[Role of diagnostic imaging in the diagnosis of acute appendicitis: a comparison between ultrasound and computed tomography]. / Ruolo della diagnostica per immagini nella diagnosi di appendicite acuta: confronto tra ecografia e tomografia computerizzata.

Acute appendicitis is the most common cause of acute abdomen requiring emergency surgery. In particular, it affects patients older than 20 years and diagnosis is challenging in this patient subset. The radiologic methods (ultrasound and computed tomography) play a key role in the identification, characterization and staging of the disease as well as optimal timing of surgery. The aim of our study is to assess the usefulness of ultrasound imaging in the diagnosis of acute appendicitis and in a retrospective analysis of 54 ultrasound and computed tomography exams performed in the emergency department.

How the preoperative ultrasound examination and BFI of the cervical lymph nodes modify the therapeutic treatment in patients with papillary thyroid cancer.

BACKGROUND: Ultrasound is considered the best diagnostic method for the detection of metastatic cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). According to current guidelines, all patients undergoing thyroidectomy for malignancy should undergo preoperative neck ultrasound of the thyroid and central and lateral neck LNs, followed by fine needle aspiration of suspicious LNs. Cervical LN involvement determenes the extent of surgery. Complete surgical resection disease at the initial operation decreases likelihood of future surgery for recurrent disease and may impact survival. We use a new technique, B-flow imaging (BFI), recently used for evaluation of thyroid nodules, to estimate the presence of BFI twinkling signs (BFI-TS), within metastatic LNs in patients with PTC. METHODS: Between September 2006 and December 2012, 304 patients with known PTC were examined for preoperative sonographic evaluation with gray-scale US, color Doppler US and BFI. Only 157 with at least one metastatic LN were included in our study. All patients included underwent surgery, and the final diagnosis was based on the results of histologic examination of the resected specimens. The following LN characteristics were evaluated: LN shape, abnormal echogenicity, the absent of hilum, calcifications, cystic appearance, peripheral vascularization and the presence of BFI-TS. RESULTS: A total of 767 LNs were analyzed. 329 out of 767 were metastatic, according to the histopathologic findings. BFI-TS, showed 99.5% specificity and 81,5% sensitivity. We detected BFI-TS in 6 metastatic LNs that were negative to the other conventional US features. CONCLUSIONS: Our results indicate that the BFI-TS has a diagnostic accuracy higher than the other conventional sonographic signs. Our findings suggest that BFI can be helpful in the selection of suspicious neck LNs that should be examined at cytologic examination or open biopsy for accurate preoperative staging and individual therapy selection.

[Uro-CT protocol for the diagnosis of small urothelial neoplasms of urinary tract by quantitative analysis of contrast enhancement and correlation to the histological grading]. / Protocollo uro-TC per la diagnosi di piccole formazioni eterotransizionali delle vie urinarie con analisi quantitativa dell'enhancement e correlazione al grading istologico.

In the study of urinary tract, traditional imaging modalities still play a vital role in the diagnosis of urothelial tumors of the upper urinary tract; however, the introduction of multidetector computed tomography has greatly changed the way of evaluation of urological patients. In fact, by means of a multiphasic study protocol is possible to recognize with high sensitivity small urothelial lesions and, moreover, to perform at the same time, an evaluation of local and metastatic extension also. The evaluation of the pattern of contrast enhancement in addition, allows a judgement of biological aggressiveness related to tumor grading.

US detection of renal and ureteral calculi in patients with suspected renal colic.

PURPOSE: The purpose of this study was to determine whether the color Doppler twinkling sign could be considered as an additional diagnostic feature of small renal lithiasis (_5mm). METHODS: 181 patients underwent CT scans performed for other pathologies; the images were also analyzed by a radiologists to identify the incidental presence of renal lithiasis equal to or smaller than 5 mm.These patients underwent an abdominal ultrasound examination, including grayscale analysis of the kidneys and color Doppler. Lithiasis were divided into three groups, on the basis of the diagnostic agreement provided by CT and gray scale results. Then, the twinkling sign sensitivity was assessed in the three groups. RESULTS: The twinkling sign was positive in 177 out of 206 lithiasis (86 %) visible on CT, while the grayscale was absolutely positive in 98 out of 206 lithiasis (47.6%) and doubtful positive in 71 out of 206 lithiasis (31%).The twinkling sign was positive in 100% of absolutely positive and doubtful positive lithiasis on bmode, and in 8 out of 31 lithiasis not visible on b-mode. CONCLUSIONS: In the diagnosis of small renal lithiasis, integrating gray-scale with color Doppler may be the most suitable procedure, because the color-Doppler twinkling sign is able to confirm the doubtful diagnosis of renal lithiasis and to detect some lithiasis that are not visible on b-mode.

Perception and reality in a case of suspected cervical fracture.

The case of a 36-year-old female, who following a road accident, had a cervical whiplash, is discussed. A radiographic examination of the affected region was performed at the Emergency Department. It showed a transverse radiolucent line at the basal odontoid process of the axis. A definitive interpretation was not possible and fracture of the odontoid process of the axis was suggested as differential diagnosis. On coronal CT reconstruction the presence of this fracture was ruled out. The line seen on the film was actually the product of a psychophysiologic visual illusion known as "Mach band". The use of conventional radiography correlated with digital CT images shows that the practical application of Mach band theory allows a better differentiation between normal and pathologic anatomy.

Association between monoclonal gammopathy of undetermined significance (MGUS) and diffuse idiopathic skeletal hyperostosis (DISH).

PURPOSE: To determine whether an association exists between monoclonal gammopathy of undetermined significance (MGUS) and diffuse idiopathic skeletal hyperostosis (DISH). MATERIALS AND METHODS: Radiological studies of skeleton were performed in a series of 76 patients (51 males and 25 females) affected by MGUS, observed in a consecutive period of 36 months. They revealed hyperostotic lesions similar to those described in DISH. RESULTS: Patients affected by MGUS complicated by DISH were 35 (24 males and 11 females). The prevalence of skeletal hyperostosis (46%) appears higher than that reported by the literature in the general population (mean 15 %). Typically, the vertebral column is the predominant site of abnormalities in MGUS as well as in DISH: involvement of dorsal spine was observed in 16 males and 10 females; cervical spine in 12 males and 4 females, and lumbar in 9 males and 2 females. Peripheral ossifying enthesopathy ("whiskering" in the pelvis) was found in 7 cases, 5 males and 2 females. CONCLUSIONS: DISH is probably an ossifying diathesis of unknown aetiology; its occurrence in multiple myeloma and especially in MGUS is much higher because it is a fortuitous association. Many causes (accidental, dysmetabolic or degenerative) of DISH-like syndrome complicating dysgammaglobulinemias have been supposed, but at the present time this association remains a mere guess. A pathogenetic "event" responsible for hyperostosis may be supposed: in fact, in MGUS bone stimuli induced by osteoclast activating factor (OAF) and plasma cell proliferation -- even if lower than those observed in multiple myeloma -- are much more prolonged in time (see the slow progression of this condition, before it becomes symptomatic), so that the rate of calcium mobilized from skeleton and localized into soft tissues (i.e., tendons and ligaments) is higher. In this manner, the incidence of DISH-like ossification is higher than that observed in multiple myeloma and in the general population.

Bronchial carcinoid tumors: clinical and radiological correlation.

PURPOSE: To evaluate the incidence of bronchial carcinoid tumor (BCT) in population affected by various lung tumors, retrospectively reviewed between 1986-2001, and to emphasize the radiographic patterns if they are characteristic. MATERIALS AND METHODS: In the above mentioned period, chest x-ray and CT were performed in 1110 patients, both male and female, affected by lung neoplasms. RESULTS: 20 patients were affected by BCT (16 males, and 13 females), aged between 26 and 75 years (mean age 57.5), with histopathologic diagnosis of typical (9 cases, 31%) and atypical (20 cases, 69%) bronchial carcinoid tumors. Localized right lung lesion were as follows: 7 cases in superior, 9 in middle and 4 in inferior lobes; in the left lung, 5 cases in superior, and 4 in inferior lobes. Size of the lesions was as average 2.4 cm in diameter (with a range of 0.5-12 cm). On x-ray and CT images, BCT appeared as a well marginated nodule, of which 9 were peripheral and 20 central. DISCUSSION AND CONCLUSION: BCT are classified as neuroendocrine carcinomas,and are divided in typical and atypical forms, with variable grade of malignancy. Central neoplasms are symptomatic due to bronchial obstruction (i.e., pneumonia, atelectasis, bronchiectasis, emphysema and/or lung abscess); if airway obstruction is partial, then cough, wheezing and recurrent pulmonary infections occur. Peripheral tumors are generally asymptomatic and they are discovered occasionally, when chest x-ray is made for other reasons. Radiographic features are similar in typical and atypical BCT. In central tumors a rounded well circumscribed hilar mass is noted, with lobulated or bumpy margins. Central cavitation is not referred to. Peripheral BCT appear as a solitary nodule, inferioer then 3 cm in size, marginated, surrounded by normal pulmonary tissue. Signs and symptoms of BCT are evasive and vague. No current clinical or laboratory procedures are useful in confirming the diagnosis; particularly, no imaging modalities are able to differentiate between BCT and other pulmonary tumors. For this reason, a clinical radiologic endoscopic and histopathologic approach is necessary. CT is more sensiticve then conventional radiography, especially in detecting small lesions, calcification and enlarged lymph nodes. MRI may be useful in those patients, who cannot tolerate IV contrast media. Scintigraphy may be employed in discovering relapses and long standing metastases.