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Objective: To investigate the association of mural parameters of MR-enterography (MRE) with one-year therapeutic management of Crohn’s disease (CD) patients. Methods: CD patients, undergone MRE with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps between January 2017 and June 2018, were retrospectively enrolled. Extramural complications represented an exclusion criterion because of their potential influence on the intrinsic characteristic of the bowel wall. Two groups of patients were defined on the base of the therapeutic management adopted at 1-year follow-up: Medical-group and surgical-group. The following MRE parameters were evaluated: wall-thickening, longitudinal-extension, T2-fat-suppression-mural-signal, ulcers, mural-oedema, wall-enhancement-rate/pattern, DWI-scores, ADC-values, strictures. Results: 70 CD patients were enrolled. 57/70 (81.4%) were included in Medical-group and 13/70 (18.6%) in Surgical-group. ADCmean and strictures resulted to be significantly (p < 0.01) different between the two groups. The ADCmean showed to be significantly associated to conservative management [p < 0.01; OR: 0.0003; 95% CI (0.00–0.13)], while the strictures to surgical management [p < 0.01; OR: 29.7; 95% CI (4.9–179.7)]. ROC curves for ADCmean showed that AUC was 0.717 [95% CI (0.607–0.810), p < 0.01] with an optimal cut-off value of 1.081 × 10−3 mm2 s−1. A negative predictive value of 90.2% was observed associating ADCmean values > 1.081 × 10−3 mm2 s−1 to conservative therapy. 13/17 (76%) strictures with an ADCmean > 1.081 × 10−3 mm2 s−1 benefited of conservative therapy. Conclusion: ADCmean values calculated on DWI-MRE may be associated to 1-year conservative medical therapy in patients with CD without extramural complications. Advances in knowledge: ADC maps may be proposed to select CD patients with a lower burden of mural active inflammatory cells and/or fibrosis benefiting of 1-year conservative treatment.

The objective of this article is to assess the computed tomography (CT) findings of small bowel obstruction (SBO) complicated by ischemia. SBO is a frequent clinical entity characterized by high morbidity and mortality. The radiologic aim is not just to diagnose the obstruction itself but to rule out the presence of complications related to SBO. This is crucial for differentiating which patients can be safely treated non-operatively from the ones who may need an urgent surgical approach. The main complication of SBO is intestinal ischemia. In the emergency setting, CT imaging is the modality of choice for SBO because of its ability to assess the bowel wall, the supporting mesentery and peritoneal cavity all in one. On the other hand, the radiologist who documents an intestinal ischemia should think about SBO as possible cause. In this case, the main finding which helps the radiologist in the identification of SBO is the presence of multiple and packed valvulae conniventes in the dilated bowel wall and the "transition zone" that indicates the passage between compressed and decompressed small bowel, otherwise the localization of the obstruction cause. Once the site of obstruction has been recognized, the other issue is to assess the cause of obstruction, considering that the most common cause of SBO remains "unidentified" and related to intra-abdominal adhesions. After that, the following most important point is to rule out the presence of an ischemic bowel and mesenteric changes associated to SBO. CT signs of bowel ischemia include reduced or increased bowel wall enhancement, mesenteric edema or engorgement, fluid or free air in the peritoneal cavity. This condition usually leads to an urgent laparotomy and, in some cases, to a surgical resection.

Abdominal and pelvic trauma represents a common clinical problem in the emergency department. Despite the advances in imaging technology, with powerful MDCT scanners available currently, a plethora of diagnostic and management errors still continue to exist with potentially serious consequences for patients, which is divided into two main categories: technical and methodological ones and diagnostic (perceptive) errors. Optimal CT protocols according to the mechanism of trauma, society guidelines, organizing institutional clinical governance and quality assurance meetings, and improving research and development in the fields of emergency radiology and trauma care, can reduce these errors. Finally, the radiologist is a member of the trauma team and should be 24/7 in the emergency department.

Bowel obstruction and bowel perforation are common causes of acute abdominal pain. Clinical presentation may be insidious, and results of physical examination and laboratory values are often nonspecific and nondiagnostic. Thus, an imaging assessment is required. The target of the radiological evaluation is to define the etiology, to detect signs suggesting for immediate surgery, or to help the surgeon in deciding the correct timing of intervention. In this chapter, the diagnostic approach of these two conditions and the related main imaging findings are discussed.

The effects of each trauma are strongly related to the mechanisms of lesions. Forensic medicine distinguishes two main trauma categories: blunt and penetrating in nature.

The present case report describes imaging findings (CT and MRI features) of a primary malignant fibrous hystiocitoma, presenting as a dual stage lesion, completely exophytic along liver surface with surgical and histological correlations. Imaging characteristics suggested the nature of the lesion (mesenchymal) and the behavior (expansile growth pattern) which addressed surgeons to a conservative excision.

OBJECTIVE: The purpose of this study was to prospectively evaluate the safety and effectiveness of radiofrequency ablation (RFA) by using a multiple-electrode switching system to treat unresectable medium-large (3.1–6.0 cm) HCC nodules. METHODS: RFA using a multiple-electrode switching system was performed for HCC nodules with size > 3.0 < 6.0 cm in nonsurgical candidates. Two electrodes were consecutively placed for 3.1–4.0 cm tumours, and three electrodes for 4.1–5.9 cm tumours, with a 2.0–2.5 cm spacing. The power was switched from one electrode to the next automatically when the impedance reached 30 Ω above the baseline level. 25 patients (M/F = 9/16; median age 76 years, range 61-84) with liver cirrhosis (20 HCV-positive) in Child’s Class A (22 cases) and B (3 cases) and 26 HCC nodules (median diameter 4.0 cm; range 3.2–5.5 cm) underwent treatment in 25 sessions from 2013 and 2018. Therapeutic effectiveness was assessed through CT or MRI exam at 30–40 days post-ablation. RESULTS: No procedure-related death or major complications occurred. Complete ablation was obtained in all nodules (100%). At a median follow up of 30 months, local tumor progression occurred in five out of 26 nodules (19.2%). Overall survival at 4 years was 49%. CONCLUSION: RFA with a multiple-electrode switching system may be a safe, quick and effective therapeutic option for treatment of 3.1- 6.0 cm unresectable HCC tumours. ADVANCES IN KNOWLEDGE: RFA with multiple electrodes provides favourable clinical results in patients with medium-large HCC nodules who are not suitable for surgery

A new MRI parameter representative of active tumor burden is proposed: diffusion volume (DV), defined as the sum of all the voxels within a tumor with apparent diffusion coefficient (ADC) values within a specific range. The aims of the study were: (a) to calculate DV on ADC maps in patients with cervical/endometrial cancer; (b) to correlate DV with histological grade (G) and risk classification; (c) to evaluate intra/inter-observer agreement of DV calculation.Fifty-three patients with endometrial (n=28) and cervical (n=25) cancers underwent pelvic MRI with DWI sequences. Both endometrial and cervical tumors were classified on the basis of G (G1/G2/G3) and FIGO staging (low/medium/high-risk). A semi-automated segmentation procedure was used to calculate the DV. A freehand closed ROI outlined the whole visible tumor on the most representative slice of ADC maps defined as the slice with the maximum diameter of the solid neoplastic component. Successively, two thresholds were generated on the basis of the mean and standard deviation (SD) of the ADC values: lower threshold (LT="mean minus three SD") and higher threshold (HT="mean plus one SD"). The closed ROI was expanded in 3D, including all the contiguous voxels with ADC values in the range LT-HT × 10-3mm(2)/s. A Kruskal-Wallis test was used to assess the differences in DV among G and risk groups. Intra-/inter-observer variability for DV measurement was analyzed according to the method of Bland and Altman and the intraclass-correlation-coefficient (ICC).DV values were significantly different among G and risk groups in both endometrial (p0.05) and cervical cancers (p ≤ 0.01). For endometrial cancer, DV of G1 (mean ± sd: 2.81 ± 3.21 cc) neoplasms were significantly lower than G2 (9.44 ± 9.58 cc) and G3 (11.96 ± 8.0 cc) ones; moreover, DV of low risk cancers (5.23 ± 8.0 cc) were significantly lower than medium (7.28 ± 4.3 cc) and high risk (14.7 ± 9.9 cc) ones. For cervical cancer, DV of G1 (0.31 ± 0.13 cc) neoplasms was significantly lower than G3 (40.68 ± 45.65 cc) ones; moreover, DV of low risk neoplasms (6.98 ± 8.08 cc) was significantly lower than medium (21.7 ± 17.13 cc) and high risk (62.9 ± 51.12 cc) ones and DV of medium risk neoplasms was significantly lower than high risk ones. The intra-/inter-observer variability for DV measurement showed an excellent correlation for both cancers (ICC ≥ 0.86).DV is an accurate index for the assessment of G and risk classification of cervical/endometrial cancers with low intra-/inter-observer variability.

To compare the diagnostic value of gadolinium (Gd) and ultrasmall superparamagnetic iron oxide (SPIO) contrast media for characterization of focal liver lesions (FLL), we retrospectively evaluated the results of magnetic resonance (MR) imaging in 68 patients (40 M, 28 F, age from 22 to 81 yrs) of which 36 with diagnosis of colo-rectal cancer, 26 with hepatic cirrhosis and 6 with incidental imaging detection of FLL. MR (Gyroscan Intera 1.5 T, Philips Medical Systems) study was performed using T1 and T2 fast-field-echo (FFE) and T2 turbo-spin-echo (TSE) sequences in axial and coronal views. Dynamic multi-phases gadolinium Gd-enhanced T1-FFE-Bh images were obtained in arterial, portal and equilibrium phases, followed by SPIO-enhanced T2-FFE scans. A qualitative analysis of pre- and post-contrast MR images to classify FLL as benign or malignant was performed using a 3-point scoring system: 0= benign; 1= suspicious for malignancy; 2= malignant. A total of 118 lesions were evaluated. In particular, histology (n=18), cytology (n=14) or clinical-imaging follow-up data (n=86) demonstrated 4 adenomas, 29 cysts, 3 focal steatosis, 25 hemangiomas, 1 focal vascular abnormality, 5 fibrotic lesions as well as 13 regenerative nodules, 6 dysplastic, 14 hepatocellular carcinomas (HCC), 17 metastasis and 1 cholangiocarcinoma. For MR imaging, diagnostic accuracy, sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of Gd vs. SPIO images were respectively 83% vs. 92%, 79% vs. 74%, 85% vs. 99% (P=0.002), 68% vs. 96% (P=0.005) and 91% vs. 90%, respectively. The results suggest that SPIO-MR provides a diagnostic incremental value, as specificity and PPV, particularly to characterize FLL compared to Gd-MR; thus, we strongly recommend the use of SPIO when liver lesion characterization is requested and Gd images are uncertain.