Combined diagnostic imaging and management of a breast tumor in a young woman

The typical presentation of breast cancer in a young woman is discussed. Diagnostic imaging of the breast showed the presence of an extensive pathological area, approximately 5 cm in size, at the level of the upper quadrants of left breast. On mammography the pathological sign was represented by numerous regional granular microcalcifications. On sonography an inhomogeneously hypoechoic area with intralesional hyperechoic spots was identified. On MRI a large area of pathological enhancement was visualized. For the tumor extent and the patient's young age neoadjuvant chemotherapy was performed. Post-treatment assessment showed good response to therapy, suggestive of possible better prognosis.

A case of intracystic breast cancer

The case of a 70-year-old female patient with family history of breast cancer come to the breast Unit for the presence of a nodular swelling in the right breast is discussed. On mammography and US a gross cystic neoformation with vascularized mural nodes was identified. Another contralateral solid nodular neoformation suggestive of malignancy was also present. Diagnostic completion with MRI confirmed the mixed solid, partly cystic nature of the right lesion, leading to the differential diagnosis with cystosarcoma phylloides and intracystic tumor. On the left side, MRI confirmed the presence of the second lesion whose morphologic and dynamic characteristics suggested a neoplastic lesion. At the anatomopathological examination the left lesion was shown to be an infiltrating ductal carcinoma; the right lesion was shown to be an intracystic tumor.

Anterior shoulder dislocation and injuries of the rotator cuff in patients aged over 40 years. Clinical and sonographic study

A total of 39 patients with a mean age of 64 years (41 to 88) who had had anterior shoulder dislocation were followed-up an average of 2 years after trauma in order to evaluate the conditions of the rotator cuff. All of the patients were evaluated clinically, radiographically, and sonographically. Clinical evaluation revealed significant differences between the dislocated shoulders and the contralateral ones: the mean Constant score was 67 in the group with dislocated shoulders and 87 in the contralateral group. Ultrasound revealed partial injury of the cuff in 31% of cases and complete injury in 28%. Mean score was 81.4 in the group with a normal ultrasound, 67.1 in that with partial injury of the cuff, and 46.5 in that with complete injury of one or more tendons. These data confirm the high frequency of partial or complete injuries of the rotator cuff in patients aged over 40 years that have undergone anterior shoulder dislocation. Ultrasound confirms it is an excellent diagnostic method in the pathology of the rotator cuff, demonstrating good correlation with the clinical evaluation.

[Percutaneous alcohol injection in hyperparathyroidism. Experience in 11 cases with an 18-month follow-up]

The authors report the results of US-guided percutaneous ethanol injection into parathyroid glands of 11 patients with primary (2) and secondary (9) hyperparathyroidism. Selection criteria for choosing ethanol treatment were the patient's refuse of surgery and high surgical risks for age or severe chronic intercurrent conditions. At 18 months' follow-up, PTH serum levels had normalized in 2 primary and 2 secondary hyperparathyroidism patients; in all the others but one, PTH levels markedly decreased--always > 50% relative to pretreatment values. Serum calcium and phosphorus levels also decreased, which was not always the case with alkaline phosphatase. After injection, the glands became progressively hyperechoic, gland volume decreased and calcifications appeared. Parenchymal flow disappeared on color-Doppler US images. This study confirms the capabilities of US-guided ethanol injection in hyperfunctioning parathyroids, even though complications may occur and the condition recur. This method is thus suggested as an effective alternative to surgery.

[Echography and integrated imaging in the diagnosis of hyperparathyroidism]

The authors report their personal experience with US, CT, biopsy and, lately, MRI, to localize enlarged parathyroid glands in primary and secondary hyperparathyroidism. December 1986 through December 1993, sixty-four primary and 55 secondary hyperparathyroidism patients were examined--119 in all. At biopsy and surgery, US sensitivity appeared to be 72%, with 0.94 positive predictive value; CT sensitivity was 80% with 0.91 positive predictive value. The two methods combined had 87% sensitivity in all. In the authors' experience, US proved to be a sensitive, accurate and cost-effective technique, as well as the best method to guide biopsy thanks to its multiplanar capabilities. Even though it requires great operator's experience, US is the method of choice in the localization of abnormal parathyroid glands. Its combination with CT increased overall sensitivity mainly in ectopic localizations and postoperative recurrences. Finally, technologic progress and increased MR sensitivity are likely to make MRI the imaging technique of choice, replacing CT, in the diagnostic protocol of hyperparathyroidism.

Surveillance and treatment of liver transplant recipients for candidiasis and aspergillosis

Between June 1988 and May 1991 88 orthotopic liver transplants and 1 liver and pancreas transplant were performed at the Liver Transplantation Department of the Ospedale Maggiore of Milan. All the patients underwent mycological surveillance and received antifungal prophylaxis with oral amphotericin B (6000 mg/day) or oral or intravenous fluconazole (200 mg/day) from the time of their transplant. The incidence of Candida colonization was 67%. Fluconazole was superior to oral amphotericin B in the treatment of C. albicans colonization (9/9 vs 6/15), but less effective in the treatment of colonization by other Candida spp. (0/3 vs 3/3). Deep-seated candidiasis developed in 5 patients, caused by C. albicans in 4 cases and C. krusei in 1. C. albicans infection resolved rapidly with fluconazole in 2 subjects, with intravenous amphotericin B alone in 1, and with amphotericin B plus flucytosine in the other. On the contrary, C. krusei infection did not respond to treatment with amphotericin B combined with flucytosine. Aspergillosis was diagnosed in 11 patients, of whom 4 died from invasive aspergillosis, despite 15 and 26 days of amphotericin B treatment in 2. In another patient invasive aspergillosis, diagnosed a few hours before retransplantation, improved with liposomal amphotericin B, but this man died from cytomegalovirus infection one month later. Aspergillosis was eradicated by itraconazole in 4 other patients and by topical amphotericin B in 2 whose infection was localized to surgical wound.

[The advantages of combined US-fluoroscopic guidance in the drainage of abdominal abscesses]

The authors report their experience with 19 percutaneous drainages of abdominal abscesses in 19 patients. Six collections were in the subphrenic spaces, 6 in the liver, 1 in the infracolic space, 2 in the psoas muscle, 3 within the abdominal wall, and 1 in the pararenal space. Their etiology was abdominal surgery in 10 patients, biliary obstruction in 1, and trauma in 2; in the extant patients a hematogenous infection was supposed. The procedures were performed under combined US and fluoroscopic guidance, following Seldinger technique in all but two cases. Van Sonnenberg double-lumen sump catheter was successfully employed in all cases. After a review of the technique the authors discuss the advantages of US-fluoroscopic over CT guidance. The latter is preferred if the collection is not well demonstrated by US and in the cases where a posterior approach is needed. The economic advantages of US-fluoroscopic over CT guidance are also stressed.

[A case of teratoma of the urachus]

The paper reports a case of teratoma of the urachus in a 53-year-old patient. The difficulties of diagnosing this pathology are underlined, in particular in relation to the rarity of the site of which no other examples have been reported in the literature.