Details of left ventricular radial wall motion supporting the ventricular theory of the third heart sound obtained by cardiac MR

Objective:

Obtaining new details of radial motion of left ventricular (LV) segments using velocity-encoding cardiac MRI.

Methods:

Cardiac MR examinations were performed on 14 healthy volunteers aged between 19 and 26 years. Cine images for navigator-gated phase contrast velocity mapping were acquired using a black blood segmented κ-space spoiled gradient echo sequence with a temporal resolution of 13.8 ms. Peak systolic and diastolic radial velocities as well as radial velocity curves were obtained for 16 ventricular segments.

Results:

Significant differences among peak radial velocities of basal and mid-ventricular segments have been recorded. Particular patterns of segmental radial velocity curves were also noted. An additional wave of outward radial movement during the phase of rapid ventricular filling, corresponding to the expected timing of the third heart sound, appeared of particular interest.

Conclusion:

The technique has allowed visualization of new details of LV radial wall motion. In particular, higher peak systolic radial velocities of anterior and inferior segments are suggestive of a relatively higher dynamics of anteroposterior vs lateral radial motion in systole. Specific patterns of radial motion of other LV segments may provide additional insights into LV mechanics.

Advances in knowledge:

The outward radial movement of LV segments impacted by the blood flow during rapid ventricular filling provides a potential substrate for the third heart sound. A biphasic radial expansion of the basal anteroseptal segment in early diastole is likely to be related to the simultaneous longitudinal LV displacement by the stretched great vessels following repolarization and their close apposition to this segment.Advances in cardiac imaging techniques have allowed evaluation of new details of the complex pattern of left ventricular (LV) motion. Using high temporal resolution cardiovascular MR with myocardial velocity-encoding techniques, we previously performed a detailed analysis of rotational and longitudinal motions of the left ventricle, correlating them with the orientation or cardiomyocyte aggregates within the LV wall.^1,2 However, accurate evaluation of radial motion is equally important. For example, radial wall motion abnormalities have been detected in patients with diabetes³ and hypertrophic cardiomyopathy,⁴ whereas radial dyssynchrony is almost universal in patients with heart failure.⁵ The purpose of this study was to obtain new details of global and regional radial wall motion of the left ventricle using the cardiac MR high temporal resolution myocardial velocity-encoding technique.^6,7 Considering recent interest in myocardial multilayer measurements, which provide more layer-specific information about the functional state of the myocardium at different levels,^8–13 separate calculations of all myocardial velocities and their corresponding peak times for the inner (endocardial), middle (transmural) and outer (epicardial) layers of the LV wall were performed.     

Assessment of left ventricular ejection fraction and regional wall motion with 64-slice multidetector CT: a comparison with two-dimensional transthoracic echocardiography

The aim of this study was to compare the measurement of left ventricular ejection fraction (LVEF) and regional wall motion using 64-slice multidetector CT (MDCT) with that using two-dimensional transthoracic echocardiography (2D-TTE) in a heterogeneous patient population. In 126 patients with angina pectoris, acute myocardial infarction, chronic myocardial infarction, atypical chest pain without coronary artery disease or valvular heart disease, 64-slice MDCT was performed using retrospective electrocardiography gating without dose modulation. 20 phases of the cardiac cycle were analysed to identify the end-diastolic and end-systolic phases and to assess regional LV wall motion. For these measurements, 2D-TTE served as the reference standard. MDCT and 2D-TTE were performed within 10 days of each other. An excellent correlation between MDCT and 2D-TTE was shown for the evaluation of LVEF (59.2±11% vs 57.9±10%, respectively; r _ 0.87). LVEF was slightly overestimated by MDCT, when compared with 2D-TTE, by an average of 1.4±5.6%. Good agreement was obtained between the use of the two techniques, with 94% of the segments scored identically on both modalities (κ _ 0.70). MDCT had a sensitivity of 97% and a specificity of 82% when compared with 2D-TTE as the reference standard. In conclusion, the use of 64-slice MDCT can provide comparable results to those using 2D-TTE for LVEF and regional wall motion assessment in a heterogeneous population.Accurate and reproducible determination of left ventricular (LV) function is essential for the diagnosis, disease stratification, therapeutic guidance, follow-up and estimation of prognosis for the majority of cardiac diseases [1–3]. Two-dimensional transthoracic echocardiography (2D-TTE) is the most widely used method for LV function assessment, but the modality is operator dependent and can be impaired by a poor acoustic window [4]. Cardiac MRI has been considered the clinical “gold standard” for LV function assessment, but it is expensive, of limited availability and cannot be performed in patients with implanted pacemakers or defibrillators [5–8]. Multidetector CT (MDCT) of the heart is used largely to evaluate the coronary arteries [9–11]. Currently, MDCT is increasingly being considered as a potential tool for the combined assessment of the coronary anatomy and LV function [12–14]. Retrospective electrocardiography (ECG)-gated MDCT allows for image reconstruction in any phase of the cardiac cycle. Thus, LV end-diastolic (ED) and end-systolic (ES) volumes can be assessed. In addition, ventricular wall motion can be assessed visually by the use of cine loop displays of multiple cardiac phases. According to recent reports [15–32], measurements for various LV functional parameters with MDCT were correlated and agreed with measurements obtained with MRI, 2D-TTE and ECG-gated single photon emission CT (SPECT). However, the experience with 64-slice MDCT for cardiac function assessment remains limited by small patient numbers and the inclusion of homogeneous patient populations [24–32].The purpose of this study was to assess LV ejection fraction (LVEF) and regional wall motion using 64-slice MDCT and to compare this with 2D-TTE in a heterogeneous patient population.     

Accessory or additional renal arteries show no relevant effects on the width of the upper urinary tract: a 64-slice multidetector CT study in 1072 patients with 2132 kidneys

Objective

The aim of this study was to find out on an unselected patient group whether crossing vessels have an influence on the width of the renal pelvis and what independent predictors of these target variables exist.

Methods

In this cross-sectional study, 1072 patients with arterially contrasted CT scans were included. The 2132 kidneys were supplied by 2736 arteries.

Results

On the right side, there were 293 additional and accessory arteries in 286 patients, and on the left side there were 304 in 271 patients. 154 renal pelves were more than 15 mm wide. The greatest independent factor for hydronephrosis on one side was hydronephrosis on the contralateral side (p<0.0001 each). Independent predictors for the width of the renal pelvis on the right side were the width of the renal pelvis on the left, female gender, increasing age and height; for the left side, predictors were the width of the renal pelvis on the right, concrements, parapelvic cysts and great rotation of the upper pole of the kidney to dorsal. Crossing vessels had no influence on the development of hydronephrosis. Only anterior crossing vessels on the right side are associated with widening of the renal pelvis by 1 mm, without making it possible to identify the vessel as an independent factor in multivariate regression models.

Conclusion

The width of the renal pelvis on the contralateral side is the strongest independent predictor for hydronephrosis and the width of the renal pelvis. There is no link between crossing vessels and the width of the renal pelvis.Obstructions of the ureteropelvic junction (UPJ) can be caused by intrinsic or extrinsic factors [1]. Although there are no studies of this to date, crossing the UPJ by an aberrant crossing vessel is considered the most important [2] of the extrinsic factors [3]. Crossing vessels, which are thought to cause from 40% to over 50% of the extrinsic UPJ obstructions in adults [4, 5], are located ventral more often than dorsal to the UPJ. These are usually normal vessels of the lower pole segment [4, 6–9], which can be divided into additional renal arteries arising from the aorta, and accessoric renal arteries arising from branches of the aorta [10, 11]. The primary surgical therapy of choice is endoscopic endopyelotomy [12]. The success rate of 89–90% [12, 13] is thought to be noticeably poorer in patients with crossing vessels [12, 13]; however, this is not undisputed [14, 15]. Be that as it may, to prevent bleeding complications it is necessary to be familiar with the vascular situation around the UPJ prior to the procedure [3, 16–18]. CT angiography is used for this purpose, as it is highly accurate, quick to perform and shows all relevant anatomical structures in relation to one another [3, 19, 20]. The objective of this study was to determine whether or not there are vascular morphological patterns or other factors that influence the width of the renal collecting system, regardless of the definitions of hydronephrosis.     

Prognostic factors associated with a subchondral insufficiency fracture of the femoral head

Objective

The aim of this study was to identify the risk factors associated with the prognosis of a subchondral insufficiency fracture of the femoral head (SIF).

Methods

Between June 2002 and July 2009, 25 patients diagnosed with SIF were included in this study. Sequential radiographs were evaluated for the progression of collapse. Clinical profiles, including age, body mass index, follow-up period and Singh’s index, were documented. The morphological characteristics of the low-intensity band on T₁ weighted MRI were also examined with regards to four factors: band length, band thickness, the length of the weight-bearing portion and the band length ratio (defined as the proportion of the band length to the weight-bearing portion of the femoral head in the slice through the femoral head centre).

Results

Radiographically, a progression of collapse was observed in 15 of 25 (60.0%) patients. The band length in patients with progression of collapse [22.5 mm; 95% confidence interval (CI) 17.7, 27.3] was significantly larger than in patients without a progression of collapse (13.4 mm; 95% CI 7.6, 19.3; p<0.05). The band length ratio in patients with progression of collapse (59.8%; 95% CI 50.8, 68.9) was also significantly higher than in patients without a progression of collapse (40.9%; 95% CI 29.8, 52.0; p<0.05). No significant differences were present in the other values.

Conclusion

These results indicate that the band length and the band length ratio might be predictive for the progression of collapse in SIF.Subchondral insufficiency fractures of the femoral head (SIF) often occur in osteoporotic elderly patients [1-9]. Patients usually suffer from acute hip pain without any obvious antecedent trauma. Radiologically, a subchondral fracture is seen primarily in the superolateral portion of the femoral head [4,5,10]. T₁ weighted MRI reveal a very low-intensity band in the subchondral area of the femoral head, which tends to be irregular, disconnected and convex to the articular surface [2,4,5,7,9,11]. This low-intensity band in SIF was histologically proven to correspond with the fracture line and associated repair tissue [5,9]. Some cases of SIF resolve after conservative treatment [5,11-14]; other cases progress until collapse, thereby requiring surgical treatment [4-10,15]. The prognosis of SIF patients remains unclear.The current study investigated the risk factors that influence the prognosis of SIF based on the progression to collapse.     

Pattern and predictors of volumetric change of parotid glands during intensity modulated radiotherapy

Objective:

To describe the pattern and predictors of volumetric change of parotid glands during intensity modulated radiotherapy (IMRT) for oropharyngeal cancer.

Methods:

A cohort of patients undergoing weekly CT scans during dose-painted IMRT was considered. The parotid glands were contoured at the time of treatment planning (baseline) and on all subsequent scans. For a given patient, the parotid glands were labelled as higher (H) and lower (L), based on the mean dose at planning. The volume of each gland was determined for each scan and the percent change from baseline computed. Data were fit to both linear and quadratic functions. The role of selected covariates was assessed with both logistic regression and pair-wise comparison between the sides. The analyses were performed considering the whole treatment duration or each separate half.

Results:

85 patients, 170 glands and 565 scans were analysed. For all parotids except one, the quadratic function provided a better fit than the linear one. Moreover, according to both the logistic regression and pair-wise comparison, the cumulative mean dose of radiation is independently correlated with the parotid shrinkage during the first but not the second half of the treatment. Conversely, age and weight loss are predictors of relative parotid shrinkage during the entire course of the treatment.

Conclusion:

Parotid gland shrinkage during IMRT is not linear. Age, weight loss and radiation dose independently predict parotid shrinkage during a course of IMRT.

Advances in knowledge:

The present study adds to the pathophysiology of parotid shrinkage during radiotherapy.Fractionated radiotherapy is based on the assumption that the dose distribution obtained at planning is delivered during each treatment session. However, both set-up errors and tissue deformation can modify the dose that is administered. Shifts in the location of isodose levels compared with planning become critical for techniques that are highly conformal to the target(s), such as IMRT, justifying the interest in image guidance and adaptive radiotherapy [1]. Because of the sharp dose gradient around the target(s), subtle changes in the relative position or in the volume of organs at risk may alter the planned dose that the volume of an organ receives, as has been shown for the parotid glands [2–6].In a study by Ricchetti et al [7], we found that the parotid glands are the regions of interest that undergo the largest absolute and relative changes in volume during treatments. Although at least 16 articles have documented a significant percent reduction in the volume of the parotid gland during the course of fractionated radiotherapy [2,3,7–20], there are still several unanswered questions. It is unclear why some parotid glands shrink to about 50–60% during treatment, while others show only minimal changes. Studies that have investigated predictors of shrinkage have suggested weight loss during treatment, patient age and dose of radiation to the parotid as potential factors [2,9,16–19]. However, results are inconsistent [3,8,10,14]. Some studies have suggested that dosimetrically spared parotid glands undergo only minimal volume changes during treatment [16,18], whereas others describe a similar behaviour regardless of the radiation dose [7,8,10]. Furthermore, it is unclear whether the daily percent volume change is constant [8,10,16,19] or variable [7,10,13] during the course of treatment. A variable daily percent change in the volume may indicate that there are predictive factors specific to certain portions of the fractionated radiation schedule. In the present article, we attempt to clarify these points.     

Primary vaginal cancer: role of MRI in diagnosis,staging and treatment

Primary carcinoma of the vagina is rare, accounting for 1–3% of all gynaecological malignancies. MRI has an increasing role in diagnosis, staging, treatment and assessment of complications in gynaecologic malignancy. In this review, we illustrate the utility of MRI in patients with primary vaginal cancer and highlight key aspects of staging, treatment, recurrence and complications.The incidence of primary vaginal cancer increases with age, with approximately 50% of patients presenting at age greater than 70 years and 20% greater than 80 years.¹ Around 2890 patients are currently diagnosed with vaginal carcinoma in the USA each year, and almost 30% die of the disease.² The precursor for vaginal cancer, vaginal intraepithelial neoplasia (VAIN) and invasive vaginal cancer is strongly associated with human papillomavirus (HPV) infection (93%).^3,4 In situ and invasive vaginal cancer share many of the same risk factors as cervical cancer, such as tobacco use, younger age at coitarche, HPV and multiple sexual partners.^5–7 In fact, higher rates of vaginal cancer are observed in patients with a previous diagnosis of cervical cancer or cervical intraepithelial neoplasia.^7,8As is true for other gynaecologic malignancies, vaginal cancer diagnosis and staging rely primarily on clinical evaluation by the International Federation of Gynecology and Obstetrics (FIGO).⁹ Pelvic examination continues to be the most important tool for evaluating local extent of disease, but this method alone is limited in its ability to detect lymphadenopathy and the extent of tumour infiltration. Hence, FIGO encourages the use of imaging. Fluorine-18 fludeoxyglucose-positron emission tomography (¹⁸F-FDG-PET), a standard imaging tool for staging and follow-up in cervical cancer, can also be used for vaginal tumours, with improved sensitivity for nodal involvement compared to CT alone.¹⁰ In addition to staging for nodal and distant disease, CT [simulation with three dimensional (3D) conformations] is particularly useful for treatment planning and delivery of external beam radiation. MRI, with its excellent soft tissue resolution, is commonly used in gynaecologic malignancies and has been shown to be accurate in diagnosis, local staging and spread of disease in vaginal cancer.^11,12 While no formal studies are available for vaginal cancer, in cervical cancer MRI actually alters the stage in almost 30% of patients.^13–15Treatment planning in primary vaginal cancer is complex and requires a detailed understanding of the extent of disease. Because vaginal cancer is rare, treatment plans remain less well defined, often individualized and extrapolated from institutional experience and outcomes in cervical cancer.^1,16–19 There is an increasing trend towards organ preservation and treatment strategies based on combined external beam radiation and brachytherapy, often with concurrent chemotherapy,^14,20,21 surgery being reserved for those with in situ or very early-stage disease.²² Increasing utilization of MR may provide superior delineation of tumour volume, both for initial staging and follow-up, to allow for better treatment planning.²³     

Towards clinical assessment of velopharyngeal closure using MRI: evaluation of real-time MRI sequences at 1.5 and 3 T

Objective

The objective of this study was to demonstrate soft palate MRI at 1.5 and 3 T with high temporal resolution on clinical scanners.

Methods

Six volunteers were imaged while speaking, using both four real-time steady-state free-precession (SSFP) sequences at 3 T and four balanced SSFP (bSSFP) at 1.5 T. Temporal resolution was 9–20 frames s⁻¹ (fps), spatial resolution 1.6×1.6×10.0–2.7×2.7×10.0 mm³. Simultaneous audio was recorded. Signal-to-noise ratio (SNR), palate thickness and image quality score (1–4, non-diagnostic–excellent) were evaluated.

Results

SNR was higher at 3 T than 1.5 T in the relaxed palate (nasal breathing position) and reduced in the elevated palate at 3 T, but not 1.5 T. Image quality was not significantly different between field strengths or sequences (p=NS). At 3 T, 40% acquisitions scored 2 and 56% scored 3. Most 1.5 T acquisitions scored 1 (19%) or 4 (46%). Image quality was more dependent on subject or field than sequence. SNR in static images was highest with 1.9×1.9×10.0 mm³ resolution (10 fps) and measured palate thickness was similar (p=NS) to that at the highest resolution (1.6×1.6×10.0 mm³). SNR in intensity–time plots through the soft palate was highest with 2.7×2.7×10.0 mm³ resolution (20 fps).

Conclusions

At 3 T, SSFP images are of a reliable quality, but 1.5 T bSSFP images are often better. For geometric measurements, temporal should be traded for spatial resolution (1.9×1.9×10.0 mm³, 10 fps). For assessment of motion, temporal should be prioritised over spatial resolution (2.7×2.7×10.0 mm³, 20 fps).

Advances in knowledge

Diagnostic quality real-time soft palate MRI is possible using clinical scanners and optimised protocols have been developed. 3 T SSFP imaging is reliable, but 1.5 T bSSFP often produces better images.Approximately 450 babies born in the UK every year have an orofacial cleft [1], the majority of which include the palate [2]. While a cleft palate is commonly repaired surgically at around 6 months [3], residual velopharyngeal insufficiencies require follow-up surgery in 15–50% of cases [4]. This residual defect results in an incomplete closure of the velopharyngeal port, which in turns leads to hypernasal speech. Assessment of velopharyngeal closure in speech therapy is commonly performed using X-ray videofluoroscopy or nasendoscopy [5,6]. While nasendoscopy is only minimally invasive, it may be uncomfortable and provides only an en face view of the velopharyngeal port. In contrast, X-ray videofluoroscopy is non-invasive and produces an image which is a projection of the target anatomy. Additional information may be obtained from projections at multiple angles [5,7], but anatomical structures may overlie each other. Furthermore, soft tissue contrast, such as that from the soft palate, is poor, although it may be improved using a barium contrast agent coating [8] at the expense of making the procedure more invasive and unpleasant. Arguably the greatest drawback of X-ray videofluoroscopy is the associated ionising radiation dose, which carries increased risk in paediatric patients [9].An increasing number of research studies have used MRI to image the soft palate [10-13] and upper vocal tract [14-17]. In contrast to X-ray videofluoroscopy and nasendoscopy, MRI provides tomographic images in any plane with flexible tissue contrast. As a result, MRI has been used to obtain images of the musculature of the palate at rest and during sustained phonation [10,18,19]. It has also been used to image the whole vocal tract at rest or during sustained phonation [20-27] and with a single mid-sagittal image dynamically during speech [13,15-17,28-35].For assessment of velopharyngeal closure, dynamic imaging with sufficient temporal resolution and simultaneous audio recording is required. Audio recording during imaging is complicated by the loud noise of the MRI scanner, and both the safety risk and image degradation caused by using an electronic microphone within the magnet. As a result, optical fibre-based equipment with noise cancellation algorithms must be used [36].In order to fully resolve soft palate motion, Narayanan et al [30] suggested that a minimum temporal resolution of 20 frames s⁻¹ (fps) is required. A similar conclusion was reached by Bae et al [13], based on measurements of soft palate motion extracted from X-ray videofluoroscopy. Using segmented MRI, Inoue et al [35] demonstrated that changes in the velar position that were evident at acquired frame rates of 33 fps were not observed at 8 fps. However, MRI is traditionally seen as a slow imaging modality and achieving sufficient temporal resolution at an acceptable spatial resolution is challenging. Furthermore, as the soft palate is bordered on both sides by air, the associated changes in magnetic susceptibility at the interfaces make images prone to related artefacts.Dynamic MRI of the vocal tract has been performed using both segmented [17,33,37] and real-time acquisitions [13,15,16,28,31,38]. Segmented acquisitions [39] acquire only a fraction of the k-space data required for each image during one repetition of the test phrase and, hence, require multiple identical repetitions. While these segmented techniques permit high temporal and spatial resolutions [35], they require reproducible production of the same phrase up to 256 times [34], leading to subject fatigue. Differences between repeats of up to 95 ms in the onset of speech following a trigger have also been demonstrated [36].In contrast to segmented techniques, real-time dynamic methods permit imaging of natural speech, but require extremely rapid acquisition and often advanced reconstruction methods. The turbo spin echo (TSE) zoom technique [40] has been used to perform real-time MRI of the vocal tract [29,31] and is available as a clinical tool. The zoom technique excites a reduced field of view in the phase encode direction, hence allowing a smaller acquisition matrix and shorter scan for a constant spatial resolution. While such spin echo-based techniques are less susceptible to magnetic field inhomogeneity related signal dropout artefacts than other sequences, the frame rates achieved with these sequences are limited to 6 fps [31]. Gradient echo-based techniques have also been used to achieve similar temporal resolution [12,41,42] in the upper vocal tract, but are often used at much higher frame rates in other MRI applications such as cardiac imaging [43,44]. A number of gradient echo sequence variants exist. Fast low-angle shot (FLASH) type sequences [45] spoil any remaining transverse magnetisation at the end of every sequence repetition (TR). In contrast, steady-state free-precession (SSFP) sequences are not spoiled [46] and the remaining transverse magnetisation is used in the next TR to improve the signal-to-noise ratio (SNR), but renders the images sensitive to signal loss in the presence of motion. Balanced SSFP (bSSFP) sequences include additional gradients to bring the transverse magnetisation completely back into phase at the end of every TR [47,48]. The result is that bSSFP sequences have high SNR and are less sensitive to motion than SSFP sequences, but are more sensitive to field inhomogeneities, which cause bands of signal dropout.Both TSE and the gradient echo techniques discussed here sample in a rectilinear or Cartesian fashion, where one line of k-space is sampled in each echo. However, for real-time speech imaging, the highest acquired frame rates have been achieved by sampling k-space along a spiral trajectory [15,16,30,49]. While spiral imaging is an efficient way to sample k-space and is motion-resilient, it is prone to artefacts, particularly blurring caused by magnetic field inhomogeneities and off-resonance protons (i.e. fat) [50]. Recently, one group successfully used spiral imaging with multiple saturation bands and an alternating echo time (TE) to achieve an acquired real-time frame rate of 22 fps [13,16]. The saturation bands were used to allow a small field of view to be imaged without aliasing artefacts. The alternating TE was used to generate dynamic field maps which were incorporated into the reconstruction to compensate for magnetic field inhomogeneities. However, such advanced acquisition and reconstruction techniques are only available in a small number of research centres.The aim of this work is to optimise and demonstrate high-temporal-resolution real-time sequences available on routine clinical MRI scanners for assessment of soft palate motion and velopharyngeal closure. Consequently, radial and spiral acquisitions were excluded and the work focuses on Cartesian gradient echo sequences with parallel imaging techniques. As more clinical MRI departments now have 3 T scanners, imaging was performed at both 1.5 and 3 T to enable comparisons. At each field strength, we optimised sequences and implemented four combinations of spatial and temporal resolution in six subjects with simultaneous audio recordings.     

Embolisation of the right gastric artery in patients undergoing hepatic arterial infusion chemotherapy using two possible approach routes

We used a retrospective non-randomised study to investigate the clinical effect of selective embolisation of the right gastric artery before hepatic arterial infusion chemotherapy (HAIC) using a port-catheter system. We evaluated whether the hepatic artery or the left gastric artery is the better approach for selecting the right gastric artery. A total of 367 patients (244 men and 123 women; mean age, 64.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 294 of these patients, right gastric arterial embolisation with microcoils was attempted before placement of the port-catheter system to prevent gastric mucosal lesions. Approach was either through the hepatic artery (175 patients) or through the left gastric artery (119 patients), with success rates in catheterising the right gastric artery of 78.3% and 77.3%, respectively. If the attempt was unsuccessful, the catheter was redirected to the alternative approach, which increased the final success rate to 96.3%. Only seven patients experienced gastroduodenal mucosal lesions acutely after HAIC, as revealed by endoscopy. Embolisation of the right gastric artery is a feasible procedure that can reduce the incidence of gastric mucosal lesions associated with HAIC. Approach through either the hepatic artery or the left gastric artery is equally acceptable.Long-term hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system is a treatment option for patients with unresectable advanced liver cancer [1, 2]. In the past, such catheter placement was done by surgical laparotomy under general anaesthesia [3–6], an invasive procedure. However, recent advances in interventional techniques allow the implantation of port-catheter systems percutaneously under local anaesthesia [7–14].A frequent complication is reactive gastric or duodenal mucosal lesions, which result from chemical irritation caused by infusion of chemotherapeutic agents into adjacent organs through arteries originating from the common hepatic artery [15–24]. One such complication is a gastric mucosal lesion caused by inflow of chemotherapeutic agents into the right gastric artery [15–24]. To prevent this complication, the efficacy of selectively embolising the right gastric artery with coils at the time of implantation of the port-catheter system has been noted [21, 25–27].In many cases, however, the right gastric artery is slender and angulated, with anatomical variations [26, 28–31]. Hence, it is occasionally difficult to insert a catheter selectively into the right gastric artery by antegrade catheterisation via the site of the hepatic artery. This is the approach most commonly used by interventional radiologists. Failure to embolise the right gastric artery can result [26]. As an alternative method, a retrograde approach to the right gastric artery via the left gastric artery has been introduced [32, 33].Because HAIC with an implanted port-catheter system is performed in a relatively large number of cases in our institution, we have many opportunities to embolise the right gastric artery using both approaches. The aim of the present retrospective non-randomised study, which included a large number of subjects, was to evaluate the usefulness of right gastric arterial embolisation and to determine whether the antegrade or retrograde approach is more useful.     

Simplified rules for everyday delineation of lymph node areas for breast cancer radiotherapy

The aim of this study was to present the simplified rules of delineation of lymph node (LN) volumes in breast irradiation. Practical rules of delineation of LN areas were developed in the Department of Radiation Oncology of the Institut Curie. These practical guidelines of delineation were based on different specific publications in the field of breast and LN anatomy. The principal characteristic of these rules is their clearly established relationship with anatomical structure, which is easy to find on CT slices. The simplified rules of delineation have been published in pocket format as the illustrated atlas “Help of delineation for breast cancer treatment”. In this small pocket guide, delineation using the practical rules is illustrated, with examples from anatomical CT slices. It is shown that there is an improvement in delineation after the use of these simplified rules and the guide. In conclusion, this small guide is useful for improving everyday practice and decreasing the differences in target delineation for breast irradiation between institutions and observers.The value of lymph node irradiation has already been demonstrated by various studies and meta-analyses [1–3]. In the age of new conformal techniques, there is a real need for a clear definition of treated volumes, such as breast, tumour bed, lymph node areas and organs at risk (OAR) [4–10]. Many teams have been working for several years on the definition of treated volumes. Some delineation studies are exclusively theoretical and some provide a good anatomical atlas, but this information is difficult to use in everyday practice [4–15]. The treatment position has also been shown to be an important factor of variability in the depth and situation of lymph node volumes [5, 6]. Conformal and intensity-modulated radiotherapy (IMRT) require an exact definition of target volumes in terms of their anatomical limits for delineation on CT scans. Some authors have proposed anatomically based landmarks specific for breast cancer radiotherapy in order to delineate all regional lymph nodes and the breast [5, 6, 8, 10, 15, 16]. Despite this work, two recent papers have demonstrated the individual interobserver variability and differences in target and OAR delineation for breast irradiation, especially in lymph node areas [7, 8].This study was designed to propose a practical method to improve and facilitate the everyday delineation process for the clinicians of our department.     

Correlation between computerised findings and Newman's scaling on vascularity using power Doppler ultrasonography imaging and its predictive value in patients with plantar fasciitis

Objectives

The purpose of this study was to correlate findings on small vessel vascularity between computerised findings and Newman''s scaling using power Doppler ultrasonography (PDU) imaging and its predictive value in patients with plantar fasciitis.

Methods

PDU was performed on 44 patients (age range 30–66 years; mean age 48 years) with plantar fasciitis and 46 healthy subjects (age range 18–61 years; mean age 36 years). The vascularity was quantified using ultrasound images by a customised software program and graded by Newman''s grading scale. Vascular index (VI) was calculated from the software program as the ratio of the number of colour pixels to the total number of pixels within a standardised selected area of proximal plantar fascia. The 46 healthy subjects were examined on 2 occasions 7–10 days apart, and 18 of them were assessed by 2 examiners. Statistical analyses were performed using intraclass correlation coefficient and linear regression analysis.

Results

Good correlation was found between the averaged VI ratios and Newman''s qualitative scale (ρ = 0.70; p<0.001). Intratester and intertester reliability were 0.89 and 0.61, respectively. Furthermore, higher VI was correlated with less reduction in pain after physiotherapeutic intervention.

Conclusions

The computerised VI not only has a high level of concordance with the Newman grading scale but is also reliable in reflecting the vascularity of proximal plantar fascia, and can predict pain reduction after intervention. This index can be used to characterise the changes in vascularity of patients with plantar fasciitis, and it may also be helpful for evaluating treatment and monitoring the progress after intervention in future studies.Plantar fasciitis is the most common cause of heel pain, and about 2 000 000 patients in the USA receive treatment every year because of this condition [1]. Besides mechanical loading, vascular disturbance with consequent metabolic impairment and hypoxia is thought to play an important role [2]. Indeed, fibrovascular hyperplasia and vascular proliferation were observed from microscopic specimens obtained from operative resection [3-5]. Walther et al [6] were the first group to evaluate plantar fascia vascularity non-invasively using power Doppler ultrasonography (PDU).PDU is one of the colour flow imaging techniques that encodes the amplitude of the power spectral density of the Doppler signals [7]. This method has been used to assess soft-tissue vascularity and treatment efficacy with a variety of musculoskeletal and related problems. Changes in vascularity in synovial tissues in patients with rheumatoid arthritis [8-11], osteoarthritis [12,13], tendinopathy [6,14-21] and plantar fasciitis [6] have been reported. Modulation in vascularity was observed in patients with tendinopathy after a course of intervention [14-21]. Most of these studies used the Newman''s grading scale to grade the tissue vascularity [19-21]. This qualitative grading for the PDU images had high correlation with the histopathological grading of vascularity of the synovial membrane in patients with arthritis [11]. Nevertheless, Newman''s grading system may not be objective and sensitive enough to differentiate subtle vascularity changes.Recently, computerised methods were used to quantify tissue vascularity with ultrasonography. Tissue vascularity was quantified by computing a vascular index (VI), which is calculated as the ratio of the number of colour pixels to the total number of pixels within the region of interest in patients with soft-tissue problems [8,9,11,17]. Note that most of these studies were conducted using colour Doppler ultrasonography. In this connection, PDU is superior to frequency-based colour Doppler ultrasonography, especially in tissues with low blood flow, such as the plantar fascia [6,22,23]. Ying et al [24] reported the feasibility of computerised quantification of vascularity in thyroid tissues with PDU. We were interested in evaluating whether the computerised quantification of vascularity could be applied on musculoskeletal tissue, such as the plantar fascia. Therefore, the purpose of the present study was to correlate the computerised VI and Newman''s qualitative grading scale in quantifying plantar fascia vascularity using PDU, to evaluate the intra- and intertester reliability of the computerised quantitative method and its predictive ability of recovery in patients with plantar fasciitis. Proximal plantar fascia, which is the most commonly affected area in individuals with plantar fasciitis, according to clinical examination [25,26] and previous B-mode ultrasonography [26-28], was chosen as the target testing area.     

Impact of biplane versus single-plane imaging on radiation dose,contrast load and procedural time in coronary angioplasty

Coronary angioplasties can be performed with either single-plane or biplane imaging techniques. The aim of this study was to determine whether biplane imaging, in comparison to single-plane imaging, reduces radiation dose and contrast load and shortens procedural time during (i) primary and elective coronary angioplasty procedures, (ii) angioplasty to the main vascular territories and (iii) procedures performed by operators with various levels of experience. This prospective observational study included a total of 504 primary and elective single-vessel coronary angioplasty procedures utilising either biplane or single-plane imaging. Radiographic and clinical parameters were collected from clinical reports and examination protocols. Radiation dose was measured by a dose–area–product (DAP) meter intrinsic to the angiography system. Our results showed that biplane imaging delivered a significantly greater radiation dose (181.4±121.0 Gycm²) than single-plane imaging (133.6±92.8 Gycm², p<0.0001). The difference was independent of case type (primary or elective) (p = 0.862), vascular territory (p = 0.519) and operator experience (p = 0.903). No significant difference was found in contrast load between biplane (166.8±62.9 ml) and single-plane imaging (176.8±66.0 ml) (p = 0.302). This non-significant difference was independent of case type (p = 0.551), vascular territory (p = 0.308) and operator experience (p = 0.304). Procedures performed with biplane imaging were significantly longer (55.3±27.8 min) than those with single-plane (48.9±24.2 min, p = 0.010) and, similarly, were not dependent on case type (p = 0.226), vascular territory (p = 0.642) or operator experience (p = 0.094). Biplane imaging resulted in a greater radiation dose and a longer procedural time and delivered a non-significant reduction in contrast load than single-plane imaging. These findings did not support the commonly perceived advantages of using biplane imaging in single-vessel coronary interventional procedures.The use of biplane imaging during diagnostic coronary angiography and coronary interventions has been reported to reduce the total contrast load to the patient compared with single-plane imaging [1–8]. Additionally, acquiring two simultaneous images from two orthogonal planes has been reported to be more efficient than single-plane imaging [2, 8–11]. However, there are conflicting reports as to whether the radiation dose to the patient differs between biplane and single-plane imaging during coronary studies [3, 10, 11].Biplane imaging allows two cineangiography runs to be recorded simultaneously with a single injection of contrast. With single-plane imaging, however, the same information can be acquired only by carrying out the two cineangiography runs serially with two separate injections of contrast [1, 2, 8, 10]. Biplane imaging enables the operator to visualise the target lesion in orthogonal planes simultaneously and was presumed to be more efficient than single-plane imaging, particularly in difficult procedures [1, 4, 9, 12]. Accordingly, examinations would become faster, use of fluoroscopy would be reduced, fewer cineangiography runs would be required and the average radiation dose to the patient would be comparatively lower than in the case of procedures performed with single-plane imaging. The contrast load with biplane imaging was also expected to be significantly reduced [3, 4, 11].These perceived advantages of biplane imaging have led to recommendations for its use in paediatric and adult cardiac catheter laboratories [1, 4, 5, 10, 12, 13]. A previous study comparing biplane and single-plane imaging in 1156 diagnostic coronary angiography procedures found a small, but notable, reduction in contrast load accompanied by significantly longer table times and screening times with biplane imaging, although radiation dose was not examined [14].Contrast-induced nephropathy (CIN) is a complication associated with prolonged hospitalisation and development of end-stage renal failure [15]. Patients with pre-existing renal disease, diabetes, congestive heart failure or older age are at the greatest risk in developing CIN [16–18]. These high-risk patients have a calculated incidence of CIN ranging from 10% to 30% [4, 18–20]. Pre-hydration is the primary intervention for preventing contrast nephropathy [18], but is not possible in the setting of emergency (primary) angioplasty procedures. The total contrast load during interventional procedures has been established as an independent predictor of CIN and could be effectively controlled by the operator during primary angioplasty cases [18, 21, 22]. Biplane imaging is commonly employed to minimise the contrast load, especially in patients with renal impairment and those who require primary coronary angioplasty procedures [1, 6, 7, 18, 23].Numerous studies have found that the radiation dose varies significantly according to tube angulations, particularly in the combination of steep left anterior oblique (LAO) with cranial or caudal angulations [24–27]. However, there are no published data on whether the radiation dose with biplane or single-plane imaging during coronary angioplasty differs between the three vascular territories: right coronary artery (RCA), left anterior descending (LAD) and left circumflex/intermediate (LCX). Furthermore, interventional cardiac procedures are operator dependent [28–30]. Hence, it was postulated that senior cardiologists would be more familiar with biplane equipment and thereby more able to reduce radiation dose, contrast load and procedural time than less experienced operators. To our knowledge, no studies have been published that compare the impact of biplane and single-plane imaging in coronary angioplasty procedures.The aims of this study were to determine whether biplane imaging reduces both contrast load and radiation dosage and shortens procedural time in patients undergoing primary or elective coronary angioplasty compared with single-plane imaging. We also investigated if there was a significant difference in radiation dose, contrast load and procedural time between biplane and single-plane imaging during coronary angioplasty in the three main vascular territories (RCA, LAD and LCX) and in procedures performed by operators with various levels of experience.     

Pulmonary tuberculosis associated with the reversed halo sign on high-resolution CT

We describe the case of a 32-year-old woman with pulmonary tuberculosis in whom a high-resolution CT scan demonstrated the reversed halo sign. The diagnosis of tuberculosis was made by lung biopsy and the detection of acid-fast bacilli in the sputum smear and culture. Follow-up assessment revealed a significant improvement in the lesions.The reversed halo sign is observed on high-resolution CT (HRCT) as a focal round area of ground-glass attenuation surrounded by a crescent or ring of consolidation [1, 2]. It was first described as being relatively specific for cryptogenic organising pneumonia [1], but was later observed in several other infectious [3–5] and non-infectious [6, 7] diseases.We report a case of a 32-year-old patient with tuberculosis who exhibited the reversed halo sign on chest CT. To our knowledge, this sign has not been previously described in an adult with pulmonary tuberculosis.     

Iron overload: accuracy of in-phase and out-of-phase MRI as a quick method to evaluate liver iron load in haematological malignancies and chronic liver disease

Objectives

The purpose of this prospective study was to evaluate the accuracy of in-phase and out-of-phase imaging to assess hepatic iron concentration in patients with haematological malignancies and chronic liver disease.

Methods

MRI-based hepatic iron concentration (M-HIC, μmol g^–1) was used as a reference standard. 42 patients suspected of having iron overload and 12 control subjects underwent 1.5 T in- and out-of-phase and M-HIC liver imaging. Two methods, semi-quantitative visual grading made by two independent readers and quantitative relative signal intensity (rSI) grading from the signal intensity differences of in-phase and out-of-phase images, were used. Statistical analyses were performed using the Spearman and Kruskal–Wallis tests, receiver operator curves and κ coefficients.

Results

The correlations between M-HIC and visual gradings of Reader 1 (r=0.9534, p<0.0001) and Reader 2 (r=0.9456, p<0.0001) were higher than the correlations of the rSI method (r=0.7719, p<0.0001). There was excellent agreement between the readers (weighted κ=0.9619). Both visual grading and rSI were similar in detecting liver iron overload: rSI had 84.85% sensitivity and 100% specificity; visual grading had 85% sensitivity and 100% specificity. The differences between the grades of visual grading were significant (p<0.0001) and the method was able to distinguish different degrees of iron overload at the threshold of 151 μmol g^–1 with 100% positive predictive value and negative predictive value.

Conclusion

Detection and grading of liver iron can be performed reliably with in-phase and out-of-phase imaging. Liver fat is a potential pitfall, which limits the use of rSI.Iron overload is a clinically recognised condition with variety of aetiologies and clinical manifestations [1-4]. Liver iron concentration correlates closely with the total body iron stores [5]. The excess iron accumulates mainly in the liver and the progressive accumulation of toxic iron can lead to organ failure if untreated [2,4]. Several diseases causing iron overload, such as transfusion-dependent anaemia, haematological malignancies, thalassaemia, haemochromatosis and chronic liver disease, result in a large number of patients with a potentially treatable iron overload [1,2,4].Several quantitative MRI methods for iron overload measurement by multiple sequences have been established, such as proportional signal intensity (SI) methods and proton transverse relaxation rates (R₂, R₂*) [4,6,7]. A gradient echo liver-to-muscle SI-based algorithm [8] has been widely validated and used for quantitative liver iron measurement [8-11]. MRI-based hepatic iron concentration (M-HIC, μmol g^–1 liver dry weight) with corresponding R₂* [9] can be calculated with this method which is a directly proportional linear iron indicator, virtually independent of the fat fraction, as the echo times are taken in-phase [8,9]. This method showed a high accuracy in calibrations with the biochemical analysis of liver biopsies (3–375 μmol g^–1) of 174 patients. The mean difference of 0.8 μmol g^–1 (95% confidence interval of –6.3 to 7.9) between this method and the biochemical analysis is quite similar [8] to the intra-individual variability found in histological samples [12].The quantitative MRI methods are based on progressive SI decay, with the longer echo times due to relaxing properties of iron. Interestingly, this iron-induced effect is seen in MR images with multiple echoes [4,6-11], but also in dual-echo images, namely in-phase and out-of-phase imaging [13,14]. In-phase and out-of-phase imaging has become a routine part of liver MRI, performed initially for liver fat detection [6,13,15]. Quite recently some investigators have noticed an alternative approach of the sequence to detect liver iron overload due to the more pronounced SI decrease on in-phase images with the longer echo time [13,14]. Yet, to our knowledge, this is the first prospective study evaluating the accuracy of in-phase and out-of-phase imaging to assess hepatic iron concentration.The purpose of the study was to evaluate the capability and accuracy of dual-echo in-phase and out-of-phase imaging to assess hepatic iron concentration at 1.5 T in patients with haematological malignancies and chronic liver disease. MRI-based hepatic iron concentration (M-HIC, μmol g^–1) was used as a reference standard [8,9].     

MRI features of serous oligocystic adenoma of the pancreas: differentiation from mucinous cystic neoplasm of the pancreas

Objectives

The purpose of this study was to describe the MRI features of the benign pancreatic neoplasm serous oligocystic adenoma (SOA) that differ from those of mucinous cystic neoplasm (MCN), a neoplasm with the potential for malignant degeneration.

Methods

Seven patients with SOA (seven women; mean age 36.6 years) and eight patients with MCN (eight women: mean age 39.9 years) were included. Several imaging features were reviewed: mass size, location, shape, wall thickness, cyst configuration (Type I, unilocular; Type II, multiple clustered cyst; Type III, cyst with internal septation) and signal intensity of the lesion with heterogeneity.

Results

SOA lesions were smaller (3.4 cm) than those of MCN (9.3 cm) (p=0.023). The commonest lesion shape was lobulated (85.7%) for SOA, but oval (50.0%) or lobulated (37.5%) for MCN (p=0.015). The most common cyst configuration was Type II (85.7%) for SOA and Type III (75.0%) for MCN (p=0.008). Heterogeneity of each locule in T₁ weighted images was visible in all cases of MCN, but in no case for SOA (p=0.004).

Conclusion

SOA could be differentiated from MCN by identifying the imaging features of lobulated contour with multiple clustered cyst configurations and homogeneity of each locule in T₁ weighted MR images.Serous oligocystic adenoma (SOA) is a recently described rare, benign pancreatic neoplasm and a morphological variant of serous microcystic adenoma, because it contains six or fewer cysts and the cysts are large (>2 cm) [1,2]. Pathologically, SOA is a benign pancreatic neoplasm composed of a few relatively large cysts uniformly lined with glycogen-rich cuboidal epithelial cells [3]. According to the World Health Organization classification, SOA is a subgroup of pancreatic serous cystic tumours and the term SOA is a synonym for macrocystic serous cystadenoma [3,4].The CT and MRI features of SOA of the pancreas are documented [2]. On CT and MRI, SOA typically appears as a small unilocular or bilocular cyst (<5 cm) with a thin wall (<2 mm) that lacks mural nodules or calcifications [2]. Because the cystic spaces are >2 cm, SOA images can be mistaken for mucinous cystic neoplasm (MCN), pseudocyst or intraductal papillary mucinous tumour [2,5-7]. It is very difficult to differentiate SOA from MCN by clinical and radiological features [2,6,8,9]. SOA does not require resection unless it causes symptoms, but MCN should be resected because of a potential for malignant degeneration [5,7,8]. Endoscopic ultrasound and cyst fluid aspiration have a role in distinguishing mucinous and serous lesions, but it is an invasive procedure with a risk of complications such as pancreatitis [10]. Therefore, it is clinically valuable to determine characteristic imaging findings that can distinguish SOA from MCN.Recently, Kim et al [6] and Cohen-Scali et al [5] described characteristic CT findings that can be used to differentiate SOA from MCN. MRI can demonstrate septa within a lesion with greater sensitivity than CT; therefore, MRI provides a better evaluation of tissue characteristics than CT [1,11]. However, few studies have described the MRI features of SOA [1,2]. The purpose of this study was to describe the differences in the MRI features of SOA and MCN in the pancreas.     

The challenge of segmental small bowel motility quantitation using MR enterography

Objective:

Analysis of “cine” MRI using segmental regions of interest (ROIs) has become increasingly popular for investigating bowel motility; however, variation in motility in healthy subjects both within and between scans remains poorly described.

Methods:

20 healthy individuals (mean age, 28 years; 14, males) underwent MR enterography to acquire dynamic motility scans in both breath hold (BH) and free breathing (FB) on 2 occasions. Motility data were quantitatively assessed by placing four ROIs per subject in different small bowel segments and applying two measures: (1) contractions per minute (CPM) and (2) Jacobian standard deviation (SD) motility score. Within-scan (between segment) variation was assessed using intraclass correlation (ICC), and repeatability was assessed using Bland–Altman limits of agreement (BA LoA).

Results:

Within-scan segmental variation: BH CPM and Jacobian SD metrics between the four segments demonstrated ICC R = 0.06, p = 0.100 and R = 0.20, p = 0.027 and in FB, the CPM and Jacobian SD metrics demonstrated ICC R = −0.26, p = 0.050 and R = 0.19, p = 0.030. Repeatability: BH CPM for matched segments ranged between 0 and 14 contractions with BA LoA of ±8.36 and Jacobian SD ranged between 0.09 and 0.51 with LoA of ±0.33. In FB data, CPM ranged between 0 and 10 contractions with BA LoA of ±7.25 and Jacobian SD ranged between 0.16 and 0.63 with LoA = ±0.28.

Conclusion:

The MRI-quantified small bowel motility in normal subjects demonstrates wide intersegmental variation and relatively poor repeatability over time.

Advances in knowledge:

This article presents baseline values for healthy individuals of within- and between-scan motility that are essential for understanding how this process changes in disease.Dynamic “cine” MRI acquired during MR enterography is increasingly utilized to assess bowel motility in a range of conditions, notably inflammatory bowel disease and enteric dysmotility syndromes.^1–4 Analysis of the data remains primarily subjective in clinical routine, but the ability to apply quantitative techniques makes this a potentially powerful methodology to explore gastrointestinal physiology in disease as well as an emerging application as a biomarker for drug efficacy.^5–7Despite the growing literature, a consensus has yet to be reached as to the best method of quantitatively analysing small bowel data and indeed a range of motility metrics are proposed.^2,3,8–12 The most commonly used metric is the change in luminal diameter at a fixed anatomical position through the time series. By tracking bowel diameter, a characteristic curve can be produced with the number of contractions expressed per minute (CPM) to give an intuitive and broadly accepted metric for small bowel motility (SBM).^{2–4,9,11,13–15} To date, several studies have reported a relationship between CPM and dysmotility in disease, either compared with a histopathological standard or “normal” reference bowel loops.^2–4,12 An array of additional metrics derived both from bowel diameter measures and more abstract processing techniques have further been implemented with varying degrees of effectiveness in disease and health.^{2,4,5,8,10,14,16}Although intuitively attractive, the robustness of assessing overall enteric motility using only an isolated loop of bowel has received relatively little attention to date irrespective of the precise metric applied. It is unclear how representative the selected bowel loops are of overall SBM and if normal motility intrinsically differs between bowel segments, for example, between the jejunum and ileum. Furthermore, the repeatability of single loop metrics, even in normal individuals, is not well described, knowledge of which is vital if segmental analysis is to be used to diagnose, guide treatment and monitor enteric pathology.The purpose of this study is to explore segmental variation in SBM in healthy volunteers measured using two commonly reported small bowel metrics [CPM and Jacobian standard deviation (SD)] looking at (1) within-scan motility variation between different segments and (2) between-scan variation (repeatability) across two time points.     

Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy

Objectives

The purpose of this study was to determine the relative accuracies of mammography, sonography, MRI and clinical examination in predicting residual tumour size and pathological response after neoadjuvant chemotherapy for locally advanced or inflammatory breast cancer. Each prediction method was compared with the gold standard of surgical pathology.

Methods

43 patients (age range, 25–62 years; mean age, 42.7 years) with locally advanced or inflammatory breast cancer who had been treated by neoadjuvant chemotherapy were enrolled prospectively. We compared the predicted residual tumour size and the predicted response on imaging and clinical examination with residual tumour size and response on pathology. Statistical analysis was performed using weighted kappa statistics and intraclass correlation coefficients (ICC).

Results

The ICC values between predicted tumour size and pathologically determined tumour size were 0.65 for clinical examination, 0.69 for mammography, 0.78 for sonography and 0.97 for MRI. Agreement between the response predictions at mid-treatment and the responses measured by pathology had kappa values of 0.28 for clinical examination, 0.32 for mammography, 0.46 for sonography and 0.68 for MRI. Agreement between the final response predictions and the responses measured by pathology had kappa values of 0.43 for clinical examination, 0.44 for mammography, 0.50 for sonography and 0.82 for MRI.

Conclusion

Predictions of response and residual tumour size made on MRI were better correlated with the assessments of response and residual tumour size made upon pathology than were predictions made on the basis of clinical examination, mammography or sonography. Thus, the evaluation of predicted response using MRI could provide a relatively sensitive early assessment of chemotherapy efficacy.The advantages of neoadjuvant chemotherapy are multiple and it has been used widely during the past few years [1]. Its primary role is to induce tumour shrinkage and permit breast-conserving surgery, primarily in patients with advanced breast cancer [2-4]. Neoadjuvant chemotherapy allows earlier treatment of micrometastatic disease and the study of biological markers that might predict tumour response [5]. The effectiveness of chemotherapeutic agents in treating both primary breast cancer and potential metastatic disease may be enhanced by the presence of tumour neovascularity. If chemotherapy is given before surgery, while tumour vascularity remains intact, the chemotherapeutic agents may be better able to reach the tumour and thus be more effective.Neoadjuvant chemotherapy of locally advanced breast cancer (LABC) has also been shown to improve the resectability rate, offering disease-free and overall survival rates that are at least equivalent to those offered by surgery alone [6,7]. Pathological complete response (pCR) is clinically significant because it is associated with improved long-term prognosis and decreased risk of recurrence [6,8]. Decisions regarding the continuation of current regimens and the appropriate type and timing of surgery depend on the radiological and clinical assessment of residual tumour size during neoadjuvant chemotherapy [9,10]. Until now, many studies have shown that physical examinations, mammography and sonography provide suboptimal evaluations of lesion extent that do not allow accurate assessments of pathological response or residual tumour size [5^,11-13]. In the case of LABC, physical examination, mammography or sonography may be suitable for detecting the larger lesions of non-responders, but they have limited sensitivity for responders with smaller residual lesions [14,15]. For mammography, calcifications may persist or even increase in patients who respond to neoadjuvant chemotherapy [14,16,17].Many previous studies have shown that MRI is the most reliable technique for evaluating residual disease after neoadjuvant chemotherapy, although initial reports described frequent false-negatives with smaller-volume disease [18-27]. Recent studies have increased the sensitivity of MRI, with increased resolution, reduced slice thickness and lower enhancement thresholds being used to minimise the underestimation of residual disease [15^,22-27]. It is still difficult, however, to distinguish residual scarring, necrosis and fibrosis from viable residual malignancy and to predict accurate response after neoadjuvant chemotherapy, especially in responders. Few published studies have described work with patients with inflammatory breast cancer who underwent neoadjuvant chemotherapy because the incidence of this disease is very low [28,29]. The purpose of our study was to determine the relative accuracies of mammography, sonography, MRI and clinical examination in predicting residual tumour size and pathological response after neoadjuvant chemotherapy for locally advanced and inflammatory breast cancer. We compared each prediction method with the gold standard of surgical pathology.     

In vitro assessment of the antibiotic efficacy of contrast media and antibiotics and their combinations at various dilutions

Discography is a controversial diagnostic procedure involving the injection of radiographic contrast medium (RCM) into the intervertebral disc. Iatrogenic bacterial discitis is a rare but serious complication. The intervention has been increasingly performed in our patients here in the United Arab Emirates. Prophylactic intravenous antibiotic administration can reduce post-interventional discitis; however, this may favour the development of bacterial resistance. Direct intradiscal injection of an antibiotic together with the RCM is a potential alternative. To date, there has been only one study on the efficacy of antibiotics added to an RCM. Equally, there are only limited data regarding the potential direct effect of RCM on bacterial growth. The purpose of this study was to determine whether the efficacy of antibiotics is affected when RCM are added. In an in vitro study, the effect of non-ionic RCM on the growth of five laboratory bacterial strains, alone and in combination with three broad-spectrum antimicrobials, was tested. Bacterial growth was assessed in the absence and the presence of RCM, antibiotics and their combinations. All three RCM alone demonstrated some inhibition of bacterial growth at high concentrations. In the presence of the RCM, all three antibiotics retained their inhibitory effect on bacterial growth. In conclusion, our in vitro experiments did not reveal any changes in the antimicrobial efficacy of the three antibiotics in the presence of the three tested RCM. Subsequent clinical trials will need to assess whether intradiscal antibiotic administration may be a suitable substitute for, or a supplement to, prophylactic systemic antibiotics before discography.Lindblom [1] was the first author to describe discography, which is performed to outline the morphology of the intervertebral disc. Radiographic contrast media (RCM) are injected into the nucleus pulposus of a disc [1–3]. Owing to the further development in cross-sectional imaging procedures, especially in MRI, indications for discography or CT discography have been substantially changed. At present, provocative discography is increasingly being carried out, especially in the USA and Australia, for disc stimulation in order to provoke or to reproduce discogenic pain [4–7]; special indications are lower back pain with equivocal findings on MRI, post-surgical failed lower back pain, status prior to spinal fusion or the injection of cortisone or anaesthetics into an intervertebral disc [3–5, 7–15]. The most serious complication is post-interventional bacterial discitis owing to the invasiveness of the procedure [2, 4, 5, 16]; as such, many publications deal with prophylactic intravenous (iv) administration of antibiotics. Several animal experiments in sheep, lambs and rabbits, conducted in the 1980s, 1990s and in 2006, demonstrated antibiotics in the intervertebral discs after systemic iv injection (with higher concentrations in the annulus fibrosus than in the nucleus pulposus) [17–23]. However, it was emphasised that the timing of the systemic antibiotic prophylaxis was critical [17, 21, 23]. Conversely, post-interventional systemic administration of antibiotics was not considered beneficial [21, 22]. A study in humans before lumbar spinal fusion showed that cefazolin was detectable in disc samples of these patients after iv antibiotic prophylaxis, with a peak concentration between 37 min and 53 min after iv injection [19].In 1990, Osti et al [23] conducted animal experiments and, subsequently, a clinical study in 127 patients, examining 337 discs, in whom an antibiotic was added to the intradiscally administered RCM, in addition to earlier iv prophylaxis [23]. Post-interventional discitis was not detected in either the animals or the patients.To date, different recommendations for the prevention of post-interventional discitis are in place, incorporating either systemic intravenous injection of antibiotics [16], a combination of iv and intradiscally injected antibiotics [24], or even no antibiotics at all [25]. In order to avoid increasing bacterial resistance to systemically administered antibiotics [14, 26], intradiscally injected antibiotics might be an alternative owing to the direct application of the antibiotic into the disc. One study on the efficacy of antibiotics in combination with iohexol has already been conducted by Klessig et al [26].Discography is a constantly increasing intervention in the United Arab Emirates (UAE) and, as hospital-borne infections are also a major problem in this country, the aim of our study was to investigate the effect of three different non-ionic RCM (including one new dimeric compound that is still in clinical trials), alone and in combination with three broad-spectrum antibiotics, on different laboratory bacterial strains to detect any potential effect of the RCM on antibiotic efficacy.     

Characterisation of breast papillary neoplasm on automated breast ultrasound

Intraductal papillary neoplasms of the breast form a wide spectrum of pathological changes with benign intraductal papilloma and papillary carcinoma. They can occur anywhere within the breast ductal system. This review illustrates some characteristic appearances of breast papillary neoplasms on coronal planes reconstructed by automatic breast volume scan. Such manifestations are not uncommon in papillary neoplasms, and familiarity will enable confident diagnosis.Papillary lesions of the breast are a heterogeneous group of breast lesions, including intraductal papilloma, atypical papilloma and intraductal papillary carcinoma [1,2]. Although the management of intraductal papillomas is varied, surgical excision is generally recommended as a precaution against the risk of a subsequent carcinoma [3,4]. Recently, some studies have suggested that patients with a tumour measuring <1.5 cm and an ultrasound Breast Imaging—Reporting and Data System (BI-RADS) category of 3 or 4a can be potentially selected for vacuum-assisted biopsy, but only if the tumour does not extend into the branching ducts [5,6]. Ueng et al [2] recommended that localised papillary lesions should be excised completely with a small rim of uninvolved breast tissue without any prior needle instrumentation if and when the papillary nature can be determined by imaging. Therefore, a careful imaging evaluation is necessary because it could help to identify the papillary neoplasm nature and select the high-risk lesions for proper treatment.Ultrasound has a greater sensitivity for detecting all papillary lesions than mammography [7]. Recently, automated breast ultrasound scanners have been developed, and the ultrasound volume data set of the whole breast can be acquired in a standard manner [8]. They have already shown potential for characterisation of breast tumours [9,10]. However, these studies did not detail the ultrasound features of intraductal papillary neoplasms on automated breast ultrasound. The reconstructed coronal views are also expected to provide more information and thus help to differentiate these lesions from other focal breast abnormalities.     

Assessment of myocardial infarction by CT angiography and cardiovascular MRI in patients with cocaine-associated chest pain: a pilot study

Objectives

Cocaine is a commonly used illicit drug that leads to the most emergency department (ED) visits. Chest pain is the most common presentation, reported in 40% of patients. Our aim was to evaluate the incidence of previous myocardial infarction among young cocaine users (18–40 years) with cocaine-associated chest pain by the assessment of myocardial fibrosis by cardiovascular MRI. Second, we also intended to evaluate the coronary tree by CT angiography (CTA).

Methods

24 cocaine users (22 males) who frequently complained about cocaine-associated chest pain underwent CTA and cardiovascular MRI. Mean age of patients was 29.7 years and most of them (79%) had frequently used inhalatory cocaine.

Results

The calcium score turned out to be positive in only one patient (Agatston=54). Among the coronary segments evaluated, only one patient had calcified plaques at the anterior descending coronary artery (proximal and medium segments). Assessment of regional ventricular function by the evaluation of 17 segments was normal in all patients. None of the patients showed myocardial delayed enhancement, indicative of myocardial fibrosis. CTA therefore confirmed the low cardiovascular risk of these patients, since most of them (96%) had no atherosclerosis detected by this examination. Only one patient (4%) had coronary atherosclerosis detected, without significant coronary stenosis.

Conclusion

Cardiovascular MR did not detect the presence of delayed enhancement indicative of myocardial fibrosis among young cocaine users with low cardiovascular risk who had complained of cocaine-associated chest pain.Cocaine is a commonly used illicit drug, used worldwide by more than 15 million people in 2009 [1], and the drug that leads to the most emergency department (ED) visits [2]. Chest pain is the most common presentation, reported in 40% of patients [3,4]. Cocaine-related cardiovascular complications include acute myocardial infarction (MI), arrythmias, sudden death, myocarditis, cardiomyopathy, hypertensive crises, aortic dissection and endocarditis [5,6]. The majority of patients with cocaine-associated MI events appear to be young, non-white smokers with a history of drug use in the preceding 24 h [6,7]. These characteristics are similar in patients with cocaine-associated chest pain [8], making it difficult to predict those at risk for MI, given the relatively low incidence of cocaine-associated MI [8-11].In recent years, MRI and CT angiography (CTA) have emerged as powerful non-invasive tools for myocardial assessment and evaluation of the coronary tree [12-14], which might be very important in this special scenario. The aim of this study was to evaluate the incidence of previous MI among young cocaine users with a history of chest pain through the diagnosis of myocardial fibrosis (MF) by MRI. A secondary aim was the assessment of the coronary tree by CTA.     

Miliary tuberculosis: a comparison of CT findings in HIV-seropositive and HIV-seronegative patients

The aim of this study was to determine the differences in CT findings of miliary tuberculosis in patients with and without HIV infection. Two radiologists reviewed retrospectively the CT findings of 15 HIV-seropositive and 14 HIV-seronegative patients with miliary tuberculosis. The decisions on the findings were reached by consensus. Statistical analysis was performed using the χ² test, Mann–Whitney U-test and Fisher''s exact test. All of the HIV-seropositive and -seronegative patients had small nodules and micronodules distributed randomly throughout both lungs. HIV-seropositive patients had a higher prevalence of interlobular septal thickening (p = 0.017), necrotic lymph nodes (p = 0.005) and extrathoracic involvement (p = 0.040). The seropositive patients had a lower prevalence of large nodules (p = 0.031). In conclusion, recognition of the differences in the radiological findings between HIV-seropositive and -seronegative patients may help in the establishment of an earlier diagnosis of immune status in patients with miliary tuberculosis.Miliary tuberculosis (TB), which results from lympho-haematogenous dissemination of Mycobacterium tuberculosis, is a complication of both primary and post-primary TB [1, 2]. This disease results in the formation of small discrete foci of granulomatous tissue, which are uniformly distributed throughout the lung [3].An increase in TB incidence, including miliary TB, has been associated with infection by human immunodeficiency virus (HIV) [4]. In 2005, the World Health Organization estimated that 12% of HIV deaths globally were caused by TB, and that there were 630 000 new co-infections with TB and HIV [5]. Disseminated TB accounted for 5.4–8.1% of culture-confirmed TB cases, with 10–14% of patients coinfected with HIV having clinically recognisable dissemination [6, 7].Chest radiography may be helpful in the detection and final diagnosis of miliary TB. The characteristic radiographical findings consist of the presence of fine granular or numerous small nodular opacities measuring 1–3 mm in diameter scattered throughout both lungs [1, 3, 8, 9]. However, the radiograph may appear to be normal in the early stage of disease or in cases with nodules below the threshold of perceptibility; therefore, a diagnosis of miliary TB from chest radiographs can be difficult [10].Several studies have shown that CT imaging is more sensitive for the detection of parenchymal abnormalities in patients with AIDS who have active intrathoracic disease, and it has been suggested that CT may also be helpful in the differential diagnosis [11–14]. In addition, it has been reported that certain imaging techniques provided by multidetector-row CT are useful for the diagnosis of multiple micronodular infiltrative lung disease [15]. CT findings of miliary TB have been described in previous reports [16–18]; however, only a few studies on miliary TB in patients with HIV, particularly with reference to the CD4 count, have been reported [19, 20]. The radiographic manifestations of HIV-associated pulmonary TB are thought to be dependent upon the level of immunosuppression at the time of overt disease [21–23].The purpose of this study was to determine the differences in the CT findings of miliary TB for patients with and without HIV infection and to analyse any correlation between the CT features and the level of immunosuppression in patients.