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Objective Mild autonomous cortisol secretion (MACS) has been associated with a higher prevalence of osteoporosis, although most data rely on single-center studies with limited sample size. We aimed to assess the prevalence of fragility fractures and contributing factors in a large cohort of patients with adrenal incidentalomas. Design and Methods Medical records of 1023 patients with adrenal incidentalomas from 1990 to 2019 were reviewed, and 735 patients were selected. Clinically obtained electronic radiological images closest to first endocrine evaluation, such as lateral views of spine X-rays or CT thoraco-abdominal scans, were reviewed to screen for asymptomatic morphometric vertebral fractures. Clinical fragility fractures, hormonal, and dual-energy x-ray absorptiometry (DXA) indices were also recorded. Results Four hundred seventy-four patients had nonfunctioning (NF) adrenal incidentalomas, 238 had MACS and 23 adrenal Cushing's syndrome (AC). Prevalence of fragility fractures was different (P = .018) between groups, respectively, 24.1% (NF), 34.0% (MACS), and 30.4% (AC), with significant difference between NF and MACS (P = .012). When analyzed separately by sex and menopausal status, this difference remained significant in postmenopausal women (P = .011), with a fracture prevalence of 22.2% (NF) and 34.6% (MACS). Fracture prevalence was similar in males. Women with MACS aged ≥65 years reported a 48.8% prevalence of fractures, as compared with 29.5% in NF (P < .01). In postmenopausal women, fragility fractures were associated with age (odds ratio [OR] 1.1, P < .001), smoking (OR 1.8, P = .048), and 1 mg-dexamethasone suppression test (DST) cortisol (OR 3.1, P = .029), while in men, only age was associated with fragility fractures. Conclusions A considerable fracture burden was shown in postmenopausal women with adrenal incidentalomas and MACS, with clinical implications for the evaluation and management of bone metabolism.

Purpose CT findings of hospitalized COVID-19 patients were analyzed during both the first and the second waves of the pandemic, in order to detect any significant differences between the two groups. Methods In this observational, retrospective, monocentric study, all hospitalized patients who underwent CT for suspected COVID-19 pneumonia from February 27 to March 27, 2020 (first wave) and from October 26 to November 24, 2020 (second wave) were enrolled. Epidemiological data, radiological pattern according to the RSNA consensus statement and visual score extension using a semi-quantitative score were compared. Results Two hundred and eleven patients (mean age, 64.52 years ± 15.14, 144 males) were evaluated during the first wave while 455 patients (mean age, 68.26 years ± 16.34, 283 males) were studied during the second wave. The same prevalence of patterns was documented in both the first and the second waves (p = 0.916), with non-typical patterns always more frequently observed in elderly patients, especially the “indeterminate” pattern. Compared to those infected during the first wave, the patients of the second wave were older (64.52 vs.68.26, p = 0.005) and presented a slightly higher mean semi-quantitative score (9.0 ± 2.88 vs. 8.4 ± 3.06, p = 0.042). Age and semi-quantitative score showed a positive correlation (r = 0.15, p = 0.001). Conclusions There was no difference regarding CT pattern prevalence between the first and the second waves, confirming both the validity of the RSNA consensus and the most frequent radiological COVID-19 features. Non-typical COVID-19 features were more frequently observed in older patients, thus should not be underestimated in the elderly population.

Liver cirrhosis is a leading cause of death worldwide, with 1-year mortality rates of up to 57% in decompensated patients. Hepatocellular carcinoma (HCC) is the most common primary tumor in cirrhotic livers and the second leading cause of cancer-related mortality worldwide. Annually, up to 8% of patients with cirrhosis develop HCC. The diagnosis of HCC rarely requires histological confirmation: in fact, according to the most recent guidelines, the imaging features of HCC are almost always sufficient for a certain diagnosis. Thus, the role of the radiologist is pivotal because the accurate detection and characterization of focal liver lesions in patients with cirrhosis are essential in improving clinical outcomes. Despite recent technical innovations in liver imaging, several issues remain for radiologists regarding the differentiation of HCC from other hepatic lesions, particularly benign lesions and pseudolesions. It is important to avoid misdiagnosis of benign liver lesions as HCC (false-positive cases) because this diagnostic misinterpretation may lead to ineligibility of a patient for potentially curative treatments or inappropriate assignment of high priority scores to patients on waiting lists for liver transplantation. This review presents a pocket guide that could be useful for the radiologist in the diagnosis of benign lesions and pseudolesions in cirrhotic livers, highlighting the imaging features that help in making the correct diagnosis of macroregenerative nodules; siderotic nodules; arterioportal shunts; hemangiomas, including fast-filling hemangiomas, hemangiomas with pseudowashout, and sclerosed hemangiomas; confluent fibrosis; pseudomasses in chronic portal vein thrombosis; and focal fatty changes.

Background Knowledge regarding biliary anatomy and its variations, including the cystic duct (CD), is important in the pre-surgical setting and for predicting biliary diseases. However, no large series has focused on CD evaluation using a quantitative analysis. The primary aim of this prospective study was to create a ‘taxonomic’ classification of CD anatomy in a large cohort of subjects who underwent magnetic resonance cholangiopancreatography (MRCP). The secondary aim was to evaluate the correlations between extrahepatic bile duct (EHBD) variants and biliary diseases. Methods We enrolled patients who underwent MRCP for different clinical indications from January 2017 to May 2019. Demographical, anatomical and clinical data were evaluated using statistical analyses, as appropriate. The anatomical assessment of EHBD was performed using the standard classification for CD in low, medium, and high insertions, and the lengths of CD to the duodenal papilla (DP), and EHBD was determined to conduct a new quantitative analysis. Results The final study population comprised 1004 subjects. A new classification for EHBD as per the percentile distribution of the ratio CDDP/EHBD was designed, and the following categories were obtained: type 1 (below the 25th percentile) for CDDP/EHBD ratio ≤ 50%; type 2 (25th to 75th percentile) for CDDP/EHBD ratio 51–75% and type 3 (above the 75th percentiles) for CDDP/EHBD ratio > 75%. Type 1 of the new classification of CD implantation was significantly superior in terms of the detection of low, medial and intra-pancreatic CD that was significantly correlated with a high risk of choledochal lithiasis in comparison with the standard classification (P < 0.001). Conclusions The new classification of CD implantation enables identification of the vast majority of intra-pancreatic CDs that are correlated with a high risk of choledochal lithiasis in a single category (type 1) that is easy to identify using imaging.

Context Chronic glucocorticoids excess leads to morphological and functional cardiac alterations, a substrate for arrhythmias. Autonomous cortisol secretion (ACS) in adrenal incidentalomas is a model of chronic endogenous hypercortisolism. Objective To investigate prevalence and incidence of atrial fibrillation (AF) in a large cohort of patients with ACS. Design Retrospective study. Setting University hospital. Patients Patients evaluated between 1990 and 2018 for adrenal incidentalomas (n = 632), without pheochromocytoma, primary aldosteronism, Cushing syndrome, congenital adrenal hyperplasia, and adrenal malignancy. Cortisol after 1-mg dexamethasone suppression test 50 nmol/L defined nonsecreting tumors (NST) (n = 420) and ACS (n = 212), respectively. Intervention Assessment of AF at baseline (n = 632) and during a median follow-up of 7.7 years retrospectively (NST, n = 249; ACS, n = 108). Comparison with general population. Main Outcome Measure Prevalence and incidence of AF. Results AF prevalence was higher in patients with ACS (8.5%) than NST (3.1%, P = 0.003) and the general population (1.7%; P Conclusions Patients with adrenal incidentalomas and ACS are at risk of AF. Electrocardiogram monitoring may be recommended during follow-up.

Objective: Patients with primary aldosteronism (PA) can present with high PTH levels and negative calcium balance, with some studies speculating that aldosterone could directly stimulate PTH secretion. Either adrenalectomy or mineralocorticoid receptor blockers could reduce PTH levels in patients with PA. The aim of this study was to assess the relationship between aldosterone levels and parathyroid hormone (PTH)-vitamin D-calcium axis in a cohort of patients with PA, compared with patients with nonsecreting adrenocortical tumors in conditions of vitamin D sufficiency. Methods: We enrolled a series of 243 patients retrospectively, of whom 66 had PA and 177 had nonsecreting adrenal tumors, and selected those with full mineral metabolism evaluation and 25(OH) vitamin D levels >20 ng/mL at the time of initial endocrine screening. The final cohort was composed of 26 patients with PA and 39 patients, used as controls, with nonsecreting adrenal tumors. The relationships between aldosterone, PTH levels, and biochemistries of mineral metabolism were assessed. Results: Aldosterone was positively associated with PTH levels (r = 0.260, P < .05) in the whole cohort and in the PA cohort alone (r = 0.450; P = .02). In the multivariate analysis, both aldosterone concentrations and urinary calcium excretion were significantly related to PTH levels, with no effect of 25(OH) vitamin D or other parameters of bone metabolism. Conclusion: PTH level is associated with aldosterone, probably independent of 25(OH) vitamin D levels and urinary calcium. Whether aldosterone interacts directly with the parathyroid glands remains to be established.

Pneumatosis Intestinalis (PI) is a rare radiological finding and is defined as the presence of extra- luminal gas within the intestinal wall. PI can be distinguished in a benign form and a life-threatening form, burdened with high mortality. The correct management of PI must always take into account patient's history, his clinical context, laboratory test results and radiological findings, in order to administrate a proper therapy and avoid unnecessary surgical intervention. The pathogenesis of primary PI is still unknown and several theories have been proposed. Here, we report the case of a man with a previous severe traumatic brain injury who developed a transitory PI secondary to the enteral nutrition through a tube feeding, conservatively treated and underwent a radiological follow- up. Our report strengthens the relationship with enteral tube feeding and PI suggesting that any disaccharide used as pharmacological excipient or sweetener in the formulations for enteral tube feeding can potentially promote PI development, especially if administered in large quantities and in particular predisposing conditions. For this reason, the correct management of PI must always take into account patient's history, his clinical context, laboratory test results and radiological findings, in order to achieve a clear comprehension of its aetiology and administrate a proper therapy, avoiding unnecessary and potentially harmful surgery.

Purpose Cancer treatments with immune checkpoint inhibitors (ICI) are associated with a unique set of drug toxicities called immune-related adverse events (irAES). The aim of the present study was to describe the radiological manifestation of irAES detectable by CT. Method Retrospective analysis of 284 patients treated with ICI for various types of advanced cancer; of them, 129 patients were selected, all having been treated with single-agent ICI, and all with a baseline CT scan and follow-up scans available at our Institute. CT examinations were reviewed by two radiologists involved in the study with a consensus reading. Imaging findings consistent with irAES were reported and correlated with clinical-laboratory data. Results Immune-related adverse events were found in 25/129 (19.4 %) patients. No statistically significant differences were found in either the prevalence of irAES or in the time of onset of tumour type. Thoracic complications were detected in 14/25 (56.0 %) patients consisting in: 3 radiation recall pneumonia, 3 Transient Asymptomatic Pulmonary Opacities (TAPOs), 3 hypersensitivity pneumonia, 2 diffuse alveolar damage, 2 organizing pneumonia, 1 sarcoid-like reaction. In the remaining 11/25 (44.0 %), there were extra-pulmonary complications: 3 colitis, 4 cholecystitis, 2 pancreatitis and 2 cases of visceral ischemia. Conclusions Radiologists should be aware of the wide spectrum of irAES as they could affect the outcome. Pneumonia is the most frequent irAES; however, the international classification for interstitial lung disease does not seem to be capable of describing all possible drug-related pulmonary toxicities. Additional findings included TAPOs, radiation recall pneumonia and sarcoid-like reaction.

Purpose: To evaluate the diagnostic accuracy of the four standardized categories for CT reporting proposed by the Radiological Society of North America (RSNA) to support a faster triage compared with real-time reverse-transcription polymerase chain reaction (RTPCR), which is the reference standard for suspected coronavirus disease 2019 (COVID-19), but has long reporting time (6–48 hours). Materials and Methods: A retrospective analysis of 569 thin-section CT examinations performed for patients suspected of having COVID-19 from February 27 to March 27, 2020 (peak of infection in Italy) was conducted. The imaging pattern was classified according to the statement by the RSNA as “typical,” “indeterminate,” “atypical,” and “negative” and compared with RT-PCR for 460 patients. Interobserver variability in reporting between a senior and a junior radiologist was evaluated. Use of the vascular enlargement sign in indeterminate cases was also assessed. Results: The diagnosis of COVID-19 was made in 45.9% (211/460) of patients. The “typical” pattern (n = 172) showed a sensitivity of 71.6%, a specificity of 91.6%, and a positive predictive value of 87.8% for COVID-19. The “atypical” (n = 67) and “negative” (n =123) pattern demonstrated a positive predictive value of 89.6% and 86.2% for non–COVID-19, respectively. The “indeterminate” (n = 98) pattern was nonspecific, but vascular enlargement was most frequently found in patients with COVID-19 (86.1%; P , .001). Interobserver agreement was good for the “typical” and “negative” pattern and fair for “indeterminate” and “atypical” (k = 0.5; P =.002). Conclusion: In an epidemic setting, the application of the four categories proposed by the RSNA provides a standardized diagnostic hypothesis, strongly linked to the RT-PCR results for the “typical,” “atypical,” and “negative” pattern. In the “indeterminate” pattern, the analysis of the vascular enlargement sign could facilitate the interpretation of imaging features.

Background: Adrenal lipid-poor adenomas (LPA) are defined by high unenhanced density (≥ 10 HU), and absolute and relative contrast medium washout > 60% and > 40%, respectively, at computerized tomography (CT). To date, no thorough histopathological characterization has been performed in those frequent lesions (one-third of adrenal adenomas). Our aim was to analyze the histopathological characteristics of adrenal LPA. Methods: Patients with LPA (n = 57) were selected among consecutive subjects referred for an adrenal incidentaloma or ACTH-independent Cushing syndrome. FluoroDeoxyGlucose-Positron Emission Tomography (FDG-PET) was performed in 37 patients. In patients treated by adrenalectomy (n = 17), Weiss score and Lin–Weiss–Bisceglia score (in tumors composed entirely or predominantly of oncocytes) were calculated. Results: Radiological parameters did not differ among patients with ACTH-independent Cushing syndrome (n = 6) and those with adrenal incidentalomas associated with primary aldosteronism (n = 2), autonomous cortisol secretion (n = 14), or non-functioning (n = 35). Patients treated by adrenalectomy had larger tumors (28.9 ± 11.2 vs 17.3 ± 8.4mm, P < 0.001), higher CT unenhanced density (29.1 ± 11.0 vs 23.1 ± 9.0 HU, P = 0.043), and FDG-PET adrenal uptake (9.0 ± 6.4 vs 4.4 ± 2.3 SUV, P = 0.003) than non-operated ones. Oncocytic features > 75% of the tumor were detected in 12/17 cases (70.6%). Five of those showed borderline-malignant histopathological characteristics by Lin–Weiss–Bisceglia score. Among remaining non-oncocytic tumors, 1/5 had a Weiss score ≥ 3. Overall, 6/17 tumors (35.3%) had borderline-malignant potential. Radiological parameters were similar between patients with benign and borderline-malignant tumors. Conclusions: Adrenal LPA are a heterogeneous group of tumors, mostly composed of oncocytomas. Up to 1/3 of those tumors may have a borderline-malignant potential at histopathology.

Clinical Practice Points •Immune checkpoint inhibitors (ICI) have changed the treatment landscape of advanced non–small-cell lung cancer, as they have shown their superiority to chemotherapy in the first-line setting in tumors having programmed death ligand 1 (PD-L1) expression ≥ 50% and in patients with pretreated disease, regardless of PD-L1 expression. • The efficacy and safety of ICI rechallenge in those patients whose disease failed to respond to a prior treatment with these agents remain unclear. • We report the case of a 79-year-old woman, a smoker, with locally advanced, TP53-mutated squamous non–small-cell lung cancer, whose disease responded to an anti–PD-L1 agent despite having experienced disease progression during a prior anti–programmed cell death 1 treatment that followed first-line chemoradiotherapy. The anti–PD-L1 therapy was still ongoing after 9 months. • Our case suggests that ICI rechallenge could be safe and effective, even in a subpopulation of patients with disease that did not respond to prior ICI therapy.

Context Steroid profiling by mass spectrometry has shown implications for diagnosis and subtyping of adrenal tumors. Objectives To investigate steroid profiles and their cardiovascular correlates in a large cohort of patients with nonsecreting (NS) adrenal incidentalomas and autonomous cortisol secretion (ACS). Design Cohort study. Setting University hospital. Patients Patients (n = 302) with incidentally discovered adrenal masses, divided into unilateral adenoma and hyperplasia with ACS (n = 46 and n = 52, respectively) and NS (n = 120 and n = 84, respectively). Post–dexamethasone suppression test (DST) cortisol 50 nmol/L defined NS and ACS, respectively. Intervention Analysis of 10-steroid panel by liquid chromatography–tandem mass spectrometry (LC-MS/MS) and clinical data (mean follow-up 39 months). Main Outcome Measures Difference in baseline and post-DST steroid profiles between groups. Correlation with cardiovascular profile. Results Patients with unilateral adenomas and ACS showed higher cortisol, 11-deoxycortisol, and corticosterone and lower dehydroepiandrosterone than those with NS adenomas. Patients with ACS hyperplasia showed higher cortisol and lower androgens in women than those with NS. Patients with ACS had reduced suppression of post-DST cortisol, 11-deoxycortisol, and corticosterone, irrespective of adrenal morphology. Post-DST cortisol and corticosterone were associated with higher prevalence of severe/resistant hypertension. Patients with ACS unilateral adenomas showed higher incidence of worsening of hypertensive disease and novel cardiovascular events than those with NS, with post-DST cortisol [hazard ratio (HR) 1.02; 95% CI, 1.01 to 1.03; P < 0.001] and baseline corticosterone (HR 1.06; 95% CI, 1.01 to 1.12; P = 0.031) among the main predictors. Conclusions Patients with adrenal incidentalomas showed different steroid profiles, depending on functional status and adrenal morphology, with implications for their cardiovascular status.

Objective: Primary aldosteronism is associated with higher cardiovascular morbidity as compared with essential hypertension. Vascular complications encompass myocardial infarction and cerebrovascular events. Aortic damage in primary aldosteronism has never been explored, although a few cases of ascending aorta aneurisms have been reported. Design and methods: We consecutively enrolled patients affected by primary aldosteronism (n = 45) and compared them with patients affected by essential hypertension (n = 47), on an outpatient setting. Echocardiographic data of patients with primary aldosteronism were collected during a mean follow-up of 3 years, in subjects who underwent adrenal surgery (n = 12) and those on mineralocorticoid receptor antagonists (n = 33). Results and conclusion: We found that patients with primary aldosteronism had larger ascending aorta diameters than those with essential hypertension before starting any specific treatment. Patients with primary aldosteronism did not show significant changes in the size of ascending aorta during a mean of 3 years of follow-up, irrespective of the type of treatment (medical vs. surgical treatment). A longer follow-up will better clarify if worsening of the aortic damage may be better prevented by surgery rather than by mineralocorticoid receptor antagonists.

The authors sought to evaluate the diagnostic accuracy of high-resolution computed tomography (HRCT) in the detection of pulmonary veno-occlusive disease (PVOD) in patients with pre-capillary pulmonary arterial hypertension (PAH) of unknown aetiology, and to identify the role of CT in diagnosis and therapy.The CT scans of 96 patients were retrospectively reviewed and assessed for specific HRCT findings: ground-glass opacities, septal lines and mediastinal lymph nodal enlargement (short diameter ≥1 cm). According to the HRCT findings, patients were divided into PVOD-suspicious and not PVOD-suspicious. Subsequently, a clinical-instrumental evaluation was performed, and the response to therapy and histopathological reports were evaluated.Radiological evaluation based on HRCT findings revealed 29 patients as PVOD-suspicious and 67 as not PVOD-suspicious. The final diagnosis was PVOD in 22 patients and idiopathic PAH in 74 patients. The CT scan showed 95.5 % sensitivity, 89% specificity, 72.5% positive predictive value, and 98.5% negative predictive value, with a diagnostic accuracy of 90.5% in identifying patients with PVOD.Chest CT can be considered a screening test in the assessment of patients with PAH of unknown aetiology, and the radiologist can help the clinician to identify patients with CT findings that make PVOD highly probable.