A rare case of extrahepatic cholangiocarcinoma – a multidisciplinary approach

Department of Radiology and Medical Imaging, Department of Rheumatology, Departament of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania, The IVth Congress of Radiology and Medical Imaging of the Republic of Moldova with international participation, Chisinau, May 31 – June 2, 2018Background: Bile duct carcinoma is an extremely aggressive and rare primary hepatobiliary malignancy affecting nearly 1-2/100,000 people in most countries in Europe. Biliary tract malignancies located in the distal third of the common bile duct (CBD) account for approximately 17-18% of all cholangiocarcinomas. This report aims to provide a step-by-step evaluation of a rare case of cholangiocarcinoma. Content: The current report focuses on a 65-year-old male patient who was presented to the emergency department with signs and symptoms suggestive for a biliary tract obstruction. An intense cooperation between multiple departments was required in order to perform a complete and accurate evaluation of the patient. Initially, the patient underwent an abdominal Ultrasonography (US), followed by an abdominal and pelvic Computed Tomography (CT), which revealed an intraductal tumor affecting the distal CBD. Furthermore, the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) in order to provide tissue samples and to perform a dilatation of the CBD in the affected area. The histopathology report confirmed the malignant nature of the lesion describing it as an adenocarcinoma. The surgeons performed a pancreaticoduodenectomy (Whipple procedure), managing to achieve negative tumor resection margins. However, the patient developed several complications that required multiple surgical reinterventions. Conclusions: This report presents a fully investigated less common type of cholangiocarcinoma, highlighting the principles of diagnosis and management as well as of a multidisciplinary approach in such patients

Quantitative evaluation of fatty liver using spectroscopic sequence – correlation between Magnetic Resonance Spectroscopy and histopathology

Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, Craiova, Romania, The IVth Congress of Radiology and Medical Imaging of the Republic of Moldova with international participation, Chisinau, May 31 – June 2, 2018Introduction: La stéatose hépatique entraîne l’accumulation des lipides dans les hépatocytes. La tomographie computerisée (CT) et l’échographie (US) peuvent évaluer qualitativement la graisse du foie. La technique d’imagerie la plus précise en termes de quantification de la stéatose hépatique est la Spectroscopie par Résonance Magnétique (MRS). L’objectif de l’étude était de valider le rôle de MRS 3T dans l’évaluation quantitative de la stéatose hépatique. Matériel et méthodes: Le foie de 33 patients a été évalué qualitativement par des tests de laboratoire et d’échographie. Tous les patients ont été étudiés avec une 3T haute résolution IRM, constituée de séquences en phase, déphasées et de séquences spécifiques pour la steatose en T1 pondérées, ainsi que des séquences en T2 pondérées et de séquences de spectroscopie. L’évaluation qualitative a été réalisée en utilisant la fraction de graisse calculée manuellement après l’analyse par spectroscopie. La stéatose a été classée 0 = jusqu’à 10%, grade 1 = 10-33%, grade 2 = 34-66%, grade 3 = ≥67%. La biopsie hépatique a été réalisée chez des patients opérés pour différentes pathologies. Résultats: Limitée par un petit nombre de patients et par les manoeuvres chirurgicales invasives de la biopsie hépatique, l’étude montre que cinq patients présentaient une stéatose classée en grade 0, treize – en grade 1, six – en grade 2 et un – en grade 3, offrant une bonne corrélation entre MRS et histopathologie. Conclusions: En dépit d’être une étude pilote, nous pouvons conclure que MRS est une technique non invasive efficace qui peut être extrêmement utile dans le diagnostic et la quantification de la stéatose hépatique.Background: Hepatic steatosis results in the accumulation of lipids within hepatocytes. Computed Tomography (CT) and Ultrasound (US) can qualitatively assess liver fat. The most accurate imaging technique in terms of quantifying hepatic steatosis is Magnetic Resonance Spectroscopy (MRS). The study aimed to validate the role of 3T MRS in quantitative assessment of liver steatosis. Material and methods: The liver of 33 patients was qualitatively assessed through lab and ultrasound tests. All patients were investigated with a 3T high resolution MRI consisting of T1 weighted sequences with in-phase, out-of-phase and fat specific phases and also T2 weighted and spectroscopy sequences. The qualitative assessment was carried out using the fat fraction calculated manually after spectroscopy computer analysis. The steatosis was graded as grade 0 = up to 10%, grade 1 = 10-33%, grade 2 = 34-66%, grade 3 = ≥ 67%. Liver biopsy was performed in patients who underwent surgery for different pathologies. Results: Limited by a small number of patients and surgical invasiveness of liver biopsy, the study shows that five patients had grade 0 steatosis, thirteen had grade 1, six patients – grade 2 and one patient – grade 3, offering a good correlation between MRS and histopathology. Conclusions: Despite being a pilot study, we can conclude that MRS is an effective noninvasive technique that can be extremely useful in diagnosing and quantifying hepatic steatosis

Role of gadoxetic-acid enhanced 3T MRI and diffusion in liver nodules diagnosis

Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, Craiova, Romania, The IVth Congress of Radiology and Medical Imaging of the Republic of Moldova with international participation, Chisinau, May 31 – June 2, 2018Introduction: La capacité multiparamétrique et l’imagerie par résonance magnétique (IRM) 3T à haute résolution jouent un rôle clé dans la caractérisation non invasive des lésions hépatiques focales (LHF). Certaines LHF ont des caractéristiques atypiques. De nouvelles techniques telles que les séquences à diffusion pondérée et les agents de contraste spécifiques aux hépatocytes sont actuellement utilisées en pratique clinique pour améliorer la détection et la caractérisation des LHF. L’étude visait à valider un protocole d’imagerie hépatique de haute qualité en utilisant une IRM à haute résolution combinée à un milieu de contraste spécifique à la diffusion et à l’hépatocyte pour le diagnostic de la LHF. Matériel et méthodes: 110 patients hépatiques ont été étudiés en utilisant une IRM à haute résolution de 3T (Phillips Ingenia) en utilisant une bobine de matrice en phase de corps. Le protocole inclue les séquences Dixon-all T1, T2, SPAIR et de diffusion. L’IRM améliorée a supposé l’utilisation des séquences Dixon-T1 de l’acide gadoxétique (PRIMOVIST), y compris la phase hépatobiliaire à 20 minutes et 30 minutes. Résultats: 65 patients ont été diagnostiqués avec précision des lésions bénignes, y compris les hémangiomes, les kystes, l’hyperplasie nodulaire focale et les adénomes. Parmi 45 lésions malignes, nous avons trouvé des métastases, un carcinome hépatocellulaire (CHC) et une pseudotumeur inflammatoire. Les lésions ont été suivies ou une pathologie a été obtenue. Conclusions: L’IRM est capable de fournir des informations diagnostiques complètes et très précises, avec l’avantage supplémentaire de l’absence de rayonnements ionisants nocifs. Un protocole IRM de haute qualité pour le foie est également nécessaire pour établir un diagnostic correct.Background: The multiparametric ability and high-resolution 3T magnetic resonance imaging (MRI) plays a key role in non-invasive characterization of focal liver lesions (FLL). Some FLL have atypical features. New techniques such as diffusion-weighted sequences and hepatocyte-specific contrast agents are being currently used in clinical practice improving the detection and characterization of FLL. The study aimed to validate a high-quality hepatic imaging protocol using high-resolution MRI combined with diffusion and hepatocyte-specific contrast media for FLL diagnosis. Material and methods: 110 patients were liver investigated using a 3T high-resolution MRI (Phillips Ingenia) using body-phase array coil. The protocol included Dixon-all T1, T2, SPAIR and diffusion sequences. The enhanced MRI assumed the use of gadoxetic-acid (PRIMOVIST) Dixon-T1 sequences, including the hepatobiliary phase at 20 minutes and 30 minutes. Results: 65 patients were accurately diagnosed with benign lesions, including hemangiomas, cysts, focal nodular hyperplasia and adenomas. Among 45 malignant lesions we found metastasis, hepatocellular carcinoma (HCC) and one inflammatory pseudotumor. The lesions were followed-up or pathology was obtained. Conclusions: MRI is able to provide comprehensive and highly accurate diagnostic information, with the additional advantage of lack of harmful ionizing radiation. Also a high-quality liver MRI protocol is needed in order to establish a correct diagnosis

Federated Learning Approach with Pre-Trained Deep Learning Models for COVID-19 Detection from Unsegmented CT images

(1) Background: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by SARS-CoV-2. Reverse transcription polymerase chain reaction (RT-PCR) remains the current gold standard for detecting SARS-CoV-2 infections in nasopharyngeal swabs. In Romania, the first reported patient to have contracted COVID-19 was officially declared on 26 February 2020. (2) Methods: This study proposes a federated learning approach with pre-trained deep learning models for COVID-19 detection. Three clients were locally deployed with their own dataset. The goal of the clients was to collaborate in order to obtain a global model without sharing samples from the dataset. The algorithm we developed was connected to our internal picture archiving and communication system and, after running backwards, it encountered chest CT changes suggestive for COVID-19 in a patient investigated in our medical imaging department on the 28 January 2020. (4) Conclusions: Based on our results, we recommend using an automated AI-assisted software in order to detect COVID-19 based on the lung imaging changes as an adjuvant diagnostic method to the current gold standard (RT-PCR) in order to greatly enhance the management of these patients and also limit the spread of the disease, not only to the general population but also to healthcare professionals

COVID-19—A Trigger Factor for Severe Immune-Mediated Thrombocytopenia in Active Rheumatoid Arthritis

Thrombocytopenia is defined as a platelet count below 150,000/mm3 for adults. There is still controversy about whether individuals with platelet counts of 100,000/mm3 to 150,000/mm3 should be classified as having genuine thrombocytopenia or borderline thrombocytopenia. Thrombocytopenia is considered mild when the platelet count is between 70,000 and 150,000/mm3 and severe if the count is less than 20,000/mm3. Thrombocytopenia in rheumatoid arthritis is a rare complication, with an incidence estimated between 3 and 10%. The main etiological aspects include drug-induced thrombocytopenia and immune thrombocytopenic purpura. The most common hematological abnormalities in SARS-CoV-2 infection are lymphopenia and thrombocytopenia. It has been observed that the severity of thrombocytopenia correlates with the severity of the infection, being a poor prognosis indicator and a risk factor for mortality. COVID-19 can stimulate the immune system to destroy platelets by increasing the production of autoantibodies and immune complexes. Autoimmunity induced by viral infections can be related to molecular mimicry, cryptic antigen expression and also spreading of the epitope. During the COVID-19 pandemic, it is of great importance to include the SARS-CoV-2 infection in differential diagnoses, due to the increased variability in forms of presentation of this pathology. In this review, our aim is to present one of the most recently discovered causes of thrombocytopenia, which is the SARS-CoV-2 infection and the therapeutic challenges it poses in association with an autoimmune disease such as rheumatoid arthritis

Tumor Area Highlighting Using T2WI, ADC Map, and DWI Sequence Fusion on bpMRI Images for Better Prostate Cancer Diagnosis

Prostate cancer is the second most common cancer in men worldwide. The results obtained in magnetic resonance imaging examinations are used to decide the indication, type, and location of a prostate biopsy and contribute information about the characterization or aggressiveness of detected cancers, including tumor progression over time. This study proposes a method to highlight prostate lesions with a high and very high risk of being malignant by overlaying a T2-weighted image, apparent diffusion coefficient map, and diffusion-weighted image sequences using 204 pairs of slices from 80 examined patients. It was reviewed by two radiologists who segmented suspicious lesions and labeled them according to the prostate imaging-reporting and data system (PI-RADS) score. Both radiologists found the algorithm to be useful as a “first opinion”, and they gave an average score on the quality of the highlight of 9.2 and 9.3, with an agreement of 0.96

Novel Biomarkers, Diagnostic and Therapeutic Approach in Rheumatoid Arthritis Interstitial Lung Disease—A Narrative Review

Rheumatoid arthritis (RA) is considered a systemic inflammatory disease marked by polyarthritis which affects the joints symmetrically, leading to progressive damage of the bone structure and eventually joint deformity. Lung involvement is the most prevalent extra-articular feature of RA, affecting 10–60% of patients with this disease. In this review, we aim to discuss the patterns of RA interstitial lung disease (ILD), the molecular mechanisms involved in the pathogenesis of ILD in RA, and also the therapeutic challenges in this particular extra-articular manifestation. The pathophysiology of RA-ILD has been linked to biomarkers such as anti-citrullinated protein antibodies (ACPAs), MUC5B mutation, Krebs von den Lungen 6 (KL-6), and other environmental factors such as smoking. Patients at the highest risk for RA-ILD and those most likely to advance will be identified using biomarkers. The hope is that finding biomarkers with good performance characteristics would help researchers better understand the pathophysiology of RA-ILD and, in turn, lead to the development of tailored therapeutics for this severe RA manifestation

Computer-Aided Diagnosis of Pulmonary Nodules in Rheumatoid Arthritis

(1) Background: Rheumatoid arthritis (RA) is considered a systemic inflammatory pathology characterized by symmetric polyarthritis associated with extra-articular manifestations, such as lung disease. The purpose of the present study is to use CAD in the detection of rheumatoid pulmonary nodules. In addition, we aim to identify the characteristics and associations between clinical, laboratory and imaging data in patients with rheumatoid arthritis and lung nodules. (2) Methods: The study included a number of 42 patients diagnosed with rheumatoid arthritis according to the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria, examined from January 2017 to November 2022 in the Departments of Rheumatology and Radiology and Medical Imaging of the University of Medicine and Pharmacy of Craiova. Medical records were reviewed. A retrospective blinded review of CT for biopsy-proven pulmonary nodules in RA using Veolity LungCAD software was performed (MeVis Medical Solutions AG, Bremen, Germany). Imaging was also reviewed by a senior radiologist. (3) Results: The interobserver agreement proved to be moderate (κ = 0.478) for the overall examined cases. CAD interpretation resulted in false positive results in the case of 12 lung nodules, whereas false negative results were reported in the case of 8 lung nodules. The mean time it took for the detection of lung nodules using CAD was 4.2 min per patient, whereas the detection of lung nodules by the radiologist was 8.1 min per patient. This resulted in a faster interpretation of lung CT scans, almost reducing the detection time by half (p < 0.001). (4) Conclusions: The CAD software is useful in identifying lung nodules, in shortening the interpretation time of the CT examination and also in aiding the radiologist in better assessing all the pulmonary lung nodules. However, the CAD software cannot replace the human eye yet due to the relative high rate of false positive and false negative results

Interobserver Reliability of Magnetic Resonance Imaging of Sacroiliac Joints in Axial Spondyloarthritis

Introduction: Axial spondyloarthritis (axSpA) is characterized by damage to the axial skeleton and entheses, and is often associated with extra-articular manifestations, in the presence of the human leukocyte antigen (HLA) B27. The aim of our study is to assess the performance of rheumatologists in interpreting the inflammatory and structural damage to sacroiliac joints, in comparison to radiologists. Material and Methods: The present study included a total of 34 patients diagnosed with axSpA, according to the Assessment of SpondyloArthritis International Society (ASAS) criteria for axSpA, examined from January 2021 to November 2021 in the Departments of Rheumatology and Radiology and Medical Imaging of the University of Medicine and Pharmacy of Craiova. All patients underwent physical examination, laboratory tests, and magnetic resonance imaging (MRI) of the sacroiliac joints. The images were interpreted by a senior radiologist (SR), a junior radiologist (JR), a senior rheumatologist (SRh), and a junior rheumatologist (JRh), who were blinded to the clinical and paraclinical data. Results: The overall κ was 0.7 for the JR (substantial agreement), 0.707 for the SRh (substantial agreement), and 0.601 for the JRh (moderate agreement), in comparison with the SR. Regarding the overall inflammatory changes, the SRh and JR were proven to have substantial agreement (κ = 0.708 and 0.742, respectively) with the SR, while the JRh was proven to have moderate agreement (κ = 0.607). The structural damage observed by the JR showed substantial agreement (κ = 0.676) with the SR, while the SRh and JRh had substantial and moderate agreement (κ = 0.705 and 0.596, respectively) with the SR. Conclusions: Our study showed substantial agreement between the senior radiologist, senior rheumatologist, and junior radiologist, and moderate agreement with the junior rheumatologist