Scientific Status Quo of Small Renal Lesions: Diagnostic Assessment and Radiomics

Background: Small renal masses (SRMs) are defined as contrast-enhanced renal lesions less than or equal to 4 cm in maximal diameter, which can be compatible with stage T1a renal cell carcinomas (RCCs). Currently, 50-61% of all renal tumors are found incidentally. Methods: The characteristics of the lesion influence the choice of the type of management, which include several methods SRM of management, including nephrectomy, partial nephrectomy, ablation, observation, and also stereotactic body radiotherapy. Typical imaging methods available for differentiating benign from malignant renal lesions include ultrasound (US), contrast-enhanced ultrasound (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI). Results: Although ultrasound is the first imaging technique used to detect small renal lesions, it has several limitations. CT is the main and most widely used imaging technique for SRM characterization. The main advantages of MRI compared to CT are the better contrast resolution and tissue characterization, the use of functional imaging sequences, the possibility of performing the examination in patients allergic to iodine-containing contrast medium, and the absence of exposure to ionizing radiation. For a correct evaluation during imaging follow-up, it is necessary to use a reliable method for the assessment of renal lesions, represented by the Bosniak classification system. This classification was initially developed based on contrast-enhanced CT imaging findings, and the 2019 revision proposed the inclusion of MRI features; however, the latest classification has not yet received widespread validation. Conclusions: The use of radiomics in the evaluation of renal masses is an emerging and increasingly central field with several applications such as characterizing renal masses, distinguishing RCC subtypes, monitoring response to targeted therapeutic agents, and prognosis in a metastatic context.

Liver transplantation for iatrogenic injuries secondary to cholecystectomy: a systematic review

INTRODUCTION

Iatrogenic injury to the liver hilum during cholecystectomy is a severe surgical complication, with liver transplantation (LT) as the final drastic solution. The authors report the experience of our center and conduct a review of the literature on the outcomes of LT performed in this setting.

METHODS

Data sources included MEDLINE, EMBASE, and CENTRAL from inception to 19 June 2022. Studies reporting on patients treated with LT for liver hilar injuries following cholecystectomy were included. Incidence, clinical outcomes, and survival data were synthesized through a narrative review.

RESULTS

Twenty-seven articles were identified, including 213 patients. Eleven (40.7%) articles highlighted deaths within 90-days post-LT. Post-LT mortality was reported in 28 (13.1%) patients. Severe complications (≥Clavien III) occurred in at least 25.8% ( n =55) of patients. Within larger cohorts, 1-year overall survival (OS) was 76.5-84.3%, and 5-year OS was 67.2-83.0%. The authors also highlight our own experience managing 14 patients with liver hilar injury secondary to cholecystectomy, of which two required LT.

CONCLUSION

While short-term morbidity and mortality is significant, available long-term data suggests reasonable OS in these patients following LT. Future studies are necessary to better understand the relationship between different types of liver hilar injury, transplant indication, and outcomes of LT in this setting.

Successful living donor liver transplantation from an HIV and HCV positive donor: report from the first case in the world

HIV (human-immunodeficiency-virus) and HCV (hepatitis-C-virus) infections cause millions of deaths across the world every year. Since the introduction of effective therapies for HIV, in the middle of 1990s, and HCV, after 2013, those two untreatable infections became completely controlled. Donor safety is the main goal in living donor liver transplantation (LDLT). An accurate predonation screening is mandatory for excluding risk factors related with any increase of donors' short-term and long-term morbidity. We present the first LDLT from a donor with both HIV and HCV previous infections. Donor and recipient did not experience any complication. Individuals with well controlled HIV/HCV infections and without any risk factors may be suitable for donation of a part of their healthy liver. Abstract video, http://links.lww.com/QAD/C833.

Impact of Nutritional Status on Postoperative Outcomes in Cancer Patients following Elective Pancreatic Surgery

BACKGROUND

Pancreatic surgery has been associated with important postoperative morbidity, mortality and prolonged length of hospital stay. In pancreatic surgery, the effect of poor preoperative nutritional status and muscle wasting on postsurgery clinical outcomes still remains unclear and controversial.

MATERIALS AND METHODS

A total of 103 consecutive patients with histologically proven carcinoma undergoing elective pancreatic surgery from June 2015 through to July 2020 were included and retrospectively studied. A multidimensional nutritional assessment was performed before elective surgery as required by the local clinical pathway. Clinical and nutritional data were collected in a medical database at diagnosis and after surgery.

RESULTS

In the multivariable analysis, body mass index (OR 1.25, 95% CI 1.04-1.59, p = 0.039) and weight loss (OR 1.16, 95% CI 1.06-1.29, p = 0.004) were associated with Clavien score I-II; weight loss (OR 1.13, 95% CI 1.02-1.27, p = 0.027) affected postsurgery morbidity/mortality, and reduced muscle mass was identified as an independent, prognostic factor for postsurgery digestive hemorrhages (OR 0.10, 95% CI 0.01 0.72, p = 0.03) and Clavien score I-II (OR 7.43, 95% CI 1.53-44.88, p = 0.018). No association was identified between nutritional status parameters before surgery and length of hospital stay, 30 days reintervention, 30 days readmission, pancreatic fistula, biliary fistula, Clavien score III-IV, Clavien score V and delayed gastric emptying.

CONCLUSIONS

An impaired nutritional status before pancreatic surgery affects many postoperative outcomes. Assessment of nutritional status should be part of routine preoperative procedures in order to achieve early and appropriate nutritional support in pancreatic cancer patients. Further studies are needed to better understand the effect of preoperative nutritional therapy on short-term clinical outcomes in patients undergoing pancreatic elective surgery.

Statins increase pathological response in locally advanced rectal cancer treated with chemoradiation: a multicenter experience

Aims: To investigate the influence of various concomitant medications on outcomes in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation. Materials & methods: The authors retrospectively identified 246 patients from 2003 to 2018, collecting demographic and clinicopathological data of interest. Odds ratio (OR) was used to assess the association between concomitant drugs and outcomes. Results: The authors found an association between statins and a Dworak regression grade of 3-4 (OR = 8.78; p = 0.01). Furthermore, statins were significantly associated with more frequent chemoradiation-related toxicity (OR = 2.39; p = 0.0098) and chemotherapy dose reduction or discontinuation (OR = 2.26; p = 0.03). Conclusion: Despite higher frequency of radiotherapy and chemotherapy interruption or dose reduction, the concomitant use of statins during neoadjuvant chemoradiation proved to be associated with better tumor regression.

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study

Gastric cancer (GC) accounts for 4% of all cancers in Europe. Sarcopenia is a complex syndrome characterized by a loss of muscle mass and function associated with age, often present in neoplastic patients. Recently, several studies have shown a significant association between sarcopenia and poor prognosis in various pathological conditions. The current observational retrospective study investigates the association between sarcopenia and overall survival (OS) and recurrence-free survival (RFS) in patients with GC undergoing up-front surgery with curative intent. Resected GC patients' clinical records and CT images were retrospectively assessed. The preoperative CT calculation of the skeletal muscle index (SMI) at L3 level allowed us to categorize patients as sarcopenic or not. Kaplan-Meyer and univariate and multivariate Cox regression analyses were performed to determine the difference in survival and presence of independent prognostic factors. Fifty-five patients, 28 male and 27 female, out of 298 studied for gastric cancer were enrolled in the current study from two cancer referral centers in Italy. The preoperative CT calculation of the SMI at L3 level allowed us to identify 39 patients with and 16 without sarcopenia. A statistically significant difference between the sarcopenic and non-sarcopenic groups was observed in both OS and RFS (p < 0.023; p < 0.006). Moreover, sarcopenia was strongly correlated to a higher risk of recurrence in univariate and multivariate analysis (p < 0.02). Sarcopenia can be considered a critical risk factor for survival in patients with resectable GC treated with up-front surgery. Identifying sarcopenic patients at the time of diagnosis would direct selection of patients who could benefit from early nutritional and/or physical treatments able to increase their muscle mass and possibly improve the prognosis. More extensive multicenter studies are needed to address this issue.

Body composition and inflammation impact in non-small-cell lung cancer patients treated by first-line immunotherapy

Background: Immunotherapy changed the landscape of non-small-cell lung cancer (NSCLC). Efforts were made to implement its action. This study aims to describe body composition, nutritional and inflammatory status in NSCLC patients treated by first-line immunotherapy, their correlation, variation and impact. Patients and methods: We retrospectively analyzed 44 consecutive patients who received pembrolizumab treatment. Results: During the therapy, inflammation and visceral fat increased, whereas muscle and subcutaneous fat decreased. Parameters related to inflammation had an interesting prognostic impact. High numbers of white blood cells remained significantly correlated with a high risk of death in multivariate model. Conclusion: For the best treatment choice, a combination of clinical and biological factors will be most likely be necessary. Prospective and larger studies with a multidimensional approach are needed.

Sarco-Model: A score to predict the dropout risk in the perspective of organ allocation in patients awaiting liver transplantation

BACKGROUND & AIMS

Sarcopenia in liver transplantation (LT) cirrhotic candidates has been connected with higher dropouts and graft losses after transplant. The study aims to create an 'urgency' model combining sarcopenia and Model for End-stage Liver Disease Sodium (MELDNa) to predict the risk of dropout and identify an appropriate threshold of post-LT futility.

METHODS

A total of 1087 adult cirrhotic patients were listed for a first LT during January 2012 to December 2018. The study population was split into a training (n = 855) and a validation set (n = 232).

RESULTS

Using a competing-risk analysis of cause-specific hazards, we created the Sarco-Model2 . According to the model, one extra point of MELDNa was added for each 0.5 cm2 /m2 reduction of total psoas area (TPA) < 6.0 cm2 /m2 . At external validation, the Sarco-Model2 showed the best diagnostic ability for predicting the risk of 3-month dropout in patients with MELDNa < 20 (area under the curve [AUC] = 0.93; P = .003). Using the net reclassification improvement, 14.3% of dropped-out patients were correctly reclassified using the Sarco-Model2 . As for the futility threshold, transplanted patients with TPA < 6.0 cm2 /m2 and MELDNa 35-40 (n = 16/833, 1.9%) had the worse results (6-month graft loss = 25.5%).

CONCLUSIONS

In sarcopenic patients with MELDNa < 20, the 'urgency' Sarco-Model2 should be used to prioritize the list, while MELDNa value should be preferred in patients with MELDNa ≥ 20. The Sarco-Model2 played a role in more than 30% of the cases in the investigated allocation scenario. In sarcopenic patients with a MELDNa value of 35-40, 'futile' transplantation should be considered.

The Prognostic Role of Early Skeletal Muscle Mass Depletion in Multimodality Management of Patients with Advanced Gastric Cancer Treated with First Line Chemotherapy: A Pilot Experience from Modena Cancer Center

Background: Few data about the link between nutritional status and survival are available in the metastatic gastric cancer (GC) setting. The aim of this work was to evaluate the prognostic role of tissue modifications during treatment and the benefit of a scheduled nutritional assessment in this setting. Methods: Clinical and laboratory variables of 40 metastatic GC patients treated at Modena Cancer Center were retrieved: 20 received a nutritional assessment on the oncology’s discretion, the other 20 received a scheduled nutritional assessment at baseline and every 2–4 weeks. Anthropometric parameters were calculated on Computed Tomography (CT) images at the baseline and after 3 months of chemotherapy. Results: A correlation between baseline Eastern Cooperative Oncology Group Performance Status (ECOG PS), Lymphocyte to Monocyte Ratio (LMR), C-reactive protein (PCR), Prognostic Nutritional Index (PNI) and Overall survival (OS) was highlighted. Among the anthropometric parameters, early skeletal muscle mass depletion (ESMMD) >10% in the first months of treatment significantly impacted on mOS (p = 0.0023). A link between ESMMD and baseline LDH > 460 U/L, baseline CRP > 2.2 mg/dL and weight decrease during treatment emerged. Patients evaluated with a nutritional scheduled support experienced a mean gain in subcutaneous and visceral fat of 11.4% and 10.21%, respectively. Conclusion: We confirm the prognostic impact of ESMMD > 10% during chemotherapy in metastatic GC. The prognostic role of a scheduled nutritional assessment deserves further confirmation in large prospective trials.

Surgical treatment of deep endometriosis with adenomyosis externa: a challenging case in an infertile woman

OBJECTIVE

To describe the management and the fertility-enhancing potential of surgery in an infertile patient with deep-infiltrating endometriosis and adenomyosis externa.

DESIGN

Video case report.

SETTING

Minimally invasive and robotic gynecologic surgery unit of a university hospital.

PATIENT(S)

A 31-year-old nulliparous patient with dysmenorrhea, dysuria, dyspareunia, and primary infertility.

INTERVENTION(S)

Bimanual examination, transvaginal ultrasound, and magnetic resonance imaging (MRI) were performed as a comprehensive preoperative workup. The findings were consistent with bladder endometriosis and a 4-cm right pararectal cystic mass suggestive of adenomyosis externa. Laparoscopic excision of all visible endometriosis was performed. A pararectal lesion was found, completely developing in the retroperitoneal spaces, from the right medial pararectal space to the rectovaginal space, reaching the pelvic floor fascia without infiltration of the levator ani muscle. According to Koninckx classification, this kind of lesion corresponds to type III endometriosis or adenomyosis externa. Nerve-sparing eradication of the nodule was performed. The decision to use these techniques was taken with the intention to treat the patient, and not with the aim of testing the procedures performed. Therefore, as a common clinical practice in our institution and for the above reasons, there was no need for consultation of the institutional review board for approval.

MAIN OUTCOME MEASURE(S)

Improvement of symptoms and spontaneous conception after surgical removal of all endometriotic implants.

RESULT(S)

There were no intraoperative or postoperative complications, and the patient was discharged after 3 days. She discontinued postoperative hormone therapy with gonadotropin-releasing hormone analogue after 3 months because she desired fertility. She conceived spontaneously after 2 months of attempting. She delivered vaginally and had no complications during pregnancy and labor. Neither recurrence of pain symptoms nor voiding or rectal dysfunctions were reported by the patient.

CONCLUSION(S)

In the management of a case of deep endometriosis, the preoperative assessment should be carefully carried out to give the surgeon the most accurate information about the extent of the disease and the patient's main objectives. Imaging techniques such as ultrasound and MRI play a fundamental role along with the clinical evaluation in also detecting lesions that are not visible at first laparoscopic inspection. In this case of a young woman without any detectable fertility issues except for endometriosis, the laparoscopic excision of endometriosis was feasible, safe, and effective in improving the patient's fertility and pain symptoms. The fertility-enhancing potential of complete eradication of pelvic endometriosis, including removal of deep posterior localizations such those presented in this case, has been hypothesized by various investigators. It has been suggested that skilled surgical management for symptomatic deep endometriosis may be followed by a high pregnancy rate, with most pregnancies resulting from postoperative natural conception even in patients with primary infertility.

Impact of body composition, nutritional and inflammatory status on outcome of non-small cell lung cancer patients treated with immunotherapy

BACKGROUND AND AIMS

Body composition and balance of nutritional and inflammatory status are important for the immune system. Alterations of these aspects may impact on response, outcome and toxicities of immunotherapy. In this review we try to clarify some definitions and tools used for the assessment of the different aspects of nutritional disorders, body composition and inflammatory status with a focus on lung cancer.

METHODS

We primary investigate the definitions of malnutrition, cachexia, sarcopenia and overweight. Secondary, tools used to measure body composition, nutritional and inflammatory status, mainly in lung cancer are reviewed.

RESULTS

All these features, in the time of precision medicine may improve assessment and selection of patients, incorporating also early palliative care in standard therapy.

CONCLUSIONS

A multimodal approach based on nutrition assessment and physical exercise should be evaluated to improve aspects of the immune response against cancer and to propose the best treatment to every patient.

Robotic Liver Resection Versus Percutaneous Ablation for Early HCC: Short- and Long-Term Results

BACKGROUND

The correct approach for early hepatocellular carcinoma (HCC) is debatable, since multiple options are currently available. Percutaneous ablation (PA) is associated in some series to reduced morbidity compared to liver resection (LR); therefore, minimally invasive surgery may play a significant role in this setting.

METHODS

All consecutive patients treated by robotic liver resection (RLR) or PA between January 2014 and October 2019 for a newly diagnosed single HCC, less than 3 cm in size (very early/early stages according to the Barcelona Clinic Liver Cancer (BCLC)) on chronic liver disease or liver cirrhosis, were enrolled in this retrospective study. The aim of this study was to compare short- and long-term outcomes to define the best approach in this specific cohort.

RESULTS

60 patients fulfilled the inclusion criteria: 24 RLR and 36 PA. The two populations were homogeneous in terms of baseline characteristics. There were no statistically significant differences regarding the incidence of postoperative morbidity (RLR 38% vs. PA 19%, p = 0.15). The cumulative incidence of recurrence (CIR) was significantly higher in patients who underwent PA, with the one, two, and three years of CIR being 42%, 69%, and 73% in the PA group and 17%, 27%, and 27% in the RLR group, respectively.

CONCLUSIONS

RLR provides a significantly higher potential of cure and tumor-related free survival in cases of newly diagnosed single HCCs smaller than 3 cm. Therefore, it can be considered as a first-line approach for the treatment of patients with those characteristics in high-volume centers with extensive experience in the field of hepatobiliary surgery and minimally invasive approaches.

MRI of placenta accreta: diagnostic accuracy and impact of interventional radiology on foetal-maternal delivery outcomes in high-risk women

OBJECTIVE

To assess accuracy and reproducibility of MRI diagnosis of invasive placentation (IP) in high-risk patients and to evaluate reliability of MRI features. Secondary aim was to evaluate impact of interventional radiology (IR) on delivery outcomes in patients with IP at MRI.

METHODS

26 patients (mean age 36.24 y/o,SD 6.16) with clinical risk-factors and echographic suspicion of IP underwent 1.5 T-MRI. Two readers reviewed images. Gold-standard was histology in hysterectomised patients and obstetric evaluation at delivery for patients with preserved uterus. Accuracy and reproducibility of MRI findings were calculated.

RESULTS

Incidence of IP was 50% (13/26) and of PP was 11.54% (3/26). MRI showed 100% sensitivity (95% CI = 75.3-100%) and 92.3% specificity (95% CI = 64.0-100%) in the diagnosis of IP. Gold-standard was histology in 10 cases and obstetric evaluation in 16. MRI findings with higher sensitivity were placental heterogeneity, uterine bulging and black intraplacental bands. Uterine scarring, placental heterogeneity, myometrial interruption and tenting of the bladder showed better specificity. MRI inter-rater agreement with Cohen's K was 1. 11 patients among 14 with MRI diagnosis of IP received IR assistance with positive impact on delivery outcomes in terms of blood loss, red cells count, intense care unit length of stay, days of hospitalisation and risk of being transfused.

CONCLUSION

MRI is an accurate and reproducible technique in prenatal diagnosis of IP. MRI helps planning a safe and appropriate delivery eventually assisted by IR, which positively affects foetal and maternal outcomes.

ADVANCES IN KNOWLEDGE

The adoption of MRI evaluation in patients with high risk of invasive placentation allows a more accurate diagnosis in terms of both presence of the disease and its extension to or through or even beyond the myometrium. This led to a better dedicated delivery management with eventual adoption of interventional radiology with a global positive effect on foetal and maternal outcomes.

Predictive Role Of Body Composition Parameters In Operable Breast Cancer Patients Treated With Neoadjuvant Chemotherapy

Background

Fat tissue is strongly involved in BC tumorigenesis inducing insulin resistance, chronic inflammation and hormonal changes. Computed tomography (CT) imaging instead of body mass index (BMI) gives a reliable measure of skeletal muscle mass and body fat distribution. The impact of body composition parameters (BCPs) on chemosensitivity is still debated. We examined the associations between BCPs and tumor response to neoadjuvant chemotherapy (NC) in patients treated for operable breast cancer (BC).

Methods

A retrospective review of BC patients treated with NC in Modena Cancer Center between 2005 and 2017 was performed. BCPs, such as subcutaneous fat area (SFA), visceral fat area (VFA), lumbar skeletal muscle index (LSMI) and liver-to-spleen (L/S) ratio were calculated by Advance workstation (General Electric), software ADW server 3.2 or 4.7. BMI and BCPs were correlated with pathological complete response (pCR) and survival outcomes.

Results

407 patients were included in the study: 55% with BMI < 25 and 45% with BMI ≥ 25. 137 of them had pre-treatment CT scan imagines. Overweight was significantly associated with postmenopausal status and older age. Hormonal receptor positive BC was more frequent in overweight patients (p<0.05). Postmenopausal women had higher VFA, fatty liver disease and obesity compared to premenopausal patients. No association between BMI classes and tumor response was detected. High VFA and liver steatosis were negative predictive factors for pCR (pCR rate: 36% normal VFA vs 20% high VFA, p= 0.048; no steatosis 32% vs steatosis 13%, p=0.056). Neither BMI classes nor BCPs significantly influenced overall survival and relapse-free survival.

Conclusion

Visceral adiposity as well as steatosis were closely involved in chemosensitivity in BC patients treated with NC. Their measures from clinically acquired CT scans provide significant predictive information that outperform BMI value. More research is required to evaluate the relationship among adiposity site and survival outcomes.

Not just minor resections: robotic approach for cystic echinococcosis of the liver

INTRODUCTION

Human echinococcosis is among the 17 neglected tropical diseases recognized by the World Health Organization. It is responsible for over $3 billion of health costs every year being endemic in large areas worldwide, and liver is affected in 70% of the cases. Surgery associated to medical treatment is the gold standard and robotic approach may be a valuable tool to achieve safe, parenchyma sparing resections.

METHODS

We retrospectively analyzed the outcomes of patients that underwent robotic radical surgical treatment for hydatid liver disease, from prospectively maintained databases of three Italian centers.

RESULTS

15 patients were included in this study, median age 51 years (24-76). 1 right hepatectomy, 2 left lateral sectionectomies, 5 segmentectomies (including 1 caudatectomy), 3 wedge resections and 5 cyst-pericystectomies were performed. Median estimated blood loss was of 100 ml (50-550 ml), and median operative time including docking was 210 min (95-590 min), with no need for conversion to open. Median hospital stay was 4 days, with only one readmission for fever. Only one patient experienced recurrence in a different liver segment.

CONCLUSIONS

In our experience, robotic approach for cystic echinococcosis of the liver proved to be a safe and effective strategy also in the so-called "difficult segments", with short post-operative stay and quick return to daily activities, along with the absence of surgical site recurrences. To the best of our knowledge, this is the largest report of robotic approach to hydatid liver disease.

Breast ultrasonography (BU) in the screening protocol for women at hereditary-familial risk of breast cancer: has the time come to rethink the role of BU according to different risk categories?

This article evaluates the breast cancer (BC) screening efficacy of biannual ultrasound (US) in three different risk categories. In a single-center, prospective, nonrandomized comparison study, BRCA mutation carriers and women with high risk (HR) or intermediate risk (IR) received mammography (MMG), ultrasound, (US) and Magnetic Resonance Imaging (MRI), scheduled according to the risk categories. Single and combined sensitivity were evaluated in specific groups of risk and the US performance at six-monthly interval was notably considered. Among 2,313 asymptomatic women at different risk (136 mutation carriers, 1,749 at HR and 428 at IR) 211 developed a BC, of which 193 (91.5%) were screen detected BC (SDBC) and 18 (8.5%) were interval BC (IBC). The SDBC detection rate (DR) was 11.2 per 1.000 person-years (37.9, 8.5 and 16.1 for BRCA, HR and IR, respectively); 116 BC were detected by MMG (DR = 6.6 × 1,000 persons-years), 62 by US (DR = 3.6 × 1,000 persons-years) and 15 by MRI, that was applied only in 60 BRCA women (DR = 37 × 1,000 persons-years). At the six-monthly US, 52 BC were detected (DR = 3.0 × 1,000 persons/years), of which 8 were BRCA-related. The most sensitive technique was MRI (93.7%) followed by MMG (55%) and US (29.4%). Combined sensitivity for MMG plus US was 100% in HR and 80.4% for IR women (p < 0.01). In BRCA mutated patients, MRI alone with annual US performed after six months, could be offered. In HR patients, MMG plus biannual US provide the most sensitive diagnosis and for IR group an annual MMG could be sufficient.

Multimodal oncological approach in patients affected by recurrent hepatocellular carcinoma after liver transplantation

OBJECTIVE

Hepatocellular Carcinoma (HCC) represents the fifth most common malignancy and the third cancer-related cause of death worldwide. Liver transplantation (LT) is an excellent treatment for patients with small HCC associated with cirrhosis. The purpose of this review is to investigate the possible strategies for the treatment of HCC recurrence after LT based on current clinical evidence.

MATERIALS AND METHODS

A systematic literature search was performed independently by two of the authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. The search was limited to studies in humans and to those reported in the English language.

RESULTS

Thanks to the introduction of strict selection criteria, LT for HCC has achieved a survival rate of 85% at five years. However, the recurrence of HCC after transplantation remains a serious problem that affects about 20% of post-transplant cases. While most recurrences occur within the first 2 years, late recurrences have been described. The prognosis of recurrence is poor despite numerous proposals of the therapeutic option. Lower levels of immunosuppressive therapy and use of mammalian targets of rapamycin (mTORs) is a potential preventive strategy to reduce HCC recurrence post-Lt. Surgical resection and locoregional therapies (mainly TACE and RFA) play a very important role and are associated with improved survival. Conversely, multikinase inhibitors such as Sorafenib and their association with mTOR inhibitors play a role in cases of advanced HCC recurrence not suitable for the surgical or ablative approach.

CONCLUSIONS

Treating HCC recurrence is a multidisciplinary workup involving hepatologists, surgeons, oncologists and radiologists in order to offer a patient-tailored therapy.

Giant elephantiasis neuromatosa in the setting of neurofibromatosis type 1: A case report

Elephantiasis neuromatosa (EN) can arise from a plexiform neurofibroma of the superficial and deep nerves developing from a hyperproliferation of the perineural connective tissue infiltrating adjacent fat and muscles. To date, the clinical association between EN and neurofibromatosis type 1 (NF1) has been poorly defined, particularly with regard to the role of lymphatic alterations and the consequent lymphedema. The present study reports the clinical and biomolecular features of EN in a NF1 patient with the clear clinical diagnostic criteria of multiple cafè-au-lait macules, neurofibromas, EN, a positive family history and a novel NF1 germline c.1541_1542del mutation. Lymphoscintigraphy (LS) highlighted marked dermal backflow in the affected limb, hypertrophy of the ipsilateral inguinal and external iliac lymph nodes, and a bilateral lower limb lymph flow delay. These data support the hypothesis that an extensive hyperproliferative process involving perineural connective, limb soft tissues, bones and the lymphatic system can be responsible for EN in NF1 patients, on the basis of adipocyte metaplasia triggered by lymphostasis and lymphedema, and bone overgrowth and gigantism caused by chronic hyperemia. LS and magnetic resonance imaging can be efficacious tools in the diagnosis and clinical characterization of the early onset of the disease.

Post-transplantation hepatocellular carcinoma recurrence: Patterns and relation between vascularity and differentiation degree

AIM: To evaluate the relationship between hepatocellular carcinoma (HCC) vascularity and grade; to describe patterns and vascular/histopathological variations of post-transplantation recurrence.

METHODS: This retrospective study included 165 patients (143 men, 22 women; median age 56.8 years, range 28-70.4 years) transplanted for HCC who had a follow-up period longer than 2 mo. Pre-transplantation dynamic computed tomography or magnetic resonance examinations were retrospectively reviewed, classifying HCC imaging enhancement pattern into hypervascular and hypovascular based on presence of wash-in during arterial phase. All pathologic reports of the explanted livers were reviewed, collecting data about HCC differentiation degree. The association between imaging vascular pattern and pathological grade was estimated using the Fisher exact test. All follow-up clinical and imaging data were reviewed for evidence of recurrence. Recurrence rate was calculated and imaging features of recurrent tumor were collected, classifying early and late recurrences based on timing (< or ≥ 2 years after transplantation) and intrahepatic, extrahepatic and both intrahepatic and extrahepatic recurrences based on location. All intrahepatic recurrences were classified as hypervascular or hypovascular and the differentiation degree was collected where available. The presence of variations in imaging enhancement pattern and pathological grade between the primary tumor and the intrahepatic recurrence was evaluated and the association between imaging and histopatholgical variations was estimated by using the χ² test.

RESULTS: Of the 163 patients with imaging evidence of viable tumor, 156 (95.7%) had hypervascular and 7 (4.3%) hypovascular HCC. Among the 125 patients with evidence of viable tumor in the explanted liver, 19 (15.2%) had grade 1, 56 (44.8%) grade 2, 40 (32%) grade 3 and 4 (3.2%) grade 4 HCC, while the differentiation degree was not assessable for 6 patients (4.8%). A significant association was found between imaging vascularity and pathological grade (P = 0.035). Post-transplantation recurrence rate was 14.55% (24/165). All recurrences occurred in patients who had a hypervascular primary tumor. Three patients (12.5%) experienced late recurrence; the location of the first recurrence was extrahepatic in 14 patients (58.3%), intrahepatic in 7 patients (29.2%) and both intrahepatic and extrahepatic in 3 patients (12.5%). Two patients had a variation in imaging characteristics between the primary HCC (hypervascular) and the intrahepatic recurrent HCC (hypovascular), while 1 patient had a variation of histopathological characteristics (from moderate to poor differentiation), however no association was found between imaging and histopathological variations.

CONCLUSION: A correlation was found between HCC grade and vascularity; some degree of variability may exist between the primary and the recurrence imaging/histopathological characteristics, apparently not correlated.

Preoperative carboplatin-paclitaxel-bevacizumab in triple-negative breast cancer: final results of the phase II Ca.Pa.Be study

PURPOSE

The phase II Ca.Pa.Be trial evaluated preoperative carboplatin-paclitaxel in combination with bevacizumab in triple-negative breast cancer patients with previously untreated stage II-III disease. The primary aim was the assessment of the rate of pathologic complete response (pCR). Secondary aims included safety, breast-conserving surgery rate, and early response assessment with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

METHODS

Patients with hormone receptor-negative, HER-2-negative stage II-III breast cancer were eligible. Treatment included paclitaxel 80 mg/mq + carboplatin area under the curve (AUC) 2 on days 1, 8, and 15, combined with bevacizumab 10 mg/kg on days 1 and 15 each 28 days, for 5 courses. At baseline, patients underwent breast DCE-MRI, followed by a single dose of bevacizumab 5 mg/kg (day -6). DCE-MRI was repeated before the initiation of chemotherapy.

RESULTS

Forty-four patients were enrolled. Forty-three patients underwent surgery, and 22 (50 %) received breast-conserving surgery (conversion rate from mastectomy indication at baseline, 34.4 %). A pCR in breast and axillary lymph nodes occurred in 22 patients (50 %). Bevacizumab-associated adverse events (AEs) were mild: G1-2 hypertension and bleeding occurred in 6 (13.6 %) and 12 (27 %) patients, respectively. No G4 nonhematologic AEs were recorded. More frequent G3 AEs were liver function test abnormalities (6.8 %), and diarrhea and fatigue (4.5 % each). The only G3-4 hematologic toxicity was neutropenia (G3, 25 %; G4, 9 %). Early assessed DCE-MRI response parameters failed to predict pCR.

CONCLUSIONS

The neoadjuvant anthracycline-free combination of weekly paclitaxel and carboplatin plus bevacizumab is active and safe in triple-negative breast cancer, and the rate of pCR is comparable to that observed with more intensive carboplatin- and bevacizumab-containing regimens. Further investigation is warranted.

Skeletal and cranio-facial signs in Gorlin syndrome from ancient Egypt to the modern age: sphenoid asymmetry in a patient with a novel PTCH1 mutation

Gorlin syndrome is an autosomal dominant disorder linked to PTCH1 mutation, identified by a collection of clinical and radiologic signs. We describe the case of a family in which father and son fulfilled clear cut diagnostic criteria for Gorlin syndrome including multiple basal cell carcinomas, keratocystic odontogenic tumors, atypical skeletal anomalies and a novel PTCH1 germline mutation (c.1041delAA). Craniofacial and other skeletal anomalies displayed at 3D and helical CT scan were: macrocephaly, positional plagiocephaly, skull base and sphenoid asymmetry, bifidity of multiple ribs and giant multilocular odontogenic jaw cysts. Extensive multilamellar calcifications were found in falx cerebri, tentorium, falx cerebelli and in the atlanto-occipital ligament. The inclusion of bifid ribs as a novel major criteri may be useful for the recognition and characterization of misdiagnosed cases.

Microsurgical testis-sparing surgery in small testicular masses: seven years retrospective management and results

OBJECTIVE

To retrospectively evaluate the clinical outcomes of 20 patients diagnosed with a nonpalpable or small testicular mass (2 cm) at 2 academic urological department. Testis-sparing surgery (TSS) is currently performed routinely for the management of nonpalpable testicular masses. High reliability of frozen section examination (FSE) and high-frequency ultrasound (US) and the adoption of microsurgical techniques improved safety and feasibility of this technique.

METHODS

From January 2004 to March 2011, 23 patients underwent microsurgical TSS. An inguinal approach was performed in 22 cases and a suprapubic incision in one bilateral case. All procedures were performed with an operating microscope, with warm ischemia in 21 cases and cold ischemia in 2 cases. Intraoperative US was performed before opening the albuginea. Mean operative time was 89 minutes.

RESULTS

After mass excision, FSE was performed; only 2 seminomatous tumors were identified, and the remaining masses were benign lesions. After a mean follow-up >12 months, all patients are free of disease; no hypogonadism developed.

CONCLUSIONS

TSS performed using an operating microscope allowed the preservation of testes for 21 patients diagnosed with small testicular and/or nonpalpable mass (<2 cm), without evidence of disease recurrence or de novo onset. This approach could be mandatory in the treatment of bilateral tumors or in solitary testis. Maintaining fertility is not the main goal of TSS because a great number of patients affected by testicular tumors are already infertile. Esthetic outcomes and sparing hormonal function are the main reasons for TSS.

Banked depopulated vena caval homograft: a new strategy to restore caval continuity

This study reports one case of primary inferior vena cava (IVC) leiomyosarcoma. A 67-year-old woman was referred to the authors' clinic for evaluation. She presented complaining of epigastric and right upper abdominal quadrant pain. Contrast-enhanced abdominal computed tomography scan revealed a 5.2 × 6.4 cm heterogeneously enhancing mass involving the anteromedial aspect of the IVC, below the renal vein (segment I), deforming the duodenum. There was a partial intraluminal extension in the IVC. Laparotomic resection was performed, with total en bloc excision of the lower IVC tumor. The caval continuity was restored with concomitant interposition of a banked depopulated vena cava homograft. Histological findings showed leiomyosarcoma originating from IVC. The postoperative course was uneventful: Neither recurrence nor metastasis was evident at 4 years postsurgery.

Magnetic resonance imaging and ultrasonography in predicting infiltrating residual disease after preoperative chemotherapy in stage II-III breast cancer

BACKGROUND

This study was designed to evaluate the accuracy of breast magnetic resonance imaging (MRI) and ultrasonography (US) in predicting the extent of breast residual disease after preoperative chemotherapy.

METHODS

Patients with stage II-III invasive breast tumors who received preoperative chemotherapy and were imaged with post-treatment MRI were included. Histopathological verification was available for all patients. The longest diameter of residual tumor measured with MRI and US has been compared with the infiltrating residual tumor size at pathologic evaluation.

RESULTS

A total of 108 patients were enrolled: 59 were imaged with both MRI and US (MRI group), and 49 were imaged with US only (non-MRI group). The non-MRI group was enrolled as an external control to avoid possible bias in the selection of patients. In the MRI group, the means of the deltas between MRI residual tumor size and pathologic size and between US and pathologic size were 0.16 cm and -0.06 cm respectively (P = not significant). Overall, a discrepancy limited in the interval from -0.5 cm to +0.5 cm compared with the pathologic size was observed in 54% and 51% of the patients with MRI and US, respectively (P = not significant). The linear correlation between the radiological measurement and pathologic tumor size was r = 0.53 for MRI and r = 0.66 for breast US. In the non-MRI group, the mean of the deltas between US residual tumor size and pathologic size was 0.06 cm, and the linear correlation was r = 0.79.

CONCLUSIONS

In this series of patients, MRI and US do not show significant differences in predicting the breast residual infiltrating tumor after preoperative chemotherapy.

Liver transplantation due to iatrogenic injuries: two case reports

The transjugular intrahepatic portosystemic shunt (TIPS) is an acceptable procedure that has proven benefits in the treatment of patients who have complications from portal hypertension due to liver cirrhosis. In the literature few reports have described complications after TIPS placement. Initial surgery and local hemostasis have been needed to manage abdominal bleeding: if this treatment is insufficient, it may be necessary to perform a liver transplantation. This report describes the role of liver transplantation to manage dangerous complications in 2 patients after TIPS placement, when surgical procedures and hemostasis were unable to stop the bleeding.

Role of magnetic resonance cholangiography in biliary complications of orthotopic liver transplantation

PURPOSE

The aim of this study was to evaluate the role of magnetic resonance cholangiography (MRC) in the detection of biliary complications following orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Seventy-eight transplant patients with clinically suspected biliary complications were evaluated with 1.5-T magnetic resonance imaging (MRI) using a surface coil. All patients were imaged with the following sequences: axial T1-weighted and axial and coronal T2-weighted, 2D spin echo (SE) breath-hold radial cholangiography, and coronal 3D single-shot turbo spin echo (SS-TSE) with respiratory triggering. Patients with negative MRI underwent clinical and sonographic followup. When biliary complications were present, diagnostic confirmation was obtained by endoscopic retrograde cholangiopancreatography (ERCP) (n=13), percutaneous transhepatic cholangiography (PTC) (n=20), ultrasonography (n=10) or computed tomography (CT) (n=2). In 11 cases, surgical confirmation was also obtained.

RESULTS

MRC detected biliary complications in 44/78 patients, in particular, 42 biliary strictures (37 anastomotic and five intrahepatic), 40 of which were confirmed by other imaging modalities. In 25/37 cases of anastomotic stricture, preanastomotic dilatation of the biliary tract was also demonstrated. Other MRC-detected biliary complications were biliary sludge (n=4), biloma (n=5), and biliary stones (n=3). In four cases, PTC revealed biliary complications that had not been detected with MRC (false negative results). In two cases, MRC showed unconfirmed strictures of the intrahepatic ducts and biliodigestive anastomosis (false positive results). The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy of MRC were 93.5%, 94.4%, 96.7%, 89.5% and 93.9%, respectively.

CONCLUSIONS

Our results confirm that MRC is a reliable technique for depicting biliary anastomoses and detecting biliary complications after OLT. The high diagnostic accuracy of MRC indicates that this examination should be routinely employed in all OLT patients with clinically suspected biliary complications.

Contrast-enhanced MRI and PET-CT in the evaluation of patients with suspected local recurrence of rectal carcinoma

PURPOSE

This study aimed to evaluate the role of contrast-enhanced magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) in the assessment of local recurrence of rectal cancer.

MATERIALS AND METHODS

Among 200 patients scheduled for CT follow-up, 60 (48 low risk; 12 high risk) were selected due to CT findings suspicious for or suggestive of local recurrence. Patients underwent contrast-enhanced MRI and PET-CT within 2 weeks. Biopsy was considered the gold standard in 39 cases and follow-up at 6 and 12 months in the remaining 21.

RESULTS

Local recurrence was confirmed by histology in 15 cases (7 low risk; 8 high risk) and was excluded in 21 cases by long-term follow-up and in 24 by histology. Sensitivity, specificity, positive and negative predictive value and accuracy were 86.7%, 68.9%, 48.1%, 93.9% and 73.3% for contrast-enhanced MRI and 93.3%, 68.9%, 50%, 96.9% and 75% for PET-CT.

CONCLUSIONS

Contrast-enhanced MRI and PET-CT can help in the detection of local recurrence of rectal cancer, even though their roles in early detection remains debatable, as the value of these techniques in current surveillance protocols is still to be defined.

Contrast-enhanced ultrasound in the characterisation of breast masses: utility of quantitative analysis in comparison with MRI

OBJECTIVE

To evaluate the reliability of contrast-enhanced ultrasound quantitative analysis (CE-US) in characterizing breast lesions, in comparison with MRI.

MATERIALS

Thirty-nine patients with breast lesions BI-RADS 3-5 at US or mammography underwent CE-US and MRI. All lesions underwent histological and quantitative enhancement evaluation with both imaging methods. B-mode US, colour/power Doppler US and CE-US were used; an amplitude and phase modulation technique (CPS) read the signals produced by microbubbles and dedicated software produced the following parameters on time/intensity (T/I) curves: peak %, time to peak (TTP), mean transit time (MTT), regional blood volume (RBV) and regional blood flow (RBF). Student's t test was used to calculate the diagnostic accuracy of CE-US parameters compared with histological results. MRI (1.5 T) was performed before and after bolus gadolinium enhancement. Time/intensity curves were generated for all nodules and Fischer's multimodal score was used to classify them.

RESULTS

Pathology showed 43 nodules (11 benign; 32 malignant). Peak and RBF were the most significant parameters in differential diagnosis, with p values of 0.02 and 0.004, respectively. Positive predictive value (PPV) of CE-US evaluation was 91%, negative predictive value (NPV) was 73% with a high concordance index (k = 0.59) with MRI.

CONCLUSIONS

CE-US quantitative analysis offers an objective and reproducible assessment of lesion vascularisation, with good correlation with the results of MRI.

Magnetic resonance imaging and ultrasonography in predicting pathologic extent after preoperative chemotherapy in stage II-III breast cancer

Abstract #4024

Introduction and aims: the main advantage of preoperative chemotherapy (PCT) is tumor down-staging, that can allow either mastectomy in large, inoperable primaries, or breast conserving surgery (BCS) for patients initially candidate to mastectomy. Therefore, an accurate measurement of residual disease after PCT is critical in the optimal surgical planning. Aim of this study is to evaluate the accuracy of breast magnetic resonance imaging (MRI) and ultrasonography (USG) in predicting the extent of breast residual disease.&#x2028; Patients and Methods: patients with stage II-III invasive breast tumor receiving PST and imaged with post-treatment MRI, USG or both were included; deltas were calculated as differences between the longest tumor diameter as measured by MRI and USG and the pathologic size of residual breast tumor. Differences between deltas were tested by using T test for paired data.&#x2028; Results: 45 patients treated with PCT in our Institution were eligible. Patients characteristics were as follows: mean age 50 yrs (range 30-70 yrs); stage IIA 31%, IIB 49%, IIIA-B: 20%. Eighty-nine % of the cases had ductal histology, 69% had ER positivity, and 24% had HER2 over-expression. The mean T size at diagnosis was 3.8 cm (range 1.5-8 cm). PCT type was anthracycline-based (24%) or anthracycline-taxane combination (76%). Forty-four patients have been evaluated after PCT by MRI, 41 by USG, 40 patients by both MRI and USG. The mean T size (range) after PCT was 2 cm (0-6.5 cm) and 1.7 cm (0-5 cm) as measured by MRI and USG respectively. The mean interval between breast imaging and surgery was 20 days (range 1-63). Type of surgery was mastectomy in 45% and BCS in 55% of the cases; 6 patients (13%) achieved a pathologic complete response (pCR). The mean pathologic T size was 1.98 cm (range 0-6 cm). The mean of the deltas were 0.04 (SD 1.91) and -0.19 (SD 1.53) for MRI and USG respectively (p=0.22). A complete response by MRI was observed in 9 cases: 3 cases were confirmed as pCRs; 2 cases presented with scattered microscopic residual disease. An USG complete response was observed in 8 cases (4 confirmed pCRs).&#x2028; Conclusion: in this series of patients, MRI and USG do not show significant differences in predicting the breast residual tumor after PCT. The major challenge for breast imaging after PCT is represented by scattered residual disease.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4024.

Radiologic imaging of the transplanted bowel

Background

The radiologic evaluation of the transplanted bowel is largely unknown and rather complex because it involves several techniques that depend on indications and times that have not been fully defined.

Methods

From December 2000 to November 2002 in the Section of Radiology I of the University of Modena and Reggio Emilia (Modena, Italy), 11 patients with transplanted bowel were studied with different methods: traditional radiologic evaluation with contrast agent (all patients), evaluation of transit time with radiopaque markers (five patients), ultrasonographic (US) evaluation of the intestinal wall and Doppler US of the vascular axes (five patients), computed tomographic (CT) evaluation (all patients), and magnetic resonance (MR) evaluation of the bowel and the vascular axes (five patients). Traditional contrast examination enabled evaluation of the gastroesophageal transit and cardia functionality; anatomy and integrity of the anastomoses (proximal and distal); time of gastric emptying; morphology, tone, and kinesis of the transplanted small bowel loops and time of global transit. The study of transit with radiopaque markers was carried out in five patients to define the time of transit through the entire transplanted bowel, confirm recovery of intestinal motility, and identify possible abnormalities. The US examination was carried out in five patients to evaluate the morphology, thickness, and echo structural features of the intestinal loops. Color Doppler was performed to visualize the superior mesenteric artery and a wall arteriole of the sampled loop. CT examination was performed 2 to 4 weeks after surgery to evaluate the anatomy of the transplanted organs, arterial and venous anastomoses in case of complications identified with other methods or suspected, and periodically in the follow-up of patients who underwent transplantation due to Gardner syndrome. The protocol for MR evaluation of the bowel included coronal single-shot fast spin-echo T2-weighted sequences, axial and/or sagittal single-shot fast spin-echo T2-weighted sequences, coronal fast multiplanar spoiled gradient-echo (FMP- SPGR) sequences, coronal FMPSPGR sequences with and without administration of intravenous paramagnetic contrast agent, and axial or sagittal FMPSPGR fat-saturated sequences performed after dynamic gadolinium administration.

Results and conclusion

The study of transit with radiopaque markers was useful in patients with chronic intestinal pseudo-obstruction because it identified recovery and normalization of motility. Traditional contrast examination of the gastrointestinal tract continues to play an important role in transplanted patients because it is a simple examination that allows evaluation of the graft anatomy and recovery of motility of the residual native bowel and the transplanted loops. Moreover, it plays a crucial role in early detection of major postoperative complications such as intestinal obstruction, perforation, fistulas, and anastomotic complications (stenosis and dehiscence). CT examination is crucial for the detection of fluid collections, abscesses, and fistulas because it can serve as a guide of drainage and during follow-up of patients with Gardner syndrome can be used to investigate all possible sites in which desmoids might arise in addition to their relation to the graft. Because patients with transplanted bowel are generally rather a young population of reproductive age and because of technologic advances, MR may represent an effective method that does not use ionizing radiation and can therefore substitute for traditional radiologic evaluation. US represents a quick examination technique that is easily available and well tolerated by patients, and it has a role to play in the follow-up of transplanted patients and in the identification of major postoperative complications. However, its role in monitoring possible rejection remains to be defined with studies on wider and more representative samples.

MRI evaluation of myometrial invasion by endometrial carcinoma. Comparison between fast-spin-echo T2w and coronal-FMPSPGR Gadolinium-Dota-enhanced sequences

PURPOSE

The depth of myometrial invasion by endometrial carcinoma strongly affects the incidence of metastasis to regional nodes and influences the surgical strategies. The aim of this paper is to compare the results of FSE T2-w and Gadolinium-enhanced FMPSGR MR sequences in assessing the depth of myometrial invasion by endometrial cancer.

MATERIALS AND METHODS

Forty-five women with histopathologically-proven endometrial carcinoma underwent preoperative MRI. Axial SE T1w, axial, sagittal and para-coronal FSE T2w and para-coronal Gadolinium-enhanced FMPSGR sequences were performed using a high field strength magnet (1.5T). Within one month of MR all patients underwent hysterectomy, and anatomical evaluation of the surgical specimen was done sectioning the uterus along the short axis. Based upon the results of the histological evaluation the results of the FSE T2w and Gadolinium-enhanced sequences were compared and the statistical difference between the results obtained was statistically evaluated.

RESULTS

The histological evaluation showed intramucosal neoplasm in 11 patients, myometrial infiltration less than 50% in 31 patients, myometrial infiltration more than 50% in 12 patients and transmural cancer in 1 patient. Statistical evaluation showed that the FSE T2w sequence had a global sensitivity and specificity of 80.6% and 87.6%, respectively, with a mean Negative Predictive Value of 92.6% and a mean Positive Predictive Value of 86%. Gadolinium-enhanced FMPSPGR sequence had a global sensitivity and specificity of 90.6% and 93.3%, respectively, with a mean Negative Predictive Value of 96,3% and a mean Positive Predictive Value of 88%. The staging accuracy (chi2 test) on FMPSPGR images (95%) was higher than that on FSE T2w images (78%).

CONCLUSIONS

In our experience Gadolinium-enhanced dynamic sequences increase the accuracy of MR imaging in diagnosing the depth of myometrial invasion. In particular they improve the visualisation of the inner myometrium, the so called subendometrial enhancing zone, whose disruption or changes are essential for diagnosing myometrial invasion. The major diagnostic advantages of the enhanced sequences were found in postmenopausal women, where visualisation of the junctional zone may be difficult in the T2w sequences. We believe that Gadolinium-enhanced dynamic sequences should be used whenever the diagnosis is unclear at FSE T2w sequences.

[Focal nodular hyperplasia of the liver. A case report]

Focal nodular hyperplasia (FNH) of the liver is a benign disorder that usually occurs in women during their reproductive years. Multiple FNH is very rare. A case of multiple FNH of the liver occurring in a 34-year-old woman is described. FNH diagnosis was confirmed by means of US, CT, MR, scintigraphy and hepatic biopsy. There was no further change in either size or appearance of liver masses in the ensuing 6 years of follow-up.

Association of breast arterial calcifications detected by mammography and coronary artery calcifications quantified by multislice CT in a population of post-menopausal women

PURPOSE

To assess the correlation between the presence and extent of breast arterial calcifications (BAC) detected at mammography and the extent of coronary atherosclerosis, as evaluated by multislice computed tomography (MSCT) coronary calcium quantification in a population of post-menopausal women.

MATERIALS AND METHODS

Seventy-four post-menopausal women aged under 65 years who had undergone mammography at our Department were studied by MSCT for coronary calcium quantification. The mammograms were screened for vascular calcifications which were graded according to severity and extension. The presence of coronary artery calcifications was assessed by MSCT using the <<Smart Score>> cardiac reconstruction software. The data obtained were analyzed using the statistical package SPSS (version 10.1) for Windows.

RESULTS

The presence and severity of breast arterial calcifications showed a strong correlation with coronary calcifications in both models.

DISCUSSION AND CONCLUSIONS

The study demonstrated that the presence of BAC is strongly correlated with the amount of coronary calcium detected by MSCT and therefore with the extent of coronary atherosclerosis. Moreover, there is a linear correlation between BAC severity and coronary calcium content, each incremental increase in BAC severity being associated with an average increase in coronary calcium content. Therefore, the presence and severity of BAC may provide indirect qualitative and quantitative information on the calcium present in the coronaries. As mammography is increasingly used as a screening test for breast carcinoma, breast arterial calcifications may represent an important sign with epidemiological and clinical significance for primary prevention.

Gadolinium-enhanced MRI with dynamic evaluation in diagnosing the local recurrence of rectal cancer

BACKGROUND

At early stages, the diagnosis of local recurrence of rectal cancer is often difficult and magnetic resonance imaging (MRI) is currently considered the most accurate method for diagnosing recurrence. We evaluated the role of unhenhanced and gadolinium-enhanced MRI for the diagnosis of local recurrence of rectal cancer.

METHODS

Thirty-six patients, suspected of having a pelvic recurrence of rectal cancer, were evaluated by a high field strength MRI unit. Unenhanced spin-echo T1- and T2-weighted sequences and gadolinium-enhanced dynamic fast multiplanar spoiled gradient recalled sequences were performed in all patients. The dynamic images were re-elaborated with semiquantitative postprocessing by plotting intensity-time curves and calculating the percentage of signal increase at the end of the first postcontrast dynamic sequence. The pelvic lesions were classified as recurrent or not recurrent by applying the following diagnostic criteria: (a) morphology and signal intensity of the lesion in unenhanced sequences and (b) percentage of enhancement in dynamic enhanced sequences. Diagnosis was confirmed by computed tomography-guided needle biopsy (12 patients), surgery (four patients), clinical and imaging follow-up (20 patients).

RESULTS

The diagnosis was local recurrence in 15 patients and noncancerous lesions in 21 patients. Unenhanced MRI had 80% sensitivity and 86% specificity. Analysis of the percentage of enhancement showed 87% sensitivity and 100% specificity.

CONCLUSION

In agreement with the literature, our results showed a high sensitivity and specificity for dynamic MRI. This technique thus can be considered an important adjunct to unenhanced MRI, especially in selected cases in which unenhanced MRI cannot rule out local recurrences. However, these results must be validated by further investigations.

Magnetic resonance imaging in evaluating functional disorders of female pelvic floor

PURPOSE

To evaluate the diagnostic capabilities of MRI in the study of functional diseases of the female pelvic floor.

MATERIALS AND METHODS

Ten healthy volunteers and 30 patients with clinically suspected pelvic floor deficiency, with or without pelvic organ prolapse, were evaluated by a high field strength magnet operating at 1.5 T. In each case SSFSE sequences (TR/TE:25720/67) in axial, coronal and sagittal planes, both at rest and during Valsalva's manoeuvre, were performed. Based on the MRI findings using fixed and mobile anatomical landmarks, the functional disease of the pelvic floor was diagnosed and quantified based on the identification and grading of visceral prolapse. The MRI findings were compared with the clinical findings in all cases and with the surgical data in the 7 patients who had undergone surgery.

RESULTS

The MR image quality was adequate in all cases. In the group of symptomatic women MRI diagnosed: urethral hypermobility syndrome: 22 cases; isolated abnormalities of the anterior compartment: 8 cases of cystocele (low grade: 2, middle grade: 2, severe: 4); isolated abnormalities of the middle compartment: 6 cases of hysterocele (low grade: 2, middle grade: 4); isolated abnormalities of the posterior compartment: 5 cases of low-grade rectocele; 2 cases of enterocele (1 low grade, 1 middle grade); multi-compartment abnormalities: 11 cases; joint prolapse of anterior and middle compartment: 5 cases; joint prolapse of posterior and middle compartment: 3 cases; joint prolapse of anterior, middle and posterior compartment: 3 cases. The values of both fixed and mobile landmarks were significantly higher in the symptomatic group compared with the healthy volunteers. MRI confirmed the pelvic examination findings in all cases; in particular MRI findings were in total agreement with the clinical severity of prolapse, as defined by the Baden-Walker classification. In 7 cases MRI detected additional alterations (4 cases of hysterocele and 3 of enterocele) that had been missed at clinical evaluation.

DISCUSSION AND CONCLUSIONS

In our experience MRI made an important contribution to the diagnosis and grading of functional disorders of the female pelvic floor and pelvic organ prolapse. The ability to simultaneously demonstrate both muscular and ligamentous structures and pelvic viscera, without using X-rays or contrast agents, is the main reason for the good results achieved by MRI and for its widespread use in this disorder. Furthermore the use of fast, breath-hold sequences can provide high-quality images both at rest and during Valsalva's manoeuvre. In conclusion MRI proved to be an accurate imaging tool that is more sensitive than clinical pelvic evaluation in diagnosing and grading functional disorders of the female pelvic floor and pelvic visceral prolapse.