Hallazgos iniciales en la radiografía de tórax como predictores de empeoramiento en la infección pulmonar por SARS-CoV-2. Correlación en 265 pacientes

Background and aimsWe aimed to analyze the relationship between the initial chest X-ray findings in patients with severe acute respiratory syndrome due to infection with SARS-CoV-2 and eventual clinical worsening and to compare three systems of quantifying these findings.Material and methodsThis retrospective study reviewed the clinical and radiological evolution of 265 adult patients with COVID-19 attended at our center between March 2020 and April 2020. We recorded data related to patients’ comorbidities, hospital stay, and clinical worsening (admission to the ICU, intubation, and death). We used three scoring systems taking into consideration 6 or 8 lung fields (designated 6 A, 6 B, and 8) to quantify lung involvement in each patient's initial abnormal chest X-ray and to classify its severity as mild, moderate, or severe, and we compared these three systems. We also recorded the presence of alveolar opacities and linear opacities (fundamentally linear atelectasis) in the first chest X-ray with pathologic findings.ResultsIn the χ2 analysis, moderate or severe involvement in the three classification systems correlated with hospital admission (p = 0.009 in 6 A, p = 0.001 in 6 B, and p = 0.001 in 8) and with death (p = 0.02 in 6 A, p = 0.01 in 6 B, and p = 0.006 in 8). In the regression analysis, the most significant associations were 6 B with alveolar involvement (OR 2.3; 95%CI 1.1.–4.7; p = 0.025;) and 8 with alveolar involvement (OR 2.07; 95% CI 1.01.–4.25; p = 0.046). No differences were observed in the ability of the three systems to predict clinical worsening by classifications of involvement in chest X-rays as moderate or severe.ConclusionModerate/severe extension in the three chest X-ray scoring systems evaluating the extent of involvement over 6 or 8 lung fields and the finding of alveolar opacities in the first abnormal X-ray correlated with mortality and the rate of hospitalization in the patients studied. No significant difference was found in the predictive ability of the three classification systems proposed.     

Hallazgos en la tomografía computarizada de tórax en las fases evolutivas de la infección por SARS-CoV-2

ObjectiveTo compare the findings on chest computed tomography (CT) in patients with COVID-19 during different phases of the disease and to evaluate the reproducibility of a visual radiologic score for estimating the extent of lung involvement.MethodsWe retrospectively reviewed chest CT studies from 182 patients with RT-PCR findings positive for SARS-CoV-2. Patients were classified according to the time elapsed from the onset of symptoms, as follows: early (0-4 days), intermediate/progressive (5-9 days), or advanced (≥10 days). We analyzed the frequency of each radiologic finding, as well as the pattern, appearance, and predominant distribution of lung involvement. A visual tomographic score (range, 0-25) was used to estimate the extent of involvement in each lobe and in the total lung volume.ResultsThe predominant CT finding was the ground-glass pattern (n=110; 60.4%), the most common distribution was peripheral (n = 116; 66.7%), and the most prevalent appearance was typical (n=112; 61.5%). The halo sign was seen most frequently in the early phase (25%), whereas ground-glass opacities were more common in the intermediate/progressive and advanced phases. The median severity score was 10 (IQR: 5-13), and the scores increased as the disease progressed. The interobserver agreement (kappa) was 0.92 for the appearance, 0.84 for the distribution, 0.70 for the predominant pattern, and 0.89 for the visual score.ConclusionThe CT findings in patients with COVID-19 vary with the course of the infection. The proposed visual radiologic score is a simple, reproducible, and reliable tool for assessing lung involvement in COVID-19 pneumonia.     

Linfangiohemangiomas múltiples con afectación torácica y abdominal. Presentación de un caso

We present a case of multiple lymphangiohemangiomas (hematolymphangiomas, hemangiolymphangiomas, or combined lymphatic venous malformation) with thoracic and abdominal involvement in an asymptomatic patient. We describe and illustrate the imaging findings in this disease, which are quite characteristic and can enable an accurate diagnosis. To our knowledge, there are no other reports of similar cases in the scientific literature.     

Aplicaciones de la técnica de difusión por resonancia magnética en el manejo de la patología tumoral osteomuscular

Magnetic resonance imaging (MRI) is the technique of choice in the diagnosis, staging, and follow-up of musculoskeletal tumors. Diffusion imaging is a new functional MRI technique that provides information that is complementary to that obtained in conventional MRI sequences. Diffusion imaging has proven useful in different clinical situations like the characterization of disease involving the bone marrow (bone metastases, benign fractures, or hematological disease), the evaluation of tumors of the bones and soft tissues, and the monitoring of the response to treatment in patients with tumors. The aim of this article is to review the diffusion technique in MRI and its current clinical applications in the management of musculoskeletal tumors.     

Comparación de la calidad de imagen y dosis de radiación en angio-tomografía computarizada de arterias periféricas con 80 y 100 kV

ObjectiveTo compare the image quality and dose of radiation in two groups of patients undergoing CT angiography of the lower limbs, one with tube voltage of 80 kV and the other with tube voltage of 100 kV.Material and methodsWe performed CT angiography of the lower limbs in 60 patients with suspected peripheral arterial disease. Patients were randomly assigned to one of two groups; in one group, CT angiography was performed using a tube voltage of 80 kV, whereas in the other it was performed using 100 kV. The remaining acquisition parameters were the same in both groups. The images were analyzed by quantifying vascular density (VD) and noise (N) and by calculating the quotients density/noise (QVDN) and contrast/noise (QCN). Two radiologists working independently evaluated the subjective quality of the images. We calculated the estimated effective dose (EED) based on the dose-length product (DLP).ResultsIn the group studied at 80 kV, VD was significantly higher (462.5 UH ± 95.6 vs. 372 UH ± 100.9; P <. 001), QVDN was significantly higher (241.9 ± 48.1 vs. 194.3 ± 49.6; P < .001), and there were trends toward higher N (21.3 UH ± 13 vs. 16.3 UH ± 3.5; P = .098) and toward higher QCN (21.4 ± 12.1 vs. 22.9 ± 9.1; P = .15). No significant differences were found in the subjective quality of the images. The EED was significantly lower in the group studied at 80 kV (4.73 mSv ± 1.1 vs. 9.6 mSv ± 2.2; P <. 001).ConclusionUsing 80 kV instead of 100 kV for CT angiography of the lower limbs reduces the dose of radiation without affecting the diagnostic efficacy of the study.     

Comparación de las técnicas de inyección ecográfica y radioscópica en artro-TC y artro-RM de cadera

ObjectiveTo evaluate the usefulness of ultrasound-guided versus fluoroscopy-guided injection in CT arthrography and MR arthrography.Material and methodsWe reviewed all CT arthrography and MR arthrography studies done at our center between October 1, 2014 and October 1, 2015. We analyzed 32 studies: 26 with fluoroscopic guidance and 6 with ultrasound guidance. We compared the two techniques on the following parameters: presence of sufficient contrast material in the joint, extravasation or injection of contrast material in the soft tissues (presence of contrast material in the psoas or other soft tissues), and intra-articular gas bubbles. We used SPSS V. 20 to compare the techniques with Pearson's chi-square tests.ResultsContrast material was observed in soft tissues in 56.3% of ultrasound-guided injections, making 6.3% of the procedures invalid for diagnostic purposes. Extravasation of contrast material was observed in 53.8% of fluoroscopy-guided procedures, making 3.8% invalid for diagnostic purposes. Intra-articular gas was observed in 21.9% of ultrasound-guided studies and in 38.5% of fluoroscopy-guided studies. None of the differences between techniques were statistically significant at p < 0.05.ConclusionsOur study shows that ultrasound is as useful as fluoroscopy for injecting contrast material for CT arthroscopy and MR arthroscopy; ultrasound has the advantage of not using ionizing radiation.     

Localización de nódulos pulmonares con arpón guiado con TC para resección atípica por toracoscopia en pacientes pediátricos: aspectos prácticos

In the multidisciplinary treatment of pediatric oncologic patients, multiple imaging tests, biopsies, and resections are required for diagnosis, initial staging, and posterior restaging. In these patients, pulmonary nodules are not always metastases, so the correct diagnosis of these lesions affects their treatment and the patient's survival. Percutaneous localization of pulmonary nodules is key for two reasons: it enables the surgeon to resect the smallest amount of lung tissue possible and it guarantees that the nodule will be included in the resected specimen. Without percutaneous localization, it can be impossible to accomplish these two objectives in patients with very small nodules that are separated from the pleural surface and therefore impossible to see by thoracoscopy. This article reviews the technique for hook-wire localization of pulmonary nodules and the keys to ensuring the best results.     

Hallazgos tomográficos entre sobrevivientes y no-sobrevivientes con COVID-19 y utilidad clínica de una puntuación de tomografía torácica

BackgroundMany patients with coronavirus disease 2019 (COVID-19) have been diagnosed with computed tomography (CT). A prognostic tool based on CT findings could be useful for predicting death from COVID-19.ObjectivesTo compare the chest CT findings of patients who survived COVID-19 versus those of patients who died of COVID-19 and to determine the usefulness the clinical usefulness of a CT scoring system for COVID-19.MethodsWe included 124 patients with confirmed SARS-CoV-2 infections who were hospitalized between April 1, 2020 and July 25, 2020.ResultsWhereas ground-glass opacities were the most common characteristic finding in survivors (75%), crazy paving was the most characteristic finding in non-survivors (65%). Atypical findings were present in 46% of patients. The chest CT score was directly proportional to mortality; a score ≥ 18 was the best cutoff for predicting death, yielding 70% sensitivity (95%CI: 47%-87%).ConclusionsOur results suggest that atypical lesions are more prevalent in this cohort. The chest CT score had high sensitivity for predicting hospital mortality     

Imagen por resonancia magnética en la estadificación y planificación del tratamiento del cáncer de cérvix

ObjectiveTo review the key points that are essential for the correct staging of cervical cancer by magnetic resonance imaging.ConclusionMagnetic resonance imaging is the method of choice for locoregional staging of cervical cancer. Thorough evaluation of prognostic factors such as tumor size, invasion of adjacent structures, and the presence of lymph node metastases is fundamental for planning appropriate treatment.     

Cáncer de esófago: particularidades anatómicas,estadificación y técnicas de imagen

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.     

Rédito diagnóstico de la resonancia magnética y el estudio por congelación intraoperatorio en la determinación de la invasión miometrial profunda en cáncer de endometrio

Background and objectivesThe standard treatment for endometrial cancer is simple hysterectomy with bilateral salpingo-oophorectomy. Patients with high risk also benefit from lumbo-aortic lymphadenectomy. High risk patients include those with grades and histologic subtypes associated with poor prognosis and depth of myometrial invasion greater than 50% (M2). To determine which patients would benefit from lumbo-aortic lymphadenectomy, the depth of myometrial invasion can be assessed by intraoperative frozen section or by magnetic resonance imaging (MRI). We aimed to determine the diagnostic yield of intraoperative frozen section and MRI for detecting the presence of M2 in patients with endometrial cancer.Materials and methodsThis cross-sectional study included women with a histologically confirmed diagnosis of endometrial cancer who underwent baseline MRI and surgical intervention in our institution between 1 January 2010 and 31 December 2017. We reviewed the MRI studies and the intraoperative frozen section reports and compared them with the information in the histopathology report. We compared the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the two tests. We also calculated the diagnostic accuracy of each method and the percentages of underestimation and overestimation. Finally, we calculated the predictive value of MRI for the presence of M2, adjusting it for the histologic variables known to be associated with poor prognosis.ResultsTo detect M2, MRI had 63% sensitivity, 87% specificity, 73% PPV, and 81% NPV; the diagnostic accuracy was 78.8%, with 13.12% underestimation and 8.13% overestimation of M2. Intraoperative frozen section had 69% sensitivity, 86.7% specificity, 69% PPV, and 86% NPV; the diagnostic accuracy was 81.5%, with 9.24% underestimation and 9.24% overestimation of M2. The degree of concordance between the two methods was moderate (k=0.54, p < 0.00001).ConclusionsIn our experience, MRI and intraoperative frozen section have adequate diagnostic yields for determining M2, though intraoperative frozen section is slightly better. The contribution of MRI in determining the presence and the site of deep myometrial invasion, as well as the factors that can confound the diagnosis, when added to the contribution of intraoperative frozen section, means that both methods help reduce the number of unnecessary lymph node dissections and the morbidity, mortality, and health costs associated with this practice.     

Introducción práctica al análisis hemodinámico del sistema cardiovascular mediante la técnica «4D Flow»

The 4 D Flow MRI technique provides a three-dimensional representation of blood flow over time, making it possible to evaluate the hemodynamics of the cardiovascular system both qualitatively and quantitatively. In this article, we describe the application of the 4 D Flow technique in a 3 T scanner; in addition to the technical parameters, we discuss the advantages and limitations of the technique and its possible clinical applications. We used 4 D Flow MRI to study different body areas (chest, abdomen, neck, and head) in 10 volunteers. We obtained 3 D representations of the patterns of flow and quantitative hemodynamic measurements. The technique makes it possible to evaluate the pattern of blood flow in large and midsize vessels without the need for exogenous contrast agents.     

Elaboración de modelos predictivos de la gravedad y la mortalidad en pacientes con COVID-19 que acuden al servicio de urgencias,incluida la radiografía torácica

ObjectivesTo develop prognosis prediction models for COVID-19 patients attending an emergency department (ED) based on initial chest X-ray (CXR), demographics, clinical and laboratory parameters.MethodsAll symptomatic confirmed COVID-19 patients admitted to our hospital ED between February 24th and April 24th 2020 were recruited. CXR features, clinical and laboratory variables and CXR abnormality indices extracted by a convolutional neural network (CNN) diagnostic tool were considered potential predictors on this first visit. The most serious individual outcome defined the three severity level: 0) home discharge or hospitalization ≤ 3 days, 1) hospital stay >3 days and 2) intensive care requirement or death. Severity and in-hospital mortality multivariable prediction models were developed and internally validated. The Youden index was used for the optimal threshold selection of the classification model.ResultsA total of 440 patients were enrolled (median 64 years; 55.9% male); 13.6% patients were discharged, 64% hospitalized, 6.6% required intensive care and 15.7% died. The severity prediction model included oxygen saturation/inspired oxygen fraction (SatO2/FiO2), age, C-reactive protein (CRP), lymphocyte count, extent score of lung involvement on CXR (ExtScoreCXR), lactate dehydrogenase (LDH), D-dimer level and platelets count, with AUC-ROC = 0.94 and AUC-PRC = 0.88. The mortality prediction model included age, SatO2/FiO2, CRP, LDH, CXR extent score, lymphocyte count and D-dimer level, with AUC-ROC = 0.97 and AUC-PRC = 0.78. The addition of CXR CNN-based indices did not improve significantly the predictive metrics.ConclusionThe developed and internally validated severity and mortality prediction models could be useful as triage tools in ED for patients with COVID-19 or other virus infections with similar behaviour.     

Detección precoz mediante resonancia magnética de un angioma cavernoso tras radioterapia craneal por ependimoma anaplásico en un niño

Radiotherapy forms part of most therapeutic, preventive, and conditioning regimens in pediatric oncology. Numerous late secondary effects of cranial radiation are well known. However, radiation-induced cavernous angiomas (RICA) have been reported only sporadically and even fewer cases of earlier presentation of RICA have been reported. In this brief report, we describe a RICA that appeared in a boy treated for a CNS tumor (an infratentorial anaplastic ependymoma) after a short latency period between the end of radiotherapy and the development of the RICA.We comment on the different variables proposed to explain the formation of these lesions, as well as on their imaging features, treatment, prognosis, and follow-up.     

Guía SEOM-SERAM-SEMNIM sobre el empleo de las técnicas de imagen funcional y molecular en el cáncer de pulmón no microcítico avanzado

Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.