1-weighted image (E), T2-weighted image (F) and T2-weighted image with fat saturation (G). Two-chamber early and late gadolinium enhancement images (H …

The causes of diagnostic errors during daily medical practice can be several, mainly attributable to perceptual, interpretive and communication factors. The eventuality of radiological error is much more amplified in the emergency setting where a high number of complex multidetector-row computed tomography (MDCT) images must be evaluated quickly and critical time decisions need to be taken. In particular, in this context, the diagnosis of vascular intestinal diseases represents a crucial and difficult challenge in case of acute abdominal pain given the importance of being able to identify patient with high suspicious for intestinal ischemia and for a specific patient to judge if his ischemia is reversible or irreversible. Awareness of potential biases which can lead to diagnostic errors together with an extensive knowledge of the imaging features of these pathologies can lead to promptly recognize them with fewer mistakes, improving patients' outcome. This article reviews the MDCT findings of acute intestinal ischemia and acute colonic ischemia and analyzes the main types of diagnostic errors, underlining the importance of being familiarized with them to avoid misdiagnosis.

To evaluate thyroid, arytenoid, and cricoid cartilage invasion on computed tomography (CT) imaging in patients undergoing total laryngectomy for both primary and recurrent laryngeal carcinoma. Secondary endpoint was to compare laryngeal cartilage invasion between primary and recurrent tumours. Pre-treatment CT of 40 patients who had undergone total laryngectomy was retrospectively evaluated and compared with histology. Focal erosions of thyroid cartilage were accounted for neoplastic invasion of the inner cortex. Full-thickness thyroid cartilage invasion was defined as a tumour-like tissue replacing thyroid cartilage or extended in extra-laryngeal soft tissues. Sclerosis and erosion of arytenoid and cricoid cartilages were assessed as signs of neoplastic invasion. CT erosion showed perfect agreement for thyroid inner cortex and cricoid cartilage invasion and almost perfect agreement (87%) for arytenoid cartilage invasion. For tumours in contact with thyroid cartilages, the absence of CT erosion underestimated inner cortex infiltration. CT showed perfect agreement in predicting full-thickness thyroid cartilage invasion only in the case of extra-laryngeal neoplastic extension. Arytenoid sclerosis showed poor correlation with neoplastic invasion. For primary tumours, CT demonstrated good (inner cortex 75%; full-thickness 85%), substantial (67.5%), and perfect (100%) accuracy in thyroid, arytenoid, and cricoid cartilage invasion, respectively. No CT differences were observed between primary and recurrent laryngeal tumours. Tumour-like tissue extension in the extra-laryngeal soft tissues was accurate in predicting thyroid cartilage full-thickness invasion. Erosions of arytenoid, cricoid, and thyroid cartilages’ inner cortex on CT were highly indicative of neoplastic infiltration. No CT difference in cartilage infiltration between primary and recurrent tumours was observed.

In this comprehensive review we present an overview of the main aspects of classification, radiological signs and nuclear imaging findings of typical lung carcinoids (TCs). A literature search on the PubMed literature database was conducted using the terms “positron emission tomography—PET”, “PET/CT”, “FDG”, “18F-fluorodeoxyglucose”, “MDCT—Contrast-enhanced multi-detector computed tomography” “typical lung carcinoid” “SRS—Somatostatin receptor scintigraphy”, “68 Ga DOTA-peptides” alone and in combination, extending until December 2019. TCs are rare tumours, accounting for only 1–2% of all pulmonary neoplasms. They tend to occur usually in the fourth-to-sixth decade of life and are characterized by mitotic count of less 2/2 mm2 and absent necrosis. Contrast-enhanced multi-detector computed tomography (MDCT) is the most largely used imaging modality for the localization, characterization and staging of lung TCs. Nuclear medicine imaging assists MDCT in the diagnosis of these rare tumour entities, especially by somatostatin receptor scintigraphy, PET imaging with Gallium-68-tetrazacyclododecanetetraacetic acid (68 Ga DOTA-peptides) and with 18F-fluorodeoxyglucose (18F-FDG). TCs of lung are rare lung tumours placed within a defined classification system. MDCT morphological features combined with functional nuclear medicine imaging are an important tool for the detection of these rare neoplasms and contribute to their characterisation and staging. Therefore, MDCT and nuclear medicine parameters could give a preliminary orientation before the pathological examination, on the biological behaviour and the prognostic outcome of TCs.