Primary Aldosteronism: Complete Remission after Adrenal Venography

A remission of adrenal adenoma producing aldosterone is described as a consequence of adrenal venous catheterization. The patient did not undergo surgery but she was kept on frequent clinical controls. The complete remission of the syndrome is still persisting three years after the incident. Since adrenal insufficiency is described after adrenal venous catheterization, the authors suggest that this procedure is to be restricted to well selected patients. When this incident occurs in pathological glands, a remission of endocrine syndrome may be expected.

Renal embolization as an alternative to surgical nephrectomy in children

PURPOSE

Complete renal embolization may be an alternative to surgical nephrectomy. The indications for renal embolization do not differ from those for surgical nephrectomy, but the less invasive nature of the technique is a major advantage. Few case reports are available in the pediatric age group. Our experience showed that complete renal embolization was feasible in pediatric patients with results comparable to those obtained in adults.

MATERIALS AND METHODS

Twelve pediatric patients underwent 14 renal embolizations. The indications for embolization were as follows: (1) severe hypertension in 7 patients with end-stage renal failure; in these cases, a unilateral native nephrectomy was recommended prior to renal transplantation; (2) end-stage hydronephrosis in 3 patients with moderate hypertension or recurrent urinary infection; (3) nephrotic syndrome in 1 patient; or (4) ablation of an irreversibly rejected renal allograft in 1 patient. The embolization was performed under epidural anesthesia in 10 patients and under general anesthesia in 2 patients, by means of a polyvinyl alcohol injection with hemostatic gelatin powder and placement of coils. Postembolization course was followed.

RESULTS

The embolization was successful in all 12 patients. In 1 patient, the procedure had to be repeated as a small accessory artery had revascularized the upper pole. In another patient, the procedure was bilateral in 2 separate sessions. In 10 patients, severe flank pain required narcotic analgesia. Two patients had fever. None had hypertension peaks. Median hospital stay was 4 days. At mean follow-up of 16 months, the results were stable.

CONCLUSION

Renal embolization can avoid surgical nephrectomy also in pediatric patients. The advantages are less morbidity and shorter hospital stay. Our results in the short and medium term were equal to those of surgical removal. The procedure appeared to be safe and minimally invasive.

Dacryocystostenting: technical and long-term results

PURPOSE

We describe our experience in treating epiphora caused by chronic inflammation and obstruction of the nasolacrimal system by endonasal placement of a polyurethane stent in the nasolacrimal duct, with long-term assessment of patency (4 years).

MATERIAL AND METHODS

Between July 1998 and May 2001, 57 stents were inserted using Song's technique. All procedures were carried out in the radiology suite following mild sedation and local anaesthesia of the conjunctival and nasal mucosa. The follow-up investigation concerns 23 stents assessed 24-48 months after placement.

RESULTS

At follow-up after 4 years, 20 stents (86.9%) were obstructed. Fifteen of the stents removed underwent histological analysis that showed occlusion of the stent with granulation tissue (eight cases), necrotic material (four cases) and fibrosis (three cases).

CONCLUSIONS

Although encouraging in terms of safety, simplicity and reproducibility, the results obtained with the polyurethane stent demonstrate poor long-term efficacy and stimulate the search for new strategies such as programmed stent removal or the development of a more biocompatible material.

Magnetic resonance imaging in the diagnosis of melanoma: in vivo preliminary studies with dynamic contrast-enhanced subtraction

The aim of this study was to analyse the potential of fast dynamic subtraction magnetic resonance (MR) imaging in differentiating in vivo melanomas from benign melanocytic lesions. Dynamic MR imaging was performed after intravenous administration of gadopentetate dimeglumine (Gd-DTPA) in 18 patients with melanocytic skin lesions. Using a post-processing algorithm, time-signal intensity curves were obtained for the lesions and classified according to their shapes as type I (steady enhancement increase), type II (plateau of signal intensity) or type III (wash-out of signal intensity). Other parameters evaluated for their potential to differentiate melanomas from benign lesions were the enhancement rate (percentage of signal intensity increase) in the first minute after Gd-DTPA administration, the peak value of the enhancement rate, and the wash-out slope. The pigmented lesions were then surgically excised and the MR results compared with the histological assessment. In melanomas, the mean value of the enhancement rate in the first minute was 611%, whereas in benign lesions it was 131% (P = 0.001). The distribution of curve types was also different: seven of the nine naevi showed type I curves, while eight of the nine melanomas displayed a type III curve. In addition, distinctive wash-out dynamics were observed: the enhancement rate began to decrease between the first and third minutes for melanomas, but continued to increase until the sixth minute for naevi (P = 0.000). These findings, which are most likely related to the neoangiogenesis present in melanomas, indicate that dynamic MR imaging can be helpful in the differential diagnosis of pigmented skin lesions.

Treatment of intraosseous arteriovenous fistulas of the extremities

Intraosseous arteriovenous fistulas of the extremities are rare malformations frequently associated with severe systemic hemodynamic alterations. In many cases, it is quite difficult to eliminate these anomalous vascular structures, but the possibilities for successful treatment are much greater when surgery is combined with interventional radiology. Selective embolization of the malformed vessels can be produced with a variety of agents that are injected into afferent arteries, via percutaneous puncture or through direct surgical access. The intraosseous portion of the fistula should be resected at the time of embolization or later. The authors describe the successful treatment of three patients having intraosseous arteriovenous fistulas of the upper extremities, who have had follow-up for 2 to 10 years.

[Preoperative ultrasonographic measurement of melanoma thickness with 20 MHz probe]

The authors report on the preoperative evaluation of melanoma thickness with very high frequency US probes (20 MHz). Thirty patients with clinical suspicion of melanoma were examined preoperatively with US. The high quality of the images obtained with 20-MHz US probes allowed the lesions involving the superficial derma or, in more advanced cases, all derma, to be demonstrated and tumor thickness to be measured accurately. The latter is a major prognostic factor and indeed Breslow's classification is based on tumor thickness. The preoperative US study of melanoma thickness allows the surgeon to plan excision depth, which is necessary for accurate and safe tumor resection, that is, whose margins are proportionate to melanoma thickness. In the 30 patients submitted to preoperative US measurements of tumor thickness, US and histologic findings were in agreement. US overestimated melanoma thickness by 7 to 11%, which however had no impact on prognosis and surgical planning. While US can differentiate melanomas from other types of benign or malignant pigmented skin lesions such as blue nevus, pigmented basalioma or pigmented seborroic cheraosis, no unquestionable US signs have been found yet to differentiate melanoma from nevus, which makes US useless for the differential diagnosis. Nonetheless, surgeons can use preoperative US to adapt the exeresis of melanoma to its actual severity and to reduce scars to a minimum. Possible skin metastases can also be detected by US and thus removed.

[Percutaneous transluminal renal angioplasty. Italian experience at 13 centers]

The data relative to 13 years' experience with percutaneous transluminal renal angioplasty (PTRA) in the 13 major interventional radiology centers in Italy were collected and analyzed to evaluate technical and clinical results. Our aim was to collect homogeneous results in a large series of patients, evaluating both the technical and the clinical success with a long-term follow-up (1 month-13 years). One thousand three hundred forty seven PTRA procedures (including 42 restenoses) in 1,073 patients were retrospectively reviewed. In 807 cases the cause of stenosis was atherosclerosis, in 442 cases fibromuscular dysplasia and in 24 cases arteritis in 12 cases, stenoses were present in patients that had undergone a surgical by-pass. Sixty-two stenoses in patients with solitary kidney and 102 in patients with renal failure were studied separately. The technical success (based on the morphology of the dilated tract) obtained in 91% of cases was considered, together with the clinical success (in 81% of cases), based on the decrease in blood pressure evaluated according to Martin's classification. The blood pressure values collected after the maneuver were also evaluated separately for the different types of stenosis etiology: atherosclerosis, fibromuscular dysplasia or arteritis; moreover, blood pressure was studied in solitary kidney patients and in those with renal failure. Complications were classified as major (4.2%) and minor (4.9%). The high success rate and the low incidence of complications we observed in our series suggest PTRA as the procedure of choice for high blood pressure patients with renal artery stenosis > 50% of the normal caliber.

[Integrated imaging of hepatocarcinoma. Personal experience]

Hepatocellular carcinoma (HCC) is the commonest primary tumor of the liver; of late, its incidence has increased in the Western world. The authors report their experience with 42 patients affected with HCC; 36 cases were confirmed by fine-needle biopsy (FNAB), and 2 by surgery. All patients were studied with US and CT; 25 of them underwent color-Doppler US, and 30 angiography. In 9 patients, Lipiodol-CT was performed after hepatic arterial chemo-embolization. Thirty-six expansive and expansive-infiltrative lesions were observed, 4 infiltrative ones, and 1 neoplastic thrombosis of the portal vein with no evidence of parenchymal mass; 28 cases were multinodular in nature. US showed the primary lesion in all cases, while CT missed 2 lesions of 15 mm in diameter. In 19 of 25 cases studied with color-Doppler US, arterial pathologic signals were observed. Angiography confirmed all the primary lesions diagnosed by US in 30 patients and was found to be the most sensitive method to reveal multinodular lesions 8-15 mm phi, whereas Lipiodol-CT had higher resolution in detecting nodules up to 3 mm phi. The retrospective review of our results pointed out the capabilities of diagnostic imaging techniques in characterizing and staging HCCs--which is the reason why the role of biopsy has not been emphasized. The whole of the morphofunctional data obtained with the different techniques allowed lesion tissue characterization.

Transvenous sclerotherapy of the gonadal veins for treatment of varicocele: long-term results

Percutaneous occlusion of the spermatic vein has been performed on 136 consecutive patients with varicocele scroti during the last six years. The authors report their long-term results on the first 119 cases to have a follow-up of at least six months. Occlusion of the insufficient gonadal vein is induced by the selective transcatheter injection of sclerosing agent with local anesthesia. Their patients are always evaluated before and after the procedure by Doppler examination. A spermiogram is done before the procedure and after six months. In this series they registered only 4 recurrences with no major complications.

Therapeutic embolization of renal artery to control severe hypertension due to renal trauma

In a young patient with a post-traumatic renal hematoma, severe systemic hypertension, secondary to the activation of the renin-angiotensin axis, developed. Because of persistent hypertension, after 3 months of drug therapy, selective percutaneous embolization of the damaged vessels was performed. One year after procedure, the patient is normotensive without drugs.

[Pleural colonization of thymoma]

Six observations of peculiar pleural implants completely separated from invasive thymomas (examined by conventional chest x-ray and CT) were reviewed. CT was more effective than chest x-ray; number, size and extent of pleural lesions were underestimated by plain film studies. Moreover CT provides a densitometric evaluation of the pleural pathology being useful in differential diagnosis. CT can also be helpful as a guide to needle biopsy.

[Contrast dose and signal/noise ratio in digital angiography]

In a digital angiographic system the variations of the signal to noise ratio in relation to the contrast medium quantity and to the exposure data are analyzed. On these basis, the greater flexibility of the digital angiographic equipments in comparison with conventional ones is underlined.

Surgical approach to renal cell carcinoma extending into the right atrium through the inferior vena cava

Successful management of a patient with an intracardiac tumor thrombus of renal carcinoma is described. This case and a few others in the literature have led us to consider the clinical signs of cavo-atrial obstruction, frequently silent and unspecific; the diagnostic methodology, especially based upon CAT scan and cavography, and the type of surgery and surgical technique called for, especially as regards the approach and the possible use of extracorporeal circulation (ECC).

Echographic follow-up of an abdominal aortic aneurysm treated with a prosthetic bypass

The history of a patient with two thoracoabdominal aneurysms and lumbar Pott's disease is reported. A bypass was implanted from the ascending to the abdominal aorta. In the postoperative course the patient experienced acute low back pain. Ultrasonography suggested patency of the vascular graft. Therefore the symptoms were attributed to the vertebral pathology, and so the correct treatment could be given. The utility of ultrasonography in the early postoperative course, when aortography is contraindicated, is stressed.

[Computerized tomography in the location of hepato-splenic echinococcal cysts. Presentation of 2 cases]

Computerised tomography (CT) was used in a study of liver and spleen hydatids in two patients. CT is of primary importance, even when such cysts occur in unusual sites, i.e. the spleen, because it clinches the diagnosis in all cases where daughter cysts are present. Scintigraphy, angiography, and conventional radiology may be regarded as of secondary importance. Even when CT is not specific due to the absence of daughter cysts, it offers a panorama of the hydatid territory, its boundaries, and the displacement and compression it imposes on neighbouring organs. It immediately defines the liquid content. In addition, the diagnostic values of CT goes beyond that of ultrasonography, which may be impeded by meteorism and surgical sequelae, such as adhesions and scars.

Advanced carcinoma of the cervix treated by continuous pelvic arterial infusion with cytostatics and radiation therapy

Regional chemotherapy by infusion of cytostatic drugs (methotrexate and adriamycin) into the hypogastric arteries has been used in 25 cases of advanced carcinoma of the cervix (IIIB and IV stage). A method for the percutaneous introduction of catheters into these arteries and their permanence for a period of time of 8-12 days is described. After chemotherapy there was such a satisfactory reduction in size of the tumour that patients could then be treated with radiotherapy and/or surgery.

Angiographic study of digital arteries in workers exposed to vinyl chloride

Five patients exposed to vinyl chloride were studied by hand angiography and other non-invasive methods, including photoplethysmography, rheography, and thermography. Raynaud's phenomenon was present in all five subjects, while acro-osteolysis affected only one. Organic vascular lesions, such as narrowing, segmentary occlusions of digital arteries and bridge collaterals, were found in angiographic studies. Only one patient did not show clear segmentary occlusions, but his vessels were crooked and diffusely narrowed. Angiographic results appear to correlate well with the changes shown by non-invasive techniques.

[Uncommon locations of celomic cysts: a possible cause of error in mediastinal radiology (author's transl)]

Five cases of uncommon locations of mediastinal celomic cysts are presented. All cases were surgically proved. The importance of these locations in the differential diagnosis of mediastinal masses is stressed. The evaluation of their inner structure by computerized tomography is, without doubt, the best progress in radiological diagnosis of the mediastinum. This method allows, atraumatically, to confirm or exclude the cystic nature of the lesion in one with its precise spatial localization.

Bilateral pseudocystic pheochromocytoma

A case of bilateral pheochromocytoma presenting as primarily cystic suprarenal masses is reported. The computed tomographic manifestations, possible etiology, and differential diagnosis of these cystic suprarenal lesions are discussed.

Portosystemic arteriovenous fistulas

The authors report the angiographic demonstration of arteriovenous fistulas in three patients. The fistula was believed to be spontaneous in one case, related to abdominal surgery and to abdominal trauma in the other two cases. The importance of angiography in the diagnosis and evaluation of this disease has been emphasized in the literature. Early diagnosis is valuable, either to prevent hepatic damage or to give an opportunity for recovery once it has taken place. Follow-up of the three patients has shown that hepatic function notably improved after surgery.

[Lumbar epidural anesthesia in peripheral arteriography]

A brief survey of the difficulties associated with the intra-arterial administration of contrast media during peripheral arteriography is followed by an assessment of anaesthesiological and arteriographic results obtained with lumbar peridural anaesthesia in a group of patients. Complete analgesia, block of the sympathic, and motor block gave particular assistance in the securing of optimum definition of the radiographical picture of the peripheral circulation. These and other advantages offered by peridural anaesthesia suggest that it is a valid technique for peripheral arteriography.

Computerized Tomography in Lymphomas: A Simple Method for the Control of Abdominal Localizations after Treatment

The authors, according to their experience of repeated controls of abdominal computed tomography (CT) in 10 patients with Hodgkin's and non Hodgkin's lymphomas, obtained a clear demonstration of therapy response and disease evolution. The reduction or enlargement after therapy of periaortic, pericaval, hepatic, splenic and pancreatic lymph nodes not always opacified from lymphographic contrast medium is evaluated. It was possible, during the same examination, to evaluate liver, spleen, kidneys parenchyma and regional bone. CT results were always well correlated with clinical findings.

[Percutaneous biopsy of the lungs: 136 biopsies in 80 patients (author's transl)]

The authors analyze their experience on 136 percutaneous biopsies of the lung performed on 80 patients during 3 years. Indications are given with particular reference to the technique, to the type of the needles used and the expedients adopted in order to reduce the complications. Patients to be subjected to biopsy should be correctly and carefully selected. To this purpose, the authors present a protocol used for the patients affected by localized or diffused, single or multiple pulmonary lesions. Percutaneous needle biopsy of the lung assumes a precise role in the numerous diagnostic studies on these patients. The technique is considered in some cases essential to the right management of the patient. In other cases, instead, it is considered superfluous or too risky for the presence of contraindications. As demonstrated by authors' experience, supported by others, the method has appeared easy to perform and apt to provide good diagnostic results.

[The single ventricle: plain film and contrastographic radiologic findings (author's transl)]

The radiologic findings on the plain film are investigated in a series of 9 patients with single ventricle. In 3 of them the cardioangiographic patterns are described. The possible association of malformations is stressed. The value of the cardioangiographic investigations is discussed in planning a possible surgical treatment of the disease.

[Value of CT and lymphography in the staging of lymphomas (author's transl)]

The contribution of CT is evaluated in association with conventional diagnostic investigations in the staging of lymphomas. The data obtained by means of CT are an integration of those obtained by means of lymphography. On the other hand CT offers elements which cannot be obtained by others methods, especially concerning the retroperitoneal region. This diminishes the average of patients who must undergo laparoscopy and laparotomy. Moreover CT allows to follow the evolution of the disease and to control the results of the treatment.