CT in oncology: the evaluation of response to treatment

Diagnostic and Interventional Radiology, University of Pisa, Italy, The IVth Congress of Radiology and Medical Imaging of the Republic of Moldova with international participation, Chisinau, May 31 – June 2, 2018Background: In the last decades, cancer treatment has increased in complexity and cost, therefore a careful monitoring of the response to treatment has become increasingly relevant in our clinical practice. Content: In this presentation the discussion will focus on a few clinical examples able to give an overview of the state-of-the art in cancer treatments and of the most relevant issues in the evaluation of the response to treatment, with particular reference to the role of computed tomography (CT). Patient series of different oncologic subspecialties will be also analyzed, highlighting challenges and opportunities in terms of the use of CT for assessing the response to treatment. The materials will be put in a clinical perspective to give practical guidance to the participating physicians. Conclusions: The presentation aims will be achieved if the participating physicians will improve their knowledge of the most relevant issues in the evaluation of the response to oncologic treatments

Emergency radiology without the radiologist: the forensic perspective

Purpose. The aim of this paper is to describe two cases from the authors\u27 forensic archive database in which teleradiology was related to unfavourable outcomes. Material and methods. Two patients underwent autopsy after unexpected death following road accidents. In one case, death was caused by multiple cervical fractures following minor neck injury in the presence of diffuse idiopathic skeletal hyperostosis. In the other case, death was due to delayed isthmic aortic rupture occurring after thoracic blunt trauma in a young adult. Both conditions were diagnosed at autopsy only. Results. In both cases, the lethal outcome was due to the failure to obtain radiological reports of the X-rays performed in the emergency department. Radiological diagnoses could have been established by activating the teleradiology service which, according to the hospitals\u27 teleradiology protocols, is available on demand in cases of emergency only, as selected by the physician requesting the service. Conclusions. These cases suggest the high risk of excluding the radiologist from the management of patients whose images are transmitted via a teleradiology system.Obiettivo. Gli autori intendono descrivere due casi tratti dal proprio archivio autoptico medico-legale nei quali l\u27esito sfavorevole ? connesso all\u27uso della teleradiologia. Materiali e metodi. Sono descritte le risultanze dell\u27indagine autoptica eseguita su due soggetti deceduti in maniera inattesa dopo incidente della strada. In un caso la morte ? dipesa da fratture cervicali multiple determinatesi, in soggetto affetto da DISH (iperostosi scheletrica idiopatica diffusa), per un trauma minore del collo. Nel secondo caso un giovane adulto riportava una contusione del torace con "rottura in due tempi" dell\u27istmo aortico. Entrambe le patologie traumatiche sono state diagnosticate solo in sede di esame autoptico. Risultati. La mancata diagnosi in vita ha tratto origine, in entrambi i casi, dalla "non refertazione" degli esami radiologici eseguiti in urgenza; la diagnosi radiologica avrebbe potuto effettuarsi mediante attivazione del sistema di teleradiologia, utilizzabile, secondo il protocollo gestionale della struttura, solo in casi urgenti, selezionati dal medico richiedente la prestazione. Conclusioni. Questi due casi suggeriscono che l\u27esclusione del radiologo dalla gestione dei pazienti le cui immagini sono trasmesse in teleradiologia comporta un rischio molto elevato di prestazioni inadeguate

RICKETS AT THE MEDICI COURT OF FLORENCE: THE CASE OF DON FILIPPINO (1577-1582)

Among the children found in the crypt of the Grand Duke Giangastone in S. Lorenzo Basilica (Florence), the skeletal remains of a 5-year-old child still wearing his fine high social status clothing were recovered. This child of the Medici family was identified as Don Filippino (1577-1582), son of the Grand Duke Francesco I (1541-1587) and Giovanna from Austria (1547-1578). The prince showed several pathological deformities of the cranial and post-cranial skeleton, including enlargement of the cranium, thinning of the cranial vault bones (craniotabes), platybasia and marked bending of femora, tibiae and fibulae. Differential diagnosis suggests that Don Filippino was affected by rickets. The occurrence of this metabolic disease related to vitamin D deficiency in a Renaissance high social class individual can be explained by the practice of very prolonged breast-feeding, up until to sunlight. Historical sources describe Don Filippino as frail and sickly, with frequent illnesses and persistent slight fevers, and it can be supposed that the child was frequently confined indoors, especially in the cold season. Integration of osteoarchaeological evidence with historical documentation suggests that bone lesions observed in the skeletal remains of Don Filippino are compatible with a diagnosis of rickets, caused by the custom of prolonged breast-feeding associated with inadequate sunlight exposure two years of age. Maternal milk contains insufficient vitamin D ratios and retarded weaning severely exposes children to a higher risk of developing rickets, especially if dietary habits are combined with inadequate exposure

A possible case of Garre's sclerosing osteomyelitis from Medieval Tuscany (11th-12th centuries)

tArchaeological excavations carried out at the castle of Monte di Croce near Florence brought to light asmall cemetery complex belonging to the castle church, dated back to the 11th–12th centuries. An elitestone tomb contained the skeletal remains of a male aged 35–45 years with obvious pathology of theright tibia. The proximal metaphysis and the upper half of the diaphysis appear massively enlarged as aresult of severe chronic periostitis. A transverse section illustrates complete obliteration of the medullarycavity by new spongy bone, with some large cavitations. The primary, but completely remodeled tibialshaft is still recognizable. This finding and the strong sclerotic reaction with some central cavitationsrule out any form of bone tumor and indicate a chronic inflammatory disease. The morphological andradiological picture and the tibial localization suggest a diagnosis of chronic sclerosing osteomyelitis ofGarré, a rare form of chronic osteomyelitis characterized by an intense periosteal reaction with little orno suppuration

The skulls of Borgo Cerreto (Perugia): medical, surgical, and anatomical activity of Baronio Vincenzi (XVII century)

In the Sixties of the last century the vault of a 17th century private chapel was opened, revealing three isolated skulls with evidence of surgical and anatomical activity. The chapel was built by Baronio Vincenzi, who lived and practiced medicine in Borgo Cerreto, a village in the province of Perugia, between the 16th and the 17th century. The skull bc 01 belongs to an adult male, aged 25-35 years. It shows a hole on the left front-parietal region (30 x 31 mm), that can be identified as the result of a skull trepanation. The margins of the lesion are regularly smoothed and inclined internally and the diplopic tissues result almost completely obliterated by a cicatricial bone. A bone splinter (10 x 8 mm), completely reabsorbed, can be observed on the right side of the hole. These findings are the proof of a long survival of the subject. X-ray examination confirms a regular process of ossification, without infection. Trepanation was performed with a Hippocratic trypanon, largely used in cranial surgery of Modern Age. The specimen bc 02 is without skullcap and the right upper part of the face; it belongs to an adult male, 25-30 years aged. The cuts were produced by a bone saw with a thin blade. The choice of these regions suggests the willingness to study the basal skull, the right eye cavity and the paranasal sinuses. The skull bc 03 consists only in a skullcap of an adult individual, which shows the signs of a bone saw. In conclusion, the recovery of a trepanned skull, at present the first specimen of this type recovered so far in Umbria, together with two others skulls with the signs of postmortem examination, inside the Vincenzi family vault can be probably related to the professional activity of Baronio. He was an experienced surgeon and a skilled anatomist, who certainly experienced the empirical surgery of the nearby surgical School of Preci, famous throughout Europe for the treatment of urinary bladder stones, cataract as well as the ability in skull trepanation

A Case of Gout from Imperial Rome (1st-2nd Century AD)

The study of pathological alterations in ancient skeletal remains may contribute to the reconstruction of the history of diseases and health conditions of ancient populations. Therefore, in recent research palaeopathology provides an important point of view in bioarchaeology and medicine. This work describes the bone alterations observed in the skeleton of an adult woman found during archaeological excavations in the greatest necropolis of the Imperial Age in Rome. The skeletal remains showed some pathological anomalies and the most evident alterations consisted of multiple osteolytic lesions involving mainly the small bones of the feet, which presented round cavitations and scarce signs of bone repair. Differential diagnosis suggests that this individual was affected by gout, probably associated with hypothyroidism that determined her short stature

Comparative structural analysis of polyurethane and silicone catheters of totally implantable venous access devices by micro-computed tomography

Objectives: To investigate microstructural alterations of explanted long-term central venous catheters of totally implantable venous access devices, using micro-computed tomography. Methods: A total of 16 catheters (9 made of silicone and 7 made of polyurethane), all non-fractured, have been analyzed in this study. Eight catheters were implanted for an average duration of 994 days (min-max: 98-2731 days), while the remaining eight catheters (four for each material, forming the SIref and PUref control groups) were analyzed before implant and used as a reference. X-ray micro-computed tomography was used to reconstruct the three-dimensional geometry of selected segments of each catheter (ca. 10 cm per sample). Results: Morphometric analysis of the catheters revealed increases wall thickness and section area in the polyurethane group as compared with the reference central venous catheters of the same materials (wall thickness: 403 ± 12 μm in the polyurethane (PU) group vs 382 ± 4 μm in PUref, p = 0.014; wall cross-section area: 2.04 ± 0.09 mm2 in PU vs 1.91 ± 0.03 mm2 in PUref, p = 0.04), whereas implanted silicone catheters showed a larger luminal cross section as compared with their controls (lumen cross-section area = 0.851 ± 0.020 mm2 in silicone (SI) group vs 0.811 ± 0.007 mm2 in SIref, p = 0.007). All analyzed samples in this study presented some type of alteration in the catheter walls, namely, hyperdense spots (below 0.1 mm size), air gaps/bubbles and displacements of inner and outer axes causing heterogeneous wall thickness. The incidence of air gaps showed no difference with respect to both material type and duration of implant, whereas the SI group revealed more hyperdense spots as compared to all other groups. Conclusion: Morphological change and local structural alteration can occur in both silicone and polyurethane catheters. This evidence suggests the need for further studies connecting those morphological changes with modification of mechanical robustness, which ultimately can play a role for patient safety

Noise reduction and spatial resolution in CT imaging with the ASIR iterative reconstruction algorithm at different doses and contrasts – a phantom study

Aims and objectives The aim of this study was to quantitatively assess noise reduction and spatial resolution in computed tomography (CT) imaging with the ASIR (Adaptive Statistical Iterative Reconstruction, GE Healthcare) reconstruction algorithm at different kVp, mAs and contrasts. Methods and materials Acquisitions of the Catphan-504 phantom were performed on a PET/CT scanner (Discovery-710, GE Healthcare). CT images were reconstructed using both filtered back projection (FBP) and ASIR with different percentages of reconstruction (20%, 40%, 60%, 80%, 100%). The image noise was estimated for different values of scanning parameters (i.e. tube-load, kilovoltage, pitch, slice thickness). Then, 3D/2D/1D noise power spectrum was estimated. Also, spatial resolution was assessed by obtaining the modulation transfer function (MTF) for a wide range of scanning parameters values and different contrast objects by the circular Edge Spread Function method (using CTP404 modulus) and the Point Spread Function method (using CTP528 modulus). . Results Image noise decreased (up to 50% as compared to FBP) with increasing the percentage of ASIR reconstruction (behaviour more relevant for higher spatial frequencies). Only for low tube load (<56 mAs) and low contrast objects (polistirene with respect to PMMA) acquisitions, MTF analysis showed that ASIR-reconstructed images were characterized by an appreciable reduction in spatial resolution, when compared to FBP-reconstructed images. Conclusion When compared to FBP, ASIR allows a relevant noise reduction without appreciably affecting image quality, except for very low dose and contrast acquisitions