Indocyanine green: The guide to safer and more effective surgery

In this editorial we comment on the article by Kalayarasan and co-workers published in the recent issue of the World Journal of Gastrointestinal Surgery. The authors present an interesting review on the use of indocyanine green fluorescence in different aspects of abdominal surgery. They also highlight future perspectives of the use of indocyanine green in mini-invasive surgery. Indocyanine green, used for fluorescence imaging, has been approved by the Food and Drug Administration and is safe for use in humans. It can be administered intravenously or intra-arterially. Since its advent, there have been several advancements in the applications of indocyanine green, especially in the surgical field, such as intraoperative mapping and biopsy of sentinel lymph node, measurement of hepatic function prior to resection, in neurosurgical cases to detect vascular anomalies, in cardiovascular cases for patency and assessment of vascular abnormalities, in predicting healing following amputations, in helping visualization of hepatobiliary anatomy and blood vessels, in reconstructive surgery, to assess flap viability and for the evaluation of tissue perfusion following major trauma and burns. For these reasons, the intraoperative use of indocyanine green has become common in a variety of surgical specialties and transplant surgery. Colorectal surgery has just lately begun to adopt this technique, particularly for perfusion visualization to prevent anastomotic leakage. The regular use of indocyanine green coupled with fluorescence angiography has recently been proposed as a feasible tool to help improve patient outcomes. Using the best available data, it has been shown that routine use of indocyanine green in colorectal surgery reduces the rates of anastomotic leak. The use of indocyanine green is proven to be safe, feasible, and effective in both elective and emergency scenarios. However, additional robust evidence from larger-scale, high-quality studies is essential before incorporating indocyanine green guided surgery into standard practice.

Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors

BACKGROUND

Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.

AIM

To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.

METHODS

To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.

RESULTS

The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.

CONCLUSION

Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.

Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing

PURPOSE

Anal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure.

METHODS

This is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure.

RESULTS

The findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months.

CONCLUSION

Our data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Colonic Crohn’s disease – decision is more important than incision: A surgical dilemma

The most common localization for intestinal Crohn’s disease (CD) is the terminal ileum and ileocecal area. It is estimated that patients with CD have one in four chance of undergoing surgery during their life. As surgery in ulcerative colitis ultimately cures the disease, in CD, regardless of the extent of bowel removed, the risk of disease recurrence is as high as 40%. In elective surgery, management of isolated Crohn’s colitis continues to evolve. Depending on the type of surgery performed, colonic CD patients often require further medical or surgical therapy to prevent or treat recurrence. The elective surgical treatment of colonic CD is strictly dependent on the localization of disease, and the choice of the procedure is dependent of the extent of colonic involvement and previous resection. The most common surgical options in colonic CD are total proctocolectomy (TPC) with permanent ileostomy, segmental bowel resection, subtotal colectomy. TPC completely removes all colonic and rectal disease and avoids the use of a potentially diseased anus. We will review current options for the elective surgical treatment of colonic CD, based on the current literature and our own personal experience.

Assessment of severity of acute pancreatitis in a Sars-CoV-2 pandemia

HUMAN AND ANIMAL RIGHTS

Every patient has given permission for publication of information from the medical history as long as it is used for medical research purposes.

INFORMED CONSENT

Informed consent was obtained from all the individual participants of the study.

Unusual presentation of a giant jejunal gastrointestinal stromal tumor

AIM

Gastrointestinal stromal tumours (GISTs) are rare tumours. Tumour rupture is an additional adverse prognostic factor and should be recorded, regardless of whether it took place before or during surgery.

CASE REPORT

A case report of hemoperitoneum from spontaneous rupture of a gastrointestinal stromal tumor of the jejunum is presented. The patient underwent an urgent laparotomy. An "en bloc" resection was performed.

CONCLUSION

The information in the literature is examined. Spontaneous rupture of the tumor with concomitant hemoperitoneum is an important prognostic factor in these patients. The hemoperitoneum contributes to a worse prognosis because of its ability to produce peritoneal seeding KEY WORDS: Gist.

Gastrointestinal Uses of Botulinum Toxin

Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.

Association between cholesterol gallstones and testosterone replacement therapy in a patient with primary hypogonadism

A 16-year-old boy had a past medical history of primary hypogonadism, due to bilateral anorchia. He presented with gallstones located in the gallbladder and a mild dilatation of the intrahepatic biliary tree. The histology study reported cholesterol gallstones. The patient had been treated with testosterone replacement therapy since infancy. We suggest a possible correlation between testosterone replacement therapy and the presence of cholesterol gallstones.

Cerenkov luminescence imaging (CLI) for image-guided cancer surgery

Cerenkov luminescence imaging (CLI) is a novel molecular optical imaging technique based on the detection of optical Cerenkov photons emitted by positron emission tomography (PET) imaging agents. The ability to use clinically approved tumour-targeted tracers in combination with small-sized imaging equipment makes CLI a particularly interesting technique for image-guided cancer surgery. The past few years have witnessed a rapid increase in proof-of-concept preclinical studies in this field, and several clinical trials are currently underway. This article provides an overview of the basic principles of Cerenkov radiation and outlines the challenges of CLI-guided surgery for clinical use. The preclinical and clinical trial literature is examined including applications focussed on image-guided lymph node detection and Cerenkov luminescence endoscopy, and the ongoing clinical studies and technological developments are highlighted. By intraoperatively guiding the oncosurgeon towards more accurate and complete resections, CLI has the potential to transform current surgical practice, and improve oncological and cosmetic outcomes for patients.

Adjuvant taxanes and the development of breast cancer-related arm lymphoedema

BACKGROUND

Despite affecting approximately one-quarter of all patients undergoing axillary lymph node dissection, the pathophysiology of breast cancer-related lymphoedema (BCRL) remains poorly understood. More extensive locoregional treatment and higher body mass index have long been identified as major risk factors. This study aimed to identify risk factors for BCRL with a specific focus on the potential impact of chemotherapy on the risk of BCRL.

METHODS

This was a retrospective analysis of a cohort of consecutive patients with breast cancer treated at a major London regional teaching hospital between 1 January 2010 and 31 December 2012. All patients had node-positive disease and underwent axillary lymph node dissection. Data regarding tumour-, patient- and treatment-related characteristics were collected prospectively. The diagnosis of BCRL was based on both subjective and objective criteria. Multivariable Cox proportional hazards regression was used to assess the association between treatment and risk of BCRL.

RESULTS

Some 27.1 per cent of all patients (74 of 273) developed BCRL over the study period. Administration of taxanes showed a strong association with the development of BCRL, as 52 (33.5 per cent) of 155 patients who received taxanes developed BCRL. Multivariable Cox regression analysis demonstrated that patients who received taxanes were nearly three times more likely to develop BCRL than patients who had no chemotherapy (hazard ratio 2.82, 95 per cent c.i. 1.31 to 6.06). No such increase was observed when taxanes were administered in the neoadjuvant setting.

CONCLUSION

The present findings suggest that adjuvant taxanes play a key role in the development of BCRL after surgery. This may support the use of taxanes in a neoadjuvant rather than adjuvant setting.

Age at diagnosis and distant metastasis in breast cancer--a surprising inverse relationship

INTRODUCTION

Predictors for site of distant metastasis and impact on survival in breast cancer are incompletely understood.

METHODS

Clinico-pathological risk factors for site of distant metastasis and survival were analysed in patients with invasive breast cancer treated between 1986 and 2006.

RESULTS

Of 3553 patients, with median follow-up 6.32years, 825 (23%) developed distant metastasis. The site of metastasis was bone in 196/825 (24%), viscera in 540/825 (65%) and unknown in 89 (11%). Larger primary invasive tumour size, higher tumour grade and axillary nodal positivity increased risk of metastasis to all sites. Lobular carcinoma was more likely to first metastasise to bone compared to invasive ductal carcinoma (NST). Oestrogen receptor (ER) negative, progesterone receptor (PgR) negative and/or Human epidermal growth factor (HER2) positive tumours were more likely to metastasise to viscera. A striking relationship between increasing age at diagnosis and a reduction in risk of distant metastasis to bone and viscera was observed. Median time to death from onset of metastatic disease was 1.52 (Interquartile range (IQR) 0.7-2.9)years for patients with bone metastasis and 0.7 (IQR 0.2-1.5)years for visceral metastasis. On multivariate analysis, despite the decrease in risk of distant metastasis with increasing age, there was an elevated hazard for death in patients >50years at diagnosis of metastasis if they developed bone metastasis, with a similar trend observed in the >70years age group if they developed visceral metastasis.

CONCLUSION

These findings indicate that there are biological mechanisms underlying the impact of age on the development of distant metastasis and subsequent death. This may have important implications in the treatment of breast cancer.

Ultrasound guided fine-needle aspiration biopsy of thyroid nodules: Guidelines and recommendations vs clinical practice; a 12-month study of 89 patients

INTRODUCTION

Given the high prevalence of thyroid nodules in the general population it is essential to develop a method for identifying those nodules which require fine-needle aspiration biopsy (FNAB) due to suspicion for malignancy in order to avoid over- or under treatment of this disease. The ultrasound (US) criteria identified by Kim et al. and the American Association of Clinical Endocrinologists appear to be the most sensitive and most specific. The purpose of this study was to analyze a sample of patients who underwent FNAB of the thyroid and to compare the obtained data with the international guidelines and the recommendations for management of thyroid nodules.

MATERIALS AND METHODS

This study analyzed the clinical, anamnestic and US reasons for which 97 nodules located in 89 patients underwent FNAB, and the data were compared with the criteria set by the guidelines and with the cytological results.

RESULTS

Echogenicity was indication for FNAB in 99% of cases, appearance of the margins in 75.3%, presence of calcifications in 93.8% and presence of vascularity in 73.2%. In a total of 4.1% of cases, cytological outcome was positive for malignancy, 21.6% necessitated monitoring, 4.1% were referred to surgery and histological examination of the surgical specimen and 63.9% resulted negative for malignancy.

DISCUSSION

The finding of hypoechoic nodules often leads to continued investigation; the presence of intranodular vascularization detected at Doppler US is perceived as suspicious and the presence of microcalcifications always leads to further investigation. On the request of the endocrinologist the dominant nodule in a goiter is in most cases subjected to FNAB even if the volume has not increased. Adequate US criteria can help identify potentially malignant nodules and guide implementation of FNAB. However, identification of malignant nodules using instrumental investigation cannot disregard medical records and clinical laboratory tests. According to the authors' experience, a close collaboration between endocrinologists, radiologists and pathologists is essential for a correct evaluation of patients with thyroid nodules in order to avoid over or under estimation of the risk of malignancy of a nodule and therefore of the necessity to perform further examinations.

Abstract P4-09-13: Predicting Potential Patterns of Metastatic Spread and Outcomes in Breast Cancer

Background: Metastasis progression in breast cancer can be viewed as a stepwise sequence of events that occurs with distinct temporal patterns and in unique organ sites. Our previous results indicate that metastatic spread occurs along distinct pathways governed by biological characteristics of the primary tumour.

Aim: To examine clinical and histopathological factors that predict for patterns of metastatic spread and survival in breast cancer. Materials and Methods: A study population consisting of 5569 patients diagnosed with breast cancer between 1975 and 2006 was studied. Median follow-up was 7.7 years, interquartile range (IQR) 3.4-14.3 years. The median metastasis-free interval was 6.7 years, IQR 2.6-14.6 years. Survival analysis was performed using Kaplan-Meier method and group comparisons made with a log-rank test. Both univariate and stepwise Cox proportional hazard models were used to investigate the relationship between prognostic factors and breast cancer survival. Results: Of 5569 patients, 1718 (31%) developed distant metastasis; 499 (29%) to bone, 990 (58%) to other organs and 229 (13%) to bone followed by a second metastatic event in another organ site within 6 months after the first event (bone + 2nd site).

Patterns of metastatic spread: In univariate analysis, ER-ve tumours were 45% more likely to spread to other organs or to bone + 2nd site. Grade 3 cancers, compared with grade 1 tumours, had a 2-fold increase in the likelihood of metastasising to bone only, 4-fold to bone + 2nd site and 7.5-fold to other organs. In multivariate analysis, node positivity, higher grade and larger tumour size predicted for metastasis to bone or any other organ site whilst node positivity and ER negativity predicted for metastasis to bone + 2nd site. Patients &gt;70 years were 60% less likely to have bone metastasis compared with patients &lt;50 years. ER+ve tumours did not show an increased predilection to bone metastasis on multivariate analysis. Survival from 1st onset of metastasis (breast cancer-related deaths): The median survival in months [95% CI] for patients who developed bone metastasis was 24 [21,26], bone + 2nd site 12 [9, 13] and other organ sites 14 [13, 16] months, respectively. There was a highly significant exponential decrease in survival with increasing age (P&lt;0.02). This effect was even more pronounced in those patients &gt;70 years age who developed bone + 2nd site metastasis (5 times greater hazard of dying compared with &lt;50 years), and was further amplified in grade 3 tumours in this group of patients. Furthermore, node positivity and grade 3 tumours had the maximum negative effect on survival in this group compared with patients who had metastasised to bone only or to other organ sites. Conclusion: The clinical and histopathological factors that predict for patterns of metastatic spread and survival in breast cancer in this large cohort support some previous observations, refute others and demonstrate new findings. These observations merit further investigation and, potentially, future trials of adjuvant therapy that are designed according to predictive patterns of metastatic spread.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-13.

Stem cells and breast cancer

Proliferation in continuously renewing tissues, including the mammary gland, is hierarchically organized with a small number of slowly dividing stem cells and a greater number of more rapidly proliferating 'transit amplifying' cells. Mammary stem cells have been recently identified and purified based on their surface antigen expression. The recognition of mammary epithelial stem cells had led to the hypothesis that these may be at the root of breast cancer. In support of this, a highly tumorigenic subpopulation of cancer cells - cancer stem cells - has recently been identified in primary and metastatic breast cancer samples and in a number of established breast cancer cell lines. The existence of cancer stem cells would explain why only a small minority of cancer cells is capable of extensive proliferation and transferral of the tumour. In this article we aim to review the evidence in support of the existence of both normal mammary stem cells and breast cancer stem cells, and provide further insight into how taking this subpopulation of cells into account may affect the way we treat epithelial cancers in the future.

Radiofrequency ablation of pulmonary lesions

PURPOSE

Radiofrequency ablation uses the thermal energy produced by a generator to create a coagulative necrosis. The method is well established for the treatment of a variety of primary and secondary cancers of the liver but is less well studied for the treatment of lung malignancies.

MATERIALS AND METHODS

From March 2005 to March 2006, 11 patients (seven men and four women) with single or multiple pulmonary nodules underwent radiofrequency ablation of 12 unresectable pulmonary tumours. Follow-up computed tomography (CT) was performed at 1, 3, 6, and 12 months after radiofrequency ablation. Lesions were evaluated for dimensions and contrast enhancement.

RESULTS

Radiofrequency ablation was well tolerated by all patients. Postprocedural complications included four cases of pneumothorax treated with simple aspiration without tube placement and one case of small parenchymal haemorrhage. There were no major complications.

CONCLUSIONS

Radiofrequency ablation of primary or secondary pulmonary lesions is a safe and technically feasible option for the management of unresectable pulmonary malignancies.

“Inflammatory” breast cancer

BACKGROUND

"Inflammatory" breast cancer is a rare and very aggressive form of the disease characterised by rapid onset and dismal outcome.

METHODS

This review describes the clinical and molecular aspects of inflammatory breast cancer. The relevant English language literature on of inflammatory breast cancer was searched via Medline and ISI Web of Knowledge Cross Search (1924-2005), cross-referencing with key articles on the subject.

RESULTS AND CONCLUSION

An increasing body of evidence demonstrates that inflammatory breast cancer is a unique form of breast cancer. A prompt diagnosis and multidisciplinary approach (based on neoadjuvant chemotherapy, loco-regional treatment with surgery and/or radiotherapy, followed in some cases by adjuvant systemic therapy) are the two factors most likely to have an impact on survival. As the molecular basis of the disease is becoming increasingly more defined, new potential therapeutic targets may arise in the future.

Internal mammary nodes and breast cancer

Prognostic significance

[Computerized tomography-guided neurolytic block of the splanchnic nerve]

CT-guided neurolytic splanchnic nerve block is a technique for relieving abdominal cancer pain; the goal is the alcoholic neurolytic interruption of the sensitive structures in retroperitoneal space. CT yields accurate anatomical detailing and the course for needle placement and alcohol spread. January, 1993, to July, 1996, twenty-one bilateral splanchnic nerve blocks were performed through the posterior access. Forty-eight hours after alcoholization, 14 patients (66%) had complete pain regression; 52% of the patients needed no analgesics for 6 to 54 days and only 9 patients (42%) needed another low opioid therapy. Complications included hypotension and diarrhea in all cases. One had a cardiac arrest and died 8 days after the procedure. There were no other complications. The whole procedure usually lasted 60 min (range: 45 to 90 min). Splanchnic nerve neurolysis is a useful treatment in the patients with severe chronic abdominal pain. It is used as a second line treatment when large lesions change celiac anatomy and complicate the percutaneous block of the celiac plexus.

[Renovascular hypertension-bilateral kidney: autotransplantation and reconstruction of the aorta with autologous saphena]

The authors describe a patient with stenosis of the renal artery undergoing bilateral kidney autotransplantation and reconstruction of the aorta with autologous saphena. This study also provides a general evaluation of renovascular hypertension incidence, etiopathogenesis, symptomatology, diagnostic criteria, therapy. The presence of a diastolic pressure > 110 mmHg, with normal creatinin levels and urinalysis results, is very significant and leads to invasive investigations. Site and size of the anatomic anomaly are evaluated by arteriography. Surgery is the treatment of choice.

[CT-guided celiac ganglion block. The authors' own experience]

Celiac plexus neurolysis is considered an effective technique for relieving abdominal cancer pain. CT yields accurate anatomical detailing, thus allowing the indirect location of the celiac plexus and the planning of needle trajectory and positioning. September 1992 to December 1993, twenty-eight celiac plexus neurolyses for pain relief were performed in 26 patients (13 men and 13 women), 17 through the anterior and 11 through the posterior access. These patients had been referred to our department for pain management. Forty-eight hours after alcoholization, 20 patients (71%) had complete pain regression and their analgesic treatment was thus discontinued. 36% of the patients did not need any analgesics for 30 to 169 days. No neurologic complications were observed. Only transient orthostatic hypotension requiring no treatment developed in all our patients during the first 24 hours after the block. To conclude, we believe celiac plexus alcoholization under CT guidance to be a safe and effective technique for relieving abdominal pain due to cancer or benign conditions. We prefer the anterior approach because it is better accepted by the patients and more easily performed by the operators.

Vein of Galen aneurysm: MRI with a fast gradient refocusing pulse sequence

A case of vein of Galen aneurysm, studied with a fast gradient refocusing pulse MRI sequence, is presented. Fast MRI sequences allowed the acquisition of additional hemodynamic information that was not available with either routine MRI or angiography.

[Role of echo-Doppler in the screening of renal artery stenosis in children with kidney transplants]

Renal artery stenosis (RAS) in renal transplanted pediatric patients is a long-term complication. The clinical suspicion must be considered when patients exhibit signs of impaired renal function or refractory hypertension, not associated with other complications of renal transplantation -i.e., acute or chronic rejection, glomerulonephritis, cyclosporine toxicity. The intermediate step between clinical suspicion and angiography is represented by Doppler US. The authors report their experience with Doppler US in the screening of RAS in a pediatric series of transplanted patients. The incidence of RAS in our series (54 transplanted kidneys, 46 of them included in the study) was 4.3%. A severe stenosis was demonstrated by both Doppler US and angiography in 2 patients, with 100% Doppler sensitivity. In both stenoses, Doppler US showed high systolic peaks (blood flow velocity > or = 2.5 m/s) and post-stenotic turbulence. Thanks to its high sensitivity, Doppler US is considered to be very useful in the screening of vascular complications in renal transplanted children.

[Magnetic resonance in the diagnosis of aneurysmal bone cyst]

A patient of 12 suffering from aneurysmal cyst of the ischium was studied with traditional radiology, computed tomography (CT) and magnetic resonance imaging (MRI). The advantages of MRI in the study of this pathology compared to traditional radiography and CT are assessed. It was shown that the CT and MRI techniques are superior to standard X-ray examinations in anatomic definition and in evaluating the lesions's relationships with neighbouring structures and, in particular, that MRI is superior to CT in extension.