[Potential of ultrasonography and ultrasonography-guided biopsy in the diagnosis of local recurrence following radical prostatectomy]. / Possibilità dell'ecografia e della biopsia ecoguidata nella diagnosi delle recidive locali dopo prostatectomia radicale.

INTRODUCTION: [corrected] We investigated the diagnostic role of combined transrectal US (TRUS) and biopsy to detect recurrent cancer after radical prostatectomy, in patients with negative bone scintigraphy and elevated prostate specific antigen (PSA) levels. MATERIALS AND METHODS: From March, 1997, to May, 1998, we examined 12 patients with persistently detectable serum PSA levels and negative bone scintigraphy. At the time of diagnosis, an average 36 months had elapsed since prostatectomy. Digital rectal examination (DRE) and disease stage at the time of surgery were also considered. Patients age ranged 47 to 83 years (mean: 65). All patients underwent TRUS with a 7.5 MHz biplane probe; biopsy was performed with a 16 G cutting needle. TRUS findings were considered suspicious if the scan showed any unusual hypoechoic tissue adjacent to the bladder neck, in retrotrigone or peri-retroanastomotic site. In these cases a transperineal US-guided biopsy was performed. RESULTS: The biopsy proved cancer in 10/12 cases (in 12 cases after two biopsies), showing a better diagnostic accuracy than DRE, which poorly distinguished postoperative changes from recurrent or residual cancer. CONCLUSIONS: The early detection of recurrences after radical prostatectomy in patients with negative bone scintigraphy is feasible when the above examinations are performed in the same order as described: PSA levels, if altered, indicate the patients to be submitted to TRUS. The latter may be falsely negative in some cases because small recurrences may exhibit no findings at US, and therefore US-guided biopsy of peri-retro-anastomotic regions should be always performed too. The recurrence must be confirmed at histology because histologic findings help choose adjuvant treatment and/or radical irradiation.

[Ultrasonic diagnosis of De Quervain's stenosing tenosynovitis]. / Diagnosi ecografica della tenosinovite stenosante di De Quervain.

This study was aimed at stressing the role of US of the first dorsal compartment of the wrist as the initial diagnostic approach in the study of De Quervain's syndrome, thanks to the high diagnostic yield of this technique. We report on 14 cases of De Quervain's stenosing tenosynovitis whose onset of the symptoms ranged 3-24 months before the US exam. The patients were subdivided into three groups, according to disease stage and US patterns; 5 patients were in group 1, six in group 2 and 3 in group 3. The most frequent US findings were: thickening of the tendons, which appeared as separate structures or as a single structure (pseudofusion); diffuse or, in most cases, focal thickening of the sheaths; changes in tendon echogenicity; impaired tendon sliding, which was reduced or absent due to fibrous adhesions and compression by the sheaths. Diffuse tendon and sheath thickening was prevalent in group 1, where the onset of symptoms ranged 3-10 months earlier. Focal sheath thickening and tendon pseudofusion were prevalent in group 2, where the onset of symptoms ranged 8-15 months earlier. Tendon degeneration and fibrous adhesions between tendons and sheaths, as well as the US changes observed in group 2, were found in group 3 where the onset of symptoms ranged 18-24 months earlier. These US changes were not influenced by medical therapy, with the exception of local injections of corticosteroids. To conclude, we propose a classification of De Quervain's syndrome into three stages, according to the US signs characterizing the different stages of disease evolution and the time of onset of the symptoms.

[An esophagoaortic fistula due to a foreign body]. / Fistola esofagoaortica da corpo estraneo.

Starting from a case of aortoesophageal fistula caused by a foreign body, some aspects of the treatment of upper gastrointestinal hemorrhage of uncertain etiology are discussed. The time between bleeding and perforation often notes it possible to perform resolutive diagnostic tests (aortography, esophagoscopy, CT).

[Urography: problems and errors in the diagnosis of renal masses]. / Urografia: problemi ed errori nella diagnostica delle masse renali.

New imaging modalities have gained a prominent role in both detection and diagnosis of kidney disorders. However, excretory urography (IVU) remains the screening examination of choice in everyday diagnostic routine, even though its value in characterising renal masses is poor. The search for more sensitive and less invasive diagnostic modalities has brought about some new dilemmas--e.g., which modality should be performed first when the clinical picture is suggestive of renal tumor, the presence of a malignancy with a negative IVU, small renal tumors as occasional findings--, and has enhanced previous problems,--e.g., technique, administration of i.v. contrast media. After defining the above problems, the authors discuss mistakes in the evaluation and interpretation of urograms. The problems are operator-dependent, or else they may be related to examination technique--e.g., inadequate preparation of the patient, poor image quality--, to the method of examination--e.g., inadequate injection of contrast agents (i.e., type, amount, method of injection)--, to kidney function and, finally, to lesion type. As for lesion type, errors can be related to the detection of the lesion itself--e.g., small renal masses (less than 3 cm phi)--and to lesion definition, due to atypical patterns or to difficult differentiation of tumors from normal findings, from anatomical variants or extrarenal structures.

[Ultrasonography in syringocele of the male urethra (ultrasound-urethrography)]. / Ecografia nel siringocele dell'uretra maschile (sono-uretrografia).

The authors have studied 5 patients with syringocele--or cystic dilatation of the excretory ducts in Cowper's glands--using a 7.5 MHz linear high-definition US probe. The urethra was distended with a saline solution introduced through a small Foley's balloon catheter placed in the navicular fossa. Longitudinal and transverse scans were employed at both the penis and the perineal region. The syringocele appears on US scans as a tubular image at the bulbous urethra, parallel to the urethral canal, with a "double tube" appearance. It is easily differentiated from urethral stenosis, while it may be confused with congenital urethral duplication, which is extremely uncommon. US with a small-part probe can be considered an useful imaging technique and a valid alternative to conventional radiology, especially in young patients, to avoid high dose exposure.

[Surgical ultrasonography of the seminal vesicles in andrologic pathology. Research in progress]. / L'ecografia operativa delle vescicole seminali nella patologia andrologica. Ricerca in "itinere".

The authors describe their experience with percutaneous transperineal puncture (PTP) of the seminal vesicles in andrologic pathologic conditions, using transrectal US guidance. Three cases are reported: 2 anomalies of the genital ducts and one prostatic-vesicular abscess. In the first two cases PTP allowed a diagnosis to be reached on the basis of the analysis of vesicular fluid. Moreover, the examination allowed the selection of the patients to be submitted to surgery for seminal duct anomaly (endoscopic resection of the colliculus seminalis). In cases 1 and 3 PTP allowed the aspiration of the fluid from a cyst in the left ejaculatory duct and from a prostatic-vesicular abscess, respectively. These procedures were facilitated using US guidance. The clinical possibilities and utility of PTP have not yet been completely defined. The authors suggest a diagnostic protocol to be used in the presence of azoocytospermia, where US must be performed only in patients with excretory infertility. The present paper must be considered a work in progress. Further study is required to identify the clinical indications of interventional US of the seminal vesicles in patients with andrologic pathologic conditions.

[Echography vs urography in the study of small-size renal carcinoma]. / Ecografia ed urografia a confronto nello studio dei nefrocarcinomi di piccole dimensioni.

Since 1981 we have studied 34 patients with renal cell carcinomas smaller than 3 cm, diagnosed by US and IVP, to evaluate the diagnostic viability of these 2 procedures. Their respective results were compared to pathologic findings and tumor grading. No correlation was found between the type of sonographic patterns and the pathologic findings. On the contrary the correlation between the acoustic pattern and the grading, performed on small tumors and on a control group of large tumors, showed that most tumors in the former group (70%) had lower grading than those in the latter. We conclude that the introduction of US has changed the approach to the diagnosis of renal tumors, allowing their early recognition and characterisation. It is thus hoped that the clinical course of such tumors will be improved.

[Ureteral obstruction secondary to aortofemoral bypass]. / Ostruzione ureterale secondaria ad interventi di by-pass aorto-femorale.

Hydroureteronephrosis is reported as a frequent late complication of aorto-femoral bypass grafts in patients with aorto-iliac obstruction. To define the actual incidence of this potentially critical complication, renal ultrasonography (US) was performed on 79 asymptomatic patients who had previously undergone aortic reconstruction, after a mean interval of 71.6 months. Unilateral hydronephrosis was found in 6 cases (7.6%). Dilatation was mild or moderate (grade I or II) in 4 cases, and severe (grade III) in 2. Ivp was performed in this selected group: hydronephrosis was mild in 3 patients with ureteral stenosis where the iliac limb of the graft crossed the ureter. In 2 cases nonfunctioning kidneys were demonstrated corresponding to severe sonographic hydronephrosis. These 2 patients underwent anterograde and retrograde pyelography, that showed the site and extent of the obstruction. One patient was a false positive because of obstruction of pyelo-ureteral junction. Even though X-rays showed high sensitivity and specificity in detecting this complication of aorto-femoral reconstruction, US is noninvasive and less expensive and does not require contrast medium. A routine pre- and post-operative ultrasound study is suggested in patients undergoing by-pass surgery to early recognise ureteral obstruction and to avoid irreversible renal damage.

[Diagnosis by imaging of secondary neoplastic lesions of the digestive tract]. / La diagnostica per immagini delle lesioni neoplastiche secondarie del canale alimentare.

Secondary neoplasms involving the alimentary tract are not common. This work is aimed at evaluating their characteristic roentgenological features, providing, when possible, the criteria for discriminating secondary from primary lesions. Forty-five patients with secondary neoplasms of the alimentary tract were examined by conventional radiology, ultrasonography and CT. Both CT and US are highly accurate in such cases, since these lesions are displayed directly. However, double-contrast gastrointestinal examination must be performed, because it indirectly demonstrates both intrinsic and extrinsic lesions, thus providing all elements for a correct local staging.

[Echostructural polymorphism of prostatic carcinoma. Anatomo-pathologic correlations in various developmental stages]. / Polimorfismo ecostrutturale del carcinoma prostatico. Correlazioni anatomo-patologiche nelle diverse fasi evolutive.

The sonographic appearance of prostatic carcinoma was correlated with the corresponding histopathologic studies in 57 patients after transperineal biopsy. In 21 cases the lesions observed were less than or equal to 2 cm (circumscribed) and in 36 were greater than 2 cm (diffuse). Within the first group there was a prevalence of hypoechoic forms (61,9%). While isoechoic and hyperechoic foci were observed in 14.3% and 23.8%. In diffuse prostatic carcinoma, mixed echogenicity was observed in 50% of patients, hypoechoic in 27.8% and isoechoic in 22.2%. The variations in the appearance of prostatic cancer indicate that sonographic texture is related to the size and histopathologic features of the neoplastic growth.

Small hepatocellular carcinoma: an Italian experience.

Recent reports have demonstrated the possibility of using ultrasound to detect hepatocellular carcinomas under 3 cm (small HCC). Our aim was to assess the incidence of small HCC in an Italian ultrasonographic series. Among 17,133 scans of unselected patients, we detected 85 HCC, 9 of which were under 3 cm. All patients had cirrhosis and 6 were HBsAg positive. An echo-guided biopsy was performed in all cases, and the diagnosis was always correct. We conclude that echographic follow-up is warranted in Italy for cases at risk for HCC such as HBsAg+ cirrhotics and patients with chronic aggressive HBsAg+ hepatitis older than 35, in agreement with the reports of Far Eastern authors.

[Diagnostic images of renal angiomyolipoma]. / Diagnostica per immagini dell'angiomiolipoma renale.

The authors report 26 cases of renal angiomyolipomas (AML) detected in a three-years period (1983-85). In all cases echography, in 6 renal arteriography and in 13 CT were performed. The review of the pathway and of literature stress some new aspects in diagnostic problems of AML. The extensive use of diagnostic ultrasound shows an higher rate of tumors than in the pre-echographic period. Most of these lesions are asymptomatic and incidentally detected as small nodules. Ultrasound, combined with CT, can resolve the diagnostic dilemma of benign lesion. An echographic follow-up is sufficient to confirm this evaluation in typical cases. In large or bleeding tumors and when there is a prevalence of connective and/or muscular tissue, a diagnostic and ablative surgery is mandatory.

[Rounded atelectasis of the lung]. / Atelettasia rotonda del polmone.

Rounded atelectasis is an uncommon but increasingly recognized form of pulmonary collapse that often mimics a pulmonary neoplasm. It is suggested that these lesions can occur many years after exposure to asbestos or exudative pleural effusions. The authors report 16 cases of rounded atelectasis seen during a period of over 10 years, 9 of which in the last 18 months. They describe the plain film, tomographic and CT appearances of the lesion. The radiographic features that allow a diagnosis are rounded or oval shadows lying along the posterior surface of the lower lobe, adjacent to thickened pleura. Lateral tomography and CT show the blood vessels and bronchi curving toward the mass and converging on one edge, like a comet tail. Differentiation of rounded atelectasis from neoplastic disease is essential in avoiding unnecessary thoracotomy.