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Purpose: To evaluate the role of multidetector computed tomography (MDCT) in recognizing the complications of extracorporeal shock wave lithotripsy (ESWL) and providing a prognostic grading system for the therapeutic approach. Materials and Methods: A total of 43 patients who underwent ESWL because of urinary stone disease were assessed by 320-row MDCT examination before and after ESWL. Pre-ESWL CT unenhanced scans were performed for diagnosing stone disease. Post-ESWL CT scans were acquired before and after intravenous injection of contrast medium searching for peri-renal fluid collection or hyper-density, pyelic or ureteral wall thickening, blood clots in the urinary tract, peri- or intra-renal hematoma or abscess, active bleeding. A severity grading system of ESWL complications was established. Results: Patients were affected by renal (n = 36) or ureteral (n = 7) lithiasis. Post-ESWL CT examination detected small fluid collections and hyper-density of peri-renal fat tissue in 35/43 patients (81%), pyelic or ureteral wall thickening in 2/43 (4%), blood clots in the urinary tract in 9/43 (21%), renal abscesses or hematomas with a diameter of

Purpose To assess the role of STIR, T2-weighted TSE and DWIBS sequences for detecting and characterizing breast lesions and to compare unenhanced (UE)-MRI results with contrast-enhanced (CE)-MRI and histological findings, having the latter as the reference standard. Materials and Methods Two hundred eighty consecutive patients (age range, 27–73 years; mean age ± standard deviation (SD), 48.8 ± 9.8 years) underwent MR examination with a diagnostic protocol including STIR, T2-weighted TSE, THRIVE and DWIBS sequences. Two radiologists blinded to both dynamic sequences and histological findings evaluated in consensus STIR, T2-weighted TSE and DWIBS sequences and after two weeks CE-MRI images searching for breast lesions. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for UE-MRI and CE-MRI were calculated. UE-MRI results were also compared with CE- MRI. Results UE-MRI sequences obtained sensitivity, specificity, diagnostic accuracy, PPV and NPV values of 94%, 79%, 86%, 79% and 94%, respectively. CE-MRI sequences obtained sensitivity, specificity, diagnostic accuracy, PPV and NPV values of 98%, 83%, 90%, 84% and 98%, respectively. No statistically significant difference between UE-MRI and CE-MRI was found. Conclusion Breast UE-MRI could represent an accurate diagnostic tool and a valid alternative to CE-MRI for evaluating breast lesions. STIR and DWIBS sequences allow to detect breast lesions while T2-weighted TSE sequences and ADC values could be useful for lesion characterization.

To assess the diagnostic accuracy and inter-observer variability of ultrasound (US) in recognizing signs of intra or extra-capsular rupture of silicone breast implants by using the magnetic resonance imaging (MRI) findings as the reference standard.150 patients for a total of 300 implants underwent breast US and subsequently MR examination searching for signs of intra or extra-capsular rupture. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for breast US having MRI findings as the reference standard. Cohen's kappa statistics was used in order to assess inter-observer agreement for US.170/300 (57 %) implant ruptures were detected at US (intra-capsular n = 110, extra-capsular n = 60). By comparing US findings with MR results, overall sensitivity, specificity, accuracy, PPV, and NPV of 79, 63, 70, 65, and 77 %, respectively, were found for breast US. In case of intra-capsular rupture, sensitivity, specificity, accuracy, PPV, and NPV of 63, 63, 63, 45, and 77 %, respectively, were obtained; 100 % values were found for extra-capsular rupture US diagnosis.US can be used as the first examination in patients with breast implants. US intra-capsular rupture detection requires further evaluation by MRI; in case of extra-capsular rupture US diagnosis, surgical implant removal could be proposed without further investigations.valutare l’accuratezza diagnostica e la variabilità inter-osservatore dell’ecografia nel riconoscimento dei segni di rottura intra od extra-capsulare di protesi mammarie in silicone avendo i segni RM con standard di riferimento.150 pazienti per un totale di 300 impianti sono stati sottoposti ad ecografia mammaria e successivamente ad esame RM ricercando segni di rottura intra od extracapsulare. Sono stati calcolati i valori di sensibilità, specificità, valori predittivi positivo (VPP) e negativo (VPN) ed accuratezza diagnostica avendo i segni RM come standard di riferimento. L’accordo inter-osservatore è stato calcolato mediante test statistico kappa di Cohen.170/300 (57 %) rotture di impianti sono state identificate all’esame ecografico (intra-capsulari,l’ecografia mammaria può essere utilizzata come metodica di primo livello nei pazienti con protesi mammarie. In caso di diagnosi ecografica di rottura intra-capsulare, è indicato approfondimento diagnostico con esame RM; in caso di rottura extra-capsulare rilevata all’esame ecografico, è proponibile la sostituzione chirurgica dell’impianto senza ulteriori indagini diagnostiche.

Acute adrenal ischemia represents a rare cause of adrenal insufficiency which should be promptly diagnosed in order to preserve adrenal vitality and function. Our study aims to retrospectively evaluate the diagnostic accuracy of the CT capsular sign as an indicator of adrenal ischemia and its association with vascular involvement. Between January 2013 and January 2014, 69 consecutive patients (47 men, 22 women; mean age 46; range 22-67) with suspected adrenal insufficiency based on clinical and biochemical data underwent 320-row CT examination in our Emergency Department. Written informed consent was obtained for the CT examinations, and the institutional review board approval was obtained for our retrospective study. CT multi-planar images were retrospectively and independently analyzed by two radiologists searching for the patency of adrenal vessels, enlarged adrenals, the presence of the "capsular sign" represented by a peripheral subtle hyperdense line around a hypodense enlarged adrenal, and the presence of any periadrenal inflammatory changes. All CT findings were then compared with the surgical findings (n = 5), follow-up examinations (n = 20), or autopsy (n = 4). Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV), and negative predictive value (NPV) were calculated for the "capsular sign" and were further evaluated by ROC analysis. Acute adrenal ischemia occurred in 29/69 patients (42 %), unilateral in 20, and bilateral in 9. Forty of sixty-nine patients (58 %) had no evidence of adrenal disease on CT. Thrombosis of the main adrenal vein was found in 20/29 (69 %) and non-venous ischemia in 9/29 (31 %). The capsular sign was found in 24/29 patients (83 %). Sensitivity, specificity, DA, PPV, and NPV values of 83, 100, 93, 100, and 89 %, respectively, were obtained. The capsular sign represents a CT indicator of acute adrenal ischemia, with a specificity of 100 % and leading to a prompt diagnosis in the early phase of the disease.

The automatic segmentation of kidneys in medical images is not a trivial task when the subjects undergoing the medical examination are affected by Autosomal Dominant Polycystic Kidney Disease.

Screening programs use mammography as primary diagnostic tool for detecting breast cancer at an early stage. The diagnosis of some lesions, such as microcalcifications, is still difficult today for radiologists. In this paper, we proposed an automatic model for characterizing and discriminating tissue in normal/abnormal and benign/malign in digital mammograms, as support tool for the radiologists. We trained a Random Forest classifier on some textural features extracted on a multiscale image decomposition based on the Haar wavelet transform combined with the interest points and corners detected by using Speeded Up Robust Feature (SURF) and Minimum Eigenvalue Algorithm (MinEigenAlg), respectively. We tested the proposed model on 192 ROIs extracted from 176 digital mammograms of a public database. The model proposed was high performing in the prediction of the normal/abnormal and benign/malignant ROIs, with a median AUC value of \(98.46\%\) and \(94.19\%\), respectively. The experimental result was comparable with related work performance.

Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of multiple gas-filled cysts within the submucosa or subserosa of the intestinal wall. We report a case of PCI in a 54-year-old man 4 weeks after liver transplantation due to hepatitis B virus (HBV)-associated liver cirrhosis presenting with illness, diarrhea and abdominal pain. CT scans revealed normal shape of the abdominal parenchymal organs and no intra-hepatic complication due to liver transplantation. Main abdominal venous and arterial vessels resulted patent. Colic loops appeared diffusely thickened for the presence of variable diameter air-filled cysts located within the bowel wall. The patient underwent conservative treatment and the CT control after 4 weeks showed a complete PCI resolution. PCI after adult liver transplantation is probably due to the pre-transplantation chemotherapy, immunosuppressive therapy and opportunistic enteric infections. Abdominal CT represents the gold standard technique for diagnosing PCI and for evaluating its extension and complications providing data on other abdominal pathologies. It appears as variable diameter gas-filled cysts located within the bowel wall and it is often associated with pneumo-peritoneum probably due to the rupture of subserosal cysts. PCI has a favorable outcome and requires conservative treatment. Major differential diagnosis includes intestinal pneumatosis due to bowel ischemia. PCI after liver transplantation represents an uncommon bowel disease with a favorable prognosis. CT represents the reference imaging technique for diagnosing the disease and evaluating the response to therapy which is usually conservative rather than surgical.

Purpose Our purpose was to retrospectively evaluate the incidence and morphologic features of diabetic mastopathy in a group of patients with diabetes, searching for specific sonographic characteristics of diabetic mastopathy. Methods One hundred twenty diabetic patients underwent breast clinical examination, mammography, and sonography. All detected breast lesions were confirmed histopathologically. Results Breast lesions were found in 11 of the 120 patients (9%), including two cases of invasive ductal carcinomas and nine cases of diabetic mastopathy. In seven of those nine cases (77%), diabetic mastopathy appeared as a hypoechoic solid mass with irregular margins, inhomogeneous echotexture, and marked posterior shadowing. In the other two cases (23%), it appeared as a mildly inhomogeneous, hypoechoic solid mass. Conclusions Diabetic mastopathy is a diagnostic challenge and needs to be suspected in all patients with diabetes mellitus. Imaging features are nonspecific and highly susggestive on breast sonography in most cases. Core-needle biopsy confirmation remains mandatory for a definitive diagnosis. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound, 43:113–117, 2015

Purpose Mammography is the most effective and low-cost method for the early detection of breast cancers. The aim of this study was to develop an automated model in order to improve detection and characterization of clustered microcalcifications on full-field digital mammograms (FFDM). Methods We analyzed 98 digital mammograms extracted from the public database Breast Cancer Digital Repository with 276 microcalcification clusters; these images were previously evaluated in double blind by two radiologists which had identified the microcalcification clusters. We identified some regions of interest (ROI) on mammograms after pre-processing by using the Circular Hough Transform algorithm in order to recognize circles corresponding to the microcalcifications. Then, we selected morphological and morphometric features for each ROI, such as Speeded Up Robust Feature, as well as classic statistical features based on Haar Transform. These features were used for giving instructions to a Random Forest classifier in order to recognize – riga clustered microcalcifications normal and abnormal ROIs. Finally, we tested the performance of – riga this automated model in cross-validation and with statistical measurements. Results Statistical results ( Table 1 ) showed good performance of proposed model in automatic detection of breast clustered microcalcifications on FFDM (sensitivity over 90% with 3.54 false positives – riga per image), even in young patients with dense breast tissue (sensitivity over 88%) and according to published data [1] . Also classification performance of clustered microcalcifications (AUC 98,6 ± 0,1, Accuracy 97,6 ± 0,2%, Sensitivity 97,7 ± 0,4%, Specificity 96,2 ± 0,4%) was comparable with the state of the art [2] . Conclusions The proposed automated model enables to improve detection of clustered microcalcifications that could be characterized by difficult diagnostic interpretation especially when occurred in dense breast parenchyma. The proposed model results highly performing and comparable to the state-of-art approaches.

In this paper, we propose a deep learning approach for breast lesions classification, by processing breast images obtained using an innovative acquisition system, the Tomosynthesis, a medical instrument able to acquire high-resolution images using a lower radiographic dose than normal Computed Tomography (CT). The acquired images were processed to obtain Regions Of Interest (ROIs) containing lesions of different categories. Subsequently, several pre-trained Convolutional Neural Network (CNN) models were evaluated as feature extractors and coupled with non-neural classifiers for discriminate among the different categories of lesions. Results showed that the use of CNNs as feature extractor and the subsequent classification using a non-neural classifier reaches high values of Accuracy, Sensitivity and Specificity.

Iodine-131 ((131)I) total-body scintigraphy is a commonly used post-thyroidectomy imaging procedure in the management of differentiated thyroid cancer (DTC), in particular in patients with an intermediate or high risk of persistent or recurrent disease, in combination with serum thyroglobulin (Tg) determinations and ultrasonography of the neck. It can show the persistence of residual thyroid tissue after thyroidectomy and local and distant metastases. Although this is a highly sensitive method for detecting normal and pathologic thyroid tissue, especially when performed after an ablative dose of (131)I, false-positive scans (i.e., uptake in the absence of residual thyroid tissue or metastases) can occur in different situations.We report a case of a 42-year-old woman with recurrent chest infections and bronchiectasis, who had a total thyroidectomy and (131)I treatment because of a papillary thyroid carcinoma. She presented with marked bilateral (131)I uptake in the lungs mimicking metastatic involvement of the lungs by thyroid cancer, but interpreted as nonspecific bilateral uptake by her bronchiectatic bronchial tree.Our case, as well as others reported in the literature, calls attention to the fact that (131)I lung uptake may be related to chronic inflammatory lung disease, thus representing a potential diagnostic pitfall in patients with DTC.(131)I uptake should be interpreted on the bases of clinical context, imaging, and laboratory findings (serum Tg). Recognition of potential false-positive (131)I scans is critical to avoid unnecessary exposure to further radiation from repeated therapeutic doses of (131)I with possible side effects and even worsening of lung disease itself.

Objectives: To evaluate the primary lesions, the complications and the evolution of disease in patients affected by H1N1 viral infection. Materials and Methods: 24 Patients affected by H1N1 infection, diagnosed by polymerase chain reaction (PCR) on throat swabs, underwent CT examination. Seven patients were hospitalized in intensive care unit (ICU). In five patients the evolution of disease was monitored. The following features were evaluated: primary lesions significant for viral infection, their possible complications and the evolution of disease in controlled patients. Results: Primary lesions variously associated with each other were found in 22 out of 24 patients: ground glass opacities (19/24, 79.2%), interstitial thickening (13/24, 54.2%), centrilobular nodules (3/24, 12.5%) and consolidation (8/24, 33.3%). The following complications were observed: 3 consolidations with air bronchogram, 9 pleural effusions, 7 ARDS and 1 barotrauma. In the 5 patients who underwent follow-up (including 3 admitted to ICU), complete resolution was demonstrated in 4 cases and focal fibrotic evolution in one case. 3 ICU patients affected by ARDS died. Conclusions: In case of H1N1 virus infection. CT is an important tool for staging the disease, recognize complications and to study disease evolution

Purpose Dual-energy contrast-enhanced spectral mammography (CESM) has emerged as a potential new option for breast cancer staging. This imaging technique allows acquisition of multiple views of both breasts after a single injection of iodinated Contrast Medium (CM). It based on the fact that the CM injected will have different uptake path between hypervascularized breast lesions and background parenchyma. The aim of this paper is to evaluate the performance of identifying and characterizing the breast lesions, costs and comfort of patients of a supervision CESM single-step path with respect to a traditional double-step path mammography and MRI. Methods We collected data on 46 patients who performed CESM: we have selected a subsample that also performed mammography in tomosynthesis and MRI. A total of 33 lesions have been identified by histological examination (28 malignant and 5 benign). The findings of all the techniques have been submitted to double blind check by two radiologists. The test was performed on 2D synthetic images of tomosynthesis and confirmed in low-energy images of CESM as reported in literature [1] . We have performed a statistical analysis of the diagnostic performances of each method in order to estimate the efficiency of the proposed diagnostic path with the only CESM technique with respect to the traditional path. Results This study have shown consistent results in terms of sensitivity (over 90%) and between paths. The total costs of CESM alone were lower than the combination of digital mammography and MRI with CM, and between the different methods, while the greater discomfort was reported by patients undergoing MRI. Conclusions The comparison between the methods has underlined the validity of the CESM supervision model both as morphological examination with respect to traditional mammography, and as dynamic examination with respect to MRI, according to the literature. In addition, CESM is more tolerated by patients than MRI and less expensive than the traditional paths.

Purpose Contrast-Enhanced Spectral Mammography (CESM) allows the acquisition of low- and high-energy digital mammograms with Dual-Energy technique after a single injection of iodinated contrast medium (CM) obtaining the production of recombined mammographic images [1] , [2] . The aim of this paper is to characterize ROI and measure the gray-level parenchymal background in order to improve the lesion detection in CESM. Methods We have selected 42 patients positive to the methodic for the presence of at least one findings after histological examination.We have evaluated 65 lesions (52 malignant and 13 benign) from 0.5 to 13.5 cm. Primary and secondary (if present) lesions have been identified and their diameters have been measured in axial projection. Regions including the parenchymal background and the non-contrasted background were also marked in both low-energy and recombined images.For each region the statistical parameters of gray levels were recorded by CESM instrumentation and have been elaborated by multivariate statistics and machine learning techniques in order to characterize each region and define a background intensity indicator, not yet defined objectively. Results The analysis on our available dataset seems to underline significant differences between ROIs with lesions and regions marked on the parenchymal background with respect to the coefficient of variation, i.e. standard deviation of the gray levels of the marked area compared to the mean value of the same) in recombined images.We have found an increase of the coefficient of ROIs greater than 20% with respect to the coefficient of the regions marked on parenchymal background in 57 lesions. Conclusions As preliminary results, an indicator to detect the parenchymal background can be identified as the coefficient of variation. Data collection is currently ongoing because a more massive data sample will be useful to increase the sensitivity in the lesion detection by CESM device, even in patients with a medium-high value of background.

The use of an abbreviated magnetic resonance (MR) protocol has been recently proposed for cancer screening. The aim of our study is to evaluate the diagnostic accuracy of an abbreviated MR protocol combining short TI inversion recovery (STIR), turbo-spin-echo (TSE)-T2 sequences, a pre-contrast T1, and a single intermediate (3 minutes after contrast injection) post-contrast T1 sequence for characterizing breast lesions.A total of 470 patients underwent breast MR examination for screening, problem solving, or preoperative staging. Two experienced radiologists evaluated both standard and abbreviated protocols in consensus. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for both protocols were calculated (with the histological findings and 6-month ultrasound follow-up as the reference standard) and compared with the McNemar test. The post-processing and interpretation times for the MR images were compared with the paired t test.In 177 of 470 (38%) patients, the MR sequences detected 185 breast lesions. Standard and abbreviated protocols obtained sensitivity, specificity, diagnostic accuracy, PPV, and NPV values respectively of 92%, 92%, 92%, 68%, and 98% and of 89%, 91%, 91%, 64%, and 98% with no statistically significant difference (P .0001). The mean post-processing and interpretation time were, respectively, 7 ± 1 minutes and 6 ± 3.2 minutes for the standard protocol and 1 ± 1.2 minutes and 2 ± 1.2 minutes for the abbreviated protocol, with a statistically significant difference (P .01).An abbreviated combined MR protocol represents a time-saving tool for radiologists and patients with the same diagnostic potential as the standard protocol in patients undergoing breast MRI for screening, problem solving, or preoperative staging.

AIM: To evaluate the role of computed tomography (CT) for diagnosing traumatic injuries of the pancreas and guiding the therapeutic approach. METHODS: CT exams of 6740 patients admitted to our Emergency Department between May 2005 and January 2013 for abdominal trauma were retrospectively evaluated. Patients were identified through a search of our electronic archive system by using such terms as “pancreatic injury”, “pancreatic contusion”, “pancreatic laceration”, “peri-pancreatic fluid”, “pancreatic active bleeding”. All CT examinations were performed before and after the intravenous injection of contrast material using a 16-slice multidetector row computed tomography scanner. The data sets were retrospectively analyzed by two radiologists in consensus searching for specific signs of pancreatic injury (parenchymal fracture and laceration, focal or diffuse pancreatic enlargement/edema, pancreatic hematoma, active bleeding, fluid between splenic vein and pancreas) and non-specific signs (inflammatory changes in peri-pancreatic fat and mesentery, fluid surrounding the superior mesenteric artery, thickening of the left anterior renal fascia, pancreatic ductal dilatation, acute pseudocyst formation/peri-pancreatic fluid collection, fluid in the anterior and posterior pararenal spaces, fluid in transverse mesocolon and lesser sac, hemorrhage into peri-pancreatic fat, mesocolon and mesentery, extraperitoneal fluid, intra-peritoneal fluid). RESULTS: One hundred and thirty-six/Six thousand seven hundred and forty (2%) patients showed CT signs of pancreatic trauma. Eight/one hundred and thirty-six (6%) patients underwent surgical treatment and the pancreatic injures were confirmed in all cases. Only in 6/8 patients treated with surgical approach, pancreatic duct damage was suggested in the radiological reports and surgically confirmed in all cases. In 128/136 (94%) patients who underwent non-operative treatment CT images showed pancreatic edema in 97 patients, hematoma in 31 patients, fluid between splenic vein and pancreas in 113 patients. Non-specific CT signs of pancreatic injuries were represented by peri-pancreatic fat stranding and mesentery fluid in 89% of cases, thickening of the left anterior renal fascia in 65%, pancreatic ductal dilatation in 18%, acute pseudocyst/peri-pancreatic fluid collection in 57%, fluid in the pararenal spaces in 45%, fluid in transverse mesocolon and lesser sac in 29%, hemorrhage into peri-pancreatic fat, mesocolon and mesentery in 66%, extraperitoneal fluid in 66%, intra-peritoneal fluid in 41% cases. CONCLUSION: CT represents an accurate tool for diagnosing pancreatic trauma, provides useful information to plan therapeutic approach with a detection rate of 75% for recognizing ductal lesions.

Context: An empty sella is a relatively common condition, often being an incidental finding at MRI or CT scan. It can develop because of the intrasellar herniation of Cerebro-spinal Fluid (CSF) and arachnoid membrane through an absent or rudimentary diaphragm sellae in concomitance of a sudden and even transient increment of intracranial pressure, leading to a picture in which the pituitary is flattened along the floor of the sella. Case Description: A young female with headache, nausea, dizziness, diplopia and visual impairment showed an empty sella on MRI and increased CSF pressure at the lumbar puncture. After an initial improvement, there was a progressive worsening of the headache, especially in orthostatic position, with transient relief after bed rest and hydration. At MRI the empty sella was no longer evident, cerebellar tonsils were displaced in the occipital foramen and there was an impregnation of the meninges after contrast medium, a picture of CSF hypotension, probably due to the previously performed lumbar puncture causing a fistula with leak of CSF and consequent disappearance of the empty sella. The patient gradually improved after being submitted to epidural blood patch. Conclusions: The case here reported demonstrates that an empty sella can be a reversible condition in rare cases. Its disappearance can be due to the reduction in intracranial pressure caused by the lumbar puncture itself. The changes in the characteristics of the headache, in particular its worsening in the orthostatic position, should lead to the suspicion of CSF leak through a fistula and consequent intracranial hypotension, a dangerous and sometimes life-threatening condition.

Introduction Malignant melanoma is one of the most rapidly increasing cancer in the world. Breast metastases from melanoma are uncommon but could reflect a widespread disease. Presentation of case We report a case of malignant widespread melanoma presenting with bilateral breast nodules in a 39 year-old pre-menopausal Caucasian woman with an history of cutaneous melanoma of the trunk. Breast clinical examination revealed the presence of a hard and mobile lump located on the left breast. Ultrasound detected two bilateral nodules corresponding to oval opacities with well-defined edges and without calcifications or architectural distortion on mammography. Fine needle aspiration cytology performed on both breast nodules confirmed that the breast lesions were metastases from primary cutaneous malignant melanoma. A total-body CT examination detected brain, lung and abdominal lymph nodes metastases. Discussion The breast represents an uncommon site of metastatic disease from extra-mammary tumors. Imaging features of breast metastases from melanoma usually do not allow a differential diagnosis with breast primary tumors. Breast metastases may be asymptomatic or palpable as dense and well-circumscribed nodules. Breast metastases indicate a widespread disease and should lead to avoid aggressive surgical procedures because of the poor prognosis of patients affected by metastatic melanoma. Conclusion The detection of bilateral breast metastases from melanoma is highly suggestive of metastatic multi-organ disease and could be useful to address the therapeutic approach.

INTRODUCTIONHepatic angio-sarcoma represents an uncommon malignant tumor of the liver with a poor prognosis and a high rate of bleeding complications.PRESENTATION OF CASEWe report a case of hepatic angio-sarcoma with a multi-nodular pattern complicated by intra-hepatic bleeding. The diagnosis was performed by computed tomography (CT). Angiographic procedure was unsuccessfully attempted as a treatment option. Autoptic examination confirmed the vascular nature of the malignant tumor.DISCUSSIONHepatic angio-sarcoma represents the most common malignant mesenchymal tumor of the liver. The diagnosis is provided by the histological examination and by specific endothelial markers. However, CT examination allows to recognize the disease and to detect intra-abdominal bleeding occurring in one-fourth of cases. Surgical resection represents the only definitive treatment of hepatic angio-sarcoma. In case of haemoperitoneum, trans-catheter arterial embolization represents the primary procedure used to stop the acute arterial bleeding.CONCLUSIONCT represents the reference technique for the diagnosis of hepatic angio-sarcoma and allows to recognize the intra-abdominal bleeding which represents its most common complication. This condition always requires an immediate therapeutic approach.

Aims and Background Computed tomography (CT) does not represent the primary method for the evaluation of breast lesions; however, it can detect breast abnormalities, even when performed for other reasons related to thoracic structures. The aim of this study is to evaluate the potential benefits of 320-row multidetector CT (MDCT) in evaluating and differentiating incidentally detected breast lesions by using vessel probe and 3D analysis software with net enhancement value. Methods and Study design Sixty-two breast lesions in 46 patients who underwent 320-row chest CT examination were retrospectively evaluated. CT scans were assessed searching for the presence, location, number, morphological features, and density of breast nodules. Net enhancement was calculated by subtracting precontrast density from the density obtained by postcontrast values. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of CT were calculated for morphological features and net enhancement. Results Thirty of 62 lesions were found to be malignant at histological examination and 32 were found to be benign. When morphological features were considered, the sensitivity, specificity, accuracy, PPV, and NPV of CT were 87%, 100%, 88%, 100%, and 50%, respectively. Based on net enhancement, CT reached a sensitivity, specificity, accuracy, PPV, and NPV of 100%, 94%, 97%, 94%, and 100%, respectively. Conclusions MDCT allows to recognize and characterize breast lesions based on morphological features. Net enhancement can be proposed as an additional accurate feature of CT.

Our purpose was to retrospectively evaluate the incidence and morphologic features of diabetic mastopathy in a group of patients with diabetes, searching for specific sonographic characteristics of diabetic mastopathy.One hundred twenty diabetic patients underwent breast clinical examination, mammography, and sonography. All detected breast lesions were confirmed histopathologically.Breast lesions were found in 11 of the 120 patients (9%), including two cases of invasive ductal carcinomas and nine cases of diabetic mastopathy. In seven of those nine cases (77%), diabetic mastopathy appeared as a hypoechoic solid mass with irregular margins, inhomogeneous echotexture, and marked posterior shadowing. In the other two cases (23%), it appeared as a mildly inhomogeneous, hypoechoic solid mass.Diabetic mastopathy is a diagnostic challenge and needs to be suspected in all patients with diabetes mellitus. Imaging features are nonspecific and highly susggestive on breast sonography in most cases. Core-needle biopsy confirmation remains mandatory for a definitive diagnosis.

Objectives Diffusion-weighted imaging with background body signal suppression (DWIBS) provides both qualitative and quantitative imaging of breast lesions and are usually performed before contrast material injection (CMI). This study aims to assess whether the administration of gadolinium significantly affects DWIBS imaging. Methods 200 patients were prospectively evaluated by MRI with STIR, TSE-T2, pre-CMI DWIBS, contrast enhanced THRIVE-T1 and post-CMI DWIBS sequences. Pre and post-CMI DWIBS were analyzed searching for the presence of breast lesions and calculating the ADC value. ADC values of ≤ 1.44 × 10- 3 mm2/s were considered suspicious for malignancy. This analysis was then compared with the histological findings. Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV) and negative (NPV) were calculated for both sequences and represented by ROC analysis. Pre and post-CMI ADC values were compared by using the paired t test. Results In 150/200 (59%) patients, pre and post-CMI DWIBS indicated the presence of breast lesions, 53 (35%) with ADC values of > 1.44 × 10- 3 mm2/s and 97 (65%) with ADC ≤ 1.44 × 10- 3 mm2/s. Pre-CMI and post-DWIBS sequences obtained the same sensitivity, specificity, DA, PPV and NPV values of 97%, 83%, 89%, 79% and 98%. The mean ADC value of benign lesions was 1.831 ± 0.18 × 10- 3 mm2/s before and 1.828 ± 0.18 × 10- 3 mm2/s after CMI. The mean ADC value of the malignant lesions was 1.146 ± 0.16 × 10- 3 mm2/s before and 1.144 ± 0.16 × 10- 3 mm2/s after CMI. No significant difference was found between pre and post CMI ADC values (p > 0.05). Conclusion DWIBS imaging is not influenced by CMI. Breast MR protocol could be modified by placing DWIBS after dynamic contrast enhanced sequences in order to maximize patient cooperation.

Acute intestinal ischemia is an abdominal emergency occurring in nearly 1% of patients presenting with acute abdomen. The causes can be occlusive or non occlusive. Early diagnosis is important to improve survival rates. In most cases of late or missed diagnosis, the mortality rate from intestinal infarction is very high, with a reported value ranging from 60% to 90%. Multi-detector computed tomography (MDCT) is a fundamental imaging technique that must be promptly performed in all patients with suspected bowel ischemia. Thanks to the new dedicated reconstruction program, its diagnostic potential is much improved compared to the past and currently it is superior to that of any other noninvasive technique. The increased spatial and temporal resolution, high-quality multi-planar reconstructions, maximum intensity projections, vessel probe, surface-shaded volume rending and tissue transition projections make MDCT the gold standard for the diagnosis of intestinal ischemia, with reported sensitivity, specificity, positive and negative predictive values of 64%-93%, 92%-100%, 90%-100% and 94%-98%, respectively. MDCT contributes to appropriate treatment planning and provides important prognostic information thanks to its ability to define the nature and extent of the disease. The purpose of this review is to examine the diagnostic and prognostic role of MDCT in bowel ischemia with special regard to the state of art new reconstruction software.

We report the case of a 72 year old man with clinical suspicion of giant cell arteritis (GCA); in this case 18F-FDG PET/CT has been useful from the diagnosis to the control of the response to therapy. He performed the first 18F-FDG PET/CT that showed increased uptake of 18F-FDG in the aortic arch, brachial artery, common iliac and femoral arteries and in the temporal cerebral sites bilaterally. The patient then began a cortisonic therapy that led straight to the improvement of clinical symptoms, and repeated 18F-FDG PET/CT 3 months later the beginning of therapy that showed reduced uptake in the same sites of the first 18F-FDG PET/CT. This patient continued the cortisonic therapy, progressively reducing it until the definitive ending.

The purpose of this study was to evaluate the adult transient intestinal intussusceptions on CT before and after the administration of gastrointestinal contrast material. We evaluated two different gastrointestinal contrast materials: hyperdense and hypodense. In all cases the gastrointestinal contrast agent solved the invaginations. In the group of patients treated with hypodense contrast medium relapses occurred in the short and long term; no recurrence was observed in the other group. CT is useful in the recognition of intestinal intussusception. The gastrointestinal contrast agent could define the real transience of intussusceptions and hyperdense contrast agent could be more effective in short and long term resolution.

The purpose of this study was to evaluate the diagnostic potential of multi-planar and volumetric reconstructions obtained from isotropic data by using 16-slice computed tomography (CT) in the diagnosis and staging of chronic pancreatitis. In a group of 42 patients CT images were evaluated searching for alterations in morphology and structure of the pancreas, alterations of the Wirsung duct, dilatation of the bile ducts, fluid collections, and vascular involvement of the digestive tract. The disease was then staged in mild, moderate and severe and correlated with the clinical staging. CT allowed the recognition of chronic pancreatitis in all cases. The staging was correct in 25/42 patients, with an accuracy rate of 59.5%. In the staging of moderate and severe forms, CT correlation with clinical and laboratory data was valid, but in mild forms it appeared less significant. Multi-detector CT is accurate in the recognition of moderate, advanced forms of chronic pancreatitis and in the identification of its complications, while it is poorly correlated with the clinical staging in mild forms of the disease.

The prognosis for hepatobiliary malignancies is dismal. Surgery remains the primary curative option. The positron emission tomography/computed tomography (PET/CT) provides simultaneous metabolic and anatomic information on tumors in the same imaging session. The role of PET/CT in detecting hepatobiliary malignancies has not yet been established. The purpose of this review was to examine the literature on the use of PET/CT in cholangiocarcinomas, also in order to improve the preoperative staging and the restaging, for a proper oncology management of patients.

Objectives Diffusion imaging represents a new imaging tool for the diagnosis of breast cancer. This study aims to investigate the role of diffusion-weighted MRI with background body signal suppression (DWIBS) for evaluating breast lesions. Methods 90 patients were prospectively evaluated by MRI with STIR, TSE-T2, contrast enhanced THRIVE-T1 and DWIBS sequences. DWIBS were analyzed searching for the presence of breast lesions and calculating the ADC value. ADC values of ≤ 1.44 × 10 - 3 mm 2 /s were considered suspicious for malignancy. This analysis was then compared with the histological findings. Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV) and negative (NPV) were calculated. Results In 53/90 (59%) patients, DWIBS indicated the presence of breast lesions, 16 (30%) with ADC values of > 1.44 and 37 (70%) with ADC ≤ 1.44. The comparison with histology showed 25 malignant and 28 benign lesions. DWIBS sequences obtained sensitivity, specificity, DA, PPV and NPV values of 100, 82, 87, 68 and 100%, respectively. Conclusion DWIBS can be proposed in the MRI breast protocol representing an accurate diagnostic complement.

The purpose of this study was to evaluate the computed tomography (CT) signs of free and covered small-bowel perforations and the potential of CT in recognising the aetiology. Thirty-five patients with surgically proven small-bowel perforation were retrospectively evaluated. Fundamental signs (extraluminal air, solution of continuity) and secondary signs (thickening of the mesentery, free or perilesional fluid, wall thickening) were considered. CT alterations were found in 31/35 (88.6 %) patients: extraluminal air (30/35, 85.7 %), solution of continuity (11/35, 31.4 %), intra-abdominal fluid (27/35, 77.1 %), thickening of the mesentery (20/35, 57.1 %), and wall thickening (14/35, 40 %). In 25/35 cases (71.4 %) pneumoperitoneum was detected, associated with secondary signs (23/25, 82 %), confirmed as free perforations at surgery. In 5/35 patients (14.2 %), peri-intestinal air bubbles and secondary signs were evident, while in 1/35 cases (2.8 %) only secondary signs were seen, namely covered perforations. In 4/35 patients (11.4 %) with a covered perforation, the CT scan was negative. The nature of the perforations was completely recognisable in 26/31 cases (83.9 %), partially identifiable in 4/31 (12.9 %), not evident in 1/31 (3.2 %). CT investigation is essential in the recognition of a small-bowel perforation and in the definition of its nature.

Purpose. To evaluate the accuracy of the washout in the differential diagnosis between adenomas and nonadenomas and to compare the obtained results in delayed CT scans at 5, 10 and 15 minutes.Methods. Fifty patients with adrenal masses were prospectively evaluated. CT scans were performed by using a 320-row MDCT device, before and after injection of contrast material. In 25 cases, delayed scans were performed at 5′ and 10′ (group 1), while in the remaining 25, at 5′ and 15′ (group 2). Absolute and relative wash-out percentage values (APW and RPW) were calculated.Results. Differential diagnosis between adenomas and nonadenomas was obtained in 48/50 (96%) cases, with sensitivity, specificity, and accuracy values of 96%, 95%, and 96%, respectively. In group 1, APW and RPW values were, respectively, 69.8% and 67.2% at 5′ and 75.9% and 73.5% at 10′ for adenomas and 25.1% and 15.8% at 5′ and 33.5% and 20.5% at 10′ for nonadenomas. In group 2, APW and RPW values were 63% and 54.6% at 5′ and 73.8% and 65.5% at 15′ for adenomas and 22% and 12.5% at 5′ and 35.5% and 19.9% at 15′ for nonadenomas.Conclusions. The evaluation of the wash-out values in CT scans performed at 5′, 10′, and 15′ provides comparable diagnostic results. CT scans performed at 5′ are, therefore, to be preferred, since they reduce the examination time and patient discomfort.

To evaluate spatial displacement of breast lesions from prone MR to supine ultrasound positions, and to determine whether the degree of displacement may be associated with breast density and lesion histotype.380 patients underwent breast MR and second-look ultrasound. The MR and ultrasound lesion location within the breast gland, distances from anatomical landmarks (nipple, skin and pectoral muscle), spatial displacement (distance differences from the landmarks within the same breast region) and region displacement (breast region change) were prospectively evaluated. Differences between MR and ultrasound measurements, association between the degree of spatial displacement and both breast density and lesion histotypes were calculated.In 290/380 (76%) patients, 300 MR lesions were detected. 285/300 (95%) lesions were recognized on ultrasound. By comparing MR and ultrasound, spatial displacement occurred in 183/285 (64.3%) cases while region displacement in 102/285 (35.7%) cases with a circumferential movement along an arc centred on the nipple, having supine ultrasound as the reference standard. A significant association between the degree of lesion displacement and breast density was found (p 0.00001) with a significant higher displacement in case of fatty breasts. No significant association between the degree of displacement and lesion histotype was found (p = 0.1).Lesion spatial displacement from MRI to ultrasound may occur especially in adipose breasts. Lesion-nipple distance and circumferential displacement from the nipple need to be considered for ultrasound lesion detection.Second-look ultrasound breast lesion detection could be improved by calculating the lesion-nipple distance and considering that spatial displacement from MRI occurs with a circumferential movement along an arc centred on the nipple.

Objectives To assess the contribute of intra-prosthetic MRI virtual navigation for evaluating breast implants and detecting implant ruptures. Methods Forty-five breast implants were evaluated by MR examination. Only patients with a clinical indication were assessed. A 1.5-T device equipped with a 4-channel breast coil was used by performing axial TSE-T2, axial silicone-only, axial silicone suppression and sagittal STIR images. The obtained dicom files were also analyzed by using virtual navigation software. Two blinded radiologists evaluated all MR and virtual images. Eight patients for a total of 13 implants underwent surgical replacement. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were calculated for both imaging strategies. Results Intra-capsular rupture was diagnosed in 13 out of 45 (29%) implants by using MRI. Basing on virtual navigation, 9 (20%) cases of intra-capsular rupture were diagnosed. Sensitivity, specificity, accuracy, PPV and NPV values of 100%, 86%, 89%, 62% and 100%, respectively, were found for MRI. Virtual navigation increased the previous values up to 100%, 97%, 98%, 89% and 100%. Conclusion Intra-prosthetic breast MR virtual navigation can represent an additional promising tool for the evaluation of breast implants being able to reduce false positives and to provide a more accurate detection of intra-capsular implant rupture signs.

This study aims to assess the diagnostic accuracy of virtual gastroscopy obtained by 320-row computed tomography (CT) examination in differentiating benign from malignant gastric ulcers (GUs). 49 patients (30 M, 19 F, mean age 58.6) with endoscopic and histological diagnosis of GU underwent CT examination. A hypotonizing drug was administered and gastric walls were distended by air in order to perform virtual endoscopy. Based on morphological features, GUs were subdivided into benign or malignant forms by two blinded radiologists. Interobserver agreement was evaluated using Cohen’s kappa (k) test. CT results were then compared with endoscopic and histological findings, having the latter as the reference standard. Thirty-five out of 49 patients (71%) were affected by malignant ulcers, while in the remaining 14 cases diagnosis of benign GU was made. Virtual gastroscopy showed diagnostic accuracy, sensitivity, and specificity values of 94%, 91%, and 100%, respectively, in differentiating benign from malignant ulcers. Almost perfect agreement between the two readers was found (k = 0.86). CT virtual gastroscopy improves the identification of GUs and allows differentiating benign from malignant forms.

Pneumatosis intestinalis may be caused by bowel ischemia and may display different patterns of appearance. We report a case of pneumatosis intestinalis with an atypical target pattern, detected by multidetector computed tomography (CT) in a 66-year-old male presenting with acute abdominal syndrome. Abdominal CT scan showed a double gas collection within the wall of a jejunal segment, with a characteristic target air distribution. The patient was surgically treated and successfully discharged from our hospital with the diagnosis of acute bowel ischemia. The target air sign can be an initial CT finding of the typical pneumatosis intestinalis and it can be useful in the early diagnosis of bowel ischemia.

The occurrence of false-positives (FPs) is still an important concern and source of unreliability in computer-aided diagnosis systems developed for 3D virtual colonoscopy. This work presents three different supervised approaches, based on supervised artificial neural networks (ANNs) architectures tested on 16 rows helical multi-slice computer tomography. The performance of the best ANN architecture developed, by using the volumes belonging to only 4 of 7 available nodules diagnosed by expert radiologists as polyps and non-polyps were evaluated in terms of FPs and false-negatives. It revealed good performance in terms of generalization and FPs reduction, correctly detecting all 7 polyps.

Objective This study aims to evaluate the diagnostic accuracy of a new CT sign in order to define or exclude a malignant aetiology of bowel obstruction. Materials and methods CT scans of 137 patients affected by bowel obstruction were reviewed. Colonic obstruction occurred in 47 (34%) cases, small bowel obstruction in 90 (66%). Neoplastic aetiology was found in 42 cases (31%), while in the remaining 95 (69%) obstruction was caused by non-neoplastic conditions. Definitive diagnosis was surgically confirmed in all patients. CT images were evaluated searching for bowel obstruction's signs and for the presence of the “protruding lips” sign on the proximal surface of stenosis, which is represented by the evidence of a protrusion within the dilated loop. Results The sign was found in 31 (23%) cases, all of neoplastic origin. When malignant obstruction was diagnosed, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy values of the described sign were 74%, 100%, 100%, 90% and 92%, respectively. Conclusions The “protruding lips” sign represents an alteration to be searched when bowel obstruction is diagnosed by CT examination. Its evidence correlates to a malignant condition with a 100% probability and when it is not found, the probability of a non-neoplastic condition is 90%.

Diagnostic imaging provides useful anatomical and morphological information of cervico-mediastinal goiters. The aim of this study was to assess the usefulness of multidetector computed tomography (MDCT) with multiplanar reformatting and volume rendering reconstructions for the preoperative evaluation of retrosternal goiters in patients for whom magnetic resonance imaging is contraindicated.From March 2006 to January 2009, 34 patients (20 women and 14 men; mean age, 48 years; range, 42-74 years) with suspected cervico-mediastinal goiter were assessed by MDCT after intravenous injection of contrast material. The following parameters were evaluated: morphology, size, and enhancement of thyroid lobes; presence, location, and mediastinal extension of thyroid tissue; and relations with mediastinal vessels and organs. All patients underwent thyroidectomy. A reference group of 34 patients evaluated by single-detector computed tomography was created. The two groups of patients were compared searching for operative time (OT, in hours), hospital stay (HS, in days), and morbidity rate observed after thyroid surgery in all cases.In 29/34 patients, thyroid was enlarged with left mediastinal extension in 12 cases, right extension in 10 cases, and posterior extension in 7 cases. In 3/34 patients, a normal cervical thyroid connected to the mediastinal goiter through a thin parenchymal stripe was observed. In 2/34 patients, thyroid lobes were enlarged, without mediastinal extension. By comparing the two groups of patients for OT and HS values, a significant reduction to 3.7 +/- 0.1 hours and 4.3 +/- 0.1 days, respectively, was found in the group of MDCT patients, and also a trend to the reduction for morbidity rate (21%) could be recognized.MDCT represents a noninvasive tool in the evaluation of retrosternal goiters. High-quality multiplanar reformatting and volume rendering reconstructions allow an optimal analysis of the plunged gland and could reduce OT, HS, and probably the morbidity rate.

In patients with acute respiratory distress syndrome (ARDS), a focal distribution of loss of aeration in lung computed tomography predicts low potential for alveolar recruitment and susceptibility to alveolar hyperinflation with high levels of positive end-expiratory pressure (PEEP).We tested the hypothesis that, in this cohort of patients, the table-based PEEP setting criteria of the National Heart, Lung, and Blood Institute's ARDS Network (ARDSnet) low tidal volume ventilatory protocol could induce tidal alveolar hyperinflation.In 15 patients, physiologic parameters and plasma inflammatory mediators were measured during two ventilatory strategies, applied randomly: the ARDSnet and the stress index strategy. The latter used the same ARDSnet ventilatory pattern except for the PEEP level, which was adjusted based on the stress index, a monitoring tool intended to quantify tidal alveolar hyperinflation and/or recruiting/derecruiting that occurs during constant-flow ventilation, on a breath-by-breath basis.In all patients, the stress index revealed alveolar hyperinflation during application of the ARDSnet strategy, and consequently, PEEP was significantly decreased (P0.01) to normalize the stress index value. Static lung elastance (P = 0.01), plasma concentrations of interleukin-6 (P0.01), interleukin-8 (P = 0.031), and soluble tumor necrosis factor receptor I (P = 0.013) were significantly lower during the stress index as compared with the ARDSnet strategy-guided ventilation.Alveolar hyperinflation in patients with focal ARDS ventilated with the ARDSnet protocol is attenuated by a physiologic approach to PEEP setting based on the stress index measurement.

The purpose of the report was to evaluate the role of fluorine-18 fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) in staging gastric cancer comparing it with contrast enhancement computed tomography (CECT). This retrospective study included 45 patients who underwent performed whole body CECT and 18F-FDG PET/CT before any treatment. We calculated CECT and 18F-FDG PET/CT sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) for gastric, lymphnode, and distant localizations; furthermore, we compared the 2 techniques by McNemar test. The role of 18F-FDG PET/CT semiquantitative parameters in relation to histotype, grading, and site of gastric lesions were evaluated by ANOVA test. Sensitivity, specificity, accuracy, PPV and NPV of CECT, and 18F-FDG PET/CT for gastric lesion were, respectively, 92.11%, 57.14%, 86.66%, 92.11%, 57.14% and 81.58%, 85.71%, 82.22%, 96.88%, 46.15%. No differences were identified between the 2 techniques about sensitivity and specificity. No statistical differences were observed between PET parameters and histotype, grading, and site of gastric lesion. The results of CECT and 18F-FDG PET/CT about lymphnode involvement were 70.83%, 61.90%, 66.66%, 68%, 65% and 58.33%, 95.24%, 75.55%, 93.33%, 66.67%. The results of CECT and 18F-FDG PET/CT about distant metastases were 80%, 62.86%, 66.66%, 38.10%, 91.67% and 60%, 88.57%, 82.22%, 60%, 88.57%. 18FDG PET/CT specificity was significantly higher both for lymphnode and distant metastases. The 18F-FDG PET/CT is a useful tool for the evaluation of gastric carcinoma to detect primary lesion, lymphnode, and distant metastases using 1 single image whole-body technique. Integration of CECT with 18F-FDG PET/CT permits a more valid staging in these patients.

Metastatic pulmonary calcification (MPC) is a rare pathological condition consisting of lung calcium salt deposits which commonly occurs in patients affected by chronic kidney disease probably for some abnormalities in calcium and phosphate metabolism. CT represents the technique of choice for detecting MPC findings including ground glass opacities and partially calcified nodules or consolidations. We present a case of MCP in a patient affected by hepato-renal autosomic-dominant polycystic disease; chest CT revealed extensive lobar-segmental parenchymal calcification with a peculiar cauliflower shape which we called “calcified cauliflower” sign. The “calcified cauliflower” sign can be reported as a new CT pattern of uremic lung that needs to be identified for a correct diagnosis and patient management.