Publications by authors named "Ulysses S Torres"

50 Publications

Reproducibility of MRI Features of Uterine Leiomyomas: A Study on Interobserver Agreement and Inter-Method Agreement With Surgery.

Can Assoc Radiol J 2021 Aug 16:8465371211038546. Epub 2021 Aug 16.

Department of Diagnostic Imaging, Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.

Purpose: To evaluate interobserver agreement in the interpretation of different MRI features of uterine leiomyomas (UL) according to observers' experience, and to assess the inter-method reproducibility (MRI versus surgery) regarding the International Federation of Gynecology and Obstetrics (FIGO) classification.

Methods: Retrospective study including UL patients who underwent MRI and surgical treatment. Four blinded observers (2 >10 years of experience) assessed UL regarding dimensions and volume; inner and outer mantles; FIGO classification; vascularization; degeneration; and diffusion-weighted imaging features. Uterine dimensions and volume were calculated. FIGO classification as ascertained by observers was compared to surgical findings. Intraclass correlation coefficient (ICC) estimates were used for interobserver comparison of numerical variables, and kappa statistic for categorical variables.

Results: Thirty-five patients (26y-73y) with 61 UL were included in the interobserver analyses, and 31 patients (54 UL) had available data allowing retrospective surgical FIGO classification for assessment of inter-method reproducibility. Both groups of observers had good to excellent agreement in assessing UL (ICC = 0.980-0.994) and uterine volumes (ICC = 0.857-0.914), mantles measurement (ICC = 0.797-0.920), and apparent diffusion coefficient calculation (ICC = 0.787-0.883). There was substantial agreement for both groups regarding FIGO classification (κ = 0.645-0.767). Vascularization, degeneration and restricted diffusion had lower agreement, varying from reasonable to moderate. Inter-method agreement was reasonable (κ = 0.341-0.395).

Conclusions: Interobserver agreement of MRI for UL was higher for quantitative than qualitative features, with a little impact of observers' experience for most features. MRI agreement with surgery was reasonable. Further efforts should be taken to improve interobserver and inter-method reproducibility for MRI in this scenario.
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http://dx.doi.org/10.1177/08465371211038546DOI Listing
August 2021

Critical preparedness and operational response actions directed for the acute and post-acute COVID-19 pandemic in Brazil: the experience of a nationwide outpatient healthcare group.

Medicine (Baltimore) 2021 Apr;100(15):e25495

Department of Radiology, Grupo Fleury, São Paulo, Brazil.

Abstract: While the new Coronavirus Disease 2019 (COVID-19) pandemic rapidly spread across the world, South America was reached later in relation to Asia, Europe and the United States of America (USA). Brazil concentrates now the largest number of cases in the continent and, as the disease speedily progressed throughout the country, prompt and challenging operational strategies had to be taken by institutions caring for COVID-19 and non-COVID-19 patients in order to assure optimal workflows, triage, and management. Although hospitals in the USA, Europe and Asia have shared their experience on this subject, little has been discussed about such strategies in South America or by the perspective of outpatient centers, which are paramount in the radiology field. This article shares the guidelines adopted early in the pandemic by a nationwide outpatient healthcare center composed by a network of more than 200 patient service centers and nearly 2,000 radiologists in Brazil, discussing operational and patient management strategies, staff protection, changes adopted in the fellowship program, and the effectiveness of such measures.
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http://dx.doi.org/10.1097/MD.0000000000025495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052010PMC
April 2021

Performance of imaging interpretation, intra- and inter-reader agreement for diagnosis of pelvic endometriosis: comparison between an abbreviated and full MRI protocol.

Abdom Radiol (NY) 2021 08 27;46(8):4025-4035. Epub 2021 Mar 27.

Grupo Fleury, Rua Cincinato Braga, 282, Bela Vista, São Paulo, SP, 01333-010, Brazil.

Purpose: To compare the performance of imaging interpretation, intra- and inter-reader agreement between an abbreviated (aMRI) and full (fMRI) MRI protocol for diagnosis of pelvic endometriosis.

Methods: Seventy consecutive fMRI exams performed under suspicion of pelvic endometriosis were selected. Four radiologists (Rd) (1-10 years experience) independently evaluated presence/absence of endometriosis at 9 anatomic sites (AS). The readers evaluated aMRI (coronal T2 TSE volumetric images and axial T1 GRE fat-sat without contrast, extracted from fMRI) and fMRI protocols randomly, with at least 4 weeks interval between readings. The degree of confidence for diagnosis at each AS was evaluated with a 1-3 Likert Scale (1: low; 3: high). Intra- and inter-reader agreement between protocols were evaluated by kappa statistics and took reading experience into account. The gold standard for assessing the performance of imaging interpretation (sensitivity, specificity and accuracy) used a consensus reading of two other Rd (> 15 years experience).

Results: There was no significant difference in the accuracy of imaging interpretation between the abbreviated (0.83-0.86) and full (0.83-0.87) protocols (p = 0.15). Intra-reader agreement between protocols ranged from substantial to almost perfect (0.74-0.96). A substantial inter-reader agreement was found for both protocols for readers with similar levels of experience (0.67-0.69) and in the global analysis (0.66 for both protocols). No difference was found in terms of degree of confidence between protocols, for all readers.

Conclusion: An abbreviated MRI protocol for pelvic endometriosis provided an accuracy of interpretation comparable to that of a complete protocol, with similar degrees of confidence and reproducibility, regardless the level of experience.
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http://dx.doi.org/10.1007/s00261-021-03052-5DOI Listing
August 2021

Structured MRI reporting increases completeness of radiological reports and requesting physicians' satisfaction in the diagnostic workup for pelvic endometriosis.

Abdom Radiol (NY) 2021 07 24;46(7):3342-3353. Epub 2021 Feb 24.

BP- A Beneficência Portuguesa de São Paulo, São Paulo, Brazil.

Purpose: MRI plays an important role in the diagnosis and surgical planning of pelvic endometriosis (PE), and imaging reports should contain all relevant information (completeness). As structured reports are being increasingly utilized, we aimed to evaluate whether structured MRI reporting increases the quality of reports regarding completeness and, consequently, their perceived value by gynecologists, in comparison to free-text reports. We also aimed to compare the diagnostic performance of both formats.

Methods: We retrospectively included 28 consecutive women with histologically proven PE who underwent MRI within one month before surgery. Two abdominal radiologists (Rd1/Rd2, 3y/12y experience), blinded to clinical and surgical data, individually elaborated free-text reports and, four months later, structured reports. Completeness (defined as description of six key anatomical sites deemed essential for surgical planning in a consensus of four-blinded external experts) and diagnostic performance (sensitivity and specificity) by site (histology as reference) were compared between reports using the McNemar test. The satisfaction of gynecologists was compared using the marginal homogeneity test.

Results: Structured reporting increased completeness for both Rd1 (rectosigmoid, retrocervical/uterosacral ligament, vagina, and ureter) and Rd2 (vagina, ureter, and bladder) (p < 0.05), without compromising sensitivity or specificity at any of the evaluated sites. Gynecologists' satisfaction was superior with structured reports in most comparisons.

Conclusion: Structured MRI reports perform better in fully documenting essential features of PE and are similar in terms of diagnostic performance, therefore having higher potential for surgical planning. Gynecologists found them easier to assess and were more satisfied with the information provided by structured reports.
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http://dx.doi.org/10.1007/s00261-021-02966-4DOI Listing
July 2021

HCC Detection on Surveillance US: Comparing Focused Liver Protocol Using US LI-RADS Technical Guidelines to a General Complete Abdominal US Protocol.

J Ultrasound Med 2021 Jan 19. Epub 2021 Jan 19.

Department of Diagnostic Imaging, Escola Paulista de Medicina, Universidade Federal de São Paulo-UNIFESP, São Paulo, Brazil.

Objective: Focused US examinations of the liver in the routine hepatocellular carcinoma (HCC) screening reduce the time spent on evaluating other structures deemed irrelevant to the clinical setting. It is still unknown, however, if such a strategy may additionally improve the frequency of nodules detection. We aimed to assess the impact of an HCC surveillance program in high-risk patients by means of targeted liver US following LI-RADS technical guidelines in comparison to a complete upper abdominal scan.

Methods: In this IRB-approved, single-center, prospective study, patients at high-risk for HCC enrolled from 06/2016 to 09/2019 were randomly assigned to 1 of the 2 institutional protocols: Group A (targeted liver US) or Group B (complete upper abdominal scan). Twenty examiners with similar experience in abdominal US were randomly assigned to perform the examinations exclusively in 1 of the groups (10 in each group). Frequency of hepatic nodules between groups was compared by using Fisher's exact test.

Results: Four hundred and sixty-five patients were enrolled, with no significant differences in both groups regarding sex, age, etiology of liver disease, MELD scores, and alpha-fetoprotein levels. A significantly higher frequency of nodules detection was found in Group A (230 patients; 23 nodules detected; 10% of the sample) in comparison to Group B (235 patients; 3 nodules; 1.3% of the sample) (p <.001). Five patients in Group A and 1 in Group B were positive for HCC after full diagnostic work-up.

Conclusion: Adopting an HCC screening program based on targeted liver US improved the detection of hepatic nodules among high-risk individuals.
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http://dx.doi.org/10.1002/jum.15637DOI Listing
January 2021

Ultrasound as a Valuable Imaging Modality in Sclerosing Lymphocytic Lobulitis: Imaging Features Based on a Retrospective Cohort Analysis of 51 Cases.

Can Assoc Radiol J 2021 Jan 18:846537120983122. Epub 2021 Jan 18.

Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, Brazil.

Purpose: Sclerosing lymphocytic lobulitis (SLL) is a rare benign breast condition usually associated with diabetes mellitus and whose imaging features have been assessed in few studies, limiting the adoption of diagnostic guidelines. We aimed to identify the main morphological features associated with SLL on imaging examinations (mainly ultrasound and mammography) and to retrospectively evaluate the role that each method played in the diagnostic workup (detection and indication for biopsy).

Methods: A retrospective study was conducted in a high-volume single center, encompassing 51 consecutive patients (100% female; 26-78 y; 43.7 ± 15.5 y) with histopathologically proven SLL (59 lesions; 0.5-6.1 cm).

Results: Most lesions (31/59; 53%) were found in asymptomatic individuals. Ultrasound detected 91.1% (51 out of 56 lesions assessed by this modality), of which 94.1% were non-circumscribed masses (BI-RADS® 4). Mammography detected 41.6% (15 out of 36 lesions assessed by this modality), with a predominance (80%) of non-calcified ones (masses, asymmetries and distortion). Two-year follow-up was achieved in 29 lesions (49%), showing complete remission (45%) or stability (41%) in most cases.

Conclusions: Most lesions in this retrospective sample have been detected by means of ultrasound and had their need for biopsy indicated by this modality. Female diabetic patients younger than 40 years presenting with a palpable lesion and a non-circumscribed mass on ultrasound could be submitted to core biopsy; histopathologic findings suggestive of SLL should be considered concordant in this scenario, with subsequent conservative treatment.
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http://dx.doi.org/10.1177/0846537120983122DOI Listing
January 2021

MRI as a complementary tool for the assessment of suspicious mammographic calcifications: Does it have a role?

Clin Imaging 2021 Jun 12;74:76-83. Epub 2021 Jan 12.

Department of Diagnostic Imaging, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.

Introduction: Mammography remains the standard imaging modality for the identification and characterization of breast calcifications. However, its low specificity results in high biopsy rates in cases of suspicious calcifications.

Objectives: To evaluate the diagnostic performance of MRI as an additional tool in the assessment of suspicious mammographic calcifications and to identify the enhancement patterns most related to malignancy.

Methods: An observational, prospective, cross-sectional, bi-centre study was conducted including consecutive patients with suspicious calcification groups on mammography (BI-RADS® 4 and 5). Anatomopathological results obtained from biopsies were considered the reference standard, and the patients were followed up for at least two years. MRI examinations were interpreted by two radiologists in consensus. The chi-square test was used to evaluate the correlation between MRI features and histological results. The overall diagnostic performance of MRI for malignancy was calculated.

Results: 162 female patients were included (mean age, 53 years; range 34-82 years), with 163 mammographic lesions, of which 77 (47.2%) were benign, 64 (39.3%) malignant, and 22 (13.5%) precursor lesions on histopathology. Malignant lesions demonstrated a significantly higher presence of enhancement (56/64; 87.5%) than benign lesions (17/77; 22.1%) (p < 0.001). Non-mass enhancement (NME) was the morphology most related to malignant lesions (38/56; 67.9%). The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of MRI for malignancy were 81.5%, 87.5%, 77.8%, 71.8%, and 90.5%, respectively.

Conclusion: MRI performed as an adjunct tool allows to increase imaging specificity for malignancy in suspicious calcifications, which may contribute to reduce the need for biopsy.
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http://dx.doi.org/10.1016/j.clinimag.2021.01.001DOI Listing
June 2021

Autoimmune hepatitis in practice, from diagnosis to complications: What is the role of imaging? A clinicoradiological review.

Clin Imaging 2021 Jun 5;74:31-40. Epub 2021 Jan 5.

Fleury Group, São Paulo, Brazil; Department of Diagnostic Imaging, Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease of unknown origin that can lead to liver cirrhosis, hepatocellular carcinoma (HCC), liver transplantation or death. The diagnosis is performed upon a multifactorial score. Treatment is based on the combination of immunosuppressants and aims at clinical, laboratory and histological remission, the latter being the most difficult to be achieved and proven. The absence of liver inflammation, defined by biopsy, is the main determinant in remission or therapeutic modification. Imaging exams have a limited role in this clinical management and the main findings are those related to chronic liver disease. Imaging's relevance, therefore, lies mainly in helping to exclude overlapping syndromes and in assessing complications related to cirrhosis, such as in screening for HCC. In recent years, however, the radiological literature has been witnessing increasing advances with regard to imaging biomarkers in liver disease, leading some authors to consider a future of virtual liver biopsy performed by magnetic resonance imaging. The present study aims to review the role of imaging in the management of AIH in the light of recent advances in the current literature and to provide an illustrated guide with the main findings described in the disease.
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http://dx.doi.org/10.1016/j.clinimag.2020.12.032DOI Listing
June 2021

Bosniak classification of cystic renal masses version 2019 does not increase the interobserver agreement or the proportion of masses categorized into lower Bosniak classes for non-subspecialized readers on CT or MR.

Eur J Radiol 2020 Oct 15;131:109270. Epub 2020 Sep 15.

Hospital Sao Paulo, Universidade Federal de Sao Paulo (UNIFESP) - R. Botucatu, 740 - Vila Clementino, São Paulo, SP, 04023-062, Brazil; Grupo Fleury - R. Cincinato Braga, 282 - Bela Vista, São Paulo, SP, 01333-910 Brazil.

Purpose: In a condition so prevalent as renal cysts, classifications should display satisfactory reproducibility not only among subspecialized readers. We aimed to compare the interobserver agreement of the Bosniak classification version 2019 (BC19) and current Bosniak classification (CBC) for non-subspecialized readers on CT and MRI and to verify whether BC19 leads to a downgrade of renal cystic masses when compared to CBC.

Methods: We evaluated 50 renal cystic masses in 47 patients on MR and CT (25 per method). Eighteen readers (nine third-year radiology residents and nine abdominal imaging fellows) assessed the images using BC19 and CBC with an eight-week interval. Kappa statistic was used to assess agreement. An average score of Bosniak categories across all raters evaluated if there was downgrading of lesions on BC19.

Results: The highest values of Kappa were found for fellows on CBC-MR (κ = 0.51), and the lowest values were found for residents on CBC-MR and fellows on BC19-MR (both κ = 0.36). On CBC, interobserver agreement was moderate for MR and CT (κ = 0.42 and 0.43, respectively), whereas on BC19, it was fair (κ = 0.38 and 0.40, respectively). The best agreements were in categories I (κ = 0.49-0.69) and IV (κ = 0.45-0.51). The poorest agreements occurred at IIF (κ = 0.18 on BC19-CT). There was a moderate median increase from CBC to BC19 in terms of Bosniak categories for both methods (MR [Z=-2.058, p = 0.040] and CT [Z=-2.509, p = 0.012]).

Conclusion: BC19, when compared to CBC, did not improve interobserver agreement nor diminished the proportion of masses categorized into lower Bosniak classes among non-subspecialized readers.
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http://dx.doi.org/10.1016/j.ejrad.2020.109270DOI Listing
October 2020

Higher frequency of hepatic steatosis at CT among COVID-19-positive patients.

Abdom Radiol (NY) 2020 Sep 18;45(9):2748-2754. Epub 2020 Jul 18.

Grupo Fleury, Rua Cincinato Braga, 282, Bela Vista, São Paulo, SP, 01333-010, Brazil.

Purpose: Recent studies have demonstrated that obesity is significantly associated with increased disease severity, hospitalizations and mortality in COVID-19, with a potential role in the pathogenesis and prevalence in the new pandemic. The association with hepatic steatosis, however, a condition closely related to obesity within the spectrum of systemic metabolic dysfunctions, remains to be elucidated. We aimed to evaluate the frequency of hepatic steatosis as incidentally detected in chest CT examinations of COVID-19 positive patients in comparison to non-infected controls.

Methods: A retrospective study was performed with 316 patients (204 RT-PCR positive; 112 RT-PCR negative and chest CT negative). Steatosis was measured with placement of a single ROI in the right lobe of the liver (segments VI-VII) and defined as a liver attenuation value ≤ 40 HU.

Results: The frequency of hepatic steatosis was higher in the RT-PCR positive group in comparison to controls (31.9% vs. 7.1%, p < 0.001). Logistic linear regression analysis showed a 4.7 times odds of steatosis in the COVID-19 positive group as compared to controls after adjusting for age and sex (OR 4.698; 95% IC 2.12-10.41, p < 0.001).

Conclusion: A significantly higher prevalence of steatosis was found among COVID-19 positive individuals. These findings are in accordance with other recent studies linking obesity and COVID-19 infection, as there is an intricate relationship between liver steatosis, metabolic syndrome and obesity. Further studies are required to confirm if such association remains after accounting for multiple variables, as well as possible relationships with disease severity and worst clinical outcomes.
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http://dx.doi.org/10.1007/s00261-020-02648-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368629PMC
September 2020

Imaging of male breast disease: the good, the bad and the ugly - A pictorial review.

Clin Imaging 2020 Dec 17;68:45-56. Epub 2020 Jun 17.

Grupo Fleury, São Paulo, Brazil; Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, Brazil.

The male breast is affected by a broad spectrum of conditions, ranging from benign to malignant, many of which are similar to those occurring in its female counterpart. Despite the challenge motivated by different imaging characteristic features, correct imaging interpretation in male breast disease may aid at differentiation between benign and suspected conditions, narrow the differential diagnosis and guide subsequent management. The purpose of this review is to showcase a wide array of male breast diseases, discuss their imaging presentations and key features for diagnosis.
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http://dx.doi.org/10.1016/j.clinimag.2020.06.025DOI Listing
December 2020

Emergency CT of abdominal complications of ingested fish bones: what not to miss.

Emerg Radiol 2021 Feb 6;28(1):165-170. Epub 2020 Jun 6.

Grupo Fleury, Rua Cincinato Braga, 282, Bela Vista, São Paulo, SP, 01333-010, Brazil.

Fish bones are the most commonly ingested structures and the most common cause of foreign body perforation of the gastrointestinal tract (GIT). Clinical presentation of foreign body GIT perforation is nonspecific, in many cases with clinical signs of acute abdomen, which can mimic appendicitis, diverticulitis, ulcer peptic disease, and other common inflammatory conditions. Besides, patients commonly do not refer that a fish bone was swallowed. Since this condition is usually not suspected by referring physicians of the emergency department (ED), radiologists play a key role in this diagnosis; the spectrum of these imaging features must be known in order to be accurately reported in the ED.
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http://dx.doi.org/10.1007/s10140-020-01800-6DOI Listing
February 2021

Pelvic hemorrhagic lesions in women: MRI findings and differential diagnosis.

Clin Imaging 2019 Dec 12;60(1):16-25. Epub 2019 Dec 12.

Grupo Fleury, Rua Cincinato Braga, 282, Bela Vista, São Paulo, SP 01333-010, Brazil. Electronic address:

A large spectrum of pathologic pelvic conditions can present with hemorrhage in structures or organs. These may present acutely, subacutely, chronically or as incidental findings. Clinical history and MRI characteristics can often narrow the differential diagnosis and guide management. The purpose of this article is to showcase a wide array of pelvic lesions, in which the presence of blood is a key imaging feature, and their differential diagnosis.
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http://dx.doi.org/10.1016/j.clinimag.2019.12.008DOI Listing
December 2019

The Mesenteric Organ: New Anatomical Concepts and an Imaging-based Review on Its Diseases.

Semin Ultrasound CT MR 2019 Dec 28;40(6):515-532. Epub 2019 Feb 28.

Department of Imaging, Universidade Federal de São Paulo, São Paulo, Brazil; Grupo Fleury, São Paulo, Brazil.

The proposal of reclassifying the mesentery as an organ prompts clinicians and radiologists to reappraise their approach to it and to mesenteric diseases (mesenteropathies). Recent updates in mesenteric anatomy and the better comprehension of its structure constitute a basis to push forward the process of disease management and allow the development of less radical (including endoscopic, radiological, and pharmacotherapeutic) treatments. Radiological evaluation currently plays a pivotal role in the noninvasive characterization of abdominal diseases. Mesenteric-based radiological assessments form an essential component in planning radiological interventions and postoperative surveillance programs. The purpose of this article, therefore, is to provide an update on the new anatomical concepts related to the mesentery, also performing an imaging-based review of mesenteric diseases by categorizing them as primary and secondary.
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http://dx.doi.org/10.1053/j.sult.2019.02.001DOI Listing
December 2019

The "streamline phenomenon" of the portal vein flow and its influence on liver involvement by gastrointestinal diseases: current concepts and imaging-based review.

Abdom Radiol (NY) 2020 02;45(2):403-415

Grupo Fleury, Rua Cincinato Braga, 282, Bela Vista, São Paulo, SP, 01333-010, Brazil.

The streamline flow in the portal system is a phenomenon by which blood from superior mesenteric vein goes preferentially to the right hepatic lobe, while splenic and inferior mesenteric veins divert preferentially to the left lobe. Such a phenomenon results in different patterns of distribution of several liver diseases. The purpose of this article is to discuss the concepts behind the theory of streamline flow and to perform an imaging-based review of representative cases, demonstrating how it may influence the patterns of liver involvement in different gastrointestinal diseases.
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http://dx.doi.org/10.1007/s00261-019-02335-2DOI Listing
February 2020

Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: Systematic review and meta-analysis.

PLoS One 2019 9;14(4):e0214842. Epub 2019 Apr 9.

Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil.

Introduction: Intestinal endometriosis is considered the most severe form of deep endometriosis, the rectosigmoid being involved in about 90% of cases of bowel infiltration. Transvaginal sonography (TVS) and magnetic resonance imaging (MRI) have been used for noninvasive diagnosis and preoperative mapping of rectosigmoid endometriosis (RE), but no consensus has been reached so far regarding which method is the most accurate in this setting.

Objective: We aimed at performing a systematic review and meta-analysis to compare the accuracy of TVS versus MRI in the diagnosis of RE in a same population.

Methods: A systematic review was conducted in accordance with the PRISMA guidelines. Studies were identified by searching the MEDLINE, Embase, and LILACS databases, as well the reference lists of retrieved articles, through February 2019. We included all cross-sectional studies that evaluated the accuracy of TVS versus MRI in the diagnosis of RE within a same sample of subjects and that used surgical findings with histological confirmation as the gold standard. The QUADAS-2 instrument was used to evaluate study quality. Sensitivity, specificity, positive likelihood ratios (LR+), and negative likelihood ratios (LR-) for the diagnosis of RE were calculated. This study is registered with PROSPERO, number CRD42017064378.

Results: Eight studies (n = 1132) were included in the meta-analysis. The pooled sensitivity, specificity, LR+, and LR- values of MRI for RE were 90% (95% CI, 87-92%), 96% (95% CI, 94-97%), 17.26 (95% CI, 3.57-83.50), and 0.15 (95% CI, 0.10-0.23); values of TVS were 90% [95% CI, 87-92%], 96% (95% CI, 94-97%), 20.66 (95% CI, 8.71-49.00) and 0.12 (95% CI, 0.08-0.20), respectively. Areas under the S-ROC curves (AUC) showed no statistically significant differences between MRI (AUC = 0.948) and TVS (AUC = 0.930) in the diagnosis of RE (P = 0.13). Moreover, considering the average prevalence among the studies of 47.3%, both methods demonstrated similarly high positive post-test probabilities (93.9% for TVS and 94.8% for MRI), and the combined use of them yielded a post-test probability of 99.6%.

Conclusion: MRI and TVS have similarly high accuracy and positive post-test probabilities in the noninvasive diagnosis of RE. Combination of MRI and TVS may increase even further the positive post-test probabilities to near 100%.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214842PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456198PMC
January 2020

CT-guided Transthoracic Core-Needle Biopsies of Mediastinal and Lung Lesions in 235 Consecutive Patients: Factors Affecting the Risks of Complications and Occurrence of a Final Diagnosis of Malignancy.

Arch Bronconeumol (Engl Ed) 2019 Jun 5;55(6):297-305. Epub 2018 Dec 5.

Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil.

Objective: To assess the impact of patient-, lesion- and procedure-related factors on the risks of complications and final diagnosis of malignancy in PCNB of mediastinal and lung lesions.

Material And Methods: We studied a large single-center cohort of 235 consecutive patients (66.8% men; 58.5±18.0 years) with a range of thoracic benign and malignant lesions, who underwent PCNB performed along 24 months by a single experienced radiologist. Diagnostic accuracy analyses of PCNB for malignancy were performed, as well as estimations of relative risk and logistic regression models in order to assess possible associations between such factors and malignancy/complications.

Results: 155 lesions (65.9%) were diagnosed as malignant. Overall accuracy was 91.1%, with sensitivity of 87.1%, specificity of 98.8%, positive predictive value of 99.3%, and negative predictive value of 79.8%. Pneumothorax (49/235; 20.8%) and hemorrhage (37/235; 15.7%) were the most common complications. Emphysema, smoking, older age, intrapulmonary location, deeper location, smaller size, presence of cavitations and irregular contours of the lesions, and smaller needle-pleural angles were the most consistent factors related to the occurrence of complications. Emphysema, older age, smoking, solid and deeper lesions were also significantly associated with a final diagnosis of malignancy after PCNB.

Conclusion: CT-guided PCNB of mediastinal and lung lesions is a safe procedure with high diagnostic accuracy for malignancy.
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http://dx.doi.org/10.1016/j.arbres.2018.09.021DOI Listing
June 2019

Cavernous Hemangioma Between the Elastomer and Fibrous Capsule of a Breast Implant.

Aesthetic Plast Surg 2018 Oct 5;42(5):1257-1260. Epub 2018 Jun 5.

Grupo Fleury, Rua Cincinato Braga, 282, Bela Vista, São Paulo, SP, 01333-910, Brazil.

Hemangiomas are described in many locations, but breast hemangioma (BH) is rare, accounting for only 0.4% of all breast tumors. These tumors are difficult to diagnose preoperatively using conventional imaging modalities because they lack pathognomonic characteristics. Mammographic and sonographic appearances of BH were described in just a few case reports, and breast implant-related hemangiomas are even rarer. We report a case of the tumor arising in an atypical location-between the elastomer and fibrous capsule of a breast implant.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-018-1153-7DOI Listing
October 2018

Computed Tomography and Magnetic Resonance Imaging Findings of Inflammatory Pseudotumors in the Abdomen and Pelvis: Current Concepts and Pictorial Review.

Semin Ultrasound CT MR 2018 Apr 21;39(2):220-229. Epub 2017 Sep 21.

Grupo Fleury, São Paulo, Brazil; Department of Imaging, Universidade Federal de São Paulo, São Paulo, Brazil.

The group of inflammatory pseudotumors (IPTs) encompasses a variety of rare neoplastic and nonneoplastic entities described to occur in almost every location in the body and whose clinical features and aggressive imaging findings (varying from infiltrative to mass-forming lesions), frequently mimic those of malignant tumors. The radiologic features of IPTs are variable and nonspecific, the imaging findings depending on the body location and involved organ. Abdominopelvic IPTs are rare and the purposes of this review, therefore, are to familiarize the radiologist with the wide spectrum of computed tomography and magnetic resonance imaging findings of IPTs in various locations throughout the abdomen and pelvis, discussing the imaging features that allow consideration of IPTs in the differential diagnosis of soft-tissue masses within the pertinent clinical setting. Radiologists should be aware of this group of entities, as a preoperative histopathologic diagnosis upon radiological suspicion may help to differentiate IPTs from malignancy and to allow the most appropriate clinical work-up for these patients.
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http://dx.doi.org/10.1053/j.sult.2017.09.005DOI Listing
April 2018

Common and Uncommon Benign Pancreatic Lesions Mimicking Malignancy: Imaging Update and Review.

Semin Ultrasound CT MR 2018 Apr 26;39(2):206-219. Epub 2017 Oct 26.

Grupo Fleury, São Paulo, Brazil; Department of Imaging, Universidade Federal de São Paulo, São Paulo, Brazil.

There is a broad range of inflammatory, pseudotumoral, and benign lesions that may masquerade as pancreatic malignancies, often representing a challenge to the radiologist. Unawareness of these entities can lead to inadequate differential diagnoses or misdiagnosis, with important prognostic and therapeutic consequences. The purpose of this article is to revisit a spectrum of lesions, varying from common to exceedingly rare nonmalignant, that may mimic malignant pancreatic neoplasms on imaging, identifying relevant features that may contribute to reaching the correct diagnosis. Representative cases include focal fatty replacement, intrapancreatic accessory spleen, pancreatic lobulation, lipoma, autoimmune pancreatitis, focal pancreatitis, eosinophilic pancreatitis, groove pancreatitis, hemangioma, intrapancreatic aneurysm, tuberculosis, and Castleman's disease.
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http://dx.doi.org/10.1053/j.sult.2017.10.002DOI Listing
April 2018

Pneumatosis From Esophagus to Rectum: A Comprehensive Review Focusing on Clinico-Radiological Differentiation Between Benign and Life-Threatening Causes.

Semin Ultrasound CT MR 2018 Apr 9;39(2):167-182. Epub 2017 Sep 9.

Grupo Fleury, São Paulo, Brazil; Department of Imaging, Universidade Federal de São Paulo, São Paulo, Brazil.

Pneumatosis of the alimentary tract may occur from the esophagus to rectum as a result of a wide spectrum of conditions that range from benign to life-threatening. Although distinguishing between these 2 groups is of paramount importance for an appropriate clinical management, it still remains a challenge for the radiologist in the daily practice. In the light of the current literature, we provide in the present article a comprehensive review focusing on the clinical, laboratory, and radiological findings that most consistently may allow such a differentiation. We also provide a pictorial essay illustrating this range of diagnoses, briefly discussing each one.
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http://dx.doi.org/10.1053/j.sult.2017.09.002DOI Listing
April 2018

Post-imaging colorectal cancer or interval cancer rates after CT colonography: a systematic review and meta-analysis.

Lancet Gastroenterol Hepatol 2018 05 19;3(5):326-336. Epub 2018 Feb 19.

St Mark's Academic Institute, St Mark's Hospital, Harrow, London, UK.

Background: CT colonography is highly sensitive for colorectal cancer, but interval or post-imaging colorectal cancer rates (diagnosis of cancer after initial negative CT colonography) are unknown, as are their underlying causes. We did a systematic review and meta-analysis of post-CT colonography and post-imaging colorectal cancer rates and causes to address this gap in understanding.

Methods: We systematically searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. We included randomised, cohort, cross-sectional, or case-control studies published between Jan 1, 1994, and Feb 28, 2017, using CT colonography done according to international consensus standards with the aim of detecting cancer or polyps, and reporting post-imaging colorectal cancer rates or sufficient data to allow their calculation. We excluded studies in which all CT colonographies were done because of incomplete colonoscopy or if CT colonography was done with knowledge of colonoscopy findings. We contacted authors of component studies for additional data where necessary for retrospective CT colonography image review and causes for each post-imaging colorectal cancer. Two independent reviewers extracted data from the study reports. Our primary outcome was prevalence of post-imaging colorectal cancer 36 months after CT colonography. We used random-effects meta-analysis to estimate pooled post-imaging colorectal cancer rates, expressed using the total number of cancers and total number of CT colonographies as denominators, and per 1000 person-years. This study is registered with PROSPERO, number CRD42016042437.

Findings: 2977 articles were screened and 12 studies were eligible for analysis. These studies reported data for 19 867 patients (aged 18-96 years; of 11 590 with sex data available, 6532 [56%] were female) between March, 2002, and May, 2015. At a mean of 34 months' follow-up (range 3-128·4 months), CT colonography detected 643 colorectal cancers. 29 post-imaging colorectal cancers were subsequently diagnosed. The pooled post-imaging colorectal cancer rate was 4·42 (95% CI 3·03-6·42) per 100 cancers detected, corresponding to 1·61 (1·11-2·33) post-imaging colorectal cancers per 1000 CT colonographies or 0·64 (0·44-0·92) post-imaging colorectal cancers per 1000 person-years. Heterogeneity was low (I=0%). 17 (61%) of 28 post-imaging colorectal cancers were attributable to perceptual error and were visible in retrospect.

Interpretation: CT colonography does not lead to an excess of post-test cancers relative to colonoscopy within 3-5 years, and the low 5-year post-imaging colorectal cancer rate confirms that the recommended screening interval of 5 years is safe. Since most post-imaging colorectal cancers arise from perceptual errors, radiologist training and quality assurance could help to reduce post-imaging colorectal cancer rates.

Funding: St Mark's Hospital Foundation and the UK National Institute for Health Research via the UCL/UCLH Biomedical Research Centre.
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http://dx.doi.org/10.1016/S2468-1253(18)30032-3DOI Listing
May 2018

Is liver perfusion CT reproducible? A study on intra- and interobserver agreement of normal hepatic haemodynamic parameters obtained with two different software packages.

Br J Radiol 2017 Oct 22;90(1078):20170214. Epub 2017 Aug 22.

1 Department of Imaging, Universidade Federal de São Paulo, São Paulo, Brazil.

Objective: To evaluate the agreement between the measurements of perfusion CT parameters in normal livers by using two different software packages.

Methods: This retrospective study was based on 78 liver perfusion CT examinations acquired for detecting suspected liver metastasis. Patients with any morphological or functional hepatic abnormalities were excluded. The final analysis included 37 patients (59.7 ± 14.9 y). Two readers (1 and 2) independently measured perfusion parameters using different software packages from two major manufacturers (A and B). Arterial perfusion (AP) and portal perfusion (PP) were determined using the dual-input vascular one-compartmental model. Inter-reader agreement for each package and intrareader agreement between both packages were assessed with intraclass correlation coefficients (ICC) and Bland-Altman statistics.

Results: Inter-reader agreement was substantial for AP using software A (ICC = 0.82) and B (ICC = 0.85-0.86), fair for PP using software A (ICC = 0.44) and fair to moderate for PP using software B (ICC = 0.56-0.77). Intrareader agreement between software A and B ranged from slight to moderate (ICC = 0.32-0.62) for readers 1 and 2 considering the AP parameters, and from fair to moderate (ICC = 0.40-0.69) for readers 1 and 2 considering the PP parameters.

Conclusion: At best there was only moderate agreement between both software packages, resulting in some uncertainty and suboptimal reproducibility. Advances in knowledge: Software-dependent factors may contribute to variance in perfusion measurements, demanding further technical improvements. AP measurements seem to be the most reproducible parameter to be adopted when evaluating liver perfusion CT.
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http://dx.doi.org/10.1259/bjr.20170214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5853353PMC
October 2017

Non-contrast MR angiography using three-dimensional balanced steady-state free-precession imaging for evaluation of stenosis in the celiac trunk and superior mesenteric artery: a preliminary comparative study with computed tomography angiography.

Br J Radiol 2017 Jul 7;90(1075):20170011. Epub 2017 Jun 7.

1 Department of Diagnostic Imaging, Federal University of São Paulo (Universidade Federal de São Paulo-UNIFESP), Paulista School of Medicine, São Paulo, Brazil.

Objective: Although non-contrast MR angiography (NC-MRA) is well established for the evaluation of renal artery stenosis, its usefulness in the evaluation of other abdominal aortic branches remains to be studied. This study aimed at evaluating the image quality and diagnostic accuracy of NC-MRA using a three-dimensional balanced steady-state free-precession sequence in identifying stenosis in the celiac trunk (CTR) and superior mesenteric artery (SMA) as compared with CT angiography (CTA) as the reference standard.

Methods: 41 patients underwent both NC-MRA and CTA of the abdominal aorta. Two radiologists analyzed the quality of the images (diagnostic vs non-diagnostic) and the performance (accuracy, sensitivity and specificity) of NC-MRA for the identification of arterial stenosis. Kappa tests were used to determine the interobserver agreement and the intermethod agreement between NC-MRA and CTA.

Results: NC-MRA provided diagnostic quality images of the CTR and SMA in 87.8% and 90.2% of cases, respectively, with high interobserver agreement (kappa 0.95 and 0.80, respectively). For stenosis assessment, NC-MRA had a sensitivity of 100%, a positive-predictive value of 50% and a negative-predictive value of 100% for both segments, with accuracies of 88.8% for the CTR and 94.5% for the SMA.

Conclusion: NC-MRA is an accurate method for detecting stenosis in the CTR and SMA. Advances in knowledge: Data from this study suggest that MR angiography with balanced steady-state free-precession sequence is a viable non-contrast alternative for stenosis evaluation of these branches in patients for whom a contrast-enhanced examination is contraindicated.
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http://dx.doi.org/10.1259/bjr.20170011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594983PMC
July 2017

Prevalence and risk factors for post-investigation colorectal cancer ("interval cancer") after computed tomographic colonography: protocol for a systematic review.

Syst Rev 2017 02 21;6(1):36. Epub 2017 Feb 21.

St. Mark's Academic Institute, St. Mark's Hospital, Harrow, UK.

Background: Colorectal cancer (CRC) is a common and important disease. There are different tests for diagnosis, one of which is computed tomographic colonography (CTC). No test is perfect, and patients with normal CTC may subsequently develop CRC (either because it was overlooked originally, or because it has developed in the interim). This is termed post-investigation colorectal cancer (PICRC) or "interval cancer". How frequently this occurs after CTC is not known. The purpose of this systematic review and meta-analysis is to use the primary literature to estimate the PICRC rate after CTC, and explore associated factors.

Methods: Primary studies reporting post-investigation colorectal cancer (PICRC) rates after CTC will be identified from PubMed, Embase and Cochrane Register of Controlled Trials databases. Peer-reviewed studies published after 1994 (the year CTC was introduced) will be included and the rate of PICRC within 36 months of CTC recorded. Data will be extracted from selected studies for a random effects meta-analysis. Heterogeneity, risk of bias and publication bias will be assessed, and exploratory analysis will examine factors associated with higher PICRC rates in the literature.

Conclusion: PICRC rates are the ultimate benchmark of diagnostic quality for colonic investigations. This systematic review and meta-analysis will identify and synthesise evidence to determine PICRC rates after CTC and explore factors that may contribute to higher rates.

Systematic Review Registration: PROSPERO (registration number CRD42016042437 ).
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http://dx.doi.org/10.1186/s13643-017-0432-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5320676PMC
February 2017
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