Caecal leiomyoma detected by whole-body MRI in a patient with Hodgkin lymphoma: first case report

INTRODUCTION

Hodgkin Lymphoma (HL) is one of the most curable malignant diseases. Modern treatments, like the combined radiochemotherapy and stem cell transplantation, have increased the number of malignant disease survivors. However, HL survivors are at risk of long-term effects, including the development of solid tumors. Secondary neoplasms are a major cause of late morbidity and mortality following treatment for HL.

CASE REPORT

We report the case of a male patient, treated for HL by chemotherapy, who developed a large leiomyoma of the cecum one year after the treatment. A whole-body Magnetic Resonance (WBMRI) scan performed during the follow-up allowed the detection of this incidental caecal mass that was absent in a Computed Tomography (CT) scan performed immediately after the treatment. After a CT-guided biopsy, the lesion was surgically removed and the diagnosis of caecal leiomyoma was obtained.

DISCUSSION

To our knowledge, this is the first case report, according to the scientific literature, of caecal leiomyoma developing after chemotherapy in a HL survivor. Leiomyoma is a rare benign tumor that usually appears as a solitary small mass with a nodular growth and a benign course.

CONCLUSION

This case shows that WB-MRI allows detecting relevant incidental findings during the oncologic follow-up, avoiding both radiation exposure and contrast agent administration. Furthermore, leiomyoma should be considered in the differential diagnosis between the caecal masses with high growth rate.

Appendiceal mucinous neoplasms: an uncertain nosological entity. Report of a case

INTRODUCTION

Appendiceal mucocele is a relatively rare condition characterized by progressive dilation of the appendix caused by intraluminal accumulation of mucoid substance. Its incidence is 0.07 - 0,63% of all appendectomies performed.

CASE REPORT

We report the case of a 70-year-old man who came to our observation with gravative pain in right lower abdominal region. A computed tomography abdominal scan revealed a cystic/tubular structure like an appendicular mass with wall enhancement but without calcifications suggestive of a mucocele. Into peritoneal cavity we found profuse mucinous material with a 1,5 cm size parietal nodule. We also identified a free perforation of the cecum with consensual spillage of gelatinous material mimicking a pseudomyxoma peritonei. We decided to perform a right hemicolectomy with excision of peritoneal lesion.

DISCUSSION

The controversy in the pathologic terminology can give rise to a clinical dilemma in terms of the management and follow-up plans. For mucosal hyperplasia and cystadenoma simple appendectomy is curative. Only in case of large base of implantation it may be necessary the resection of the ileum and caecum or right hemicolectomy. In case of mucinous cystoadenocarcinoma authors perform a right hemicolectomy.

CONCLUSION

Appendiceal mucinous neoplasms are different pathological entities. The correct surgical management depends on size and location of lesion. A preoperative diagnosis is obviously needed in order to perform the correct treatment. CT abdominal scan is the better diagnostic tool, but different authors show their inability to reach a preoperative diagnosis in the larger majority of cases.

Large cavernous hemangioma of the adrenal gland: Laparoscopic treatment. Report of a case

•

Identify the preoperative radiologic features of adrenal hemangioma.

•

We examine the better surgical approach for adrenal tumors and adrenal hemangioma.

•

Controindication to laparoscopic adrenalectomy.

Introduction

Cavernous hemangioma of the adrenal gland is a rare benign tumor. The diagnosis is often postoperative on histological exam with the presence of blood-filled, dilated vascular spaces.

Presentation of case

We report the clinical case of a 49 years-old woman who came to our observation with aspecific abdominal pain. A computed tomography (CT) abdominal scan revealed a 11 cm right adrenal mass. This lesion was well circumscribed, round, encapsulated. After iodinated-contrast we observed a progressive, inhomogeneous enhancement without evidence of active bleeding and with pre-operative diagnosis of adrenal hemangioma. Laparoscopic adrenalectomy was performed by a transperitoneal flank approach. Pathological examination revealed a 11 cm adrenal mass with extensive central necrotic areas mixed to sinusoidal dilation and fibrotic septa. Postoperative diagnosis was adrenal hemangioma.

Discussion

Adrenal hemangiomas occur infrequently. Generally these adrenal masses are non-functioning and there is no specific symptoms. Recent records demonstrate that laparoscopic adrenalectomy is technically safe and feasible for large adrenal tumors, but controversy exists in cases of suspected malignancy. We choose laparoscopic approach to adrenal gland on the basis of preoperative CT abdominal scan that excludes radiological signs of adrenocortical carcinoma (ACC) such as peri-adrenal infiltration and vascular invasion.

Conclusion

Laparoscopic adrenalectomy is considered the standard treatment in case of diagnosis of benign lesions. In this case report we discussed a large adrenal cavernous hemangioma treated with laparoscopic approach. Fundamental is the study of preoperative endocrine disorders and radiologic findings to exclude signs of malignancy.

Small solid renal masses: characterization by diffusion-weighted MRI at 3 T

AIM

To describe the appearance of small solid renal lesions (≤3 cm) on diffusion-weighted magnetic resonance imaging (MRI) and to determine whether ADC measurements may help to differentiate benign from malignant small solid renal masses.

METHODS AND MATERIALS

Thirty-five patients with 47 small renal masses (23 malignant, 24 benign) who underwent 3 T MRI of the kidney using diffusion-weighted sequences (b values of 0 and 1000 s/mm(2)) were retrospectively evaluated. Qualitative and quantitative analysis of diffusion-weighted images was performed.

RESULTS

Most lesions were hyperintense to kidney on high b-value diffusion-weighted images and hypointense on apparent diffusion coefficient (ADC) map. The mean ADC of the lesions was significantly lower than that of kidney (1.22 ± 0.3 versus 1.85 ± 0.12 mm(2)/s; p < 0.005). The mean ADC was significantly different between renal cell carcinomas (1.2 ± 0.01 mm(2)/s), metastases (1.25 ± 0.04 mm(2)/s), angiomyolipoma (1.07 ± 0.3 mm(2)/s) and oncocytomas (1.56 ± 0.08 mm(2)/s; p < 0.05). The mean ADC of clear cell renal cell carcinomas was significantly different from that of non-clear cell renal cell carcinomas (1.38 ± 0.34 versus 0.83 ± 0.34 mm(2)/s; p < 0.005). No significant difference was found between mean ADC of fat containing and minimal fat angiomyolipomas (1.06 ± 0.48 versus 1.11 ± 0.33 mm(2)/s).

CONCLUSION

Small solid renal masses are hyperintense on high b value and have different ADC values.

Comparison of iodinated contrast media for the assessment of atherosclerotic plaque attenuation values by CT coronary angiography: observations in an ex vivo model

OBJECTIVE

To compare the influence of different iodinated contrast media with several dilutions on plaque attenuation in an ex vivo coronary model studied by multislice CT coronary angiography.

METHODS

In six ex vivo left anterior descending coronary arteries immersed in oil, CT (slices/collimation 64×0.625 mm, temporal resolution 210 ms, pitch 0.2) was performed after intracoronary injection of a saline solution, and solutions of a dimeric isosmolar contrast medium (Iodixanol 320 mgI ml(-1)) and a monomeric high-iodinated contrast medium (Iomeprol 400 mgI ml(-1)) with dilutions of 1/80 (low concentration), 1/50 (medium concentration), 1/40 (high concentration) and 1/20 (very high concentration). Two radiologists drew regions of interest in the lumen and in calcified and non-calcified plaques for each solution. 29 cross-sections with non-calcified plaques and 32 cross-sections with calcified plaques were evaluated.

RESULTS

Both contrast media showed different attenuation values within lumen and plaque (p<0.0001). The correlation between lumen and non-calcified plaque values was good (Iodixanol r=0.793, Iomeprol r=0.647). Clustered medium- and high-concentration solutions showed similar plaque attenuation values, signal-to-noise ratios (SNRs) (non-calcified plaque: medium solution SNR 31.3±15 vs 31.4±20, high solution SNR 39.4±17 vs 37.4±22; calcified plaque: medium solution SNR 305.2±133 vs 298.8±132, high solution SNR 323.9±138 vs 293±123) and derived contrast-to-noise ratios (p>0.05).

CONCLUSION

Differently iodinated contrast media have a similar influence on plaque attenuation profiles.

ADVANCES IN KNOWLEDGE

Since iodine load affects coronary plaque attenuation linearly, different contrast media may be equally employed for coronary atherosclerotic plaque imaging.

[Hemostatic effectiveness of TachoSil® patches in radiofrequency assisted minor hepatic resection]

AIM

Intra- and postoperative bleeding represents an extremely serious and frequent complication of hepatic surgery. The aim of this study was to evaluate the effectiveness of TachoSil® to improve hemostasis in radiofrequency assisted minor hepatic resection.

METHODS

Between July 2008 and June 2010, 31 patients underwent radiofrequency assisted minor hepatic resection. At the end of the liver resection a sponge of TachoSil® was applied on the liver.

RESULTS

The mean intraoperative bleeding from the liver was 56.1 mL (range 0-300 mL). No patients received intra- and postoperative blood transfusion. Surgical drains were removed between the first and the sixth-eight postoperative day.

CONCLUSION

According to the authors Tacho-sil® is helpful to improve hemostasis and biliary leakage in patients undergoing radiofrequency assisted minor hepatic resection.

Prevalence of myocardial bridging and correlation with coronary atherosclerosis studied with 64-slice CT coronary angiography

PURPOSE

This study aimed to assess the prevalence and characteristics of myocardial bridging in patients who underwent multislice computed tomography coronary angiography (MSCT-CA) and to evaluate the correlation between bridged coronary segments and atherosclerosis.

MATERIALS AND METHODS

A total of 277 patients (mean age 60+/-11 years) we consecutively examined with 64-slice MSCT-CA for suspected or known coronary atherosclerosis were retrospectively reviewed for myocardial bridging. Segments proximal and distal to the bridging were evaluated for atherosclerotic plaque, as were the remaining coronary segments.

RESULTS

Myocardial bridging was present in 82 patients (30%, mean age 59+/-12). Bridges were of variable length (<1 cm 58%; 1-2 cm 32%; >2 cm 10%) and depth (superficial 69%, intramyocardial 31%) and frequently localised in the mid-distal segment of the left anterior descending artery (95%). Myocardial bridging cannot be considered a significant risk factor for coronary atherosclerosis (odds ratio 0.49) compared with traditional cardiovascular risk factors. Coronary segments proximal to the bridge showed no atherosclerotic disease (33%), positive remodelling (27%), <50% stenosis (20%) or >50% stenosis (20%). We identified 12 noncalcified, 32 mixed and 17 calcified plaques. The distal segments were significantly less affected (p<0.0001).

CONCLUSIONS

MSCT-CA is a reliable, noninvasive method that is able to depict myocardial bridging and associated atherosclerotic plaque in the proximal segments.

Videofluorography swallow study of patients with systemic sclerosis

PURPOSE

This study was undertaken to evaluate the role of the videofluorographic (VFG) swallow study in patients with systemic sclerosis.

MATERIALS AND METHODS

Over a 23-month period, 45 women (mean age 58 years, range 27-76 years) with a known diagnosis of systemic sclerosis and a history of dysphagia underwent a dynamic and morphological study of the oral, pharyngeal and oesophageal phases of swallowing with videofluorography. All examinations were performed with a remote-controlled digital C-arm device with 16-in image intensifier, 0.6- to 1.2-mm focal spot range and maximum tube voltage of 150 kVp in fluorography and 120 kVp in fluoroscopy. Cineradiographic sequences were acquired for the swallow study with 12 images per second and matrix 512 x 512 after the ingestion of boluses of high-density (250% weight/volume) barium. The evaluation of oesophageal peristalsis was documented with digital cineradiographic sequences with six images per second in the upright and supine positions during the swallowing of barium (60% weight/volume), and the water siphon test was performed with the patient in the supine position to evaluate the presence of gastro-oesophageal reflux disease (GORD). All patients subsequently underwent laryngoscopy, endoscopy and pH monitoring, and the data thus obtained were processed and compared.

RESULTS

The VFG swallow study identified alterations of epiglottal tilting associated with intraswallowing laryngeal penetration in 26 patients (57.8%), pooling of contrast agent in the valleculae and pyriform sinuses in 23 (51.1%) and radiographic signs of nonspecific hypertrophy of the lingual and/or palatine tonsils in 18 (40%). The study of the oesophageal phase revealed the presence of altered peristalsis in all patients, and in particular, 36 patients (80%) showed signs of atony. Altered oesophageal clearing mechanisms were evident in all 45 patients, sliding hiatus hernia in 43 (93%) and GORD in 44 (97%).

CONCLUSIONS

Our study demonstrated that in patients with systemic sclerosis, there is no primary alteration of the oral or pharyngeal phase of swallowing. In addition, alterations of epiglottal tilting associated with laryngeal penetration of contrast agent were found to be secondary to chronic GORD. Indeed, in 40% of patients, radiographic signs were found that indicated nonspecific hypertrophy of the lingual tonsil and/or palatine tonsils and nonspecific signs of chronic pharyngeal inflammation, and GORD was identified in 93% of patients, which in 40% of cases extended to the proximal third of the oesophagus. The data obtained were confirmed in 85% of cases with pH monitoring and in all cases with laryngoscopy.

Multislice human organ extraction based on GVF

Segmentation techniques based on active contours algorithm are widely used in medical imaging. Unfortunately, they require a lot of parameters to be used and this can represent an issue for those physicians with not much informatics skills. This paper proposes a software tool which allows to segment multiple slice can differ organ extraction setting a small number of parameters. Moreover, the tool offers the functionality to perform a multiple segmentation the same time, so that an entire volume composed by hundreds slices can be segmented.

Seeding after radiofrequency ablation of hepatocellular carcinoma in patients with cirrhosis: a prospective study

BACKGROUND

Neoplastic seeding of hepatocellular carcinoma may arise after radiofrequency ablation.

AIMS

In order to clarify the real risk of seeding, we observed a prospective cohort of patients undergoing radiofrequency ablation.

METHODS

Ninety-three (22.9%) out of 406 consecutive patients with hepatocellular carcinoma superimposed to cirrhosis diagnosed at our Liver Unit (2000-2005) were selected for radiofrequency ablation according to the Barcelona 2000 EASL guidelines. Seventy-one patients were treated by a percutaneous approach and 22 at laparotomy. After radiofrequency ablation ultrasound scan was repeated every 3 months and spiral-computed tomography every 6 months.

RESULTS

Overall 145 sessions were performed in 93 patients: 113 (77.9%) by a percutaneous approach and 32 (22.1%) at laparotomy. The median follow-up was 23 months (range 1-60). Only 1 of the 71 patients (1.4%; 95% C.I. 0.25-7.56) treated percutaneously and none of the 22 (0%; 95% C.I. 0-14.8) treated at laparotomy showed neoplastic seeding.

CONCLUSION

In our experience the risk of seeding of hepatocellular carcinoma after radiofrequency ablation was small (1.1% per patient, 95% C.I. 0.19-5.84; 0.7% per procedure, 95% C.I. 0.12-3.80). A stringent selection of patients for radiofrequency ablation and retraction of the needle with a hot tip may have been instrumental in obtaining this low frequency.

Survival of patients with hepatocellular carcinoma in cirrhosis: a comparison of BCLC, CLIP and GRETCH staging systems

BACKGROUND

A major problem in assessing the likelihood of survival of patients with hepatocellular carcinoma (HCC) arises from a lack of models capable of predicting outcome accurately.

AIM

To compare the ability of the Italian score (CLIP), the French classification (GRETCH) and the Barcelona (BCLC) staging system in predicting survival in patients with HCC.

METHODS

We included 406 consecutive patients with cirrhosis and HCC. Seventy-eight per cent of patients had hepatitis C. Independent predictors of survival were identified using the Cox model.

RESULTS

One-hundred and seventy-eight patients were treated, while 228 were untreated. The observed mortality was 60.1% in treated patients and 84.9% in untreated patients. Among treated patients, albumin, bilirubin and performance status were the only independent variables significantly associated with survival. Mortality was independently predicted by bilirubin, alpha-fetoprotein and portal vein thrombosis in untreated patients. CLIP achieved the best discriminative capacity in the entire HCC cohort and in the advanced untreatable cases, while BCLC was the ablest in predicting survival in treated patients.

CONCLUSIONS

Overall predictive ability of BCLC, CLIP and GRETCH staging systems was not satisfactory, and was not uniform for treated patients and untreated patients. None of the scoring systems provided confident prediction of survival in individual patients.

Digital cineradiographic study of swallowing in patients with amyotrophic lateral sclerosis

PURPOSE

This study was performed to evaluate the usefulness of digital cineradiography in detecting swallowing disorders in dysphagic patients affected by amyotrophic lateral sclerosis (ALS) with a view to planning an adequate therapeutic approach.

MATERIAL AND METHODS

From January 2005 to September 2006, 23 patients (10 men and 13 women; mean age 41.3+/-8.6 years) affected by ALS were evaluated with digital cineradiography to assess the grade of dysphagia. All patients were classified using the Hillel ALS Severity Scale (ALSSS). All examinations were performed with radiocontrolled equipment provided with a digital C-arm.

RESULTS

The cineradiographic technique enabled us to differentiate patients with disorders of the oral (17/23) and/or pharyngeal (19/23) swallowing phase from those without swallowing dysfunction (4/23). In 14/23 patients, passage of contrast medium into the upper airways was observed during swallowing, whereas in 5/23 cases, aspiration of contrast medium into the lower airways was recorded.

CONCLUSIONS

The videofluoroscopic swallowing study has high diagnostic capabilities in the evaluation of swallowing disorders, as it is able to identify the degree and causes of impairment. In addition, the study proved useful for planning speech therapy and for follow-up in patients with ALS.

Forty-slice MDCT enteroclysis: evaluation after oral administration of isotonic solution in Crohn's disease

OBJECTIVE

The aim of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) enteroclysis after oral hyperhydration with isotonic solution in detecting bowel wall alterations in patients with Crohn's disease.

MATERIALS AND METHODS

Twenty-eight patients with a diagnosis of Crohn's disease established by ileocolonoscopy and histology were enrolled in the study; 15 patients with negative ileocolonoscopy served as controls. In all cases, MDCT enteroclysis was performed after oral administration of 2,000 ml of isotonic solution and intravenous administration of N-butylscopolamine. Axial, isotropic multiplanar and volume-rendered reconstructions were used to evaluate bowel wall thickness, ulceration, contrast enhancement, extraparietal involvement and possible complications.

RESULTS

MDCT enteroclysis identified the typical signs of Crohn's disease in 26 patients (92.8%), with sensitivity of 92.8%, specificity of 100%, positive predictive value 100% and negative predictive value 75%.

CONCLUSIONS

MDCT enteroclysis after oral hyperhydration with isotonic solution showed a high level of accuracy in detecting small bowel changes in patients with Crohn's disease. It can be considered a safe and effective alternative to conventional radiography and small-bowel spiral computed tomography enema, especially in patients who refuse nasojejunal intubation.

Can ECG-gated MDCT be considered an obligatory step to plan and manage a new chest-pain unit?

The recent improvements in multi-detector computed tomography technology and its application in cardiac field allow to consider this non-invasive imaging technique as a promising comprehensive method for detecting significant coronary stenoses in a chest-pain unit. The possibility to use the ECG-synchronisation acquisition protocol, normally limited to the cardiac volume, for the entire thoracic vascular system should have the remarkable potential to reduce invasive and non-invasive procedures actually used to investigate acute chest pain and the number of unnecessary hospital admissions without reducing appropriate admissions in patients with chest pain.

Incidentally discovered thyroid nodules: incidence, and greyscale and colour Doppler pattern in an adult population screened by real-time compound spatial sonography

PURPOSE

Our aim was to assess the incidence and ultrasound features of thyroid nodules in an adult population screened by means of high-resolution ultrasonography (HRUS) and to evaluate the contribution of real-time spatial compound sonography (CS) in terms of image quality.

MATERIALS AND METHODS

A total of 704 consecutive patients (400 women, 304 men) without thyroid disease underwent HRUS and CS examination of the thyroid gland. Number, size, location, echotexture and colour Doppler pattern of detected nodules were assessed. Two radiologists also assessed image quality of the two techniques.

RESULTS

Seven hundred and eleven thyroid nodules (size range 0.18-4.1 cm; mean: 1.1 cm) were detected in 233 subjects (33.1%). Of these, 416 (58.5%) were found in 143 women whereas 295 (41.5%) were detected in 90 men. In both genders, the number of detected nodules increased with age, with the highest prevalence in the seventh decade (p<0.001). There were 461/711 (64.9%) thyroid nodules that were hypoechoic, and 449/711 (63.1%) had peripheral vascularity only (p<0.001). Fine-needle aspiration (FNA) revealed no malignancies. CS was graded better than HRUS in 621/711 (87.3%) cases (p<0.001).

CONCLUSIONS

The prevalence of benign, small, hypoechoic thyroid nodules with peripheral vascularity was high in our series, thus suggesting a conservative approach. CS provided better image quality compared with HRUS.

Gastrointestinal stromal tumour: 40-row multislice computed tomography findings

PURPOSE

The purpose of this study was to describe the findings and evaluate the role of multidetector (40-slice) computed tomography (MDCT) in the preoperative assessment of gastrointestinal stromal tumours (GISTs).

MATERIALS AND METHODS

Thirteen patients with histologically proven GIST (size: 4-30 cm; mean: 9 cm) underwent 40-slice MDCT after the ingestion of 1,000 ml of water. Images were obtained before and 70 s after intravenous injection of 120 ml of iodinated contrast agent. Two experienced radiologists reviewed the CT findings to evaluate lesion site, size, margins, attenuation, growth pattern, enhancement pattern, ascites, lymphadenopathy, direct invasion to adjacent organs and distant metastasis. Multiplanar maximum intensity projection and three-dimensional (3D) reconstructions were also obtained.

RESULTS

Seven out of 13 GISTs were located in the jejunumileum, 3/13 in the stomach, 2/13 in the rectum and in one case, the origin remained unknown. Eleven out of 13 were exophytic, and ten had well-defined borders. Two out of 13 showed calcifications. Thirteen out of 13 exhibited inhomogeneous enhancement due to areas of necrosis and cystic degeneration. Direct invasion to adjacent organs (n=3), ascites (n=3), and liver (n=1) and peritoneal (n=1) metastases were also detected. Bowel obstruction, vascular invasion and lymphadenopathy were never seen.

CONCLUSIONS

MDCT allowed reliable preoperative assessment of GIST, providing useful clues for lesion characterisation.

Coronary artery anomalies: incidence, pathophysiology, clinical relevance and role of diagnostic imaging

Conventional coronary angiography is the gold standard for the diagnosis of coronary artery anomalies. Coronary anomalies are relatively rare findings in patients undergoing conventional coronary angiography for suspected obstructive coronary artery disease. Recently, the increasing performance of diagnostic techniques, such as electron beam tomography (EBT), magnetic resonance (MR) and, more recently, multislice computed tomography (MSCT), has enabled their application to cardiac imaging. MSCT, in particular, has a prominent role in coronary imaging due to its spatial and temporal resolution and three-dimensional capabilities. We report the incidence and pathophysiology of coronary artery anomalies based on the capabilities of recent diagnostic tools with the aim of improving an accurate and noninvasive diagnostic approach.

Characterization of benign hepatic tumors arising in fatty liver with SonoVue and pulse inversion US

BACKGROUND

We describe the spectrum of contrast-enhancement patterns of benign hepatic tumors arising in fatty liver on contrast-enhanced ultrasound (US).

METHODS

Sixteen patients (12 women and four men) with 27 benign hepatic tumors (17 hemangiomas, eight focal nodular hyperplasias, and two hepatocellular adenomas) arising in fatty liver underwent baseline and pulse inversion US after administration of SonoVue. Two experienced radiologists evaluated baseline echogenicity and dynamic enhancement pattern of each lesion in comparison with adjacent liver parenchyma.

RESULTS

After administration of SonoVue, in the arterial phase 13 of 17 hemangiomas showed peripheral globular enhancement and one showed a rim of peripheral enhancement, followed by progressive centripetal fill-in, which was complete in 10 of 14 cases and incomplete in four. Three of 18 hemangiomas showed rapid and complete fill-in in the arterial phase. Eight of eight focal nodular hyperplasias became hyperechoic in comparison with adjacent liver parenchyma in the arterial phase and slightly hyperechoic or isoechoic in the portal venous and delayed phases. Both adenomas showed strong arterial contrast enhancement that became less intense in the portal venous and delayed phases.

CONCLUSION

Contrast-enhanced US after administration of SonoVue enables depiction of typical contrast-enhancement patterns in most benign hepatic tumors arising in fatty liver, thus providing useful clues for characterization.

Non-invasive assessment of coronary artery stent patency with multislice CT: preliminary experience

PURPOSE

To evaluate the diagnostic accuracy of multislice computed tomography coronary angiography (MSCT-CA) in the detection of in-stent restenosis.

MATERIALS AND METHODS

Forty-two patients (33 male, 9 female, mean age 58+/-8 years) previously subjected to percutaneous implantation of coronary stent with suspected in-stent restenosis, underwent a 16-row MSCT (Sensation 16, Siemens) examination. The average time between stent implantation and MSCT-CA was 7.4+/-5.3 months. The following scan parameters were used: collimation 16x0.75 mm, rotation time 0.42 s, feed 3.0 mm/rot., kV 120, mAs 500. After administration of iodinated contrast material (Iomeprol 400 mgI/ml, 100 ml at 4 ml/s) and bolus chaser (40 ml of saline at 4 ml/s) the scan was completed in <20 s. All segments with a stent were assessed by two observers in consensus and were graded according to the following scheme: patent stent, in-stent intimal hyperplasia (IIH) (lumen reduction <50%), in-stent restenosis (ISR) (=/>50%), in-stent occlusion (ISO) (100%). Consensus reading was compared with coronary angiography.

RESULTS

Forty-seven stents were assessed (16 in the right coronary artery; 4 in the left main; 22 in the left anterior descending; 5 in the circumflex). In 7 (17%) stents there was ISR (3) or ISO (4), and in 4 (10%) stents there was IIH. The sensitivity and negative predictive values for the detection of ISO were 80% and 98%, respectively, while for the detection of ISR+ISO they were 50% and 89%, respectively.

CONCLUSIONS

Although the results are encouraging, the follow-up of stent patency with MSCT-CA does not show a diagnostic accuracy suitable for clinical implementation.

MR findings in lipoma arborescens of the knee: our experience

PURPOSE

This paper describes the role of MR imaging in the identification of the different macroscopic patterns of lipoma arborescens.

MATERIALS AND METHODS

Between June 1995 and January 2004, a total of 6387 MR examinations of the knee were retrospectively assessed for the presence of lipoma arborescens. The MR examinations were performed using a superconductive 0.5 T MR unit with a transmitting/ receiving coil dedicated for the extremities. The MR images were acquired with SE T1-weighted, GE T2-weighted and STIR sequences in sagittal, coronal and axial planes with 3-mm thickness and 1-mm gap.

RESULTS

Lipoma arborescens was identified in 9 patients (mean age: 36 years). In 2/9 cases a localized lipoma arborescens was detected as a well-marginated single nodule on the suprapatellar bursa without irregularity or synovial hyperplasia. In the remaining 7 cases diffuse lipoma arborescens was identified on the wall of the suprapatellar bursa. In one case of diffuse lipoma arborescens there was involvement of both knees. In all cases the MR findings were verified at surgery and the final diagnosis was made by histological examination.

CONCLUSIONS

MR imaging shows a high accuracy in the identification and characterization of lipoma arborescens, due to its multiplanar capabilities and high contrast resolution. MRI allows correct evaluation of size and grade, accurate treatment planning and effective follow-up, avoiding the need for synovial biopsy.

Diagnostic accuracy of 16-row multislice CT angiography in the evaluation of coronary segments

PURPOSE

To evaluate the diagnostic accuracy of 16-row multislice spiral computed tomography coronary angiography (16-MSCT-CA) for the non-invasive assessment of significant coronary artery stenosis.

MATERIALS AND METHODS

We enrolled 40 patients (36 male, aged 59+/-11 yrs) with suspected obstructive coronary artery disease and a heart rate <65 bpm during the scan. The 16-MSCT-CA (Sensation 16, Siemens, Forchheim, Germany) was performed with electrocardiographically-gated technique after the intravenous administration of 100 ml of iodinated contrast material followed by a saline bolus chaser. The scan parameters were: collimation 16 x 0.75 mm, rotation time 0.42 s, feed/rot. 3 mm (pitch 0.25), 120 kVp, 500 mAs. All coronary segments = or >2 mm in diameter were evaluated by two independent observers for the presence of significant coronary artery stenosis (= or >50%). Consensus reading was compared to quantitative coronary angiography.

RESULTS

The average heart rate was 55+/-6 bpm. Of the 428 segments of = or >2.0 mm diameter 92 were significantly diseased. Without exclusion of any branches (428), the sensitivity, specificity, positive, and negative predictive values to identify = or >50% obstructed segments were 95.7% (88/92), 95.8% (322/336), 86.3% (88/102), and 98.8% (322/326), respectively. No occluded left main, left anterior descending, circumflex or right coronary artery segments remained undetected.

CONCLUSIONS

16-MSCT-CA in a selected low-heart-rate patient population provides high diagnostic accuracy in the evaluation of significant coronary artery stenosis.

Vesicoureteral reflux in young patients: comparison of voiding color Doppler US with echo enhancement versus voiding cystourethrography for diagnosis or exclusion

We assessed the accuracy of voiding color Doppler ultrasonography (US) with echo enhancement for diagnosis or exclusion of vesicoureteral reflux (VUR) versus voiding cystourethrography (VCUG) and evaluated patient tolerance of the echo-enhancing agent. One hundred twenty-two patients (ages range, 1 month to 17 years) with 244 ureterorenal units underwent voiding color Doppler US with echo enhancement, which was followed by VCUG on the same day. After US of the urinary tract, the bladder was filled with saline solution via catheter. Then an echo-enhancing agent was instilled, and color Doppler US was performed. Reflux was diagnosed when microbubbles appeared in the ureter or the pelvicaliceal system. VUR was detected in 98 units. All grades of reflux were identified. In 13 units (13.3%), grade I reflux diagnosed at voiding color Doppler US was not observed at VCUG. No reflux was detected in 146 units by either method. In 231 (94.2%) of the 244 ureterorenal units, there was concordance between the two methods. The echo-enhancing agent was well tolerated by all patients. Voiding color Doppler US with echo enhancement is useful for the diagnosis or exclusion of VUR, being as good as VCUG. Therefore, it may reduce the number of patients exposed to ionizing radiation.

Isolated hydatid disease of the spleen: CT findings in 4 patients and differential diagnosis

AIM

To report our experience with four cases of isolated hydatid disease of the spleen studied by spiral Computed Tomography (CT) and to review the literature with special attention to the differential diagnosis with other focal lesions of the spleen.

MATERIALS AND METHODS

The spiral CT images and clinical records of four patients (1 man, 3 women; age range 26-45 yrs) affected by isolated hydatid disease of the spleen were retrospectively evaluated. None of the patients had a history of hydatid disease. All the patients were evaluated by plain and enhanced spiral CT of the abdomen. All patients underwent preoperative chest X-ray and surgery; all surgical specimens were studied by histology.

RESULTS

Spiral CT depicted all the hydatid lesions of the spleen. It showed the location, size, low density of their content without enhancement after iv contrast medium injection, the possible presence of daughter cysts, the appearance of the wall with calcifications, and excluded the presence of complications. The preoperative chest X-ray was negative for focal pulmonary lesions in all cases. Pathology confirmed the diagnosis of hydatid disease in all cases.

CONCLUSIONS

According to our results and to the literature, spiral CT plays an important role in the pre-surgical evaluation of patients with hydatid disease of the spleen, and provides useful information for differentiating the disease from other isolated cyst-like lesions of the spleen.

Retroaortic left renal vein joining the left common iliac vein

Retroaortic left renal vein joining the left common iliac vein is a rare congenital anomaly in the development of the inferior vena cava. To our knowledge, only one case has been reported in the literature; however, its imaging features have never been described. A 27-year-old male presented with a 1-year history of recurrent right flank pain, dysuria, hematuria, and fever (39 degrees C). Computed tomography and MR venography showed a retroaortic left renal vein joining the left common iliac vein. We present the CT and MR venography findings and discuss their feasibility in showing this congenital anomaly.

[Usefulness of CT colonography in the preoperative evaluation of patients with distal occlusive colorectal carcinoma]

PURPOSE

To evaluate the role of preoperative virtual colonoscopy to study the proximal colon in patients with distal occlusive carcinomas, diagnosed by conventional colonoscopy.

MATERIAL AND METHODS

We examined 19 patients aged 46 to 83 years (13 men and 6 women) with distal occlusive colorectal carcinomas diagnosed by conventional colonoscopy, who were preoperatively studied with virtual colonoscopy. Patients with acute bowel obstruction were excluded. Results were compared with the findings of preoperative conventional colonoscopy and barium enema examination, intraoperative colon palpation, histopathologic outcome, postoperative conventional colonoscopy and barium enema examination.

RESULTS

Virtual colonoscopy identified all 19 distal occlusive colon carcinomas and 22 synchronous lesions, 2 cancers (prevalence 10,6%) and 20 polyps (prevalence 68,4%). Both synchronous cancers were confirmed intraoperatively by direct palpation. Postoperative conventional colonoscopy, which was performed in 18 patients, confirmed the presence of 15 polyps in 12 patients. Three subcentimeter polyps were removed during conventional colonoscopy and were missed at virtual colonoscopy. Two polyps shown by virtual colonoscopy were not found at conventional colonoscopy. Postoperative barium enema was performed in three patients and confirmed three polyps identified at virtual colonoscopy. Preoperative barium enema was performed in five patients and failed to adequately demonstrate the proximal colon. Virtual colonoscopy showed a sensitivity of 87% and a specificity of 75%.

CONCLUSIONS

Virtual CT colonoscopy can be considered an important diagnostic technique to evaluate preoperatively the proximal colon in patients with distal occlusive carcinomas,as it gives better results than barium enema or conventional colonoscopy, as well as being well tolerated and less invasive.

[Benign hepatic tumors: MRI features before and after administration of superparamagnetic contrast media]

PURPOSE

To assess the yield of superparamagnetic iron oxide (SPIO)-enhanced MR images in the detection and characterization of benign hepatic tumors and to evaluate the potential role and safety of SPIO administration in the diagnosis of these tumors.

MATERIAL AND METHODS

Eighteen patients underwent MRI before and after administration of SPIO particles. Spin echo (SE) T1, DP, T2 and Gradient echo (GE) T2* images were acquired with a.5 T superconductive unit. MR diagnosis was bioptically proved in 12 patients. In the remaining six patients, who had hemangiomas only, diagnosis was confirmed by at least two imaging techniques-such as MR, CT, ultrasonography, radio-labeled red cells scintigraphy-and by both clinical and imaging follow-up.

RESULTS

Thirthy-four tumors were detected on the MR images: 29/34 (85,3%) before and 33/34 (97%) after SPIO administration - 6 focal nodular hyperplasias (FNH), 6 adenomas and 22 hemangiomas. One small tumor (adenoma) was detected on the unenhanced MR images only, while 4 lesions (3 adenomas, 1 FNH) were detected after SPIO administration only.

DISCUSSION

SPIO-enhanced MRI increased the detection rate of benign hepatic tumors compared to non-enhanced MRI. Iron oxide was also useful in the characterization of such lesions as it was able to demonstrate any heterogeneity resulting from the presence of central scars or septa. Nevertheless, in our experience it was useful to compare baseline with SPIO-enhanced MRI, even if time consuming. Indeed the uptake of iron oxide particles by well-differentiated lesions and normal hepatic parenchyma, is comparable, so that well-differentiated lesions appear isointense and therefore undetectable.

CONCLUSIONS

In our experience, although numerically limited, SPIO-enhanced MRI was clinically safe and more effective than non-enhanced MRI in both the detection and characterization of benign hepatic tumors, providing useful clues for diagnosis.