Iodixanol in multidetector-row computed tomography angiography (MDCTA): diagnostic accuracy for abdominal aorta and abdominal aortic major-branch diseases using four-, eight- and 16-detector-row CT scanners.

PURPOSE: To compare iodixanol-enhanced multidetector-row computed tomography angiography (MDCTA) with digital subtraction angiography (DSA), perioperative angiography, or surgical findings in the evaluation of the abdominal aorta and its main branches. MATERIAL AND METHODS: 173 patients with known or suspected aortic aneurysms or stenosis/occlusion of the abdominal aorta or its major branches were enrolled. The iso-osmolar contrast medium iodixanol (320 mg Iota/ml) was used, and data were acquired using four-, eight-, or 16-active-detector-row scanners. Reference diagnoses were provided by surgical findings, interventional findings, or DSA. Diagnostic accuracy was estimated with reference to surgery or interventional arteriography or DSA. Image quality was assessed as excellent, good, sufficient, or insufficient, and correlations were made with attenuation values in the aortic lumen. Tolerability of iodixanol was monitored during the injection for discomfort and other adverse events, and for 72 hours after contrast injection. RESULTS: In 132 of 136 evaluable cases, MDCTA diagnosis matched the reference diagnosis, yielding an agreement rate of 97.1% (95% CI 92.6-99.2%). The quality of most MDCTA scans (147/173) was rated as excellent. Overall mean attenuation was 305.7 HU. MDCTA appeared more accurate than DSA for identification of lesion calcification, thrombus, irregularity, and ulceration. Tolerability of iodixanol was good, and no serious adverse events were reported. CONCLUSION: MDCTA using iodixanol is a promising, noninvasive alternative for evaluating patients with abdominal aortic disease.

Exploring mental status in Friedreich's ataxia: a combined neuropsychological, behavioral and neuroimaging study.

Despite much evidence of cognitive and affective disorders in Friedreich's ataxia (FRDA), the nature of mental status in FRDA has received little systematic attention. It has been proposed that the cerebellum may interfere indirectly with cognition through the cerebello-cortical loops, whereas the role of pathological changes in different areas of the central nervous system is still undetermined. In the present study, 13 patients with molecularly determined FRDA and a group of matched controls were evaluated by a comprehensive battery of neuropsychological tests and the Minnesota Multiphasic Personality Inventory. A repetitive task of simple visual-reaction times was used to investigate implicit learning in all subjects. Pathological changes in cortical areas were explored comparing cerebral activations of patients and controls during finger movements (functional MRI). The intelligence profile of FRDA patients is characterized by concrete thinking, poor capacity in concept formation and visuospatial reasoning. FRDA patients show reduced speed of information processing. The learning effect seen in controls was notably absent in patients with FRDA. The patients' personality is characterized by some pathological aspects and reduced defensiveness. Patterns of cortical activation during finger movements are heterogeneous in patients compared to controls. Cognitive impairment, mood disorders and motor deficits in FRDA patients may be the result of the cumulative damage caused by frataxin deficiency not only in the cerebellum and spinal cord but also in other brain areas.

[Enucleation-resection of pancreatic neuroendocrine tumors: 25 years of experience]. / Enucleoresezione di tumori neuroendocrini pancreatici venticinque anni di esperienza.

From 1980 to 2004, out of 109 patients who underwent surgery for neuroendocrine pancreatic tumor, 33 had a simple tumor excision. Seventy-two percent of cases were insulinomas. Age, sex, site and size of the tumor, associated diseases, hospital stay and complications were retrospectively reviewed by the clinical records. Patients (12 males and 21 females) averaged 56.8 years, range 20-86. Mean size of the tumor was 1.7 cm and 54.5% were in the pancreatic head; 78.8% of cases had medical associated diseases. Hospital stay was 12 days (median; range, 6-81 days) and mean period of gastric suction was 4 days. Forty-eight percent had a uneventful postoperative course. Complications were divided in early (related to pancreatic surgery, related to general open surgery and medical) and late events. Complication related to pancreatic surgery were 6/33 (18%); 5 pancreatic fistulas (4 low output) and 1 acute pancreatitis, while 5/33 had a general surgery complication (2 leacking due to gastric and duodenal associated operations). Medical complications were recorded in 13 cases. Late complications occurred in 4 cases (2 incisional hernias, 1 pseudocyst and 1 keloid). No patient was re-operated for pancreatic complications; 1 was reoperated for evisceration and 1 for hyper-parathyroidism in the early post-operative period. No mortality occurred. Re-evaluation of the clinical records in order to be submitted to laparoscopic surgery excluded 17/33 cases (51%) as candidate to laparoscopic approach.

[Positron emission tomography with fluorodeoxyglucose in gastro-entero-pancreatic tumors: diagnostic role and prognostic implications]. / La tomografia ad emissione di positroni con fluorodesossiglucosio nei tumori neuroendocrini gastro-entero-pancreatici: ruolo diagnostico e implicazioni prognostiche.

From November 1994 to November 2004, seventy-seven patients with neuroendocrine gastro-entero-pancreatic tumor (71% pancreatic) were investigated with 18-fluorine-deoxi-glucose positron emission tomography (FDG-PET). PET results were compared with CT-scan, MRI and octreoscan scintigraphy and clinico-pathologic features of patients and survival. Overall PET sensitivity was 57%; 78% of malignant tumors, 67% of borderline and 17% of benign tumors were detected by FDG-PET. No duodenal tumor was detected by PET scan. Only 16% of primary less than 2 cm in size was localized. In 16% of cases PET scan provided new information able to change therapeutic management. In PET positive patients the addictive information obtained by PET scan when compared with octreoscan, MRI and CT scan were respectively 50% more, 26% more and 30% more. In malignant neuroendocrine tumors PET positivity was related to short survival. No patient with malignant tumor died for disease progression in the follow-up when PET was negative, while 13/35 PET positive patients died (p <0.003). FDG-PET proved to be a second line technique in neuroendocrine digestive tumors. PET results improve clinical staging of disease and is related to survival in malignant cases; in 16% of cases may change the therapeutic option.

A rare case of retrocaval ureter associated with persistent left vena cava.

We report a rare case of a retrocaval ureter associated with a left inferior vena cava transposition and with concomitant nephrolithiasis in a young woman already surgically treated during her first years of life for cardiovascular disease. Diagnosis and surgical procedure are described, including the use of a flexible ureterorenoscope to facilitate kidney stone removal.

Value of 18-fluorodeoxyglucose positron emission tomography in the management of patients with cystic tumors of the pancreas.

OBJECTIVE: To assess the reliability of 18-fluorodeoxyglucose positron emission tomography (18-FDG PET) in distinguishing benign from malignant cystic lesions of the pancreas. SUMMARY BACKGROUND DATA: The preoperative differential diagnosis of cystic lesions of the pancreas remains difficult: the most important point is to identify malignant or premalignant cysts that require resection. 18-FDG PET is a new imaging procedure based on the increased glucose metabolism by tumor cells and has been proposed for the diagnosis and staging of pancreatic cancer. METHODS: During a 4-year period, 56 patients with a suspected cystic tumor of the pancreas underwent 18-FDG PET in addition to computed tomography scanning, serum CA 19-9 assay, and in some instances magnetic resonance imaging or endoscopic retrograde cholangiopancreatography. The 18-FDG PET was analyzed visually and semiquantitatively using the standard uptake value. The accuracy of 18-FDG PET and computed tomography was determined for preoperative diagnosis of a malignant cyst. RESULTS: Seventeen patients had malignant tumors. Sixteen patients (94%) showed 18-FDG uptake with a standard uptake value of 2.6 to 12.0. Twelve patients (70%) were correctly identified as having malignancy by computed tomography, CA 19-9 assay, or both. Thirty-nine patients had benign tumors: only one mucinous cystadenoma showed increased 18-FDG uptake (standard uptake value 2.6). Five patients with benign cysts showed computed tomography findings of malignancy. Sensitivity, specificity, and positive and negative predictive values for 18-FDG PET and computed tomography scanning in detecting malignant tumors were 94%, 97%, 94%, and 97% and 65%, 87%, 69%, and 85%, respectively. CONCLUSIONS: 18-FDG PET is more accurate than computed tomography in identifying malignant pancreatic cystic lesions and should be used, in combination with computed tomography and tumor markers assay, in the preoperative evaluation of patients with pancreatic cystic lesions. A positive result on 18-FDG PET strongly suggests malignancy and, therefore, a need for resection; a negative result shows a benign tumor that may be treated with limited resection or, in selected high-risk patients, with biopsy, follow-up, or both.

Raysum reconstruction algorithm in MR cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a new, non-invasive imaging technique for the visualization of the biliary ducts. The presence of stones within the choledocus is easily detectable in source images. However, three-dimensional reconstructions using the maximum intensity pixel (or projection) algorithm (MIP) fail to reproduce accurately the eventual presence of filling defects or parietal irregularities due to biliary stones. We used the Raysum algorithm in addition to the MIP in evaluating MRCPs of twelve patients with known choledocolithiasis. A visualization of the stones was obtained in nine (75%) patients by using the Raysum while visualization was obtained in one patient by using MIP. No additional sequences are required, and the post-processing time takes only a few seconds. The Raysum reconstruction can be successfully associated to the MIP in the three-dimensional evaluation of biliary stones in MRCP.

Macrocystic serous cystadenoma of the pancreas: clinicopathologic features in seven cases.

BACKGROUND: Serous cystic neoplasms of the pancreas are uncommon tumors classified as microcystic adenomas. In this article, the authors report clinico-pathologic features of seven cases of macrocystic variant of the serous cystadenoma. METHODS: Seven patients (5 females and 2 males) with a diagnosis of cystic lesion of the pancreas were observed after 1995. Clinical, radiological, and pathologic features, including immunohistochemistry, were reported. Enzymes and tumor markers CEA, CA 19-9, CA 125, CA 15-3, CA 72-4, and mucin-like carcinoma-associated antigen (MCA) were investigated in the serum and cyst fluid of the patients. Cytology was also performed. RESULTS: Six patients were symptomatic complaining abdominal pain. All cases had radiologic evidence of unilocular cyst of the pancreas. The suspected diagnosis was consistent with mucinous cystic neoplasm. Serum tumor markers were all in the normal range. After surgery, pathology showed in all cases a cyst lined with cuboidal, periodic acid-Schiff (PAS)-positive epithelium, without mucin content or atypia. Minute microcysts were found surrounding the main cavity. Immunohistochemical stains were positive for cytokeratin, CA19-9, CA15-3, CA 72-4, and MCA. CEA was unexpressed. CA 125 in the cyst fluid were found elevated in three cases and CA 19-9 in three cases. Cytology was negative in all cases. CONCLUSION: When a unilocular pancreatic cyst is found, without history of pancreatitis and gallstones, having low serum tumor markers levels and negativity of CA 72-4 and MCA in the cyst fluid, the diagnosis of the macrocystic variant of the serous cystadenoma may be suggested. At present, the diagnosis is still based on pathological examination after cyst removal.

Neuroendocrine tumor imaging: can 18F-fluorodeoxyglucose positron emission tomography detect tumors with poor prognosis and aggressive behavior?

We evaluated the clinical value of positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) for neuroendocrine tumor (NET) detection. Sixteen patients with cytologically or histologically proved NETs were investigated. Patients were divided in two groups of eight patients each according to the clinicopathologic features related to prognosis: slow-growing NETs and aggressive NETs. Results of FDG tumor uptake as detected by PET were compared with computed tomography (CT) scans and with scans obtained with 111In-octreotide scintigraphy (n = 13). Tumor FDG uptake was increased in the primary lesion of all eight aggressive NETs; the tracer was shown also in lymph nodes, liver metastases, or both in five of six of them (83%). In four cases, additional unknown tumor sites undetected by CT scan were identified. A slight positivity was found in only one of eight cases with a slow-growing NET. The overall octreotide scintiscan sensitivity was 85%, but in the aggressive NETs it failed to detect the primary lesion in two of seven cases. Uptake of the tracer in some but not all tumor lesions in the same patient was seen by both FDG-PET and octreotide scintiscans. From our limited experience 18F-FDG PET seems to be useful for identifying NETs characterized by rapid growth or aggressive behavior. Uptake of the FDG tracer by the tumor may be related to a worse prognosis. Despite the heterogeneity of tracer uptake in the various lesions of NETs with multiple tumor sites, FDG-PET was able to detect unsuspected distant metastases, contributing to better staging of advanced disease.

Percutaneous excimer laser angioplasty of lower limb vessels: results of a prospective 24-month follow-up.

The aim of this prospective study was to assess the effectiveness and the long-term patency effect of excimer laser angioplasty in peripheral arterial obstructive disease. Seventy-eight patients referred for excimer laser angioplasty of lower limbs have been followed up for up to 24 months. Ankle/brachial systolic pressure index, color Doppler mapping, and arterial digital subtraction angiography were performed. Immediate procedural success was achieved in a high percentage of patients (97%). Balloon angioplasty was also used in 85% of patients. Early reocclusions occurred in 8% of patients. The cumulative patency rate was 47% at the 12-month interval and 40% at the 24-month interval. Poor runoff and the length of the lesions negatively influenced the outcome. Excimer laser angioplasty is an effective procedure, indicated in selected patients showing < 10 cm occlusions and good runoff.

Activity and tolerability of courses of intra-arterial chemotherapy followed by chemoembolization in unresectable hepatocellular carcinoma.

AIMS AND BACKGROUND: We previously reported encouraging response rates and survival with combined intra-arterial (i.a.) chemotherapy and chemoembolization in unresectable hepatocellular carcinoma. We therefore evaluated a new program combining three courses of i.a. chemotherapy with chemoembolization administered every 28 days. PATIENTS AND METHODS: The treatment regimen consisted of L-leucovorin (100 mg/m2 i.v.), fluorouracil (800 mg/m2 i.a.), and carboplatin (250 mg/m2 i.a.). Chemoembolization with mitoxantrone (10 mg/m2) plus ethiodized oil and gelatin sponge was performed immediately after. The same treatment was given every 28 days for 3 times. RESULTS: Twenty-eight patients entered the study and were assessable for response and side effects. There were 24 males and 4 females (median age, 68 yrs; range, 42-75). TNM stage was II-III in 20 and IVA in 8; 17 were Child's A and 11 Child's B. Baseline alpha-fetoprotein was elevated in 15, and there was cirrhosis in 23. Twelve patients had a partial response (43%; 95% confidence interval, 24-63%), 13 had stabilization, and 3 progressive disease. Median survival was 16.6 months (range, 2-24). Sixteen patients had grade I-II pain and 14 grade I-II fever. CONCLUSIONS: Our results indicate that the regimen is safe and well tolerated. Despite 43% objective remissions, our results do not seem better than those obtained with less intensive regimens.

Expression of mucin-like carcinoma-associated antigen in the cyst fluid differentiates mucinous from nonmucinous pancreatic cysts.

OBJECTIVES: Differential diagnosis of pancreatic cystic lesions may be difficult: the main problem is to distinguish mucinous neoplasms from nonmucinous cysts. We evaluated the usefulness of the mucin-like carcinoma-associated antigen (MCA) in the fluid of pancreatic cysts for detecting mucinous neoplasms. Results were compared with those of CA 15-3, carcinoembryonic antigen (CEA), and CA 72-4 fluid content, and cytology. METHODS: Twenty-four pancreatic cyst fluids were collected from 10 pseudocysts, eight mucinous cystic tumors, and six serous cystadenomas. RESULTS: MCA was elevated in seven of eight mucinous tumors (sensitivity 87.5%, specificity 100%). A significant difference was found between MCA levels in mucinous neoplasms versus pseudocysts (p = 0.0003) and serous cystadenomas (p = 0.001). Mean MCA levels were higher (133.7 U/ml) in mucinous cystadenocarcinomas than in cystadenomas (37.5 U/ml). The sensitivity of CA 15-3, CEA, and CA 72-4 in detecting mucinous neoplasms was 50, 87.5, and 87.5%, respectively, with a specificity of 94%, 44%, and 94%, respectively. Cytology showed mucinous epithelial cells in only four of eight mucinous neoplasms, with a specificity of 100%. CONCLUSIONS: These data suggest that MCA determination in the cyst fluid is a promising new tumor marker for the preoperative diagnosis of mucinous cystic neoplasms of the pancreas.

Intra-arterial chemotherapy followed by chemo-embolisation in unresectable hepatocellular carcinoma.

Unresectable hepatocellular carcinoma is related to a poor prognosis. Encouraging response rates and survival have been reported with intra-arterial (i.a.) chemotherapy and chemo-embolisation, but limited data are available on the association of the two treatment modalities. We therefore started a new programme combining i.a. chemotherapy with chemo-embolisation. The treatment regimen consisted of L-leucovorin (100 mg/m2 i.v.), 5-fluorouracil (800 mg/m2 i.a.), and carboplatin (250 mg/m2 i.a.). Chemo-embolisation with mitoxantrone (10 mg/m2) plus ethiodized oil followed immediately. The same treatment plus gelatin sponge was given after 28 days. 26 patients entered the study and were evaluable for response and side-effects. Main patient characteristics were: males 21, females 5: median age 68 years (range 42-76 years); stage TNM II-III 17, IVA 9; Child's A 12, Child's B 14; elevated baseline alpha-fetoprotein 17; cirrhosis 25. 14 patients had a partial response (54%; 95% confidence interval 33-73%), 3 had stabilisation and 9 had progressive disease. Median survival was 11 months (range 2-20+). 16 patients had grade I-II pain and 15 grade I-II fever. Our results indicate that the regimen is safe, well tolerated and capable of inducing objective remissions in a high percentage of patients with hepatocellular carcinoma.

[Carotid dislocation. The pictures with computed tomography and magnetic resonance]. / La dislocazione carotidea. Quadri con Tomografia Computerizzata e Risonanza Magnetica.

INTRODUCTION: Prevertebral retropharyngeal soft tissue widening can be recognized in acute trauma patients in the presence of acute bleeding from cervical vertebral fracture. Abscesses, tumors and neoplastic effusions from nearby cervical spaces can also widen precervical soft tissues and a new cause has been recently suggested, that is the so-called carotid transposition. MATERIALS AND METHODS: We examined eight patients (six women and two men) aged 65 to 75 years. Carotid transposition was found in four patients during examination for acute cervical trauma, while four cases were detected at CT studies performed for other indications, mostly lymphoma staging. CT was always performed with the i.v. injection of a contrast agent and volume scans were used in four cases. MR angiography (MRA) was also used in two patients to study an internal carotid artery stenosis previously detected at color Doppler. RESULTS: Lateral radiographs of the cervical spine of our acute trauma patients showed widened soft tissues in three cases, but no calcific arterial plaques were found. The common carotid arteries were displaced in five patients and the internal carotid arteries in three. Carotid transposition was bilateral in six patients while only the right common and the left internal carotids were involved in two patients. No traumatic hemorrhagic effusion was found on CT images. CONCLUSIONS: Carotid transposition is a mostly asymptomatic abnormality, but it must be considered in acute cervical trauma patients where the precervical soft tissues are widened because hemorrhagic effusion could be misdiagnosed. Thus, this unusual location of the carotid arteries is important because these vessels may be injured during emergency or surgical procedures.

[The biopsy of pulmonary masses guided by computed tomography after iatrogenic pneumothorax]. / Biopsia delle masse polmonari con la guida della Tomografia Computerizzata dopo pneumotorace iatrogeno.

INTRODUCTION: Biopsy of lung nodules under CT guidance is frequently complicated (in 20-60% of cases) by sudden pneumothorax; when a pneumothorax occurs, the radiologist usually stops the procedure and the histologic specimen is often inadequate for diagnosis. We report our personal experience in eight patients with early pneumothorax in whom we repeated biopsy inserting the needle through the pneumothorax to try to obtain adequate material for histologic diagnosis. MATERIAL AND METHODS: 1990 to 1996, we performed 352 CT-guided biopsies to diagnose chest nodules. Early pneumothorax occurred in eight patients, in one of them when local anesthesia was being given, and was in the left-hand side in five cases and in the right-hand side in three. Biopsy was always performed with 21, 19 and 18 G needles. RESULTS: Pneumothorax occurred during posterior bioptic approach in all patients; the nodule was localized in lung parenchyma in three cases and in subpleural site in the others. Post-pneumothorax biopsy was performed with a single 18 or 19 G needle puncture in six cases and with two punctures in the other cases. An inflammatory mass was diagnosed in three patients and a hamartochondroma in two, which avoided surgery in all cases. Three adenocarcinomas were treated with surgical lobectomy and pathology confirmed the diagnosis. Moderate hemoptysis occurred in two patients and the pneumothorax worsened in two patients, requiring transpleural drainage. CONCLUSION: CT-guided biopsy of lung nodules is a safe procedure which can be performed also in the patients with sudden and early pneumothorax when the first biopsy yielded inadequate material for histologic diagnosis. In our experience, five patients avoided surgery because a benign lesion was diagnosed. The complications of post-pneumothorax biopsy were always negligible.

Prognostic factors in patients with hepatocellular carcinoma submitted to chemoembolization.

The prognosis of unresectable hepatocellular carcinoma is poor. Encouraging response rates have been reported with chemoembolization, but no survival advantage has been demonstrated. Assessment of the impact of the treatment modality on prognosis is complicated by a poor understanding of the prognostic factors in the disease. We therefore evaluated, through univariate and multivariate analysis, the role on prognosis of 16 variables in 63 patients submitted to chemoembolization. Patients were treated with epirubicin (50 mg) plus ethiodized oil and gelatin sponge (22 cases) or with a new program combining i.a, chemotherapy with chemoembolization (41 cases) as follows: L-leucovorin, 100 mg/m(2) i.v.; fluorouracil, 800 mg/m(2) i.a.; carboplatin, 250 mg/m(2) i.a. Chemoembolization with mitoxantrone, 10 mg/m(2), plus ethiodized oil and gelatine sponge was performed immediately after. Median survival for the whole group of patients was 294 days. A multivariate analysis showed a highly significant influence on survival for Child's status (p=0.002) and for TNM stage (p=0.01). Median survival for patients with Child's A disease was 13.9 months and for patients with TNM stage I-II disease 19 months. In conclusion, our data suggest that patients with limited disease and adequate liver function have a longer survival after chemoembolization.