Publications by authors named "Roberto Cannella"

66 Publications

Long-term evolution of LI-RADS observations in HCV-related cirrhosis treated with direct-acting antivirals.

Liver Int 2021 Apr 28. Epub 2021 Apr 28.

Section of Radiology - BiND, University Hospital "Paolo Giaccone", Via del Vespro 129, 90127, Palermo, Italy.

Background & Aims: The risk of progression of indeterminate observations to hepatocellular carcinoma (HCC) after direct-acting antivirals (DAA) is still undetermined. To assess whether DAA therapy changes the risk of progression of observations with low (LR-2), intermediate (LR-3), and high (LR-4) probability for HCC in cirrhotic patients and to identify predictors of progression.

Methods: This retrospective study included cirrhotic patients treated with DAA who achieved sustained virologic response between 2015 and 2019. A total of 68 patients had pre-DAA indeterminate observations and at least six months CT/MRI follow-up before and after DAA. Two radiologists reviewed CT/MRI studies to categorize observations according to the LI-RADSv2018 and assess the evolution on subsequent follow-ups. Predictors of evolutions were evaluated by using the Cox proportional hazard model, Kaplan-Meier method, and log-rank test.

Results: A total of 109 untreated observations were evaluated, including 31 (28.4%) LR-2, 67 (61.5%) LR-3, and 11 (10.1%) LR-4. During a median follow-up of 41 months, 17.4% and 13.3% of observations evolved to LR-5 or LR-M and LR-5, before and after DAA, respectively (P=0.428). There was no difference in rate of progression of neither LR-2 (P=1.000), LR-3 (P=0.833), or LR-4 (P=0.505). At multivariate analysis, only initial LI-RADS category was an independent predictor of progression to LR-5 or LR-M for all observations (hazard ratio 6.75, P<0.001), and of progression to LR-5 after DAA (hazard ratio 4.34, P=0.047).

Conclusions: DAA therapy does not increase progression of indeterminate observations to malignant categories. The initial LI-RADS category is an independent predictor of observations upgrade.
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http://dx.doi.org/10.1111/liv.14914DOI Listing
April 2021

Assessment of morphological CT imaging features for the prediction of risk stratification, mutations, and prognosis of gastrointestinal stromal tumors.

Eur Radiol 2021 Apr 21. Epub 2021 Apr 21.

Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

Objectives: To investigate the correlation between CT imaging features and risk stratification of gastrointestinal stromal tumors (GISTs), prediction of mutation status, and prognosis.

Methods: This retrospective dual-institution study included patients with pathologically proven GISTs meeting the following criteria: (i) preoperative contrast-enhanced CT performed between 2008 and 2019; (ii) no treatments before imaging; (iii) available pathological analysis. Tumor risk stratification was determined according to the National Institutes of Health (NIH) 2008 criteria. Two readers evaluated the CT features, including enhancement patterns and tumor characteristics in a blinded fashion. The differences in distribution of CT features were assessed using univariate and multivariate analyses. Survival analyses were performed by using the Cox proportional hazard model, Kaplan-Meier method, and log-rank test.

Results: The final population included 88 patients (59 men and 29 women, mean age 60.5 ± 11.1 years) with 45 high-risk and 43 low-to-intermediate-risk GISTs (median size 6.3 cm). At multivariate analysis, lesion size ≥ 5 cm (OR: 10.52, p = 0.009) and enlarged feeding vessels (OR: 12.08, p = 0.040) were independently associated with the high-risk GISTs. Hyperenhancement was significantly more frequent in PDGFRα-mutated/wild-type GISTs compared to GISTs with KIT mutations (59.3% vs 23.0%, p = 0.004). Ill-defined margins were associated with shorter progression-free survival (HR 9.66) at multivariate analysis, while ill-defined margins and hemorrhage remained independently associated with shorter overall survival (HR 44.41 and HR 30.22). Inter-reader agreement ranged from fair to almost perfect (k: 0.32-0.93).

Conclusions: Morphologic contrast-enhanced CT features are significantly different depending on the risk status or mutations and may help to predict prognosis.

Key Points: • Lesions size ≥ 5 cm (OR: 10.52, p = 0.009) and enlarged feeding vessels (OR: 12.08, p = 0.040) are independent predictors of high-risk GISTs. • PDGFRα-mutated/wild-type GISTs demonstrate more frequently hyperenhancement compared to GISTs with KIT mutations (59.3% vs 23.0%, p = 0.004). • Ill-defined margins (hazard ratio 9.66) were associated with shorter progression-free survival at multivariate analysis, while ill-defined margins (hazard ratio 44.41) and intralesional hemorrhage (hazard ratio 30.22) were independently associated with shorter overall survival.
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http://dx.doi.org/10.1007/s00330-021-07961-3DOI Listing
April 2021

Type and Gene Location of Mutations Predict Progression-Free Survival to First-Line Imatinib in Gastrointestinal Stromal Tumors: A Look into the Exon.

Cancers (Basel) 2021 Feb 27;13(5). Epub 2021 Feb 27.

Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, 90127 Palermo, Italy.

In previous studies on localized GISTs, exon 11 deletions and mutations involving codons 557/558 showed an adverse prognostic influence on recurrence-free survival. In the metastatic setting, there are limited data on how mutation type and codon location might contribute to progression-free survival (PFS) variability to first-line imatinib treatment. We analyzed the type and gene location of and mutations for 206 patients from a GIST System database prospectively collected at an Italian reference center between January 2005 and September 2020. By describing the mutational landscape, we focused on clinicopathological characteristics according to the critical mutations and investigated the predictive role of type and gene location of the exon 11 mutations in metastatic patients treated with first-line imatinib. Our data showed a predictive impact of exon 11 pathogenic variant on PFS to imatinib treatment: patients with deletion or insertion/deletion (delins) in 557/558 codons had a shorter PFS (median PFS: 24 months) compared to the patients with a deletion in other codons, or duplication/insertion/SNV (median PFS: 43 and 49 months, respectively) ( < 0.001). These results reached an independent value in the multivariate model, which showed that the absence of exon 11 deletions or delins 557/558, the female gender, primitive tumor diameter (≤5 cm) and polymorphonuclear leucocytosis (>7.5 109/L) were significant prognostic factors for longer PFS. Analysis of the predictive role of PVs showed no significant results. Our results also confirm the aggressive biology of 557/558 deletions/delins in the metastatic setting and allow for prediction at the baseline which GIST patients would develop resistance to first-line imatinib treatment earlier.
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http://dx.doi.org/10.3390/cancers13050993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7956844PMC
February 2021

Systemic therapies for hepatocellular carcinoma: the present and the future.

Recenti Prog Med 2021 Feb;112(2):110-116

Section of Gastroenterology & Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Italy.

Hepatocellular carcinoma is diagnosed in more than half of all cases at unresectable stage when no potentially curative treatments are feasible. Since 2008, sorafenib had represented the only effective first line systemic therapy over the last decade until the approval of lenvatinib, who showed to be non-inferior to sorafenib. Recently, for the first time, a combination of immunotherapy and antiangiogenic drug, atezolizumab plus bevacizumab, was associated with a significantly longer overall survival and progression free survival compared to sorafenib, becoming the new best performing first-line approach for unresectable HCC. After several randomized controlled trials (RCTs) that have attempted to find an effective second-line therapy, regorafenib, cabozantinib, ramucirumab, nivolumab and pembrolizumab represent approved treatments for patients who failed first-line treatment. However, inclusion criteria of second-line RCTs are quite heterogeneous and no direct comparisons exist among these agents. Exciting opportunities have been found either in the combination or in the sequencing of these agents, but the optimal therapeutic strategy for these patients remains elusive. Moreover, the coexistence of cirrhosis and the competing risk of liver decompensation increase the complexity of the assessment of the net health benefit of the available therapeutic approaches. The aim of this review is to summarize the evidence on systemic treatments for unresectable HCC and to explore the future perspectives on this topic.
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http://dx.doi.org/10.1701/3559.35371DOI Listing
February 2021

Targetoid appearance on T2-weighted imaging and signs of tumor vascular involvement: diagnostic value for differentiating HCC from other primary liver carcinomas.

Eur Radiol 2021 Feb 15. Epub 2021 Feb 15.

Department of Radiology, University of California San Diego, 200 W Arbor Dr., San Diego, CA, 92103, USA.

Objectives: To evaluate targetoid appearance on T2-weighted imaging and signs of tumor vascular involvement as potential new LI-RADS features for differentiating hepatocellular carcinoma (HCC) from other non-HCC primary liver carcinomas (PLCs).

Methods: This IRB-approved, retrospective study was performed at two liver transplant centers. The final population included 375 patients with pathologically proven lesions imaged between 2007 and 2017 with contrast-enhanced CT or MRI. The cohort consisted of 165 intrahepatic cholangiocarcinomas and 74 combined hepatocellular-cholangiocarcinomas, with the addition of 136 HCCs for control. Two abdominal radiologists (R1; R2) independently reviewed the imaging studies (112 CT; 263 MRI) and recorded the presence of targetoid appearance on T2-weighted images and features of tumor vascular involvement including encasement, narrowing, tethering, occlusion, and obliteration. The sensitivity and specificity of each feature were calculated for the diagnosis of non-HCC PLCs. Cohen's kappa (k) test was used to assess inter-reader agreement.

Results: The sensitivity of targetoid appearance on T2-weighted images for the diagnosis of non-HCC PLCs was 27.5% and 32.6% (R1 and R2) and the specificity was 98.2% and 97.3% (R1 and R2). Among the features of tumor vascular involvement, those providing the highest sensitivity for non-HCC PLCs were vascular encasement (R1: 34.3%; R2: 37.2%) and obliteration (R1: 25.5%; R2: 29.7%). The highest specificity for non-HCC PLCs was provided by tethering (R1: 100%; R2: 97.1%) and occlusion (R1: 99.3%; R2: 99.3%). The inter-reader agreement was moderate to substantial (k = 0.48-0.77).

Conclusions: Targetoid appearance on T2-weighted images and features of tumor vascular involvement demonstrated high specificity for non-HCC malignancy.

Key Points: • Targetoid appearance on T2-weighted imaging and signs of tumor vascular involvement have high specificity (92-100%) for the diagnosis of non-HCC PLCs, regardless of the presence of liver risk factors. • In the subset of patients with risk factors for HCC, the sensitivity of signs of tumor vascular involvement decreases for both readers (1.7-20.3%), while the specificity increases reaching values higher than 94.2%. • The inter-reader agreement is substantial for targetoid appearance on T2-weighted images (k = 0.74) and moderate to substantial for signs of tumor vascular involvement (k = 0.48-0.77).
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http://dx.doi.org/10.1007/s00330-021-07743-xDOI Listing
February 2021

Are radiological endpoints surrogate outcomes of overall survival in hepatocellular carcinoma treated with transarterial chemoembolization?

Liver Int 2021 May 1;41(5):1105-1116. Epub 2021 Mar 1.

Section of Gastroenterology & Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy.

Background& Aims: Time to progression (TTP) and progression-free survival (PFS) are commonly used as surrogate endpoints in oncology trials. We aimed to assess the surrogacy relationship of TTP and PFS with overall survival (OS) in studies of transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (u-HCC) by innovative methods.

Methods: A search of databases for studies of TACE for u-HCC reporting both OS and TTP or PFS was performed. Individual patient data were extracted from TTP/PFS and OS Kaplan-Meier curves of TACE arms. Pooled median TTP and OS were obtained from random-effect model. The surrogate relationships of hazard ratios (HRs) and median TTP for OS were evaluated by the coefficient of determination R .

Results: We identified 13 studies comparing TACE vs systemic therapy or vs TACE plus systemic therapy and including 1932 TACE-treated patients. Pooled median OS was 11.2 months (95% confidence interval [95%CI] 7.9-17.8), and pooled median TTP was 5.4 months (95%CI 3.8-8.0). Heterogeneity among studies was highly significant for both outcomes. The correlation between HR TTP and HR OS was moderate (R  = 0.65. 95%CI 0.08-0.81). R value was 0.04 (95%CI 0.00-0.35) between median TTP and median OS.

Conclusion: In studies of TACE for u-HCC, the surrogate relationship of radiology-based endpoints with OS is moderate. Multiple endpoints including hepatic decompensation, macrovascular invasion and extrahepatic spread are needed for future trials comparing systemic therapies or combination of TACE with systemic therapies vs TACE alone.
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http://dx.doi.org/10.1111/liv.14822DOI Listing
May 2021

Liver stiffness quantification in biopsyproven nonalcoholic fatty liver disease patients using shear wave elastography in comparison with transient elastography.

Ultrasonography 2020 Dec 18. Epub 2020 Dec 18.

Section of Radiology - BiND, University Hospital "Paolo Giaccone," Palermo, Italy.

Purpose: This study prospectively assessed the performance of liver stiffness measurements using point shear-wave elastography (p-SWE) in comparison with transient elastography (TE) in patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD).

Methods: Fifty-six consecutive adult patients with a histological diagnosis of NAFLD prospectively underwent TE and p-SWE on the same day. The median of 10 measurements (SWE-10), the first five (SWE-5), and the first three (SWE-3) measurements were analyzed for p-SWE. Liver biopsy was considered as the reference standard for liver fibrosis grade. Receiver operating characteristic (ROC) curves and areas under the ROC curves (AUROCs) were calculated to assess the performance of TE and p-SWE for the diagnosis of significant (F2-F4) and advanced fibrosis (F3-F4).

Results: Forty-six patients (27 men, 19 women; mean age, 54.7±9.1 years) had valid p-SWE and TE measurements. Twenty-seven patients (58.7%) had significant fibrosis and 18 (39.1%) had advanced fibrosis. For significant fibrosis, both SWE-10 (AUROC, 0.787; P=0.002) and SWE- 5 (AUROC, 0.809; P=0.001) provided higher diagnostic performance than TE (AUROC, 0.719; P=0.016) and SWE-3 (AUROC, 0.714; P=0.021), albeit without statistical significance (P=0.301). For advanced fibrosis, SWE-5 showed higher diagnostic performance (AUROC, 0.809; P<0.001) than TE (AUROC, 0.799; P<0.001), SWE-10 (AUROC, 0.797; P<0.001), and SWE-3 (AUROC, 0.736; P=0.003), although the differences were not statistically significant (P=0.496). The optimal SWE-10 and SWE-5 cutoff values were ≥8.4 and ≥7.8 for significant fibrosis, and ≥9.1 and ≥8.8 for advanced fibrosis, respectively.

Conclusion: TE and p-SWE showed similar performance for the diagnosis of significant and advanced fibrosis in NAFLD patients.
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http://dx.doi.org/10.14366/usg.20147DOI Listing
December 2020

Preoperative imaging findings in patients undergoing transcranial magnetic resonance imaging-guided focused ultrasound thalamotomy.

Sci Rep 2021 Jan 28;11(1):2524. Epub 2021 Jan 28.

Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

The prevalence and impact of imaging findings detected during screening procedures in patients undergoing transcranial MR-guided Focused Ultrasound (tcMRgFUS) thalamotomy for functional neurological disorders has not been assessed yet. This study included 90 patients who fully completed clinical and neuroradiological screenings for tcMRgFUS in a single-center. The presence and location of preoperative imaging findings that could impact the treatment were recorded and classified in three different groups according to their relevance for the eligibility and treatment planning. Furthermore, tcMRgFUS treatments were reviewed to evaluate the number of transducer elements turned off after marking as no pass regions the depicted imaging finding. A total of 146 preoperative imaging findings in 79 (87.8%) patients were detected in the screening population, with a significant correlation with patients' age (rho = 483, p < 0.001). With regard of the group classification, 119 (81.5%), 26 (17.8%) were classified as group 1 or 2, respectively. One patient had group 3 finding and was considered ineligible. No complications related to the preoperative imaging findings occurred in treated patients. Preoperative neuroradiological findings are frequent in candidates to tcMRgFUS and their identification may require the placement of additional no-pass regions to prevent harmful non-targeted heating.
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http://dx.doi.org/10.1038/s41598-021-82271-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843629PMC
January 2021

Spectrum of liver lesions hyperintense on hepatobiliary phase: an approach by clinical setting.

Insights Imaging 2021 Jan 12;12(1). Epub 2021 Jan 12.

Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

Hepatobiliary MRI contrast agents are increasingly being used for liver imaging. In clinical practice, most focal liver lesions do not uptake hepatobiliary contrast agents. Less commonly, hepatic lesions may show variable signal characteristics on hepatobiliary phase. This pictorial essay reviews a broad spectrum of benign and malignant focal hepatic observations that may show hyperintensity on hepatobiliary phase in various clinical settings. In non-cirrhotic patients, focal hepatic observations that show hyperintensity in the hepatobiliary phase are usually benign and typically include focal nodular hyperplasia. In patients with primary or secondary vascular disorders, focal nodular hyperplasia-like lesions arise as a local hyperplastic response to vascular alterations and tend to be iso- or hyperintense in the hepatobiliary phase. In oncologic patients, metastases and cholangiocarcinoma are hypointense lesions in the hepatobiliary phase; however, occasionally they may show a diffuse, central and inhomogeneous hepatobiliary paradoxical uptake with peripheral rim hypointensity. Post-chemotherapy focal nodular hyperplasia-like lesions may be tricky, and their typical hyperintense rim in the hepatobiliary phase is very helpful for the differential diagnosis with metastases. In cirrhotic patients, hepatocellular carcinoma may occasionally appear hyperintense on hepatobiliary phase.
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http://dx.doi.org/10.1186/s13244-020-00928-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801550PMC
January 2021

Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound with a 1.5 Tesla Scanner: A Prospective Intraindividual Comparison Study of Intraoperative Imaging.

Brain Sci 2021 Jan 4;11(1). Epub 2021 Jan 4.

Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy.

Background: High-quality intraoperative imaging is needed for optimal monitoring of patients undergoing transcranial MR-guided Focused Ultrasound (tcMRgFUS) thalamotomy. In this paper, we compare the intraoperative imaging obtained with dedicated FUS-Head coil and standard body radiofrequency coil in tcMRgFUS thalamotomy using 1.5-T MR scanner.

Methods: This prospective study included adult patients undergoing tcMRgFUS for treatment of essential tremor. Intraoperative T2-weighted FRFSE sequences were acquired after the last high-energy sonication using a dedicated two-channel FUS-Head (2ch-FUS) coil and body radiofrequency (body-RF) coil. Postoperative follow-ups were performed at 48 h using an eight-channel phased-array (8ch-HEAD) coil. Two readers independently assessed the signal-to-noise ratio (SNR) and evaluated the presence of concentric lesional zones (zone I, II and III). Intraindividual differences in SNR and lesional findings were compared using the Wilcoxon signed rank sum test and McNemar test.

Results: Eight patients underwent tcMRgFUS thalamotomy. Intraoperative T2-weighted FRFSE images acquired using the 2ch-FUS coil demonstrated significantly higher SNR (R1 median SNR: 10.54; R2: 9.52) compared to the body-RF coil (R1: 2.96, < 0.001; R2: 2.99, < 0.001). The SNR was lower compared to the 48-h follow-up ( < 0.001 for both readers). Intraoperative zone I and zone II were more commonly visualized using the 2ch-FUS coil (R1, = 0.031 and = 0.008, R2, = 0.016, = 0.008), without significant differences with 48-h follow-up ( ≥ 0.063). The inter-reader agreement was almost perfect for both SNR (ICC: 0.85) and lesional findings (: 0.82-0.91).

Conclusions: In the study population, the dedicated 2ch-FUS coil significantly improved the SNR and visualization of lesional zones on intraoperative imaging during tcMRgFUS performed with a 1.5-T MR scanner.
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http://dx.doi.org/10.3390/brainsci11010046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7823499PMC
January 2021

Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI.

Clin Imaging 2021 Feb 15;70:33-45. Epub 2020 Oct 15.

Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy.

Hepatocellular carcinoma (HCC) may have an infiltrative appearance in about 8-20% of cases. Infiltrative HCC can be a challenging diagnosis and it is associated with the worst overall survival among HCC patients. Infiltrative HCC is characterized by the spread of multiple minute nodules throughout the liver, without a dominant one, ultimately resulting into macrovascular invasion. On CT and MRI, infiltrative HCC appears as an ill-defined, large mass, with variable degree of enhancement, and satellite neoplastic nodules in up to 52% of patients. On MRI, it may show restriction on diffusion weighted imaging, hyperintensity on T2- and hypointensity on T1-weighted images, and, if hepatobiliary agent is used, hypointensity on hepatobiliary phase. Infiltrative HCC must be differentiated from other liver diseases, such as focal confluent fibrosis, steatosis, amyloidosis, vascular disorders of the liver, cholangiocarcinoma, and diffuse metastatic disease. In cirrhotic patients, the identification of vascular tumor invasion of the portal vein and its differentiation from bland thrombosis is of utmost importance for patient management. On contrast enhanced CT and MRI, portal vein tumor thrombosis appears as an enhancing thrombus within the portal vein, close to the main tumor and results into vein enlargement. The aim of this pictorial review is to show CT and MRI features that allow the diagnosis of infiltrative HCC and portal vein tumor thrombosis. A particular point of interest includes the tips and tricks for differential diagnosis with potential mimickers of infiltrative HCC.
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http://dx.doi.org/10.1016/j.clinimag.2020.10.011DOI Listing
February 2021

Focal liver lesions: interobserver and intraobserver agreement of three-dimensional contrast-enhanced ultrasound-assisted volume measurements.

Ultrasonography 2020 Aug 19. Epub 2020 Aug 19.

Section of Radiology - BiND, University Hospital "Paolo Giaccone", Palermo, Italy.

Purpose: This study was conducted to assess the interobserver and intraobserver agreement of three-dimensional contrast-enhanced ultrasound (3D-CEUS) volume calculations of focal liver lesions (FLLs).

Methods: Thirty-nine patients (15 men and 24 women; mean age, 55.4 years) with 39 FLLs (mean size, 3.1±1.8 cm; size range, 1 to 8 cm) prospectively underwent 3D-CEUS. Four readers calculated the volume of each lesion in an independent and blinded fashion in two separate sessions by means of a semi-automatic, commercially available proprietary software. The differences in lesion volumes (cm3) among sessions and readers were assessed using the Mann-Whitney U test and the Kruskal-Wallis test. Bland-Altman analysis was also performed. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) were calculated. The statistical significance level was set at P<0.05.

Results: Among readers, there were no statistically significant differences in the first (P=0.953) and second (P=0.592) reading sessions for volume calculations of the 39 FLLs, with almost perfect inter-reader agreement (ICC values of 0.996; 95% CI, 0.992 to 0.998 and 0.994; 95% CI, 0.990 to 0.997, respectively). For each of the four readers, there were no significant differences in volume calculations between the two sessions (P=0.503-0.927), and the intrareader agreement was almost perfect for each reader (R1: ICC, 0.995; 95% CI, 0.991 to 0.998; R2: ICC, 0.995; 95% CI, 0.988 to 0.997; R3: ICC, 0.996; 95% CI, 0.992 to 0.998; R4: ICC, 0.985; 95% CI, 0.971 to 0.992).

Conclusion: 3D-CEUS volume calculations provided consistent measurements across different readers with almost perfect intrareader agreement.
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http://dx.doi.org/10.14366/usg.20025DOI Listing
August 2020

Hepatocellular carcinoma with macrovascular invasion: multimodality imaging features for the diagnosis.

Diagn Interv Radiol 2020 11;26(6):531-540

Department of Radiology - BiND, University Hospital "Paolo Giaccone", Palermo, Italy;Department of Radiology, Fondazione Istituto Giuseppe Giglio, Cefalù (Palermo), Italy.

Hepatocellular carcinoma (HCC) is frequently associated with macrovascular invasion of the portal vein or hepatic veins in advanced stages. The accurate diagnosis of macrovascular invasion and the differentiation from bland non-tumoral thrombus has significant clinical and management implications, since it narrows the therapeutic options and it represents a mandatory contraindication for liver resection or transplantation. The imaging diagnosis remains particularly challenging since the imaging features of HCC with macrovascular invasion may be subtle, especially in lesions showing infiltrative appearance. However, each radiologic imaging modality may provide findings suggesting the presence of tumor thrombus rather than bland thrombus. The purpose of this paper is to review the current guidelines and imaging appearance of HCC with macrovascular invasion. Knowledge of the most common imaging features of HCC with macrovascular invasion may improve the diagnostic confidence of tumor thrombus in clinical practice and help to guide patients' management.
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http://dx.doi.org/10.5152/dir.2020.19569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664740PMC
November 2020

Optimizing Liver Division Technique for Procuring Left Lateral Segment Grafts: New Anatomical Insights.

Liver Transpl 2021 02 29;27(2):281-285. Epub 2021 Jan 29.

Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy.

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http://dx.doi.org/10.1002/lt.25895DOI Listing
February 2021

New advances in radiomics of gastrointestinal stromal tumors.

World J Gastroenterol 2020 Aug;26(32):4729-4738

Section of Radiology - BiND, University Hospital "Paolo Giaccone", Palermo 90127, Italy.

Gastrointestinal stromal tumors (GISTs) are uncommon neoplasms of the gastrointestinal tract with peculiar clinical, genetic, and imaging characteristics. Preoperative knowledge of risk stratification and mutational status is crucial to guide the appropriate patients' treatment. Predicting the clinical behavior and biological aggressiveness of GISTs based on conventional computed tomography (CT) and magnetic resonance imaging (MRI) evaluation is challenging, unless the lesions have already metastasized at the time of diagnosis. Radiomics is emerging as a promising tool for the quantification of lesion heterogeneity on radiological images, extracting additional data that cannot be assessed by visual analysis. Radiomics applications have been explored for the differential diagnosis of GISTs from other gastrointestinal neoplasms, risk stratification and prediction of prognosis after surgical resection, and evaluation of mutational status in GISTs. The published researches on GISTs radiomics have obtained excellent performance of derived radiomics models on CT and MRI. However, lack of standardization and differences in study methodology challenge the application of radiomics in clinical practice. The purpose of this review is to describe the new advances of radiomics applied to CT and MRI for the evaluation of gastrointestinal stromal tumors, discuss the potential clinical applications that may impact patients' management, report limitations of current radiomics studies, and future directions.
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http://dx.doi.org/10.3748/wjg.v26.i32.4729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459199PMC
August 2020

Performance of morphologic criteria for the diagnosis of cirrhosis in patients with non-alcoholic steatohepatitis compared to other etiologies of chronic liver disease: effect of level of training and experience.

Abdom Radiol (NY) 2021 03 9;46(3):960-968. Epub 2020 Sep 9.

Department of Radiology - Division of Abdominal Imaging, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.

Purpose: To compare the diagnostic performance of morphologic criteria for detection of cirrhosis in patients with alcoholic liver disease (ALD), hepatitis C (HCV), and non-alcoholic steatohepatitis (NASH).

Methods: One hundred patients (53 male) with different etiologies of chronic liver disease (NASH, n = 41; HCV, n = 39; and ALD, n = 20) and with different degrees of fibrosis on histopathologic examination (74 with cirrhosis) were retrospectively evaluated. Four readers (R1: fellowship-trained abdominal radiologist, R2: community attending radiologist, R3: senior radiology resident/research fellow, R4: junior radiology resident) analyzed the contrast-enhanced CTs for presence of commonly accepted morphologic changes of cirrhosis and portal hypertension. Each reader assigned an overall score (using a 5-point scale) for possibility of cirrhosis based on liver morphology and features of portal hypertension. Diagnostic performance, sensitivity, and specificity for the diagnosis of cirrhosis were calculated and compared between different etiologies of chronic liver disease.

Results: Performance of readers was affected by their level of training. Less experienced readers had overall lower sensitivity for diagnosis of cirrhosis in NASH group (R3: 81.5%, R4: 63.0% compared to 96.3% for both R1 and R2). Sensitivities for detection of NASH cirrhosis significantly decreased for less experienced readers in the absence of ascites (R3: 75.0%, R4: 62.0%) or other features of portal hypertension (R3: 50.0%; R4: 0%). The specificity was consistently high among different etiologies and for all readers (85.7-100%). Inter-reader agreement for morphologic features ranged widely from fair to almost perfect (k: 0.23-0.85).

Conclusion: Cirrhotic changes in NASH are subtler and can be underestimated by less experienced readers.
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http://dx.doi.org/10.1007/s00261-020-02719-9DOI Listing
March 2021

Color Doppler Ultrasound in Portal Hypertension: A Closer Look at Left Gastric Vein Hemodynamics.

J Ultrasound Med 2021 Jan 13;40(1):7-14. Epub 2020 Jul 13.

Department of Radiology, Azienda Socio Sanitaria Territoriale della Franciacorta, Presidio Ospedaliero Mellino Mellini, Chiari, Italy.

Portal hypertension is one of the most important causes of morbidity and mortality in cirrhotic patients. A color Doppler evaluation of the left gastric vein (LGV) has proven utility in the prediction of esophageal varices and variceal bleeding in patients with portal hypertension. The purpose of this review is to discuss the ultrasound evaluation, imaging findings, and clinical application of Doppler ultrasound in the assessment of the LGV. Knowledge of the color Doppler technique and imaging findings of the LGV may help clinicians improve the monitoring of portal hypertension and predict patients with a high risk of esophageal varices.
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http://dx.doi.org/10.1002/jum.15386DOI Listing
January 2021

Radiographic and chest CT imaging presentation and follow-up of COVID-19 pneumonia: a multicenter experience from an endemic area.

Emerg Radiol 2020 Dec 11;27(6):623-632. Epub 2020 Jul 11.

Department of Radiology, ASST Franciacorta, Azienda Ospedaliera M. Mellini, Viale Mazzini 4, 25032, Chiari, BS, Italy.

COVID-19 has infected more than 2 million people in the world in less than 5 months outbreak. Chest imaging is recommended for triage of suspected cases of COVID-19 with moderate-severe clinical features and high pre-test probability of disease, and may help for patient follow-up and to identify patients at higher risk of disease worsening. This pictorial essay illustrates typical and uncommon imaging findings of COVID-19 pneumonia and the role of imaging for patient management.
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http://dx.doi.org/10.1007/s10140-020-01817-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352095PMC
December 2020

Abdominal splenosis and its differential diagnoses: What the radiologist needs to know.

Curr Probl Diagn Radiol 2021 Mar-Apr;50(2):229-235. Epub 2020 May 19.

Dipartimento di Biomedicina, Neuroscienze e Diagnostica avanzata (BIND), University of Palermo, Palermo, Italy.

Splenosis is a benign acquired condition characterized by the presence of heterotopic viable splenic tissue in other organs or within cavities such as peritoneum, retroperitoneum, or thorax after splenic trauma or surgery. Abdominal splenosis is often an incidental finding and computed tomography and magnetic resonance usually allow a confident diagnosis. The typical enhancement that parallels the spleen is a useful hallmark of splenosis. Splenic implants lack contrast uptake in the hepatobiliary phase and show high signal at high b-values on diffusion-weighted images. In some cases splenosis may mimic malignant and benign conditions in the peritoneum as well as in hollow and parenchymal abdominal organs and further investigations - including scintigraphy with Tc99m-labelled heat-denatured red blood cells or biopsy - are sometimes required in challenging cases. This pictorial essay reviews the imaging presentation and potential differential diagnosis of splenosis according to the site of implantation. A prompt and accurate radiological diagnosis of splenosis can avoid unnecessary biopsy or surgery.
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http://dx.doi.org/10.1067/j.cpradiol.2020.04.012DOI Listing
May 2020

Texture analysis in susceptibility-weighted imaging may be useful to differentiate acute from chronic multiple sclerosis lesions.

Eur Radiol 2020 Nov 13;30(11):6348-6356. Epub 2020 Jun 13.

Neuroradiology Section, Department of Radiology (IDI), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.

Objectives: To evaluate the diagnostic performance of texture analysis (TA) applied on non-contrast-enhanced susceptibility-weighted imaging (SWI) to differentiate acute (enhancing) from chronic (non-enhancing) multiple sclerosis (MS) lesions.

Methods: We analyzed 175 lesions from 58 patients with relapsing-remitting MS imaged on a 3.0 T MRI scanner and applied TA on T2-w and SWI images to extract texture features. We evaluated the presence or absence of lesion enhancement on T1-w post-contrast images and performed a computational statistical analysis to assess if there was any significant correlation between the texture features and the presence of lesion activity. ROC curves and leave-one-out cross-validation were used to evaluate the performance of individual features and multiparametric models in the identification of active lesions.

Results: Multiple TA features obtained from SWI images showed a significantly different distribution in acute and chronic lesions (AUC, 0.617-0.720). Multiparametric predictive models based on logistic ridge regression and partial least squares regression yielded an AUC of 0.778 and 0.808, respectively. Results from T2-w images did not show any significant predictive ability of neither individual features nor multiparametric models.

Conclusions: Texture analysis on SWI sequences may be useful to differentiate acute from chronic MS lesions. The good diagnostic performance could help to reduce the need of intravenous contrast agent administration in follow-up MRI studies.

Key Points: • Texture analysis applied on SWI sequences may be useful to differentiate acute from chronic multiple sclerosis lesions • The good diagnostic performance could help to minimize the need of intravenous contrast agent administration in follow-up MRI studies.
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http://dx.doi.org/10.1007/s00330-020-06995-3DOI Listing
November 2020

The Poké Ball sign in mature ovarian cystic teratoma.

Abdom Radiol (NY) 2021 01 5;46(1):396-397. Epub 2020 Jun 5.

Section of Radiological Sciences, Bi.N.D, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

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http://dx.doi.org/10.1007/s00261-020-02608-1DOI Listing
January 2021

CT imaging of acute and chronic pyelonephritis: a practical guide for emergency radiologists.

Emerg Radiol 2020 Oct 22;27(5):561-567. Epub 2020 May 22.

Dipartimento di Biomedicina, Neuroscienze e Diagnostica avanzata (BIND), University Hospital "Paolo Giaccone", Via del Vespro, 129, 90127, Palermo, Italy.

Contrast-enhanced CT is not routinely indicated in uncomplicated urinary infections, but it may be necessary in patients with specific risk factors (i.e., diabetes, immunocompromised patients, history of stones, or prior renal surgery) or in patients not responding to antibiotics and in detecting complications of pyelonephritis. CT is the gold standard for imaging assessment of pyelonephritis severity. Imaging appearance of acute pyelonephritis, including focal (i.e., wedge-shaped zones of decreased attenuation or hypodense mass) and diffuse (i.e., global enlargement, poor parenchymal enhancement, lack of excretion of contrast, fat stranding) forms, needs to be differentiated from renal infarction, renal lymphoma, and interstitial nephritis. Chronic pyelonephritis-which appears as focal polar scars with underlying calyceal distortion, global atrophy, and hypertrophy of residual tissue-may mimic at imaging lobar infarcts. This pictorial essay reviews the CT imaging appearance of acute and chronic pyelonephritis, their uncommon subtypes, and their complications, with key features for early diagnosis. Their knowledge is crucial for emergency and abdominal radiologists to avoid misdiagnosis with malignancy and to guide the clinician towards the appropriate medical or surgical treatment.
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http://dx.doi.org/10.1007/s10140-020-01788-zDOI Listing
October 2020

Hepatic enhancement in cirrhosis in the portal venous phase: what are the differences between gadoxetate disodium and gadobenate dimeglumine?

Abdom Radiol (NY) 2020 08;45(8):2409-2417

Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

Purpose: To compare the level of parenchymal and portal venous enhancement in the portal venous phase (PVP) in cirrhotic patients undergoing gadoxetate disodium- and gadobenate dimeglumine-enhanced MRI.

Methods: In this retrospective study, 84 cirrhotic patients (mean age ± SD: 66 ± 13 years) who underwent contrast-enhanced MRI with both gadoxetate disodium and gadobenate dimeglumine between 2012 and 2018 were included. Two readers measured signal intensities of hepatic parenchyma, portal vein and psoas muscle on precontrast and PVP. Relative enhancement (RE), image contrast, and portal vein-to-liver contrast difference were calculated. Intraindividual differences were compared with the Wilcoxon signed rank-sum test and inter-reader differences with the intraclass correlation coefficient (ICC).

Results: In PVP, gadoxetate disodium provided lower RE than gadobenate dimeglumine (Reader 1: 42.4 ± 44.6 vs. 56.1 ± 58.8, p = 0.044; Reader 2: 42.4 ± 42.9 vs. 57.7 ± 60.5, p = 0.027;), lower image contrast (Reader 1: 0.27 ± 0.11 vs. 0.35 ± 0.11, respectively; p < 0.001; Reader 2: 0.29 ± 0.10 vs. 0.37 ± 0.07, respectively; p < 0.001), and lower portal vein-to-liver contrast difference (Reader 1: 0.89 ± 0.39 vs. 1.42 ± 0.90, p < 0.001; Reader 2: 0.95 ± 0.40 vs. 1.28 ± 0.37, p < 0.001). ICC was 0.94, 0.79, and 0.69 for RE, image contrast, and portal vein-to-liver contrast difference, respectively.

Conclusion: In cirrhotic patients, gadoxetate disodium yielded lower enhancement of the hepatic parenchyma and lower contrast of the portal vein than gadobenate dimeglumine in PVP.
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http://dx.doi.org/10.1007/s00261-020-02578-4DOI Listing
August 2020

Resting-State Functional Connectome in Patients with Brain Tumors Before and After Surgical Resection.

World Neurosurg 2020 09 16;141:e182-e194. Epub 2020 May 16.

Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.

Purpose: High-grade glioma surgery has evolved around the principal belief that a safe maximal tumor resection improves symptoms, quality of life, and survival. Mapping brain function has been recently improved by resting-state functional magnetic resonance imaging (rest-fMRI), a novel imaging technique that explores networks connectivity at "rest."

Methods: This prospective study analyzed 10 patients with high-grade glioma in whom rest-fMRI connectivity was assessed both in single-subject and in group analysis before and after surgery. Seed-based functional connectivity analysis was performed with CONN toolbox. Network identification focused on 8 major functional connectivity networks. A voxel-wise region of interest (ROI) to ROI correlation map to assess functional connectivity throughout the whole brain was computed from a priori seeds ROI in specific resting-state networks before and after surgical resection in each patient.

Results: Reliable topography of all 8 resting-state networks was successfully identified in each participant before surgical resection. Single-subject functional connectivity analysis showed functional disconnection for dorsal attention and salience networks, whereas the language network demonstrated functional connection either in the case of left temporal glioblastoma. Functional connectivity in group analysis showed wide variations of functional connectivity in the default mode, salience, and sensorimotor networks. However, salience and language networks, salience and default mode networks, and salience and sensorimotor networks showed a significant correlation (P uncorrected <0.0025; P false discovery rate <0.077) in comparison before and after surgery confirming non-disconnection of these networks.

Conclusions: Resting-state fMRI can reliably detect common functional connectivity networks in patients with glioma and has the potential to anticipate network alterations after surgical resection.
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http://dx.doi.org/10.1016/j.wneu.2020.05.054DOI Listing
September 2020

Hepatobiliary phase hypointensity predicts progression to hepatocellular carcinoma for intermediate-high risk observations, but not time to progression.

Eur J Radiol 2020 Jul 23;128:109018. Epub 2020 Apr 23.

Department of Radiology, Duke University Medical Center, Durham, NC, United States. Electronic address:

Purpose: To determine whether hepatobiliary phase hypointensity, enhancing "capsule" and size provide prognostic information regarding the risk of progression to hepatocellular carcinoma (HCC), as well as the time to progression, of intermediate to high risk observations ≥ 10 mm with arterial phase hyperenhancement (APHE).

Method: This retrospective dual-institution study included 160 LR-3 and 26 LR-4 observations measuring more than 10 mm and having APHE in 136 patients (mean age [SD], 57 [11] years old). A composite reference standard of pathologic analysis and imaging follow-up was used. The prognostic performance of hepatobiliary phase hypointensity, enhancing "capsule" and size (cut-off: 20 mm) for the prediction of probability of progression to HCC and median time to progression to HCC was assessed and compared by means of Log-rank test, Cox-regression and Kaplan-Meier curves.

Results: 110 (59%) of 186 of observations progressed to HCC, 29.1% (32) progressed within 6 months, 60% (66) within 1 year and 84.5% (93) within 2 years. Hepatobiliary phase hypointensity was a significant predictor of progression to HCC (p < 0.0001, odds ratio: 20.62) but not of time to progression (p = 0.17). Median time to progression to HCC was 284 days [IQR: 266-363] and was shorter - though not significantly - for observations with enhancing "capsule" (118 days vs 301 days; p = 0.19).

Conclusions: Hepatobiliary phase hypointensity is an independent predictor of progression to HCC in intermediate to high risk APHE observations ≥ 10 mm.
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http://dx.doi.org/10.1016/j.ejrad.2020.109018DOI Listing
July 2020

Intraoperative imaging findings in transcranial MR imaging-guided focused ultrasound treatment at 1.5T may accurately detect typical lesional findings correlated with sonication parameters.

Eur Radiol 2020 Sep 28;30(9):5059-5070. Epub 2020 Apr 28.

Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

Objectives: To assess the intraoperative neuroimaging findings in patients treated with transcranial MR-guided focused ultrasound (tcMRgFUS) thalamotomy using 1.5T equipment in comparison with the 48-h follow-up.

Methods: Fifty prospectively enrolled patients undergoing unilateral tcMRgFUS thalamotomy for either medication-refractory essential tremor (n = 39) or Parkinson tremor (n = 11) were included. Two radiologists evaluated the presence and size of concentric lesional zones (zone I, zone II, and zone III) on 2D T2-weighted sequences acquired intraoperatively after the last high-energy sonication and at 48 h. Sonication parameters including number of sonications, delivered energy, and treatment temperatures were also recorded. Differences in lesion pattern and size were assessed using the McNemar test and paired t test, respectively.

Results: Zones I, II, and III were visualized in 34 (68%), 50 (100%), and 44 (88%) patients, and 31 (62%), 50 (100%), and 45 (90%) patients after the last high-energy sonication for R1 and R2, respectively. All three concentric zones were visualized intraoperatively in 56-58% of cases. Zone I was significantly more commonly visualized at 48 h (p < 0.001). Diameter of zones I and II and the thickness of zone III significantly increased at 48 h (p < 0.001). Diameters of zones I and II measured intraoperatively demonstrated significant correlation with thermal map temperatures (p ≤ 0.001). Maximum temperature significantly correlated with zone III thickness at 48 h. A threshold of 60.5° had a sensitivity of 56.5-66.7% and a specificity of 70.5-75.5% for thickness > 6 mm at 48 h.

Conclusions: Intraoperative imaging may accurately detect typical lesional findings, before completing the treatment. These imaging characteristics significantly correlate with sonication parameters and 48-h follow-up.

Key Points: • Intraoperative T2-weighted images allow the visualization of the zone I (coagulation necrosis) in most of the treated patients, while zone II (cytotoxic edema) is always detected. • Lesion size depicted with intraoperative transcranial MRgFUS imaging correlates well with procedure parameters. • Intraoperative transcranial MRgFUS imaging may have a significant added value for treating physicians.
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http://dx.doi.org/10.1007/s00330-020-06712-0DOI Listing
September 2020

Texture analysis on preoperative contrast-enhanced magnetic resonance imaging identifies microvascular invasion in hepatocellular carcinoma.

HPB (Oxford) 2020 Nov 27;22(11):1622-1630. Epub 2020 Mar 27.

Departments of Surgery and Radiology, Liver Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA.

Background: Radiomic texture analysis quantifies tumor heterogeneity. The aim of this study is to determine if radiomics can predict biologic aggressiveness in HCC and identify tumors with MVI.

Methods: Single-center, retrospective review of HCC patients undergoing resection/ablation with curative intent from 2009 to 2017. DICOM images from preoperative MRIs were analyzed with texture analysis software. Texture analysis parameters extracted on T1, T2, hepatic arterial phase (HAP) and portal venous phase (PVP) images. Multivariate logistic regression analysis evaluated factors associated with MVI.

Results: MVI was present in 52.2% (n = 133) of HCCs. On multivariate analysis only T1 mean (OR = 0.97, 95%CI 0.95-0.99, p = 0.043) and PVP entropy (OR = 4.7, 95%CI 1.37-16.3, p = 0.014) were associated with tumor MVI. Area under ROC curve was 0.83 for this final model. Empirical optimal cutpoint for PVP tumor entropy and T1 tumor mean were 5.73 and 23.41, respectively. At these cutpoint values, sensitivity was 0.68 and 0.5, respectively and specificity was 0.64 and 0.86. When both criteria were met, the probability of MVI in the tumor was 87%.

Conclusion: Tumor entropy and mean are both associated with MVI. Texture analysis on preoperative imaging correlates with microscopic features of HCC and can be used to predict patients with high-risk tumors.
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http://dx.doi.org/10.1016/j.hpb.2020.03.001DOI Listing
November 2020

CT imaging findings of abdominopelvic vascular compression syndromes: what the radiologist needs to know.

Insights Imaging 2020 Mar 17;11(1):48. Epub 2020 Mar 17.

Sezione di Scienze Radiologiche, Biomedicina, Neuroscienze e Diagnostica avanzata (BIND), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.

Abdominopelvic vascular compression syndromes include a variety of uncommon conditions characterized by either extrinsic compression of blood vessels by adjacent anatomical structures (i.e., median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome) or compression of hollow viscera by adjacent vessels (i.e., superior mesenteric artery syndrome, ureteropelvic junction obstruction, ureteral vascular compression syndromes, portal biliopathy). These syndromes can be unexpectedly diagnosed even in asymptomatic patients and the predisposing anatomic conditions can be incidentally discovered on imaging examinations performed for other indications, or they can manifest with atypical abdominal symptoms and acute complications, which may lead to significant morbidity if unrecognized. Although computed tomography (CT) is an accurate noninvasive technique for their detection, the diagnosis remains challenging due to the uncommon clinical presentation and often overlooked imaging features. Dynamic imaging may be performed in order to evaluate patients with inconstant symptoms manifesting in a specific position. The purposes of this paper are to review the CT imaging findings of abdominopelvic vascular compression syndromes, correlating with anatomical variants and to provide key features for the noninvasive imaging diagnosis.
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http://dx.doi.org/10.1186/s13244-020-00852-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7078419PMC
March 2020