OBJECTIVE: To evaluate dose-area product, skin entrance dose and doses from fluoroscopy and radiography in voiding cystourethrography studies of pediatric patients. MATERIALS AND METHODS: Procedures performed in 37 patients by four physicians of the institution were evaluated. Measurements were performed with an equipment including an ionization chamber directly coupled to the x-ray tube window and an electrometer (Diamentor) connected to a computer for data collection. RESULTS: Some procedures heterogeneity was observed and guidelines for good radiographic techniques were not followed. On average, 11 radiographies are performed for each study, with extended fluoroscopy time delivering a higher average final dose than those reported in the literature. CONCLUSION: The adoption of radiography with high kilovoltage technique and restricted utilization of fluoroscopy can result in a significant reduction of doses during this procedure, considering that the major contribution to the final dose comes from fluoroscopy.

Keywords: X-rays, Dosimetry, Cystourethrography, Fluoroscopy, Pediatric radiology

OBJECTIVE: The objective of the present study is to analyze the optimization of fluoroscopic image quality and patient entrance surface air kerma rate in interventional radiology procedures, utilizing a phantom adapted for fluoroscopy. MATERIALS AND METHODS: The authors utilized a phantom developed for evaluating conventional radiological images adapted for fluoroscopy through the addition of two catheters with different diameters, both of them utilized in interventional radiology. The patient entrance surface air kerma rate was determined with the aid of this phantom. RESULTS: The evaluation of technical parameters for different exposure modes of a digital fluoroscopic imaging system has allowed the determination of the air kerma rate, enabling the optimization of the image quality in interventional procedures. The decrease in the patient entrance surface air kerma rate may achieve 67%. CONCLUSION: The optimization of fluoroscopic image quality achieved with a phantom allows reducing the patient entrance surface air kerma with no significant loss of diagnostic performance.

Keywords: Images optimization, Fluoroscopy, Phantom, Dose reduction

OBJECTIVE: The present study evaluates the dose distribution received by physicians involved in hemodynamic procedures of coronary angiography and coronariography. The influence of some factors such as pulsed or continuous fluoroscopy mode and vein and/or artery access site was investigated. MATERIALS AND METHODS: Measurements have been performed with LiF:Mg,Ti thermoluminescent dosimeters placed on seven different sites of the practitioners' bodies: hands, left knee, neck, forehead and chest, under and over the lead apron. Radiation doses for each procedure were evaluated in physicians who had performed 60 coronariography and 30 angioplasty procedures. The thermoluminescent dosimeters were calibrated in the operational quantity personal dose equivalent, Hp(d), at depths of 0.07, 3 and 10 mm. RESULTS: The results of the present study demonstrate the significant role played by thyroid protectors and lead aprons for reducing radiation doses received by practitioners. Occupational doses in continuous mode fluoroscopy through brachial access were higher than with pulsed mode fluoroscopy through femoral access. CONCLUSION: The present study has demonstrated the necessity of implementing additional protective measures as well as a mechanism of training in radiation protection for physicians involved in interventional cardiological procedures.

Keywords: Interventional radiology, Fluoroscopy, Hemodynamic procedures, Radiation protection, Thermoluminescent dosimetry

Objetivo: A principal utilidade da tomografia por emissão de pósitrons com 18-fluordeoxiglicose (FDG-PET) está no estadiamento do câncer de pulmão. Porém, ela também pode ser utilizada para diferenciar lesões pulmonares indeterminadas, mas seu impacto na ressecção cirúrgica de lesões benignas é desconhecido. O objetivo deste estudo foi comparar a prevalência de lesões benignas em toracotomias feitas por suspeição de câncer de pulmão, antes e após a introdução do FDG-PET, em um centro de referência de cirurgia torácica. Materiais e Métodos: Os autores analisaram, prospectivamente, uma base de dados cirúrgicos de todos os pacientes consecutivos submetidos a toracotomia por câncer de pulmão suspeito ou comprovado e compararam a prevalência de lesões benignas em dois grupos ao longo de dois anos consecutivos, respectivamente antes (grupo I) e depois (grupo II) da introdução da FDG-PET. Resultados: Ressecção cirúrgica foi feita em 1.233 pacientes durante o período do estudo. A prevalência de lesões benignas na cirurgia nos grupos I e II foi similar (44/626 e 41/607, ambas correspondendo a 7%), e também no grupo II, entre aqueles submetidos a FDG-PET e os restantes (21/301 e 20/306 respectivamente, ambos correspondendo a 7%). No grupo II, dos 21 pacientes com lesões benignas submetidos a FDG-PET, 19 tiveram um estudo falso-positivo (valor médio padrão de captação 5.3 [faixa 2.6–12.7]). Desses, respectivamente 13 e 4 pacientes tiveram broncoscopia não diagnóstica e biópsia transtorácica percutânea de pulmão antes da toracotomia. Não houve diferença na proporção de lesões benignas diferentes ressecadas entre o grupo I e aqueles submetidos a FDG-PET no grupo II. Conclusão: A introdução da FDG-PET não alterou a proporção de pacientes submetidos a toracotomia por lesões benignas, principalmente devido à avidez pelo isótopo de algumas lesões não malignas. Tais resultados falsos-positivos devem ser considerados nos casos em que se contempla a possibilidade de ressecção cirúrgica em pacientes com câncer de pulmão não confirmado.

Keywords: Tomografia por emissão de pósitrons; Tomografia computadorizada; Pulmão – lesões benignas ou congênitas; Câncer de pulmão – diagnóstico e estadiamento; Câncer de pulmão – cirurgia.

OBJECTIVE: To present a data analysis toolkit that may be utilized with the purpose of radiation protection of hospital inpatients and workers in areas where mobile apparatuses are used. MATERIALS AND METHODS: An Excel^® ActiveSheet was utilized to develop a computational toolkit with exposure measurements to generate a database of shape factors and to calculate the air kerma around hospital beds. The initial database included data collected with three mobile apparatuses. A non-anthropomorphic phantom was utilized and exposure measurements were performed on a (4.2 × 4.2) m² mesh-grid at 0.3 m steps. RESULTS: The toolkit calculates the air kerma (associated with patients' radiation exposure and with ambient equivalent dose) under secondary radiation. For distances lower than 60.0 cm, values above the maximum ambient equivalent dose threshold defined for radiation free areas (0.5 mSv/year) were verified. Data collected at 2.1 m have always presented values lower than 12% of that threshold. CONCLUSION: The toolkit can aid in the radiological protection of patients and workers, provided it is combined with appropriate data collection, since it allows the determination of radiation free areas around beds in rooms where mobile X-ray apparatuses are utilized.

Keywords: Radiology; Radiological protection; Software toolkit.

OBJETIVO: Avaliar a completude das fissuras, resposta radiológica ao tratamento e análise quantitativa por TC (AQTC) em população de pacientes com enfisema grave submetidos ao implante de valvas endobrônquicas (VEB). MATERIAIS E MÉTODOS: Foram estudados exames de TC multidetectores de 29 pacientes, realizados com protocolo de baixo dose, cortes finos, sem contraste. Dois radiologistas revisaram, retrospectivamente, os exames em consenso. A completude das fissuras foi estimada em escala de 5% e a resposta radiológica (atelectasia/perda volumétrica do lobo alvo) foi avaliada. AQTC foi realizada nos exames pré e pós-tratamento utilizando programa completamente automático. RESULTADOS: Resposta radiológica positiva foi vista em 16/29 pacientes. Os 13 pacientes sem resposta à TC apresentavam fissuras incompletas e completude média das fissuras obliquas de 72,8%, contra 88,3% no outro grupo. Os resultados mais significativos da AQTC mostraram redução do volume pulmonar (VP) total (média de 542 ml), VP tratado (700 ml) e volume de enfisema (331,4 ml) no grupo com resposta positiva, que também apresentou melhora nos testes funcionais. CONCLUSÃO: O benefício das VEB é maior em pacientes com fissuras completas e que desenvolvem atelectasia lobar. Nos pacientes sem resposta radiológica encontramos maior prevalência de fissuras incompletas e grau de incompletude das fissuras. Nossa AQTC automática detectou as alterações pós-tratamento, principalmente considerado a análise do pulmão tratado.

Keywords: Enfisema; Terapia de colapso pulmonar; Tomografia computadorizada.

OBJECTIVE: To investigate the learning about management of the technology (efficient use, acquisition and maintenance of imaging diagnosis equipment) in the radiology residency program of Escola Paulista de Medicina - Universidade Federal de São Paulo, with a view to improving the education of radiologists. MATERIALS AND METHODS: Exploratory research where residents, faculty staff and tutors of the program were quantitative and qualitatively approached with Likert scale questionnaires (46), and deepening with recorded interviews (18) and categorization based upon meaning units (thematic analysis). RESULTS: Among the participants, 66% agreed that they had the opportunity of learning about the use of radiological equipment; for 61% the program should include knowledge on the importance of acquiring equipment; and 72% emphasized the lack of learning about equipment management and maintenance. CONCLUSION: As the major moment in the education of specialists, the medical residency program provides residents with a favorable environment to the learning of the skills required to the future of their professional practice, but with limited emphasis on the management of the technology: efficient use, acquisition and mainly maintenance of equipment, still poorly explored. Both the investigated program and the medical residency in radiology should incorporate, whenever possible, the commitment with the training in supplementary skills related to equipment management, developing the competence of the future radiologists.

Keywords: Medical education; Medical residency; Health management; Radiologic technology; Radiology; Imaging diagnosis.

OBJECTIVE: To describe the radiological findings of pulmonary tuberculosis in indigenous patients from the city of Dourados, MS, Brazil, according to age and sex. MATERIALS AND METHODS: Chest radiographic images of 81 patients with pulmonary tuberculosis, acquired in the period from 2007 to 2010, were retrospectively analyzed by two radiologists in consensus for the presence or absence of changes. The findings in abnormal radiographs were classified according to the changes observed and they were correlated to age and sex. The data were submitted to statistical analysis. RESULTS: The individuals' ages ranged from 1 to 97 years (mean: 36 years). Heterogeneous consolidations, nodules, pleural involvement and cavities were the most frequent imaging findings. Most patients (55/81 or 67.9%) were male, and upper lung and right lung were the most affected regions. Fibrosis, heterogeneous consolidations and involvement of the left lung apex were significantly more frequent in males (p < 0.05). Presence of a single type of finding at radiography was most frequent in children (p < 0.05). CONCLUSION: Based on the hypothesis that indigenous patients represent a population without genetically determined resistance to tuberculosis, the present study may enhance the knowledge about how the pulmonary form of this disease manifests in susceptible individuals.

Keywords: Radiology; Tuberculosis; Chest; Radiological findings; Indigenous population.

Interventional radiology has been constantly developing in terms of the techniques, materials, and methods of intervention. It interacts with all areas of medicine, always with the ultimate goal of ensuring the well-being of patients. Advances in imaging techniques, especially in the last two decades, have led to a paradigm shift in the field of urological imaging interventions. Many urologic diseases that were previously treated only surgically can now be effectively managed using minimally invasive image-guided techniques, often with shorter hospital stays and requiring only local anesthesia or conscious sedation.

Keywords: Radiology, interventional; Urology; Fluoroscopy; Tomography, X-ray computed; Ultrasonography; Magnetic resonance imaging.

Objective: To analyze the results obtained with a modified antegrade double J catheter insertion (JJ stenting) technique in patients with urinary tract obstruction due to malignancy. Materials and Methods: This was a retrospective analysis of data collected from patients undergoing antegrade JJ stenting for malignant ureteral obstruction in the interventional radiology department of our institution between March 1, 2017 and May 31, 2019. Results: Antegrade JJ stenting was performed in 32 patients (20 women and 12 men). The mean age was 66.2 years among the females and 61.5 years among the males. A total of 53 antegrade JJ stenting procedures were performed. The procedure was successful in 50 cases and failed in 3 (due to migration of the double J catheter in 2 and due to technical failure in 1). Complications occurred in 3 patients (low back pain, in 1, subcapsular hematoma, in 1, and pyelonephritis, in 1). The procedure time ranged from 14 min to 55 min. Conclusion: In patients with ureteral obstruction due to malignancy, antegrade JJ stenting is safe and effective. The technique selected in our study is easily reproduced and can be performed by a trained professional.

Keywords: Urinary catheterization/instrumentation; Stents; Ureteral obstruction; Radiology, interventional; Urologic neoplasms.

OBJECTIVE: To investigate long-term results of biliary biopsy performed with transluminal forceps in the setting of metastatic biliary involvement. MATERIALS AND METHODS: Between September 2014 and June 2019, 25 patients—18 males (72%)—with a mean age of 65 ± 15 years, underwent 26 biliary biopsy procedures with a dedicated forceps system. All patients presented with obstructive jaundice that was suspected of being malignant and underwent pre-procedural magnetic resonance cholangiopancreatography. The biopsies were performed during percutaneous placement of an internal-external biliary drainage catheter, under fluoroscopic guidance. RESULTS: The technical success rate was 96% (corresponding to 25 of the 26 procedures). The histological diagnosis was inflammatory biliary stricture in five cases, pancreatic adenocarcinoma in six, liver metastases from colorectal cancer in eight, and hepatocellular carcinoma in three, the biliary mucosa being categorized as normal in three cases. In one case, the sample was considered insufficient and the procedure was successfully repeated, after which a diagnosis of pancreatic adenocarcinoma was made. Over a follow-up period of 6–48 months, there were five false-negative results: two findings of inflammatory biliary stricture were later identified as liver metastases from breast and gastric cancer, respectively; and all three patients in which the biliary mucosa was categorized as normal were subsequently diagnosed with metastatic hilar lymph nodes. The procedure was found to have a sensitivity of 77%, a specificity of 100%, and an overall accuracy of 80%. The complication rate was 11.5% (mild, transient hemobilia occurring in three cases). CONCLUSION: Percutaneous transluminal forceps biopsy is a safe, effective, minimally invasive procedure for histological characterization in patients presenting with obstructive jaundice due to a non-primary biliary tumor.

Keywords: Liver; Biliary tract diseases; Radiology, interventional/methods; Biopsy/methods; Fluoroscopy/methods.

Os nervos cranianos representam extensões das estruturas funcionais do cérebro que cruzam a cabeça e o pescoço. Eles estão ligados a diferentes estruturas cranianas e se relacionam com diversas doenças. Uma compreensão profunda de sua complexa anatomia e aparência normal de imagem permite ao examinador identificar e caracterizar com mais precisão as anormalidades. A ressonância magnética com contraste é uma importante ferramenta para avaliar essas estruturas, especialmente as sequências tridimensionais de precessão livre de estado estacionário, que proporcionam alta resolução espacial e de partes moles, apesar da fina espessura dos nervos cranianos. Na maioria dos casos, os achados de imagem são inespecíficos, e uma anamnese completa, exame físico dirigido e testes laboratoriais são necessários para estreitar o diagnóstico diferencial. Este ensaio iconográfico ilustra e discute doenças congênitas, traumáticas e vasculares dos nervos cranianos, mostrando imagens em uma abordagem fisiopatológica.

Keywords: Neuroimagem/métodos; Radiologia/métodos; Ressonância magnética/métodos; Nervos cranianos/diagnóstico por imagem.

OBJECTIVE: To present our clinical experience with percutaneous antegrade ureteral stenting. MATERIALS AND METHODS: This was a single-center retrospective study in which we reviewed the electronic medical records of patients who underwent percutaneous image-guided antegrade ureteral stenting between January 2016 and August 2020. We evaluated 90 patients (48 men). The mean age was 61.4 ± 15 years (range, 30–94 years). Patients were divided into two main groups: those with malignant neoplasms; and those with non-neoplastic disease. Technical and clinical success of the procedure were defined, respectively, as maintenance of the patency of the urinary tract, with a reduction in the degree of hydronephrosis, and as a reduction in the level of nitrogenous waste. Postprocedural complications were categorized as major or minor according to the CIRSE classification. RESULTS: The study sample comprised 150 antegrade stenting procedures performed in 90 patients, most of whom had previously undergone retrograde stenting that was unsuccessful. The stenting was bilateral in 60 patients and unilateral in 30. Technical success was achieved in 143 (95.3%) of the procedures, whereas seven procedures (4.6%) were unsuccessful. Failed procedures were characterized by inability to place a stent or migration of a stent after its placement. Complications occurred in 12 (8.0%) of the procedures. Of those 12 complications, two were classified as major (bleeding) and 10 were classified as minor (lumbar pain or infection). The most common techniques used were the over-the-wire technique and the modified technique (in 58.0% and 42.0% of the cases, respectively). In seven cases (4.7%), a nephrostomy tube was inserted. CONCLUSION: Percutaneous antegrade ureteral stenting is a safe, effective method for the management of ureteral injuries and obstructions, due to malignant or benign causes, when the retrograde approach has failed.

Keywords: Urinary catheterization/instrumentation; Stents; Ureteral obstruction; Radiology, interventional; Urologic neoplasms.

OBJETIVO: Avaliar os padrões tomográficos relacionados aos agentes etiológicos da pneumonia em pacientes durante o primeiro ano após transplante renal. MATERIAIS E MÉTODOS: Foram analisados dados de prontuários de 956 pacientes submetidos a transplante renal, no período de 2013 a 2018, em um centro transplantador renal do nordeste do Brasil. Nos pacientes que desenvolveram pneumonia, os agentes etiológicos foram classificados em bactérias piogênicas, micobactérias, fungos, vírus e pneumonia polimicrobiana, enquanto os padrões tomográficos foram classificados em consolidação, broncopneumonia, pneumonia intersticial e nódulos e massas. Para verificar associação estatística entre micro-organismos e padrões tomográficos, foi utilizado o teste exato de Fisher, com p < 0,001. RESULTADOS: Foram encontrados 101 casos de pneumonia, dos quais 60 (59,4%) tiveram agente etiológico identificado, sendo as bactérias piogênicas as mais frequentes, detectadas em 22 (36,7%) dos casos. Entre os pacientes com agente causal identificado, o padrão tomográfico predominante foi o de nódulos e massas, identificado em 25 (41,7%) casos. Foi observada associação entre bactérias piogênicas e o padrão de consolidação, fungos com nódulos e massas, bem como entre agentes virais e padrão intersticial. CONCLUSÃO: Foi demonstrada associação estatística entre micro-organismos causadores de pneumonia e padrões tomográficos, informação que pode contribuir para o planejamento da terapia de pacientes transplantados renais.

Keywords: Pneumonia; Transplante de rim; Tomografia computadorizada.

The image-guided gastrostomy techniques, as transoral and transabdominal, can be performed when there is a failure of the endoscopic procedure or in some specific clinical scenarios. This pictorial essay intends to show the percutaneous gastrostomy techniques, indications, technical approaches, post-procedure care, and complications.

Keywords: Gastrostomy; Radiology, interventional; Fluoroscopy; Tomography, X-ray computed.