The mechanisms by which closed chest cardiac massage produces and maintains blood flow during cardiopulmonary resuscitation are still debated. To date, two main theories exist: the “cardiac pump”, which assumes that blood flow is driven by direct cardiac compression and the “chest pump”, which hypothesizes that blood flow is caused by changes in intrathoracic pressure. Newer hypotheses including the “atrial pump”, the “lung pump”, and the “respiratory pump” were also proposed. We reviewed studies supporting these different theories as well as the clinical evidences on the utility of mechanical devices proposed to optimize cardiopulmonary resuscitation, in view of their pathophysiological assumptions with regard to the underlying theory. On the basis of current evidence, a single theory is probably not sufficient to explain how cardiac massage produces blood flow. This suggests that different simultaneous mechanism might be involved. The relative importance of these mechanisms depends on several factors, including delay from collapse to starting of resuscitation, compression force and rate, body habitus, airway pressure, and presenting electrocardiogram. The complexity of the physiologic events occurring during cardiopulmonary resuscitation, together with the need of adequate training for a correct and prompt utilization of mechanical devices, might also partially explain the disappointing results of these devices in most clinical studies.

Background and objectives: Electrochemotherapy is a novel ablation technique combining chemotherapeutic agents with reversible cell membrane electroporation. Previous experiences have shown its efficacy for cutaneous tumors. Its application for deep-seated malignancies is under investigation. We performed a prospective, pilot study to evaluate the feasibility, safety, and efficacy of intraoperative electrochemotherapy for otherwise unresectable colorectal liver metastases.Methods: Electrochemotherapy with bleomycin was combined with open liver resection and performed with linear or hexagonal needle electrodes according to an individualized pretreatment plan. The primary endpoints were: feasibility, as ratio of completed to planned treatments; safety, and efficacy, as per response assessed at 30 days with MRI and according to RECIST. The secondary endpoint was overall and progression-free survival at month 6.Results: A total of 9 colorectal liver metastases were treated in 5 patients with 20 electrode applications. No intraoperative complications were observed. At day 30, complete response was 55.5% and stable disease 45.5%. All (5) patients reached a 6 months overall survival, and 4 out of 5 patients had 6 months progression free survival.Conclusions: Electrochemotherapy is a feasible and safe adjunct to open surgery for treatment of unresectable colorectal liver metastases. Larger studies and longer follow-ups are favored to better define its role in the treatment of secondary liver malignancies. (C) 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

BACKGROUNDSeveral studies have focused on the role of epicardial fat in the pathogenesis of cardiovascular disease (CVD). The main purpose of the study was to evaluate a computerized method for the quantitative analysis of epicardial fat volume (EFV) by non-contrast cardiac CT (NCT) for coronary calcium scan and coronary CT angiography (coronary CTA).METHODSThirty patients (61±12.5 years, 73% male, body mass index (BMI) =25.9±6.3 kg/m2) referred to our Institution for suspected coronary artery disease (CAD) underwent NCT and coronary CTA. Epicardial boundaries were traced by 2 experienced operators (operator 1, operators 2) on 3 and 6 short-axis (SA) slices. EFV was computed with a semi-automatic method using an in-house developed software based on spherical harmonic representation of the epicardial surface. In order to analyze the inter-observer variability both the Coefficient of Repeatability (CR) and Intra Class Correlation (ICC) were computed.RESULTSThe total EFV was 103.62±50.97 and 94.96±67.91 cc in NCT and coronary CTA with non-significant difference (P=0.292). CR error was 10.22 cc for operator 1 and 11.31 cc for operator 2 in NCT and 7.99 cc for operator 1 and 7.75 cc for operator 2 in coronary CTA. To analyze the inter-observer variability CR and ICC were computed. CR was 8.17 and 8.39 cc with NCT and 7.07 and 7.21 cc with CTA for 6 and 3 SA slices respectively. ICC values >0.99 were obtained in all cases. The right ventricular EFV was 67.23±31.4 and 57.41±34.3 cc for NCT and coronary CTA respectively; the corresponding values for left ventricular EFV were 38.01±19.1 and 35.27±25.9 cc.CONCLUSIONSBoth NCT and coronary CTA can be used with low intra- and inter-observer variability for computer-assisted measurements of EFV. Cardiac CT may allow a fast and reliable computation of EFV in clinical setting.

Background: To assess the dynamics of aortic annulus morphology over the entire cardiac cycle in patients undergoing CT angiography for planning of transcatheter aortic valve implantation (TAVI).

Background: Myocardial bridges (MB) are considered an anatomic variant course of the main epicardial coronary arteries. MB occurrence is largely underestimated by invasive coronary angiography and diagnosis is traditionally made at necropsy or surgery. The prevalence and morphology of MB are not widely investigated in live population, though they can be responsible for anginal pain, major cardiac events and sudden death. CT coronary angiography (CTCA) is ideal for non-invasive detection of MBs, allowing simultaneous visualization of coronary arteries, myocardium and epicardial fat.

To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents.

Poster: ECR 2016 / C-1089 / Infectious emergencies of the head and neck: what every radiologist needs to know. by: Faggioni, M. Gabelloni, L. Bruschini, E. Neri, S. Berrettini, S. Sellari Franceschini, D. Caramella, C. Bartolozzi; Pisa/IT

Limited tools are available for the non-invasive monitoring of transplanted islets. In this study, we have compared the widely used superparamagnetic iron oxide nanoparticle ferumoxide (Endorem) and multiwalled carbon nanotubes (MWCNTs) for islet cell labeling and tracking. INS-1 E cells and human pancreatic islets isolated from 12 non-diabetic cadaveric organ donors (age: 62 ±16 yr, BMI: 24.6 ± 3.3 kg/m2) were incubated with 50 μg/ml Endorem or 15 μg/ml MWCNTs and studied after 7 or 14 days to assess beta cell morphology, ultrastructure, function, cell survival and in-vitro and in-vivo magnetic resonance imaging (MRI). Light and electron (EM) microscopy showed the well-maintained morphology and ultrastructure of both INS-1 E and human islets during the incubation. EM also revealed the presence of Endorem and MWCNTs within the beta but not the alpha cells. The compounds did not affect beta cell function and viability, and in-vitro MRI showed that labeled INS-1 E cells and human islets could be imaged. Finally, MWCNT labeled human islets were successfully transplanted into the subcutis of rats localized in the desired site via magnetic field and tracked by MRI. These data suggest that MWCNTs can be an alternative labeling compound to be used with human islets for experimental and transplantation studies.

In the context of Predictive, Preventive and Personalized Medicine (PPPM), radiologists play an essential role in patient management throughout the different phases of hepatocellular carcinoma (HCC). This includes diagnosis, staging, treatment planning, and evaluation of response to treatment. This chapter provides an in-depth examination of the fundamental pathophysiologic mechanisms underlying the radiologic diagnosis and assessment of HCC. Observations made in contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), in conjunction with alpha-fetoprotein (AFP) can allow the diagnosis of HCC to be made with confidence without the need for biopsy, in many cases. Treatment decisions and prognosis are strongly influenced by the tumor extension, the number and size of lesions, tumor location, biliary dilatation, ascites, and the presence of macrovascular invasion and extrahepatic tumor spread. In addition, radiologic assessment of co-morbidities and response to previous treatments must be included in the overall assessment. The patient-specific findings from diagnostic imaging and interventional radiology identified in this chapter will be designated as Information Entities (IEs) in later chapters. These IEs will ultimately be used in the generation of Digital Patient Models (DPMs) to facilitate diagnosis, prognosis, and treatment selection, i.e. Model Guided Therapy (MGT) and PPPM.

386 Background: TACE is the standard treatment for patients with intermediate-stage HCC (BCLC-B according to the Barcelona Clinic Liver Cancer [BCLC] classification). However, prognostic factors for survival after the first TACE cycle are unclear. We correlated pre-treatment characteristics and response to therapy with overall survival (OS) and time to tumor progression (TTP), in order to propose a scoring system aimed at facilitating clinical decision after the first TACE. Methods: We retrospectively analyzed 149 patients (125 males; mean age 65.1±9.2 years) with BCLC-B HCC who received ≥1 cycle of TACE (Lipidol TACE, n=106; drug-eluting beads TACE, n=43). Univariate and multivariate analysis were used to correlate pre-treatment characteristics and response to TACE with OS and TTP. Identified predictive factors were used to define a score for each patient. Results: Median OS was 23 (95% Confidence interval [CI] 11.5-27) months, and median TTP was 11 months (CI 7-11). Complete response (CR) was reported in 63 patients (42.3%) and partial response (PR) in 71 (47.7%). Age >65 years (Hazard Ratio [HR] 1.77; 95% CI: 1.18-2.67), ascites (HR 2.44; 95% CI 1.32-4.29), total diameter of nodules >61 mm (HR: 1.96; 95% CI 1.28-3.08) and response at 1 month (HR 1.70; 95% CI 1.30-2.20) were predictors of survival and were used to build the scoring system (Table). Three groups of patients with different OS and TTP were then identified. Patients with score 0-1 had a longer OS (57.8 months) and TTP (12.7 months) than those with score 2-3 (21.1 and 8.2 months) or score 4-6 (8.0 and 6.3 months) (p<0.001 for both comparisons). Conclusions: This scoring system may allow the identification of three groups of patients with different prognosis after a first cycle of TACE and may therefore be useful in guiding clinical decisions, in particular whether continuing TACE therapy after a first cycle or moving to different therapies. Validation of this scoring system on a larger population is ongoing. [Table: see text]

OBJECTIVE:To compare tumor volume reduction rate (TVRR) measured by MR volumetry after preoperative chemoradiotherapy (CRT) and pathological tumor regression grade (TRG) in locally advanced rectal cancer (LARC). MATERIAL AND METHODS:In total, 20 patients with LARC (cT3-T4) treated with CRT followed by Total Mesorectal Excision (TME) between April 2011 and April 2013 were analyzed retrospectively. Pre- and post- CRT tumor volumes (MR volumetry) were measured on 3D MR sequences. TVRR was determined using the equation TVRR (%)=(pre-CRT tumor volume-post-CRT tumor volume)×100/pre-CRT tumor volume. The downstaging (defined as ypT0-T2) of tumor mass was evaluated and the correlation between TVRR and TRG was calculated with the method proposed by Dworak using the Spearman rank test. RESULTS:The median TVRR was 77.3% (range, 26.4-99.3%); TVRR was >60% in 18 cases (90%) and in 8 of these patients (44.4 %) it was >80%. Downstaging of tumor lesions was obtained in 15 patients (75%). In 4 cases there was a complete tumor regression (TRG4) at histological examination and in the same patients there was also a TVRR>80% measured by MR volumetry. A statistically significant correlation between TVRR and TRG (r(s)=0.5466, p=0.0126) was observed. CONCLUSION:TVRR after preoperative CRT correlates with TRG in LARC. The MR volumetry is a prognostic factor to estimate the tumor response after preoperative CRT. TVRR data may be an useful biomarker for tailoring surgery and postoperative adjuvant chemotherapy.

Preoperative suspicion of malignancy in pancreatic neuroendocrine tumours (pNETs) is mostly based on tumour size. We retrospectively reviewed the contrast enhancement pattern (CEP) of a series of pNETs on multiphasic multidetector computed tomography (MDCT), to identify further imaging features predictive of lesion aggressiveness.

PURPOSE:To evaluate the usefulness of diffusion-weighted imaging (DWI) with a multiple b value SE-EPI sequence on a 3.0 T MR scanner for staging of pelvic lymph nodes in patients with prostate cancer candidate to radical prostatectomy and extended pelvic lymph node dissection (PLND). MATERIALS AND METHODS:Institutional review board approval was obtained and written informed consent was taken from all enrolled subjects. A series of 26 patients with pathologically proven prostate cancer (high or intermediate risk according to D'Amico risk groups) scheduled for radical prostatectomy and PLND underwent 3 T MRI before surgery. DWI was performed using an axial respiratory-triggered spin-echo echo-planar sequence with multiple b values (500, 800, 1000, 1500 s/mm(2)) in all diffusion directions. ADC values were calculated by means of dedicated software fitting the curve obtained from the corresponding ADC for each b value. Fitted ADC measurements were performed at the level of proximal and distal external iliac, internal iliac, and obturator nodal stations bilaterally. Lymph node appearance was also assessed in terms of short axis, long-to-short axis ratio, node contour and intranodal heterogeneity of signal intensity. RESULTS:A total of 173 lymph nodes and 104 nodal stations were evaluated on DWI and pathologically analysed. Mean fitted ADC values were 0.79 ± 0.14 × 10(-3) mm(2)/s for metastatic lymph nodes and 1.13 ± 0.29 × 10(-3) mm(2)/s in non-metastatic ones (P < 0.0001). The cut-off for fitted ADC obtained by ROC curve analysis was 0.91 × 10(-3) mm(2)/s. A two-point-level score was assigned for each qualitative parameter, and the mean grading score was 6.09 ± 0.61 for metastastic lymph nodes and 5.42 ± 0.79 for non-metastatic ones, respectively (P = 0.001). Using a score threshold of 4 for morphological, structural, and dimensional MRI analysis and a cut--off value of 0.91 × 10(-3) mm(2)/s for fitted ADC measurements of pelvic lymph nodes, per--station sensitivity, specificity, PPV, NPV and diagnostic accuracy were 100%, 7.9%, 15.6%, 100% and 21.3%, and 84.6%, 89.5%, 57.9%, 97.1% and 88.8%, respectively. CONCLUSIONS:3.0T DWI with a multiple b value SE-EPI sequence may help distinguish benign from malignant pelvic lymph nodes in patients with prostate cancer.

Purpose: To evaluate feasibility, diagnostic performance, patient acceptance, and overall examination time of CT colonography (CTC) performed through rectal administration of iodinated contrast material.Materials and methods: Six-hundred asymptomatic subjects (male: female = 270: 330; mean 63 years) undergoing CTC for colorectal cancer screening on an individual basis were consecutively enrolled in the study. Out of them, 503 patients (group 1) underwent CTC with rectal tagging, of which 55 had a total of 77 colonic lesions. The remaining 97 patients (group 2) were randomly selected to receive CTC with oral tagging of which 15 had a total of 20 colonic lesions. CTC findings were compared with optical colonoscopy, and per-segment image quality was visually assessed using a semi-quantitative score (1 = poor, 2 = adequate, 3 = excellent). In 70/600 patients (11.7%), CTC was performed twice with both types of tagging over a 5-year follow-up cancer screening program. In this subgroup, patient acceptance was rated via phone interview two weeks after CTC using a semi-quantitative scale (1 = poor, 2 = fair, 3 = average, 4 = good, 5 = excellent).Results: Mean per-polyp sensitivity, specificity, positive and negative predictive values of CTC with rectal vs oral tagging were 96.1% (CI95% 85.4 divided by 99.3%) vs 89.4% (CI95% 65.4 divided by 98.1%), 95.3% (CI95% 90.7 divided by 97.8%) vs 95.8% (CI95% 87.6 divided by 98.9%), 86.0% (CI95% 73.6 divided by 93.3) vs 85.0% (CI95% 61.1 divided by 96.0%), and 98.8% (CI95% 95.3 divided by 99.8%) vs 97.2% (CI95% 89.4 divided by 99.5%), respectively (p > 0.05). Polyp detection rates were not statistically different between groups 1 and 2 (p > 0.05). Overall examination time was significantly shorter with rectal than with oral tagging (18.3 +/- 3.5 vs 215.6 +/- 10.3 minutes, respectively; p < 0.0001).Conclusions: Rectal iodine tagging can be an effective alternative to oral tagging for CTC with the advantages of greater patient acceptance and lower overall examination time. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Poster: ECR 2015 / C-1901 / Biliary complications after orthotopic liver transplantation: diagnosis with MR cholangiography and MR imaging at 3T-device by: P. Boraschi, F. Donati, R. Gigoni, F. Filipponi, F. Falaschi, C. Bartolozzi; Pisa/IT

Poster: "ECR 2015 / B-0741 / Accuracy of ultra-low-dose CTC with iterative reconstructions in the detection of intermediate and diminutive polyps" by: "F. Pancrazi, P. Scalise, A. Mantarro, E. Guidi, D. Gambaccini, M. Bertini, E. Neri, C. Bartolozzi; Pisa/IT"

Poster: "ECR 2015 / C-2281 / CT colonography: comparison of radiation dose between 64-row and 128-row CT with adaptive statistical iterative reconstruction" by: "A. Mantarro, P. Scalise, C. Sottocornola, M. Remorini, F. Paolicchi, E. Neri, D. Caramella, C. Bartolozzi; Pisa/IT"

Poster: ECR 2015 / C-0586 / Rectal cancer: role of CT-colonography in full colon staging by: A. Colleoni1, E. Guidi2, P. Scalise2, E. Neri2, R. Maroldi1, C. Bartolozzi2; 1Brescia/IT, 2Pisa/IT

The aim of this study was to analyze the usage and the data recorded by a RIS-PACS-connected contrast medium (CM) monitoring system (Certegra(®), Bayer Healthcare, Leverkusen, Germany) over 19 months of CT activity. The system used was connected to two dual syringe power injectors (each associated with a 16-row and a high definition 64-row multidetector CT scanner, respectively), allowing to manage contrast medium injection parameters and to send and retrieve CT study-related information via RIS/PACS for any scheduled contrast-enhanced CT examination. The system can handle up to 64 variables and can be accessed via touchscreen by CT operators as well as via a web interface by registered users with three different hierarchy levels. Data related to CM injection parameters (i.e. iodine concentration, volume and flow rate of CM, iodine delivery rate and iodine dose, CM injection pressure, and volume and flow rate of saline), patient weight and height, and type of CT study over a testing period spanning from 1 June 2013 to 10 January 2015 were retrieved from the system. Technical alerts occurred for each injection event (such as system disarm due to technical failure, disarm due to operator's stop, incomplete filling of patient data fields, or excessively high injection pressure), as well as interoperability issues related to data sending and receiving to/from the RIS/PACS were also recorded. During the testing period, the CM monitoring system generated a total of 8609 reports, of which 7629 relative to successful injection events (88.6%). 331 alerts were generated, of which 40 resulted in injection interruption and 291 in CM flow rate limitation due to excessively high injection pressure (>325 psi). Average CM volume and flow rate were 93.73 ± 17.58 mL and 3.53 ± 0.89 mL/s, and contrast injection pressure ranged between 5 and 167 psi. A statistically significant correlation was found between iodine concentration and peak IDR (rs=0.2744, p<0.0001), as well as between iodine concentration and iodine dose (rs=0.3862, p<0.0001) for all CT studies. Automated contrast management systems can provide a full report of contrast use with the possibility to systematically compare different contrast injection protocols, minimize errors, and optimize organ-specific contrast enhancement for any given patient and clinical application. This can be useful to improve and harmonize the quality and consistency of contrast CT procedures within the same radiological department and across the hospital, as well as to monitor potential adverse events and overall costs.

Poster: ECR 2015 / B-0269 / CT coronary angiography with iterative image reconstruction and low iodine (270mgI/mL) concentration: comparison of image quality and injection pressure with standard (320mgI/mL) iodine concentration by: L. Faggioni, M. Gabelloni, E. Galati, M. Bianchi, P. Marraccini, E. Neri, C. Bartolozzi; Pisa/IT