Pulmonary fungal infections in patients with acute myeloid leukaemia: is it the time to revise the radiological diagnostic criteria?

The definition of pulmonary fungal infections (PFI) according to the EORTC-MSG criteria may lack diagnostic sensitivity due to the possible presentation of PFI with different radiological pictures. We evaluated the hypothesis to apply less restrictive radiological criteria to define PFI in patients with acute myeloid leukaemia (AML) submitted to chemotherapy. Overall, 73 consecutive episodes of pulmonary infiltrates associated to positive serum galactomannan test or fungal isolation or galactomannan detection from respiratory specimens were considered. CT scans acquired at the onset of symptoms (time-0) and within 4 weeks (time-1) were analysed to identify specific (group A) or aspecific radiological signs (group B). Pulmonary infiltrates fulfilled the EORTC-MSG criteria in 49 patients (group A), whereas in 24 patients (group B) they did not reach the criteria due to aspecific CT findings at time-0. Eleven of 21 (52.4%) patients of the group B evaluable for the evolution of the radiological findings fulfilled EORTC-MSG criteria at time-1. All the analysed clinical and mycological characteristics, response to antifungal therapy and survival were comparable in the two groups. Our study seems to confirm the possibility to extend the radiological suspicion of PFI to less restrictive chest CT findings when supported by microbiological criteria in high-risk haematological patients.

Prospective Comparison between two different magnetic resonance defecography techniques for evaluating pelvic floor disorders: air-balloon versus gel for rectal filling.

PURPOSE: to prospectively compare two rectal filling techniques for dynamic MRI of pelvic floor disorders (PFD). METHODS AND MATERIALS: Twenty-six patients with PFD underwent the two techniques during the same procedure, one based on rectal placement of a balloon-catheter filled with saline and air insufflation (air-balloon technique or AB); another based on rectal filling with 180 cc of gel (gel-filling technique or GF). The examinations were compared for assessment and staging of PFD, including rectal-descent, rectocele, cystocele, colpocele, enterocele, rectal invagination. Surgery and clinical examinations were the gold standard. RESULTS: AB showed sensitivity of 96 % for rectal descent, 100 % for both rectocele and colpocele, 86 % for rectal invagination and 100 % for enterocele; understaged 11 % of rectal descents and 19 % of rectoceles. GF showed sensitivity of 100 % for rectal descent, 91 % for rectocele, 83 % for colpocele, 100 % for rectal invagination and 73 % for enterocele; understaged 3.8 % of rectal descent and 11.5 % of rectoceles. Both techniques showed 100 % of specificity. Agreement between air-balloon and gel filling was 84 % for rectal descent, 69 % for rectocele, 88 % for rectal invagination, 84 % for enterocele, 88 % for cystocele and 92 % for colpocele. CONCLUSION: Both techniques allowed a satisfactory evaluation of PFD. The gel filling was superior for rectal invagination, the air-balloon for rectocele and anterior/middle compartment disorders. KEY POINTS: • A standardized MRI technique for assessing pelvic floor disorders is not yet established. • This study compares two MRI techniques based on different rectal filling: air-balloon versus gel. • Both MRI techniques proved to be valuable in assessing PFD, with good agreement. • Air-balloon technique is more hygienic and better tolerated than the gel-filling technique. • Gel was superior for rectal invagination, air-balloon for rectocele and uro-genital prolapses.

Detection of Crohn disease lesions of the small and large bowel in pediatric patients: diagnostic value of MR enterography versus reference examinations.

OBJECTIVE: The purpose of this article is to prospectively determine the accuracy of MR enterography in detecting Crohn disease lesions from the jejunum to the anorectal region in pediatric patients, in comparison with main reference investigations. SUBJECTS AND METHODS: Fifty consecutive children with known Crohn disease underwent MR enterography with oral contrast agent and gadolinium-chelate intravenous injection. Two radiologists detected and localized lesions by dividing the bowel into nine segments (450 analyzed segments in 50 patients). Ileocolonoscopy, barium studies, intestinal ultrasound, and capsule endoscopy were considered as first- and second-level reference examinations and were performed within 15 days of MR enterography. RESULTS: MR enterography detected lesions in 164 of 450 segments, with 155 true-positive and nine false-positive findings; overall sensitivity, specificity, and positive and negative predictive values for small- and large-bowel lesions were 94.5%, 97%, 94.5%, and 97%, respectively (ĸ = 0.93; 95% CI, 0.89-0.97). Sensitivity and specificity values were 88% and 97%, respectively, for the jejunum, 100% and 97% for the proximal-to-mid ileum, 100% and 100% for the distal ileum, 93% and 100% for the cecum, 70% and 97% for the ascending colon, 80% and 100% for the transverse colon, 100% and 92% for the descending colon, 96% and 90% for the sigmoid colon, and 96% and 88% for the rectum. From jejunum to rectum, the AUC value ranged between 0.916 (jejunum) and 1.00 (distal ileum). Perianal fistulas were diagnosed in 15 patients, and other complications were found in 13 patients. CONCLUSION: MR enterography showed an accuracy comparable to that of reference investigations, for both small- and large-bowel lesions. Because MR enterography is safer and more comprehensive than the reference examinations, it should be considered the primary examination for detecting Crohn disease lesions in children.

Value of MRI of the hand and the wrist in evaluation of bone age: preliminary results.

PURPOSE: To evaluate bone age determination using MRI of the hand and wrist. MATERIALS AND METHODS: A total of 179 (78 female and 101 males, 11 to 16 years old) subjects of 252 normal volunteers met entrance criteria. A low field open magnet (0.2 Tesla) was used for this study; coronal T1-weighted images with a slice thickness of 1.3mm were acquired. Two blinded radiologists evaluated the studies and the following elements were considered: the appearance of cartilage, vacuolization of cartilage, provisional calcification, progression of ossification, and complete ossification. Correlation between chronologic age and MR bone age was determined by means of simple linear regression analysis. RESULTS: Strong correlation between MR skeletal age and chronological age was observed for both investigators, Pearson correlation R2 = 0.9 for each. CONCLUSION: Determination of bone age with MRI is feasible and shows good interobserver reproducibility. Data from this study may be useful to develop an atlas of skeletal development and bone age.

Mass-forming cholangiocarcinoma and adenocarcinoma of unknown primary: can they be distinguished on liver MRI?

PURPOSE: To determine MR features suggestive of mass-forming cholangiocarcinoma (CCA) or liver metastases of adenocarcinoma of unknown primary (AUP), and to compare the ability of two experienced radiologists to establish the correct diagnosis. MATERIALS AND METHODS: 61 patients with CCA or AUP, with MRIs were placed into two groups: population 1, 28 patients with certain diagnosis of either CCA or AUP; and population 2, 33 patients with uncertain diagnosis. Using population 1 with known diagnosis, two investigators formulated imaging criteria for CCA or AUP, which represented phase 1 of the study. In phase 2, two independent radiologists categorized the patients in populations 1 and 2 as CCA or AUP using the formulated criteria. This categorization was compared with the patient medical records and pathologist review. Findings were tested for statistical significance. RESULTS: In phase 1, solitary lesion, multifocal lesions with dominant lesion, capsule retraction, and porta hepatis lymphadenopathy were features of CCA; multifocal lesions with similar size, and ring enhancement were features of AUP. The number of lesions, capsule retraction, and early tumor enhancement pattern were observed to be significant features (P < 0.05). In phase 2, agreement between the two radiologists was good (k = 0.663). For population 1, the agreement was good (k = 0.659), and was fair for population 2 (k = 0.293). Concordance between the two radiologists, medical record, and the pathologist was found in 41/61 (67%) patients. CONCLUSION: Distinctive features of CCA and AUP are identifiable on MRI images, which may aid the radiologist to establish the correct diagnosis.

Bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome: value of MRI in the differential diagnosis.

Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis.

Differences in the location and activity of intestinal Crohn's disease lesions between adult and paediatric patients detected with MRI.

OBJECTIVES: To prospectively compare paediatric patients (PP) and adult patients (AP) affected by Crohn's disease (CD) in terms of the location and activity of intestinal lesions. METHODS: Forty-three children (mean age 15 years) and 43 adults (mean age 48 years) with proven CD underwent magnetic resonance enterography (MRE) to localise lesions and detect their activity in 9 segments of the small and large bowel. The results were analysed on a per patient and per segment basis. Ileo-colonoscopy was performed in all patients. P values less than 0.05 were considered statistically significant. RESULTS: Involvement of terminal ileum was significantly different in the two groups: observed in 100 % of AP (43/43) versus 58 % (23/43) of PP (P < 0.0001). Conversely, the colon was diseased in 84 % of PP versus 64 % of AP. In particular, left colonic segments were significantly more involved in PP (descending colon 53 % versus 21 %, P < 0.01; rectum 67 % versus 23 %, P < 0.0001; sigmoid colon 56 % versus 37 %, not significant), whereas caecal involvement was equal in both groups. In children the maximal disease activity was found in left colonic segments, whereas in adults it was in the terminal ileum. CONCLUSIONS: MRE detected significant differences between the two populations, showing a more extensive and severe involvement of the left colon in children but the distal ileum in adults. KEY POINTS : • MRI is useful for assessing Crohn's disease in adult and paediatric patients. • Adult and paediatric patients show different intestinal involvement on MRI. • The distal ileum is maximally involved in adults vs. the left colon in children. • The causes of the severe left colonic disease in children are unknown. • The extensive colonic involvement in children has clinical-diagnostic implications.

Congenital absence of the portal vein in a middle-aged man.

Congenital absence of the portal vein with systemic diversion of mesenteric blood is extremely rare. We report a case of a congenital absence of the portal vein, accidentally discovered in a 59-year-old man, completely asymptomatic and not associated with other malformations or biochemical disorders. Ultrasonography imaging showed the absence of the portal vein and the distal tract of superior mesenteric and splenic veins draining together into a dilated left renal vein. Computed tomography and magnetic resonance confirmed the presence of a congenital portosystemic venous shunt and also revealed two hepatic arteries: one arising from the celiac trunk and the other from the superior mesenteric artery.