Changes in TSH levels in athyreotic patients with differentiated thyroid cancer during levothyroxine therapy: influence on dose adjustments.

PURPOSE: The aim of the study was to describe the spontaneous TSH level variations and levothyroxine dose adjustments in athyreotic patients with differentiated thyroid cancer (DTC) in real-life practice. METHODS: Patients with DTC were retrospectively evaluated at a tertiary referral center between October 2006 and November 2013. Hormone measurements (TSH and FT4 serum levels), L-T4 prescription information (dose per kg per day) and other medications were recorded at 1 month and 3, 12, 24, 36 and 48 months after primary treatment (surgery ± radioiodine therapy). RESULTS: The cohort was composed of 452 patients; about 20% of patients with stable levothyroxine dose have clinically meaningful spontaneous TSH variations (defined as ΔTSH > 2 mcUI/mL) at yearly follow-up visit. Furthermore, about 25% of athyreotic DTC patients with stable dose have a ΔTSH > 1.5 mcUI/mL and about 40% a ΔTSH > 1 mcUI/mL during each follow-up visit. We further investigated whether this TSH variation would lead to subsequent dose changes. About 19.9-37.7% of DTC patients on stable LT4 dose on the previous visit had their levothyroxine dose reduced, while 7.8-14.9% increased due to TSH variations. We further evaluated the decision to change the dose in relation with the age-specific TSH range. Up to 77.2% of patients had their dose adjusted due to TSH falling below the age-specific range. CONCLUSIONS: Spontaneous serum TSH variations determine levothyroxine replacement therapy in athyreotic patients with DTC, requiring multiple dose changes.

Rotator cable at MR imaging: considerations on morphological aspects and biomechanical role.

PURPOSE: The rotator cable (RC) is a thickening of the coracohumeral ligament. It extends from the coracohumeral ligament to the inferior border of the infraspinatus tendon, with fibres running perpendicularly to the rotator cuff fibres. According to some authors, the RC tends to thicken with age, thus allowing some individuals with a cuff lesion to preserve normal shoulder function. We evaluated the RC with magnetic resonance (MR) imaging and investigated its possible role in the biomechanics of the shoulder affected by cuff lesions. MATERIALS AND METHODS: Between November 2007 and May 2008, we performed shoulder MR examinations for shoulder pain or disability on 94 patients (46 males, 48 females; age range 16-79 years; mean age 54.09 ± 15.09 years) for a total of 104 shoulders (62 right, 42 left). RESULTS: RC was more easily detectable in oblique coronal scans where it appeared as a crescent-shaped, regularly marginated structure adjacent to the articular surface of the supraspinatus tendon and medial to the insertion point of this tendon on the greater tuberosity. Its thickness was 2.8 ± 0.3 mm. The structure was identified in 62% of cases (mean patient age 55.3 ± 14.9 years). No statistically significant difference in age was found between patients with and without evidence of RC (Student's t test=0.05; p=0.82). Among patients with partial- or full-thickness supraspinatus tendon lesions at MR imaging, no statistically significant difference was found between the presence or absence of RC and disability on Jobe's test (χ(2)=1.17; p>0.05). CONCLUSIONS: RC can be observed at MR imaging in >60% cases. In our sample it did not seem to influence shoulder function in patients with cuff lesions.

Role of perfusion-weighted imaging at 3 Tesla in the assessment of malignancy of cerebral gliomas.

PURPOSE: This study was performed to clarify the role of perfusion-weighted imaging (PWI) at 3 Tesla in the characterisation of haemodynamic heterogeneity within gliomas and surrounding tissues and in the differentiation of high-grade from low-grade gliomas. MATERIALS AND METHODS: We examined 36 patients with histologically verified gliomas (25 with high-grade and 11 with low-grade gliomas). PWI was performed by first-pass gadopentetate dimeglumine T2*-weighted echo-planar images, and cerebral blood volume (CBV) maps were computed with a nondiffusible tracer model. Relative CBV (rCBV) was calculated by dividing CBV in pathological areas by that in contralateral white matter. RESULTS: In high-grade gliomas, rCBV were markedly increased in mass [mean+/-standard deviation (SD), 4.3+/-1.2] and margins (4.0+/-1.1) and reduced in necrotic areas (0.3+/-0.3). Oedematous-appearing areas were divided in two groups according to signal intensity on T2-weighted images: tumour with lower (nearly isointense to grey matter) and oedema with higher (scarcely isointense to cerebrospinal fluid) signal intensity. Tumour showed significantly higher rCBV than did oedema (1.8+/-0.5 vs. 0.5+/-0.2; p<0.001) areas. In low-grade gliomas, mass (2.0+/-1.5) and margin (2.2+/-1.2) rCBV were significantly lower than in high-grade gliomas (p<0.001). CONCLUSIONS: Three-Tesla PWI helps to distinguish necrosis from tumour mass, infiltrating tumour from oedema and high-grade from low-grade gliomas. It enhances the magnetic resonance (MR) assessment of cerebral gliomas and provides useful information for planning surgical and radiation treatment.

3.0-T morphological and angiographic brain imaging: a 5-years experience.

Ever since the introduction of magnetic resonance (MR), imaging with 1.5 Tesla (T) has been considered the gold standard for the study of all areas of the body. Until not long ago, higher-field MR equipment was exclusively employed for research, not for clinical use. More recently, the introduction of 3.0-T MR machines for new and more sophisticated clinical applications has resulted in important benefits, especially in neuroradiology. Indeed, their high gradient power and field intensity (3.0 T) allow adjunctive and more advanced diagnostic methodologies to be performed with excellent resolution in a fraction of the acquisition time required with earlier machines. The purpose of this paper is to illustrate the distinctive semeiological characteristics of 3.0-T morphological and angiographic brain imaging compared with lower-field systems and highlight the respective advantages and drawbacks based on the experience gained in the first 5 years from the installation of a 3.0-T magnet.

Central pulmonary artery lesions in chronic obstructive pulmonary disease: A transesophageal echocardiography study.

BACKGROUND: In patients with acute pulmonary embolism, transesophageal echocardiography (TEE) often reveals presumably thrombotic lesions within the central pulmonary arteries (CPAs). These CPA lesions, when found in patients with primary pulmonary hypertension, have been attributed to in situ thrombosis or atherosclerosis. We hypothesized that similar CPA lesions may also develop in patients with chronic obstructive pulmonary disease (COPD) in the absence of pulmonary embolism. METHODS AND RESULTS: We examined by TEE 25 patients with COPD and 27 control patients with left heart disease. None of the patients had previous pulmonary embolism or ileofemoral and popliteal vein thrombosis. By use of TEE, CPA lesions were found in 12 COPD patients (48%) and 2 control patients (7.4%) (P<0.01). When CPA lesions were subdivided into types 1 (protruding and mobile) and 2 (wall-adherent), type 1 lesions proved to be uncommon, being found within the pulmonary trunk in 12% and 3.7% of COPD and control patients, respectively (P=NS). Conversely, type 2 lesions, which were always localized in the right pulmonary artery, were frequent in COPD patients (36%) and rare in control patients (3.7%) (P<0.01). When available, helical CT and MR angiography confirmed TEE findings, supporting an atherosclerotic origin of type 2 lesions, which were different from typical thrombotic lesions. FEV(1)/FVC ratio, RV/TLC ratio, PaO(2), hematocrit value, and pulmonary artery systolic pressure were not significantly different in COPD patients with and without CPA lesions. At TEE, however, COPD patients with CPA lesions showed a larger size of the main and right pulmonary arteries. CONCLUSIONS: TEE often reveals CPA lesions in stable patients with COPD even in the absence of significant pulmonary hypertension and not in close relation with the severity of pulmonary dysfunction.

Spiral CT angiography in the study of the carotid stenoses.

PURPOSE: To determine sensitivity, specificity and diagnostic accuracy of spiral CT angiography (S-CTA) compared to Digital Subtraction Angiography (DSA). MATERIALS AND METHODS: We studied 40 patients with suspected cerebro-vascular insufficiency by carotid stenosis. Diagnostic examinations by means of S-CTA and DSA were carried out within 24 hours of each other. Twelve of these patients underwent thromboendoarterectomy (TEA). Prospeed SX GE was used for S-CTA. Post-processing was performed using Maximum Intensity Projection (MIP) after deleting osteo-muscular structures and CT angiograms were displayed in an oblique anterior view at an angle of 10 degrees-15 degrees along the longitudinal axis. For DSA examinations, a Siemens Politron 1000 VR unit was used. RESULTS: In this study S-CTA showed values of sensitivity, specificity and diagnostic accuracy of 88%, 100% and 96%, respectively. CONCLUSIONS: In the future, with the improvement of non-invasive techniques (S-CTA, MRA), DSA should be replaced, as the gold-standard, in the evaluation of stenotic disease of the carotid bifurcation.

[Choledocholithiasis: semeiotic and diagnostic accuracy of cholangiography with magnetic resonance]. / Calcolosi del dotto coledoco: semeiotica e accuratezza diagnostica della colangiografia con risonanza magnetica.

The authors report their experience in the optimization of the diagnostic accuracy of Magnetic Resonance Cholangiography (MRC) to detect choledochal stones; pre- and post-MIP post-processing images were compared. Thirty patients with dilated biliary ducts (mean age: 55.6 years) were examined with MRC; two of them had stones in the intrahepatic biliary ducts. The gold standard and the inclusion criterion was ERCP. MRC was carried out with a 1.5 T superconductive magnet (Signa) with T2-weighted FAST SE sequences (TR/TE; 10000/256, matrix: 256 x 128, slice thickness: 3 mm, TA: 6 min 28 s). Coronal MR images were blindly studied before and after MIP post-processing; Friedman's test was used for statistical analysis (p < .05). ERCP showed 92 cases of choledocholithiasis, with the stones ranging .2 to 3.4 cm; MRC before MIP post-processing had 97.1% diagnostic accuracy, 97.8% sensitivity and 95.8% specificity. These values are significantly different from those obtained after MIP (91.4%, 86.9% and 95.8% respectively). In our experience, pre- and post-MIP post-processing MRC can be considered a reliable and accurate noninvasive technique to detect choledochal stones.

[Magnetic resonance angiography of the vessels of the neck: the optimization of a dynamic technic during the rapid infusion of a paramagnetic contrast medium]. / Angiografia con Risonanza Magnetica dei vasi del collo: ottimizzazione della tecnica dinamica durante infusione rapida di mezzo di contrasto paramagnetico.

INTRODUCTION: A new noninvasive technique, dynamic Magnetic Resonance Angiography (MRA) during rapid infusion of paramagnetic contrast medium, has been recently developed for the study of neck vessels. This study was carried out to optimize technical parameters. MATERIALS AND METHODS: Twenty healthy volunteers (10 men and 10 women; age range: 25 to 50 years) were examined with a 1.5 T MR unit equipped with fast imaging software and a dedicated coil. Dynamic MRA was performed using fast spoiled gradient recalled (fast SPGR) sequences acquired on the coronal plane 13 s after contrast medium injection. Imaging parameters were: Echo Time (TE): 1 ms, Repetition Time (TR): 8 ms, flip angle: 60 degrees, matrix 256 x 128, number of excitations: 1, field of view: 18 x 13 cm, number of partitions per slab: 28, slice thickness: 1 mm, acquisition time: 32 s. A dose of .2 mmol/kg of paramagnetic contrast medium was administered with an MR compatible automatic injector, at a speed rate of 1.5 ml/s. Angiographic images were postprocessed with the maximum intensity projection (MIP) and targeted MIP algorithms. RESULTS: Using the above parameters and rapid contrast medium injection, the carotid arteries on the coronal plane (including the vessels from the proximal aspect of the common carotid arteries to the intracranial tract of the internal carotid arteries) in 18 cases. In the other two cases the tortuosity and the position of the carotid arteries on two different planes, prevented their complete visualization. The vertebral arteries were completely demonstrated in 50% of the investigated population. Partial or total overlapping of jugular veins did not affect the recognition of the carotid vessels in 10 cases, also with targeted MIP postprocessing. DISCUSSION: The vascular semiology of dynamic gadolinium enhanced MRA seems to be closer to that of conventional angiography than of conventional MRA, likely due to the same modality of vessel depiction, based on contrast medium administration. Flow artifacts, the major pitfall of conventional MRA causing signal void and overestimation of stenosis grade, are not frequent in dynamic MRA. CONCLUSIONS: Gadolinium enhanced dynamic MRA ensures panoramic and high resolution angiographic-like depiction of the neck vessels, providing rapid and excellent definition of vascular morphology. Thus dynamic MRA appears to be a substantial alternative to conventional MRA and conventional angiography.

[Interhemispheric epidermoid cyst. A clinical case]. / Cisti epidermoide interemisferica. Caso clinico.

The authors report a rare case of epidermoid cyst with interhemispheric growth closely connected to the anterior portion of the corpus callosum. Although extremely sensitive in determining the site, dimensions and relations of the lesion, NMR does not allow the nature of this pathology to be diagnosed owing to the lack of signal specificity. CT, using the measurement of Hounsfield units, allows a differential diagnosis of epidermoid cysts and arachnoid cysts and lipomas to be made in almost all cases. Treatment is surgical and the complete excision of the capsule avoids recidivation.

[Stress urinary incontinence in women: magnetic resonance assessment]. / Incontinenza urinaria da sforzo della donna. Valutazione mediante Risonanza Magnetica.

The preoperative radiologic study of female stress urinary incontinence is still incomplete and often not well tolerated. MRI is becoming a major diagnostic tool for pelvis assessment also thanks to its allowing dynamic studies. Therefore, MRI was used for the static and dynamic assessment of the pelvic floor, which is compromised in stress incontinence, in a series of 21 patients. Dynamic studies were reliable in all but two cases. Our MRI technique demonstrated anatomical and functional stress urinary incontinence alterations, such as the increased distance between urethra and pubic symphysis (16 patients), vaginal changes (7 patients), levator ani muscle changes (9 patients) and urethropelvic ligaments changes (9 patients). The functional changes caused by pelvic floor collapse were observed in all the patients with reliable dynamic studies, i.e., the posterior urethrovesical angle was increased and the pelvic floor excessively lowered during pelvic strain. Our preliminary results suggest that MRI can play a major role in the preoperative assessment of stress urinary incontinence, notwithstanding the fact that the exam is performed with the patient supine and therefore with no gravity.

[Thromboembolism of the right branch of the pulmonary artery: its diagnosis by biplanar transesophageal echocardiography]. / Tromboembolia del ramo dx dell'arteria polmonare: diagnosi con ecocardiografia transesofagea biplana.

We report on a patient with pulmonary thromboembolism, primarily diagnosed by urgent TEE. The thrombus was localized in the distal portion of the right pulmonary artery and was easily recognized by transversal plane TEE inspection. Pulmonary scintigraphy was subsequently performed and confirmed TEE findings.

[Present role of diagnostic imaging in the study of extensive pathology of the parotid gland]. / Ruolo attuale della diagnostica per immagini nello studio della patologia espansiva della parotide.

After the introduction in diagnostic imaging of CT and US beside sialography (SG), today it is possible completely evaluate the ductal system as well as the parenchima of the parotid gland. The authors examine the results and limitations of these new imaging modalities, outlining their role in the evaluation of parotid masses. Echography, because of high sensitivity, seems to be the method of choice for the first approach to this pathology, while sialography and CT can be successful in some circumstances: the first allows to easy outline the inflammatory involvement of the gland, while CT seems to be essential for the study of deeply situated tumors and for a complete spatial evaluation.

[Ultrasonographic studies of non opacified gallbladder after cholecystography (author's transl)]. / Strategia de studio della calcolosi colecista: ruolo dell'ecotomografia.

The purpose of our study was to evaluate the efficacy of Real-time and B-mode cholecystosonography immediately performed after one dose oral cholecystography. 861 patients have been studied: oral cholecystography gave non diagnosis in 92 cases (10.6%). Among these, ultrasonography demonstrated: in 39% stones in identifiable gallbladder; in 11% stones in non identifiable gallbladder; in 42.3% gallbladder completely normal; in 7.7% doubtful cases.