Diagnostic protocols in oncology: workup and treatment planning. Part 1: the optimitation of CT protocol.

The increase in oncology knowledge and the possibility of creating personalized medicine by selecting a more suitable therapy related to tumor subtypes, as well as the patient's management with cancer within a multidisciplinary team has improved the clinical outcomes. Early detection of cancer through screening-based imaging is probably the major contributor to a reduction in mortality for certain cancers. Nowadays, imaging can also characterize several lesions and predict their histopathological features and can predict tumor behaviour and prognosis. CT is the main diagnostic tool in oncologic imaging and is widely used for the tumors detection, staging, and follow-up. Moreover, since CT accounts for 49-66% of overall patient radiation exposure, the constant reduction, optimization, dose inter- and intraindividual consistency are major goals in radiological field. In the recent years, numerous dose reduction techniques have been established and created voltage modulation keeping a satisfactory image quality. The introduction of CT dual-layer detector technology enabled the acquisition of spectral data without additional CT x-ray tube or additional acquisitions. In addition, since MRI does not expose the body to radiation, it has become a mainstay of non-invasive diagnostic radiology modality since the 1980s.

Diagnostic protocols in oncology: workup and treatment planning. Part 2: Abbreviated MR protocol.

Magnetic resonance imaging (MRI) is a non-invasive imaging technique (non-ionizing radiation) with superior soft tissue contrasts and potential morphological and functional applications. However, long examination and interpretation times, as well as higher costs, still represent barriers to MRI use in clinical routine. Abbreviated MRI protocols have emerged as an alternative to standard MRI protocols. Abbreviated MRI protocols eliminate redundant sequences that negatively affect cost, acquisition time, patient comfort. However, the diagnostic information is generally not compromised. Abbreviated MRI protocols have already been utilized for hepatocellular carcinoma, for prostate cancer detection, and for nonalcoholic fatty liver disease screening.

DPO: Diffuse Pulmonary Ossification - A Diagnostic Challenge.

Diffuse pulmonary ossification (DPO) is a rare condition of DLD (diffuse lung disease) characterized by the presence of metaplastic ectopic bone in the lungs and is less frequent in patients without a clear background of lung diseases. DPO is characterized by very small calcific nodules, often with bone mature located in both lungs and often in peripheral areas of the lungs. Two patterns of DPO have been recognized dendriform and nodular. The dendriform type is less common and is characterized by a coral-like network of bone spiculae along the alveolar septa and is often related to interstitial fibrosis or chronic obstructive lung disease [1]. Recent literature papers indicate that DPO may be a predictor of pulmonary fibrosis, is related to Usual Interstitial Pneumonia (UIP) pattern, and has a higher correlation with Idiopathic Pulmonary Fibrosis (IPF). We present a case of a 41-years-old male with persistent bronchitis who underwent a chest X-ray (CXR) that showed multiple pulmonary small calcified nodules in both lungs. These findings were then defined with a high-resolution computed tomography of the chest (HRCT) that showed multiple small nodules spread in both lungs with a "tree-like pattern". A lung biopsy was performed to confirm the radiological diagnostic hypothesis of DPO, and further pathological examination showed multifocal areas of mature bone tissue within the lung parenchyma.

Endoscopic resection as a safe and effective technique for treatment of pedunculated and non-pedunculated benign-appearing colorectal neoplasms measuring 40 mm or more in size.

AIM: The aim of this paper was to evaluate the outcome of endoscopic resection (ER) for pedunculated and non-pedunculated colorectal neoplasms exceeding 4 cm in size. METHODS: All patients with a colorectal neoplasms measuring 4 cm or more, who underwent ER at our institution between January 1996 and December 2008 were included in the study. RESULTS: In the study period, 67 ERs were carried out in 67 patients with a mean (±SD) age of 72±11 years. The mean neoplasms size was 48.2±12.5 mm. There were 32 sessile, 26 flat and 9 pedunculated neoplasms. The most frequent location (49.3%) was rectum. No perforation occurred, there were 4 procedural and 2 delayed bleeding, treated endoscopically, and 3 cases of transmural burn syndrome, managed conservatively. Pathologic examination showed 18 low-grade dysplasia, 43 high-grade dysplasia, 3 intramucosal and 3 invasive cancer. The most frequent type of neoplasm was villous adenoma (76.1%). The presence of malignancy was related to villous histology (P=0.005) and to age ≥ 80 of patients (P=0.04). RESULTS: During endoscopic follow-up (49.4± 26.3 months) recurrence was found in 25.8% of lesions (11 sessile and 4 flat), always treated endoscopically. Recurrence was more likely in patients with lesions larger than 60 mm (P=0.04). The three patients with invasive cancer did not undergo surgery, because of advanced age and/or severe extracolonic diseases. During follow-up no local recurrence or metastasis was found. CONCLUSION: ER is a safe and effective procedure for removing benign appearing very large colorectal neoplasms.

Magnetic resonance cholangio-pancreatography versus endoscopic retrograde cholangio-pancreatography in the diagnosis of common bile duct stones: a prospective comparative study.

AIM: As it is a non-invasive method, magnetic resonance cholangiography (MRCP) has almost completely replaced endoscopic retrograde cholangiography (ERCP) in the diagnosis of pancreato-biliary diseases. The aim of this study was to evaluate sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRCP in diagnosis of choledocholithiasis using ERCP/endoscopic sphincterotomy (ES) as gold standard. METHODS: For this study 140 individuals, suspected for lithiasis of the common bile duct (CBD), were enrolled. After a clinical and biochemical evaluation, patients underwent upper abdominal ultrasonography, then MRCP and diagnostic and/or operative ERCP. RESULTS: Only 120 out of 140 patients completed the study. MRCP diagnosed lithiasis of CBD in 84. ERCP confirmed the lithiasis in 73/84 patients who were submitted to ES. Eleven were negative after ES. ERCP documented stones in 10 patients among the 36 negative at MRCP; stones were detected only in four patients after ES. In 26 out of 36 patients negative at MRCP, ERCP confirmed this response: only 12 out of 26 patients underwent ES. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 72%, 83%, 87%, 72%. CONCLUSIONS: As the MRCP diagnostic yield is still limited with small stones, the question of which patient is the best candidate to ERCP/ES is still unsolved.

Endoscopic mucosal resection for large and giant sessile and flat colorectal polyps: a single-center experience with long-term follow-up.

BACKGROUND AND STUDY AIMS: This study examines efficacy, outcome, and complications of endoscopic mucosal resection (EMR) for large (> or = 20 mm) and giant (> or = 40 mm) sessile and flat colorectal polyps. PATIENTS AND METHODS: All EMRs carried out at our institution over a 9-year period, for large and giant sessile and flat colorectal polyps with an intensive and regular follow-up were evaluated. The rate of en bloc and piecemeal resection, complications, and recurrence were analyzed. RESULTS: A total of 148 polyps were resected in 148 patients. There were 113 large polyps (76.3 %) with a mean size of 25 +/- 4.7 mm (range 20 - 39 mm) and 35 giant polyps (23.7 %) with a mean size of 48.8 +/- 12.5 mm (range 40 - 100 mm). The most frequent location was the rectum, occurring in 43.2 %. All lesions were removed in a single session. En bloc resection was performed in 65 cases (43.9 %) and piecemeal in 83 (56.1 %). Procedural bleeding occurred in 13 EMRs (8.8 %), and one case of early and one case of delayed bleeding also occurred. There were two cases of postpolypectomy syndrome and one case of perforation. Malignancy (intramucosal and invasive cancer) was mostly present in polyps with sessile shape ( P = 0.0013). Follow-up colonoscopy was performed in 142 patients for a mean of 29.8 months. Recurrence was observed in 6/142 (4.2 %) patients and was found more in patients with giant polyps ( P = 0.014). CONCLUSIONS: In our experience EMR is a simple and safe procedure for removing large and giant sessile and flat colorectal polyps, and is associated with a very low risk of complication and local recurrence.

Cyanoacrylate glue in the management of gastric varices.

Gastric varices (GV) are less common than esophageal varices, but their management represents a particular challenge. When bleeding occurs is usually severe, requiring immediate supportive intensive care and has a high mortality rate. The best management of GV is supposed to be with a multidisciplinary approach and close cooperation between gastroenterologists, interventional radiologists and the surgical team. Many studies in literature reported high success rates with intravariceal injection of cyanoacrylate in acute GV bleeding. This agent obliterates the variceal lumen by solidification within the vein and more than 80% primary obliteration rates are achieved. In comparison with other endoscopic techniques as variceal band ligation or sclerotherapy with ethanolamine oleate, alcohol and sodium tetradecyl sulphate, cyanoacrylate has shown to be more effective, with a decrease in complications and mortality rates. The cyanoacrylate has shown effective also in the secondary prophylaxis with an incidence of re-bleeding that ranges between 15% and 30%. Actually, there is no scientific evidence supporting the application of cyanoacrylate in primary prophylaxis of bleeding from GV. Significant procedural, septic and embolic complications have been reported with cyanoacrylate glue injection. In conclusion, the endoscopic treatment with cyanoacrylate of actively bleeding GV, as well as the prophylaxis of the re-bleeding, is a safe and effective procedure and should be considered as a first-line therapy, whenever available.

Optical coherence tomography in inflammatory bowel disease: prospective evaluation of 35 patients.

PURPOSE: Optical coherence tomography is a technique using infrared light in tissues of the gastrointestinal tract and human colon affected by inflammatory diseases. We evaluated whether there are specific patterns of optical coherence tomography for inflammatory bowel disease and compared the technique performance to the histology. METHODS: Optical coherence tomography was performed in 35 patients (18 men; 31 ulcerative colitis, 4 Crohn's disease). The images were obtained from affected and normal colon at endoscopy. Two biopsies of the sites visualized were taken. Two endoscopists scored the images, and two pathologists, blind to the endoscopy and optical coherence tomography, performed the histologic evaluation. RESULTS: Three optical coherence tomography patterns were identified: 1) mucosal backscattering alteration, 2) delimited dark areas, and 3) layered colonic wall. Compared with the histology, mucosal backscattering alteration was the most effective in recognizing the disease in patients (P = 0.007 in colon segments affected, and P < 0.001 in normal segments). The sensitivity and specificity have been 100 and 78 percent, respectively. CONCLUSIONS: The in vivo optical coherence tomography correctly detected inflammatory bowel disease features in affected and apparently normal colon, and allowed to discriminate patterns for active ulcerative colitis and Crohn's disease.

[Idiopathic ischaemic infarction of the stomach. Case report]. / Infarto ischemico idiopatico dello stomaco: case report.

Idiopathic ischaemic infarction of the stomach is an extremely rare condition since only 2 other cases have been published in the Literature so far. The Authors report a case of such entity on a 75 year old male patient, admitted from the accident and emergency department because of a upper digestive tract haemorrhage with clinical signs of hypovolemic shock. The patient subsequently underwent an upper gastro-intestinal endoscopy that suspected an ulcerated gastric neoplasm. The patient therefore underwent a total gastrectomy and was discharged home on p.o. day X. The pathology report showed an Ischaemic infarction of gastric mucosal tissue with pomphoid Oedema of submucosal layer. Ulcerative superficial necrosis with venous haemorragic swarm and focal acute pseudomembranous inflammation. Not neoplastic features. Etiopathogenetic, pathophisiologic ipoteses and clinical implication of Idiopathic ischaemic infarction of the stomach are discussed.

Endoscopic treatment of Barrett's epithelium with Argon Plasma Coagulation. Long-term follow-up.

BACKGROUND: Barrett's esophagus (BE) is a premalignant condition for the development of esophageal adenocarcinoma. Recently, many endoscopic therapies based on thermal or photobiologic ablation of BE have been provided, with positive short-term results in 60-100% of cases, but long-term results are still lacking. The aim of this study is to evaluate long-term results of BE endoscopic ablation with Argon-Plasma Coagulation (APC). METHODS: Thirty-five consecutive patients were treated (every 3 weeks) with APC until the eradication of BE and the squamous epithelium restoration were assessed. During the treatment and the first 6 months of follow-up, patients received 40 mg/die omeprazole; then the proton pump inhibitors (PPI) dose was 20 mg/die. Endoscopic and histologic controls have been performed every 6 months. The study considered the fìrst 32 patients who completed at least 24 months of follow-up, whose median was 49.5 months (range: 24-60). RESULTS: The ablation of BE was achieved with a median of 2.0 APC sessions, without side- effects. The recurrence of SIM (specialized intestinal metaplasia) was detected in 3 patients, while nor dysplasia or cancer developed. CONCLUSIONS: Our results confirm that APC can lead both to eradication of BE and the restoration of squamous epithelium. As recent reports indicated the persistence of SIM beneath the new epithelium and even a neoplastic growth (adenocarcinoma) in the treated area, despite APC, 2 questions have arisen: is APC unable to radically ablate BE or on the contrary are these findings due to defects of the ablative technique needing improvement? To settle more precise conclusions, further investigation with larger numbers of patients and for longer follow-up is required.

[Biliary lesions after laparoscopic cholecystectomy]. / Lesioni biliari dopo colecistectomia laparoscopica.

Laparoscopic cholecystectomy is the suitable treatment for symptomatic cholelithiasis, even if the incidence of biliary lesions following this procedure may be up to threefold higher than that of open cholecystectomy. We report our experience concerning the incidence, aetiopathogenesis, diagnosis and treatment of complications in a homogeneous group of laparoscopic cholecystectomies. In a total of 492 laparoscopic cholecystectomies only three bile duct lesions were observed (0.6%); they were classified according to Bismuth and re-assessed according to Strasberg. They consisted in two biliary leakages and one bile duct stricture. All patients were evaluated by full blood test, ultrasonography and endoscopic retrograde cholangiopancreatography. Endoscopic treatment was successful in the two patients with biliary leakage, while the patient with a stricture required surgical therapy. In conclusion, we suggest that a correct knowledge of the aetiopathogenesis together with a multidisciplinary approach to the diagnosis appear to be the best method for the detection, complete classification and most suitable treatment of symptomatic cholelithiasis.

[Radioimmuno-guided surgery (RIGS) in breast disease]. / La chirurgia radioimmunoguidata (RIGS) in patologia mammaria.

Radioimmunoguided surgery is a new technology capable of detecting minimal neoplastic lesions using radiocolloids. We used this technique in two fields: to detect sentinel lymph nodes in breast cancer and to remove non-palpable breast lesions. Radioimmunoguided surgery was employed in 135 women; in 32 for sentinel lymph nodes and in 103 for radioguided occult lesion localization using a radioactive tracer (Technetium Tc99m) injected subdermally for sentinel nodes, or near to the non-palpable lesions under US guidance. In our experience these two applications of radioimmunoguided surgery are useful and accurate for determining the nature of lesions and for providing definitive treatment in a single surgical intervention.

Simple versus double jejunal pouch for reconstruction after total gastrectomy.

BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.

[Tracheal sleeve lobectomy in the radical surgery for lung cancer]. / Tracheal sleeve lobectomy nella chirurgia estrema del carcinoma polmonare.

Tracheal sleeve lobectomy is right upper lobectomy extended to include resection of the main bronchus, the carina and a segment of the trachea with end-to-end anastomosi of the trachea and end-to-side anstomosis of the intermediate bronchus on the main left bronchus, or the upper lobe on the trachea. This operation is possible with the aid of high frequency jet ventilation. The surgical indication of this operation is bronchoscopic and functional and guarantees a good oncological radicality in the presence of N0.

[Palliative treatment in neoplastic jaundice. Personal experience]. / Il trattamento palliativo dell'ittero neoplastico. Esperienza personale.

The palliative treatment of biliary duct neoplastic obstruction represents a problem of great importance and frequently can't leave out of consideration patients clinical conditions and phase of neoplastic disease. Authors, in this article refers their experience on palliative treatment of neoplastic jaundice and indications for surgical or endoscopic treatment. Their experience shows that surgical palliation must be performed in patients with preoperative instrumental investigations without "surgical risk", this vouches for a better quality of life than endoscopic procedure performed with diffuse neoplastic disease and in patients with surgical risk.

[Treatment and prognosis of metachronous bilateral carcinoma of the breast]. / Trattamento e prognosi del carcinoma bilaterale metacrono della mammella.

In this study the incidence, the treatment and the survival of 7 patients with bilateral metachronous breast cancer have been evaluated. From this experience, the value of careful follow-up of mastectomized patients in order reach an early diagnosis of bilateral breast cancer is stressed.

[Ciprofloxacin in the treatment of bronchopulmonary infections]. / Ciprofloxacin nel trattamento delle infezioni broncopolmonari.

Ciprofloxacin was given orally in dosages of 250 mg or 500 mg every 12 hours for a period of 8-13 days. Most patients had chronic bronchitis in the acute stage. The favourable results achieved and the complete absence of side effects show that ciprofloxacin is a useful drug in the treatment of respiratory tract infections.