Multicystic dysplastic kidney and contralateral vesicoureteral reflux. Renal growth.

BACKGROUND: To evaluate if vesicoureteral reflux (VUR) contralateral to the multicystic dysplastic kidney can interfere with the compensatory renal hypertrophy. METHODS: Twenty-seven patients (17 males, 10 females) with multicystic dysplastic kidney (MDK) (14 on the right, 13 on the left) have been treated at the Nephrology Unit of the Pediatric Department of the University of Verona from birth up to the second year of life. All these patients were diagnosed as having MDK by prenatal ultrasonography. Seven children (4 males and 3 females) had VUR (5 monolateral, 2 bilateral), diagnosed at the end of the first month of life. After diagnosis children underwent antibiotic prophylaxis with beta-lactam compounds at low doses. Four patients underwent a surgical correction of VUR associated with nephrectomy within the second year of life. The remaining 3 patients were treated with antibiotic prophylaxis; a progressive resolution or downgrading of reflux grade took place respectively in 1 and in 2 of them. Only 6 children with MDK underwent nephrectomy. Renal growth was studied by serial echographic measurements of the longitudinal renal lenght (performed at birth, at 6 months, and at 2 years of life). RESULTS: Renal length was 5.68+/-1.24 cm, 6.72+/-0.88 cm, 8.56+/-1.27 cm in children without VUR, respectively at birth, 6 months and 2 years of life. Renal length was 4.65+/-0.63 cm, 6.70+/-0.64 cm, 7.07+/-1.14 cm in children with VUR, respectively at birth, 6 months and 2 years of life. A statistically significant difference was observed between the two groups at birth (p<0.05) and at 2 years of life (p<0.01). CONCLUSIONS: The conclusion is that VUR contralateral to the MDK is associated with small kidneys and reduced renal growth both at birth and at 2 years of life.

Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis.

OBJECTIVE: To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum. DESIGN: Prospective therapeutic non-randomized, self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months. SETTING: Tertiary referral center for treatment of deep endometriosis. PATIENT(S): Eleven symptomatic patients with rectovaginal endometriosis. INTERVENTION(S): A levonorgestrel-releasing IUD was inserted and maintained for 12 months. MAIN OUTCOME MEASURE(S): Severity of dysmenorrhea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography. RESULT(S): Dysmenorrhea, pelvic pain, and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment. CONCLUSION(S): Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.

Multicystic kidney dysplasia and Turner syndrome: two cases and a literature review.

Renal malformations occur in 33%-70% of cases of Turner syndrome (chromosome 45 and variants). We describe two cases of multicystic dysplastic kidney in Turner syndrome. A literature review of renal abnormalities in Turner syndrome shows the frequency of cystic disease to be 1.76%. In multicystic dysplastic kidney, diagnostic investigation of the contralateral kidney, including voiding cystourethrography, is necessary in view of the high incidence of associated diseases (15%-20% of cases, vesicoureteric reflux) and other anomalies.

Intraoperative and percutaneous radiofrequency thermal ablation in the treatment of hepatocellular carcinoma.

AIMS AND BACKGROUND: The aim of the study was to evaluate feasibility, survival rate, complications and length of hospital stay in 47 patients with hepatocellular carcinoma (HCC) treated by radiofrequency thermal ablation (RFTA). Though the treatment of choice for HCC is surgical resection, the strong association of this disease with cirrhosis often rules out this procedure. Many investigations have been conducted in order to identify alternative therapies. Preliminary studies of radiofrequency thermal ablation have shown that the technique is effective and safe, achieving a predictable area of tumor tissue coagulative necrosis and sparing the surrounding cirrhotic parenchyma, without any significant side effects. In addition, this technique, which can be performed percutaneously, allows very short hospital stays. PATIENTS AND METHODS: We report the results of a series of 47 cirrhotic patients with 52 HCC nodules (mean diameter 2.9 cm, range 1-6 cm) treated in our Institute between May 1997 and June 1999 by RFTA using an expandable needle with four hooks at its tip. All patients had hepatic cirrhosis (32 Child A, 13 Child B and two Child C). We treated patients with both unifocal (35 patients) and multifocal HCC (12 patients); 33 patients underwent percutaneous RFTA (54 passes), while in 14 cases RFTA was performed during laparotomy (22 passes). RESULTS: The mean number of passes to achieve complete necrosis was 1.43 in 28 patients with unifocal HCC treated by percutaneous RFTA, 1.7 in 7 patients with unifocal HCC treated by intraoperative RFTA, 2.8 in 5 patients with multifocal HCC treated by percutaneous RFTA and 1.43 in 7 patients with multifocal HCC treated by intraoperative RFTA. No deaths related to the procedure or major complications occurred. Post-treatment dynamic CT was performed in all patients. All patients but one were followed-up for a mean period of 11.8 months (1-25 months). Six patients died during the follow-up (three Child A, two Child B and one Child C. The actuarial survival, computed by the Kaplan-Meier method, was 83% at 24 months. The mean hospital stay was 3.4 days in patients treated by percutaneous RFTA and 11.2 days in those treated by intraoperative RFTA. CONCLUSIONS: In our opinion RFTA is an effective, safe technique capable of achieving good results in the conservative therapy of small HCC. We believe that curative ablation is possible for HCC nodules measuring up to 3 cm in diameter. Further studies of longer duration are necessary.

[Reflux nephropathy in absence of obvious vesicoureteral reflux]. / Nefropatia da reflusso in assenza di evidente reflusso vescicoureterale.

Although the majority of patients with vesicoureteric reflux presents DMSA scan alterations, parenchimal renal scars are found also in children without vesicoureteric reflux. Two clinical cases of reflux nephropathy without evidence of reflux are presented. Several explanations could be advocated to justify this picture, including haematogenous source of infection, inadequate timing and/or procedure of cystouretrography, intermittency of reflux, ascending bacteria, previous presence of reflux, and appearance of controlateral reflux during the natural history of a monolateral documented reflux. Tailored diagnostic and therapeutic strategy should discussed for each patient.

Transrectal ultrasonography in the assessment of congenital vaginal canalization defects.

Our aim was to evaluate the reliability of transrectal ultrasonography in the preoperative assessment of congenital vaginal canalization defects. We studied nine patients, six with suspected Rokitansky syndrome and three with suspected complete transverse septum. Before corrective surgery all the patients underwent pelvic examination, transabdominal and transrectal ultrasonography. The ultrasonographic findings were compared with the surgical ones. Transrectal ultrasonography provided an accurate map of the pelvic organs showing the precise distances between the urethra and bladder anteriorly, rectum posteriorly, retrohymenal fovea caudally, and pelvic peritoneum cranially. Transrectal ultrasonography produced a picture that corresponded perfectly with the real anatomical situation. Conversely, abdominal ultrasonography provided inadequate images in six of our nine patients, and magnetic resonance imaging was responsible for a mistaken diagnosis in one patient with suspected transverse vaginal septum. In conclusion, if our results are confirmed in larger series, transrectal ultrasonography could be considered as a diagnostic procedure of choice in the assessment of vaginal canalization defects.

Transrectal ultrasonography in the assessment of rectovaginal endometriosis.

OBJECTIVE: To evaluate the validity of transrectal ultrasonography in the assessment of rectovaginal endometriosis. METHODS: We compared the findings of transrectal ultrasonographic examination performed before surgery with the operative and pathologic findings in 140 women who underwent laparoscopy or laparotomy for suspected endometriosis. The ultrasonographer was asked to investigate whether any deep endometriotic lesions were present in the rectovaginal septum and to define the lateral extension on the basis of involvement of the uterosacral ligaments. In addition, infiltration of the rectal and vaginal walls was evaluated. RESULTS: Thirty-four women had endometriosis infiltrating the rectovaginal septum confirmed by combined operative and pathologic findings. Ultrasonography showed a sensitivity and specificity of 97% and 96%, respectively, in the diagnosis of the presence of rectovaginal endometriosis. The sonographer identified infiltration of the rectal and vaginal walls correctly in all cases in whom it was present, but also reported rectal infiltration in three cases not confirmed by the surgeon and pathologist. The sensitivity and specificity in the diagnosis of uterosacral ligament infiltration were 80% and 97%, respectively. CONCLUSION: If our preliminary results are confirmed by a larger series, transrectal ultrasonography will be considered a valid diagnostic tool in the evaluation of rectovaginal endometriosis.

Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device.

OBJECTIVE: To evaluate the efficacy and tolerability of treatment with a levonorgestrel-releasing intrauterine device (IUD) in women affected by adenomyosis-associated menorrhagia. SETTING: Tertiary care center. DESIGN: Prospective, open, noncomparative study. PATIENT(S): Twenty-five women aged 38 to 45 years with recurrent menorrhagia associated with adenomyosis diagnosed at transvaginal ultrasonography participated in this study. INTERVENTION(S): An IUD releasing levonorgestel 20 mcg/day was inserted in each patient within 7 days of the start of menstrual flow. All of the patients were requested to compile a pictorial blood loss assessment chart each month. They underwent clinical and transvaginal ultrasound examinations 3, 6, and 12 months after IUD insertion. MAIN OUTCOME MEASURE(S): Menstrual pattern; serum hemoglobin, ferritin, and iron level changes. RESULT(S): One patient experienced IUD expulsion 2 months after device insertion and another requested removal of the IUD 4 months after insertion because of persistent irregular blood loss. Six months after IUD insertion, amenorrhea was observed in 2 patients and oligomenorrhea in another, spotting occurred occasionally in 7, and 13 had scanty but regular flow. One year of follow-up has been completed by the remaining 23 women: 2 with amenorrhea, 3 with oligomenorrhea, 2 with spotting, and 16 with regular flows. Significant increases in hemoglobin, hematocrit, and serum ferritin have been observed, but the lipid metabolism and clotting variables have remained unchanged. CONCLUSION(S): Our findings indicate that marked and safe relief from adenomyosis-associated menorrhagia can be obtained with the use of a levonorgestrel-releasing IUD.

PIP: The efficacy and tolerability of treatment of adenomyosis-related menorrhagia with a levonorgestrel-releasing IUD were investigated in a prospective study of 25 women recruited from a tertiary care center in Italy. All women reported recurrent menorrhagia of at least 6 months' duration and underwent abdominal and transvaginal ultrasonography, hysteroscopy, and endometrial biopsy before study entry. An IUD releasing 20 mcg/day of levonorgestrel was inserted within 7 days of the onset of menses and follow-up examinations were conducted 3, 6, and 12 months after insertion. 1 woman experienced IUD expulsion 2 months after insertion and another requested removal at 4 months because of persistent irregular blood loss. 6 months after IUD insertion, amenorrhea was observed in 2 women, oligomenorrhea in 1 woman, and occasional spotting in 7 women; the remaining 13 women had scanty but regular periods. At 12 months, 2 women reported amenorrhea, 3 had oligomenorrhea, 2 had spotting, and 16 had regular periods. All menstrual anomalies were well tolerated. IUD-related side effects included headache (24%), breast tenderness (16%), seborrhea or acne (24%), and weight gain (28%). Significant increases in hemoglobin, hematocrit, and serum ferritin were recorded; there were no changes in lipid metabolism or clotting variables. These findings suggest that insertion of a levonorgestrel-releasing IUD represents a viable alternative to hysterectomy in the treatment of adenomyosis. It is speculated that the IUD produces deciduation and subsequent marked hypotrophy of eutopic endometrium.

Inflammatory pseudotumor of the liver: case report and review of the literature.

Inflammatory pseudotumors of the liver (IPL) are extremely rare focal lesions of the parenchyma. Up to now, the ethology of IPL has not been completely understood. Usually the clinical presentation is with fever, chills, hepatic mass. The fine needle biopsy shows a large amount of inflammatory cells, while the most common imaging techniques are not specific and do not reach a definitive preoperative diagnosis between a benign and a malignant tumor. From the examination of the Literature, the Authors found a mortality rate of 40% among patients treated by antibiotic therapy, while surgical procedures were successful in all but one case. Moreover, in Authors' case, successfully treated by hepatic resection, the preoperative diagnostic procedures were not helpful in differential diagnosis with a malignant lesion. For these reasons, the Authors believe surgery is the best therapeutic choice in case of a suspected IPL without an early clinical resolution after antibiotic therapy.

Pre-operative assessment of bladder endometriosis.

The aim of our study was to verify the reliability of transvaginal ultrasonography in the pre-operative evaluation of bladder endometriosis. Six patients with suspected bladder endometriosis were studied. At referral to our department all six women underwent magnetic resonance imaging (MRI), transabdominal and transvaginal ultrasonography, cystoscopy and descending urography. Subsequently all the women underwent transperitoneal cystotomy and excision of endometriotic lesion at laparotomy. In three patients the bladder endometriotic lesions were continuous with adenomyosis in the anterior uterine wall. Histological examination confirmed the endometriotic nature of bladder nodule in all cases. Abdominal ultrasonography visualized the detrusor neoformation in all the patients but was less precise than transvaginal ultrasonography and MRI in defining the size of the lesions, infiltration of the detrusor and continuity with extravesical lesions. Transvaginal ultrasonography was more accurate and versatile than abdominal ultrasonography. The better image resolution allowed an accurate structural analysis of the bladder wall lesion. Furthermore, involvement of the uterovesical septum could be evaluated and adjacent myometrial infiltration recognized. MRI, although very precise, was less versatile than transvaginal ultrasonography and less accurate in establishing the margins of the lesions as perilesional fibrosis is visualized less clearly than areas containing haematic material. Urography was aspecific but still useful to evaluate the integrity of the upper urinary tract and ureters. In conclusion, in our patients transvaginal ultrasonography was found to be the most accurate technique in the diagnosis of bladder endometriosis.

Focal malignant hepatic lesions: MR imaging enhanced with gadolinium benzyloxypropionictetra-acetate (BOPTA)--preliminary results of phase II clinical application.

PURPOSE: To investigate enhancement with gadolinium benzyloxypropionictetraacetate (BOPTA) at magnetic resonance (MR) imaging to detect focal malignant hepatic lesions. MATERIALS AND METHODS: A phase II trial was performed in 34 patients. Gd-BOPTA-enhanced spin-echo (SE) and gradient-recalled-echo (GRE) T1-weighted MR imaging were performed at 40 and 90 minutes after intravenous injection of 0.05 and 0.10 mmol/kg Gd-BOPTA. RESULTS: The percentage of enhancement in liver parenchyma was significantly (P<.05) increased on GRE T1-weighted compared with SE T1-weighted images at 40 and 90 minutes after injection of the higher dose and compared with SE and GRE T1-weighted images obtained with the lower dose. The contrast-to-noise ratio of metastases was significantly increased on GRE T1-weighted images (0.10 mmol/kg) at 90 minutes compared with precontrast images. Significantly more small primary metastases were detected on GRE T1-weighted images (0.10 mmol/kg) at 90 minutes compared with precontrast SE T1-weighted images. CONCLUSION: Gd-BOPTA is a safe hepatobiliary contrast agent that helps detection of small metastases.

Vocal cord dysfunction in an asthmatic child: case report.

Acute functional narrowing of the glottis frequently leads to an inappropriate diagnosis of asthma. Only 2 cases have been reported of patients with asthma and concomitant vocal cord dysfunction. We present the case of an adolescent boy with asthma, who exhibited a worsening of wheezing and a reduction in peak expiratory flow rate out of proportion to symptoms due to a vocal cord dysfunction.

Intraoperative ultrasonography in pancreatic cancer.

Intraoperative ultrasonography (I.US) has been introduced in order to overcome the limits of the preoperative imaging modalities (notably, ultrasonography and computed tomography), both in pancreatic cancer diagnosis and staging. The authors' experience encompasses 32 cases, selected according to the following criteria: lesions that could not be detected both preoperatively and at surgical exploration; lesions detected but not properly characterized, requiring differential diagnosis between cancer and pancreatitis; tumoral lesions with a perspective of radical surgery, in which the preoperative judgment of resectability had to be verified. In the only case of the first group, I.US allowed the identification of a small cancer in a jaundiced patient. In the 11 cases of the second group, I.US-guided fine-needle aspiration biopsy showed three cancers; however, among the other 8 lesions classified as pancreatitis there was one false negative diagnosis (a tumoral mass with liver metastases was demonstrated by computed tomography 6 mo later). Regarding the intraoperative staging of the proven cancers (20 cases of the third group; 4 cases of the first and second groups), I.US changed the planned surgical approach in 9 cases (showing vascular involvement or detecting liver metastases and enlarged lymph nodes not seen preoperatively); in 12 cases it confirmed the possibility of radical surgery. Finally, in the remaining 3 cases, I.US provided dubious information: only vascular dissection during surgery could achieve a correct evaluation, ruling out vascular involvement and thus allowing tumor resection.

Cystic tumors of the pancreas: evaluation by ultrasonography and computed tomography.

The personal series of 30 cystic tumors of the pancreas [12 serous cystic tumors (SCT) and 18 mucinous cystic tumors (MCT)] is presented. All neoplasms were evaluated with ultrasonography (US) 28 of 30 with computed tomography (CT); the tumoral histotype could be correctly defined in 73% of cases (seven of 12 SCT and 15 of 18 MCT). Percutaneous fine-needle aspiration (FNA) with diagnostic aims (preparation of cytological smears and/or biochemical assays) was performed in only 10 of 30 cases, yielding a 100% sensitivity; on the whole, the combined use of imaging modalities and FNA allowed correct characterization of the cystic tumors in 27 of 30 cases (90%). The usefulness of a precise diagnostic workup of these neoplasms is emphasized, due to their prognostic and therapeutic outcome.

[Diagnostic imaging of pancreatic metastasis]. / Diagnostica per immagini delle metastasi pancreatiche.

The authors present their personal series of pancreatic metastases (8 cases) which were evaluated with different imaging modalities--i.e., sonography, computed tomography, and angiography. Possibilities and limitations of non-invasive modalities are pointed out, and the usefulness of angiography is emphasized for the identification of small hypervascular lesions. The fairly rare diagnosis of these tumoral lesions is due to 3 causes: low incidence of pancreatic metastases; their frequently small size which justifies eventual false negatives; the frequent lack of symptoms calling for imaging modalities. Moreover, pancreatic metastases are usually diagnosed in an advanced stage. Thus, the therapeutic approach must be planned in every single case, in relation to the perspectives of survival and to the residual quality of life.

The contribution of ultrasonography and computed tomography in the diagnosis of nonfunctioning islet cell tumors of the pancreas.

The personal series of 12 nonfunctioning islet cell tumors (NFIT) of the pancreas is reported. The ultrasound and computed tomography features of NFIT are analyzed, and a few signs are identified that may be useful in the differential diagnosis vs ductal carcinoma. The necessity to complete the diagnostic work up by means of fine needle aspiration biopsy and cytologic smears is also emphasized.

Serum levels of soluble interleukin-2 receptor in hairy cell leukaemia: a reliable marker of neoplastic bulk.

In hairy cell leukaemia (HCL), the strong membrane expression of the Tac antigen, corresponding to the p55 chain of the interleukin-2 receptor (IL-2R), is associated with the presence in the serum of high levels of a soluble form of the same molecule (sIL-2R). Previous observations that therapy-induced clinical and haematologic improvement in HCL is accompanied by a progressive decrease of sIL-2R suggest a possible correlation between sIL-2R levels and tumour burden. To verify this hypothesis, we monitored the variation of sIL-2R values in 13 non-splenectomized HCL patients admitted for treatment with recombinant interferon alpha-2. The data were correlated with the estimated weight of bone marrow (BM) and spleen infiltration, which in these patients almost entirely account for the tumour mass. The regression analysis test showed a direct correlation between sIL-2R values and both BM neoplastic involvement (r = 0.63) and spleen tumour mass (r = 0.76). In addition, the correlation was further improved (r = 0.86) when sIL-2R values were correlated with the total neoplastic mass, as calculated by the sum of spleen and BM neoplastic tissue weight. These data indicate that the detection of sIL-2R in HCL is a reliable non-invasive marker of tumour burden, which can be regarded as an additional useful tool for monitoring treatment response.

Duodenal duplication in the adult: its relationship with pancreatitis.

Seven cases of duodenal duplication in the adult are reported. The ultrasound and computed tomographic findings are analyzed. The relationship between duodenal duplication and pancreatitis is discussed.

[Role of digital intravenous angiography in the study of reversible cerebral ischemia]. / Le rôle de l'angiographie numérique par voie intra-veineuse dans l'étude de l'ischémie cérébrale régressive.

The brachiocephalic, carotid, vertebral and intra-cranial vessels of 497 patients presenting reversible ischemic attacks (R.I.A.) were evaluated with venous digital subtraction angiography (V.D.S.A.). Alterations of the vascular wall were observed in 289/497 (58.2%) patients, of whom 60% presented multiple locations (539 lesions): obstruction (12%), stenosis greater than 50% (29%), stenosis less than 50% (49.8%), kinking (9%), aneurysm (0.2%). An ulcerating arteriosclerotic plaque was observed in 24.6% of the stenoses less than 50% and in 48% of the stenoses greater than 50%. The incidence of vascular lesions was higher (p less than 0.01) in patients with multiple R.I.A. (66.6%) than in those with one isolated R.I.A. (55.6%). Among the patients (207/497) studied also with cerebral computed tomography (C.T.) no relationship could be defined between the extra-cranial vascular lesions demonstrated by V.D.S.A. and the cerebral alterations shown by C.T. Among the patients (64/497) studied also with high frequency ultrasonography (U.S.), the lesion shown by V.D.S.A. could be also demonstrated by U.S. in 84.8% of cases. The personal flow-chart in the study of R.I.A. is described emphasizing the primary role played by V.D.S.A. as well as the complementary role of the other techniques, both non invasive (U.S., C.T.) and invasive (conventional or digital subtraction angiography).

Disseminated pulmonary ossification.

A case of idiopathic disseminated parenchymal pulmonary ossification is presented. Discussion is based on the radiological and pathological findings, taking into consideration the two different forms of presentation (nodular and branching type) of this rather rare condition. The related bibliography is reviewed and discussed with particular emphasis on the aetiology and pathogenesis.