Imaging in resectable colorectal liver metastasis patients with or without preoperative chemotherapy: results of the PROMETEO-01 study.

BACKGROUND: The aim of the PROMETEO-01 Study was to define the diagnostic accuracy of imaging techniques in colorectal cancer liver metastasis (CRCLM) patients. METHODS: Patients referred to Bologna S. Orsola-Malpighi Hospital performed a computed-tomography scan (CT), magnetic resonance (MR), 18F-FDG-PET/CTscan (PET/CT) and liver contrast-enhanced-ultrasound (CEUS); CEUS was also performed intraoperatively (i-CEUS). Every pathological lesion was compared with imaging data. RESULTS: From December 2007 to August 2010, 84 patients were enrolled. A total of 51 (60.71%) resected patients were eligible for analysis. In the lesion-by-lesion analysis 175 resected lesions were evaluated: 67(38.3%) belonged to upfront resected patients (group-A) and 108 (61.7%) to chemotherapy-pretreated patients (group-B). In all patients the sensitivity of MR proved better than CT (91% vs 82%; P=0.002), CEUS (91 vs 81%; P=0.008) and PET/CT (91% vs 60%; P=0.000), whereas PET/CT showed the lowest sensitivity. In group-A the sensitivity of i-CEUS, MR, CT, CEUS and PET/CT was 98%, 94%, 91%, 84% and 78%, respectively. In group-B the i-CEUS proved equivalent in sensitivity to MR (95% and 90%, respectively, P=0.227) and both were significantly more sensitive than other procedures. The CT sensitivity in group-B was lower than in group-A (77% vs 91%, P=0.024). CONCLUSIONS: A thoraco-abdominal CT provides an adequate baseline evaluation and guides judgment as to the resectability of CRCLM patients. In the subset of candidates for induction chemotherapy to increase the chance of liver resection, the most rational approach is to add MR for the staging and restaging of CRCLM.

Randomised controlled trial of doxorubicin-eluting beads vs conventional chemoembolisation for hepatocellular carcinoma.

BACKGROUND: Transcatheter arterial chemoembolisation (TACE) is the treatment of choice for intermediate stage hepatocellular carcinoma (HCC). Doxorubicin-loaded drug-eluting beads (DEB)-TACE is expected to improve the performance of conventional TACE (cTACE). The aim of this study was to compare DEB-TACE with cTACE in terms of time-to-tumour progression (TTP), adverse events (AEs), and 2-year survival. METHODS: Patients were randomised one-to-one to undergo cTACE or DEB-TACE and followed-up for at least 2 years or until death. Transcatheter arterial chemoembolisation was repeated 'on-demand'. RESULTS: We enrolled 177 patients: 89 underwent DEB-TACE and 88 cTACE. The median number of procedures was 2 in each arm, and the in-hospital stay was 3 and 4 days, respectively (P=0.323). No differences were found in local and overall tumour response. The median TTP was 9 months in both arms. The AE incidence and severity did not differ between the arms, except for post-procedural pain, more frequent and severe after cTACE (P<0.001). The 1- and 2-year survival rates were 86.2% and 56.8% after DEB-TACE and 83.5% and 55.4% after cTACE (P=0.949). Eastern Cooperative Oncology Group (ECOG), serum albumin, and tumour number independently predicted survival (P<0.05). CONCLUSIONS: The DEB-TACE and the cTACE are equally effective and safe, with the only advantage of DEB-TACE being less post-procedural abdominal pain.

Response rate and clinical outcome of HCC after first and repeated cTACE performed "on demand".

BACKGROUND & AIMS: Aim of the study was to assess the clinical impact of conventional transarterial chemoembolization (cTACE) repeated "on demand" on HCC outcome. Outcome measures were: response rate to first and repeated cTACE, recurrence rates and overall survival. METHODS: The outcome of 151 consecutive HCC patients submitted to a first cTACE from January 2004 to December 2005 was retrospectively analyzed. RESULTS: Complete radiological response (CR) was observed in 72/151 (48%), 34/60 (52%) and 12/22 (55%) patients after first, second and third cTACE, respectively. Recurrence rates at 6 and 12months were 37% and 61% after the first cTACE, and 40% and 59% after the second cTACE, respectively. Patients not achieving CR or with a recurrence after CR not treated with curative therapies were 94 and 84 after first and second cTACE, respectively. Of these, 60/94 (64%) and 22/84 (26%) were submitted to a second and third cTACE, respectively. Median overall survival was 32.0months but 25.0months excluding transplanted patients. Factors at the time of first cTACE associated with overall shorter survival at multivariate analysis were higher bilirubin, higher AFP and not achieving CR. CONCLUSIONS: CR and recurrence rates after first and second cTACE were similar. About 64% of patients were submitted to second cTACE, while only few patients (26%) were submitted to third cTACE using an "on demand" policy. These figures may be also useful for planning trials for the evaluation of the efficacy of repeated TACE vs. TACE combined with adjuvant treatments or vs. systemic treatments.

Multi-centre phase II clinical trial of yttrium-90 resin microspheres alone in unresectable, chemotherapy refractory colorectal liver metastases.

BACKGROUND: This multi-centre phase II clinical trial is the first prospective evaluation of radioembolisation of patients with colorectal liver metastases (mCRC) who failed previous oxaliplatin- and irinotecan-based systemic chemotherapy regimens. METHODS: Eligible patients had adequate hepatic, haemopoietic and renal function, and an absence of major hepatic vascular anomalies and hepato-pulmonary shunting. Gastroduodenal and right gastric arteries were embolised before hepatic arterial administration of yttrium-90 resin microspheres (median activity, 1.7 GBq; range, 0.9-2.2). RESULTS: Of 50 eligible patients, 38 (76%) had received > or =4 lines of chemotherapy. Most presented with synchronous disease (72%), >4 hepatic metastases (58%), 25-50% replacement of total liver volume (60%) and bilateral spread (70%). Early and intermediate (>48 h) WHO G1-2 adverse events (mostly fever and pain) were observed in 16 and 22% of patients respectively. Two died due to renal failure at 40 days or liver failure at 60 days respectively. By intention-to-treat analysis using Response Evaluation Criteria in Solid Tumours, 1 patient (2%) had a complete response, 11 (22%) partial response, 12 (24%) stable disease, 22 (44%) progressive disease; 4 (8%) were non-evaluable. Median overall survival was 12.6 months (95% CI, 7.0-18.3); 2-year survival was 19.6%. CONCLUSION: Radioembolisation produced meaningful response and disease stabilisation in patients with advanced, unresectable and chemorefractory mCRC.

CT-guided percutaneous pelvic abscess drainage in Crohn's disease.

BACKGROUND: Percutaneous abscess drainage (PAD) is the current therapy for abdominal or pelvic collections. PAD has poorer curative rate for abscesses in Crohn's disease (CD), commonly complicated by wide fistulas and multiloculations. METHODS: We retrospectively evaluated abscess cure rate, complications and final outcome in 87 CD patients, 70 with spontaneous and 17 with postoperative pelvic abscesses, all treated with CT-guided PAD during the last 7 years. RESULTS: A 77% primary success rate and an 84.3% secondary success rate were obtained without major complications. The higher success rate for PAD was for postoperative (88.2%) rather than spontaneous abscesses (74.2%). Seventy-two percent of treated patients did not develop recurrent abscesses and underwent elective surgery up to 40 months later. CONCLUSION: PAD in pelvic abscess complicating CD is an effective alternative to early surgery with satisfactory curative success rates. In unsuccessful cases, due to wide fistulas or postoperative anastomotic dehiscence, PAD helped in planning elective surgery, reducing surgical complications.

Unresectable hilar cholangiocarcinoma: multimodality approach with percutaneous treatment associated with radiotherapy and chemotherapy.

Klatskin-type cholangiocarcinoma is a rare tumor, bearing a very poor prognosis: at diagnosis, most patients can only undergo palliation. Evaluation of outcome, mean survival and quality of life was performed in patients with unresectable hilar cholangiocarcinoma treated with multimodality approach in comparison with surgical palliation, biliary stenting or brachytherapy alone. Twenty-six patients with hilar cholangiocarcinoma were studied: 16 patients were enrolled in the multimodality protocol (bilateral biliary drainage; Iridium-192 brachytherapy; plastic endoprosthesis or metallic stent positioning and external radiotherapy plus systemic chemotherapy), 5 patients underwent surgical palliation and 5 percutaneous decompression alone. Nine patients completed the protocol and 7 were treated with brachytherapy followed by biliary stenting alone. The multimodality approach obtained mean survival (10 months) similar to that for surgery and higher than that of the brachytherapy and metallic stenting groups (6 and 2.75 months, respectively). The average hospital stay (15 days) was lower than that of the surgical group (20 days). A multimodality approach is a suitable alternative to palliative surgery of unresectable hilar cholangiocarcinoma.

Intra-arterial chemotherapy for liver metastases from colorectal cancer.

The aim was to investigate whether intra-arterial infusion of chemotherapy improves response to treatment in unresectable liver metastases from colorectal cancer. We treated 14 patients (pts) with intra-arterial chemotherapy. Arterial catheters were placed via percutaneous access. Treatment schedule was: 5-FU and mitomycin-C on day 1 every 21 days. Six pts also received from day 3 for 5 days, a continuous intra-arterial 24-hr infusion of interleukin-2 (IL-2). We had only one case of toxicity drug-related > grade 2 (neutropenia). We observed 2 partial response (PR) and 5 stable disease (SD). Median time to disease progression (TTP) and median survival (OS) were, respectively 4 and 15 months.

Unresectable hilar cholangiocarcinoma: multimodality treatment with percutaneous and intraluminal plus external radiotherapy.

The efficacy of multimodality treatment for unresectable hilar cholangiocarcinoma was evaluated in terms of outcome, survival and quality of life. Eleven patients were enrolled in the following protocol: percutaneous drainage of both right and left biliary systems; Iridium-192 intraluminal brachytherapy; replacement of the drainages with endoprotheses; external radiotherapy. Six patients completed the protocol and 5 were treated with brachytherapy alone. Mean survival was 10.5 months, similar to surgical results and higher than the control group treated with percutaneous stenting (2.75 months) or biliary drainage alone (1.75 months), with an average hospital stay of 10-15 days and no procedure-related mortality.

[Combined treatment of inoperable liver metastases from colorectal cancer]. / Combined treatment of inoperable liver metastases from colorectal cancer.

AIMS: Liver resection improves survival in selected patients with colorectal liver metastases. However, the majority of patients with colorectal liver metastases have an inoperable oncological disease. The aim is to investigate whether intra-arterial infusion of chemotherapy, improves response to treatment and may convert a selected group of patients with irresectable liver metastases into an operable state. MATERIALS AND METHODS: Thirty-sex patients (pts) with inoperable hepatic metastases from colorectal cancer were treated with intra-arterial chemotherapy, by angiographic technique. All patients underwent a short 5-FU-based locoregional infusion and the 13 non pretreated patients also received systemic therapy. Evaluation of response was made by CT scan. RESULTS: Total cycles administered angiographically: 132 (range, 1-11). There were no complications associated with the angiographic procedure and no cases of > grade 2 toxicity. One heavily pretreated pt experienced moderate cholangitis and superficial gastric erosion. Thirty-one pts were assessable (20 pretreated and 11 not); there was 1 complete response (CR), 3 partial remissions (PR), 2 stabilizations (SD) among non-pretreated pts (6/11; CR + PR + SD = 55%) and 1 PR and 8 SD among pretreated pts (9/20; PR + SD = 45%). The remaining 16 pts progressed. Four pts became eligible for radical hepatic resection (1 refused surgery and 3 patients were operated on). There was no peri-operative deaths. Median survival of these 3 pts was 24, 28 and 39+ months. CONCLUSIONS: Our data, even if based on a relatively small case series, appear to confirm effective local disease control in this clinical setting. Regional chemotherapy used singly or in combination with systemic chemotherapy may convert a selected group of patients with irresectable liver metastases to an oncological disease that can benefit from surgical treatment.

Role of HRCT in the identification of atypical pulmonary mycobacteriosis.

AIM: 1) To identify the principal radiological signs of atypical pulmonary mycobacteriosis by means of X-rays and CT/HRCT; 2) to compare the two methods in order to evaluate their reliability with particular interest for the diagnostic role of HRCT in the identification of the disease; 3) to establish any significant differences in the pathology between AIDS and immunocompetent patients. MATERIAL AND METHODS: The chest X-rays and CT/HRCT of 28 atypical pulmonary mycobacteriosis patients (16 with AIDS and 12 immunocompetent) have been studied. The subjects were examined during the period of October 1993 to May 2000 and were found to be positive for atypical mycobacterium and consequently underwent a standard chest X-ray. Twenty cases were followed-up with a chest CT/HRCT; of these only 17 were performed within 30 days of the traditional chest X-ray which was considered to be the time limit in order to validate the comparison between the two methods. RESULTS: The significant semeiotical findings were the parenchymal consolidations observed in 25 patients (89%) by standard chest X-rays; the CT/HRCT confirmed the findings in 4 cases while in 13 it enhanced the evaluation of their extensions. In 9 cases the standard chest X-ray established the presence of cavitations which were confirmed by the CT/HRCT in only 7 cases. Lymphadenopathy was observed in 3/28 patients (10.7%) through standard X-rays and in 15/17 cases (82%) through CT/HRCT. The latter method revealed to be extremely useful in the identification of this pathology. Nodules and micronodules were seen in 5 patients with traditional X-rays and in 9 cases with CT/HRCT. Bronchogenic spread signs of disease became visible only with CT and in particular with HRCT (11/17 patients = 65%). Comparing the two groups (AIDS and immunocompetent) taken into consideration, the most frequent lesion present in both was parenchymal consolidation resulting more bilateral in the AIDS subjects. Cavitation and pleural edema were seen more often in the AIDS group while bronchiectasia, bronchogenic spread and signs of previous pleuro-parenchymal suffering were more frequent in the immunocompetent patients. Lymphadenopathy was frequently found in the total study population but appeared slightly prevalent for the group not afflicted with AIDS. CONCLUSION: Radiological study of the chest permitted the identification of signs useful in the diagnosis of mycobacteriosis in all the patients studied. The application of CT/HRCT added helpful elements in almost all of the cases examined demonstrating to be more effective than the standard chest X-ray not only in terms of improved evaluation of known lesions but also in the identification of lesions which are difficult to determine by means of traditional radiology.

[Unresectable hilar cholangiocarcinoma: combined percutaneous and radiotherapic treatment]. / Colangiocarcinoma dell'ilo inoperabile: protocollo di trattamento combinato percutaneo e radioterapico.

PURPOSE: Evaluate, in patients with inoperable hilar CLCA, the efficacy of multimodality treatment (brachiotherapy, chemotherapy, external radiotherapy and endoprosthesis positioning) in terms of survival, quality of life and cost/benefit compared to palliative surgical treatment. MATERIAL AND METHODS: 20 patients with inoperable hilar CLCA were evaluated. Ten were considered for combined palliative and radiotherapy treatment according to the following protocol: percutaneous colangiography followed by positioning of right and left internal biliar drainage (10-12 F); intraductal brachiotherapy using Ir-192 needles was performed (7 Gy). A second administration was after 7 days. Total dose was 14 Gy; the biliar drainages were then replaced by endoprosthesis (12-14 F) and left in position for 3 months in order to model the post-attinic fibrosis and to prevent stenosis; external radiotherapy was administered starting 15 days after last brachiotherapy treatment (26 administrations (180 cGy) in 5 weeks, total 46 Gy); chemotherapy (5 FU: 350 mg/mq/die) for 5 days during the first and the fifth week of external radiotherapy; biliar endoprosthesis were removed by endoscopic and, or transhepatic mode after 3 months from end of therapy, verifying. Cholangiography assessed the patency of the biliar duct. Metallic stents were placed if results were not satisfactory; follow-up was by: hepatic lab work-up, tumoral markers, US or TC evaluated disease progression. RESULTS: In 5 of the 10 patients considered for the combined treatment, 5 patients completed the protocol and 5 were treated only with brachiotherapy because of deterioration of clinical conditions. All patients had initial complete remission of jaundice although it recurred with disease progression that led to death. No acute post-radiotherapy complication was observed. Digestive hemorrhage (chronic post-radiotherapy complication) was the cause of death in one patient. DISCUSSION AND CONCLUSIONS: Good results were observed in the patients that completed the protocol, mean survival was 7,5 months instead of 1,75 months as in patients that underwent only percutaneous drainage. Better results may be obtained taking in consideration the poor clinical conditions of the patients at the time of diagnosis. The proposed therapeutic protocol requires an average hospitalization of 10-15 days instead of 15-20 days as for palliative biliar-digestive deviation, being less invasive and thus associated to lower morbidity and no mortality.

[The percutaneous treatment of uterine fibromas by means of transcatheter arterial embolization]. / Trattamento percutaneo dei fibromi uterini mediante embolizzazione arteriosa transcatetere.

INTRODUCTION: We report our preliminary experience with arterial embolization of uterine fibroids in seven women, focusing on the technical aspects of the procedure and the clinical and morphological results during the follow-up. MATERIAL AND METHODS: February to December 1999 seven women (mean age 47) underwent transcatheter arterial embolization of both uterine arteries as a permanent treatment for fibroids. We included in this study single or multiple, bleeding and/or large fibroids, symptomatic on compression, contraindicated for myomectomy because of high surgical or anesthesiologic risks or myomata in which myomectomy could probably be converted into hysterectomy. Fibroids enlarging the uterus to the size of 25 weeks' pregnancy or more, pedunculated myomata or small submucous fibroids--smaller than 5 cm--were excluded. Uterine arterial embolization was performed bilaterally, till a total blockage of flow, by injecting permanent embolization material: polyvinyl-alcohol (PVA) particles of increasing size from 150 to 500 mu and in varying amounts from 10 to 24 mL, depending on fibroid size and degree of vascularization. RESULTS: A technical success was achieved in all cases and no late complications were seen. At 6-month clinical follow-up all compressive symptoms had disappeared; regular menses had returned in 57% of patients, milder hyper-dysmenorrhea was present in 28% compared to pretreatment symptoms; only in one case (14%) was permanent amenorrhea observed. The 3-month and 6-month US follow-up studies showed an average 40.7% (range 10-50%) and 51% (range 25-83%) reduction in the fibroid size, respectively. All the small myomata (about 2 cm in size) were unidentifiable at 6-month US follow-up. In no cases did new fibroids appear. DISCUSSION: Surgery is the traditional treatment for symptomatic uterine fibroids (hysterectomy, myomectomy). More recently, hormone therapy and operative endoscopy (laparoscopy and hysteroscopy) have been introduced as alternatives, together with uterine embolization previously applied preoperatively in extensive bleeding neoplasms or to control post-partum hemorrhage. Transcatheter embolization of the uterine arteries feeding large fibroids is a minimally invasive technique which could be safely used as an alternative to surgery, and a valuable in the definitive treatment of symptomatic, large or multiple, intramural or submucosal fibroids. In agreement with literature findings, in the present series symptoms resolved completely in over 85% of cases after embolization, with an average reduction in fibroid size over 50% at 6-month follow-up in large fibroids, whereas smaller size myomata were no longer detectable at US and no new fibroids had formed. CONCLUSIONS: Our preliminary experience confirms that arterial embolization is a promising alternative to surgery in the definitive treatment of fibroids, thanks to its high efficacy and safety, also reducing patient hospitalization and costs.

Pulmonary complications of liver transplantation: radiological appearance and statistical evaluation of risk factors in 300 cases.

The aim of this study was to evaluate the incidence, radiographic appearance, time of onset, outcome and risk factors of non-infectious and infectious pulmonary complications following liver transplantation. Chest X-ray features of 300 consecutive patients who had undergone 333 liver transplants over an 11-year period were analysed: the type of pulmonary complication, the infecting pathogens and the mean time of their occurrence are described. The main risk factors for lung infections were quantified through univariate and multivariate statistical analysis. Non-infectious pulmonary abnormalities (atelectasis and/or pleural effusion: 86.7%) and pulmonary oedema (44.7%) appeared during the first postoperative week. Infectious pneumonia was observed in 13.7%, with a mortality of 36.6%. Bacterial and viral pneumonia made up the bulk of infections (63.4 and 29.3%, respectively) followed by fungal infiltrates (24.4 %). A fairly good correlation between radiological chest X-ray pattern, time of onset and the cultured microorganisms has been observed in all cases. In multivariate analysis, persistent non-infectious abnormalities and pulmonary oedema were identified as the major independent predictors of posttransplant pneumonia, followed by prolonged assisted mechanical ventilation and traditional caval anastomosis. A "pneumonia-risk score" was calculated: low-risk score ( < 2.25) predicts 2.7% of probability of the onset of infections compared with 28.7% of high-risk (> 3.30) population. The "pneumonia-risk score" identifies a specific group of patients in whom closer radiographic monitoring is recommended. In addition, a highly significant correlation (p < 0.001) was observed between pneumonia-risk score and the expected survival, thus confirming pulmonary infections as a major cause of death in OLT recipients.

Sensitivity and specificity of chest X-ray screening for lung cancer: review article.

BACKGROUND: The incidence and mortality rates of lung carcinoma have been increasing during the last years. Despite this, medical public policy holds that chest X-ray screening is ineffective in the early detection of lung carcinoma. METHODS: The authors reviewed the most important studies published in the literature regarding the role of chest X-ray screening in the early diagnosis of lung carcinoma in a high risk population. None of the four randomized, controlled trials on lung carcinoma screening conducted in male cigarette smokers demonstrated a reduction in the mortality rate. Accordingly, no organization that formulates screening policy advocates any specific early detection strategies for lung carcinoma. RESULTS: A careful analysis of randomized, controlled trials showed that there was no improvement in the mortality rate in the screened populations, but there is considerable evidence that chest X-ray screening is associated with earlier detection and improved survival. CONCLUSIONS: In the authors' opinion, the considerable improvements in distribution by disease stage, tumor resectability, and patient survival in the screened groups demonstrate the effectiveness of chest X-ray screening in the early detection of lung carcinoma. The authors conclude that radiographic screening is the only valid method of secondary prevention in cigarette smokers.

[High-resolution volumetric computerized tomography of the lung: optimization of technique and image quality as a function of its clinical-diagnostic use and dose to the patient]. / Tomografia Computerizzata volumetrica con alta risoluzione del polmone: ottimizzazione tecnica e qualità dell'immagine in funzione delle sue applicazioni clinico-diagnostiche e della dose al paziente.

PURPOSE: The aim of this project was to analyze and validate the diagnostic applications of Volumetric High Resolution CT in the study of focal or diffuse infiltrative lung disease compared with High Resolution CT. To date HRCT is the gold standard in the assessment of infiltrative lung diseases, but it shows some limitations such as artifacts due to both respiratory and cardiac motions, as well as the need for multiple breath-holds. MATERIAL AND METHODS: September, 1996, to September, 1997, anthropomorphic test phantoms and a group of 34 subjects (8 without lung disease and 26 with aspecific lung disease: TBC, BPCO, micronodular conditions, cardiogenic interstitial pulmonary edema) were submitted to both HRCT and VHRCT. VHRCT was carried out with a 3-mm slab thickness and the images were reconstructed with a 1-mm interval and processed with MIP and MinIP reconstructions. With both techniques we compared some physical parameters (slice sensitivity profile, noise, longitudinal resolution) and some radiographic findings (central and peripheral airways lumen, peripheral vessels, nodular and interstitial abnormalities, emphysema foci, focal areas of ground glass pattern and bronchiectasis). We calculated the radiation exposure dose of both HRCT and VHRCT, also testing a low-dose protocol. RESULTS: The analysis of physical parameters showed no major differences between HRCT and VHRCT regarding longitudinal resolution, while minimal advantages were found with HRCT for slice sensitivity profile and image noise. Radiographic analysis showed additional findings in 27% of patients with nodular disease using VHRCT-MIP in 8% of patients with emphysema and 25% of cases with focal areas of ground glass opacities, using VHRCT-MinIP. Relative to HRCT findings, VHRCT better depicted all patterns but subpleural nodules. The surface radiation dose was 2.8 times higher with VHRCT than HRCT. It is possible to halve radiation exposure using a low dose protocol (120 kV, 110-150 mA). CONCLUSIONS: Our study provides conclusive results concerning the use of VHRCT with standard technical parameters because this technique showed some advantages in the study of a wide range of diffuse or focal lung diseases. We suggest that this protocol be applied only in patients with mild forms of lung disease or in the cases of difficult interpretation, such as suspicious abnormal areas at HRCT, because its doses are higher. Out low-dose protocol is currently on trial but we expect promising results.

[Clinical role of CT-guided transthoracic needle biopsy in the diagnosis of solitary pulmonary nodules]. / Ruolo clinico dell'agobiopsia transtoracica guidata con tomografia computerizzata nella diagnostica dei noduli polmonari solitari.

PURPOSE: The aim of this prospective study was to assess the overall diagnostic accuracy of CT-guided transthoracic biopsy of solitary pulmonary nodules, to compare the reliability of the diagnosis of malignancy made at prebiopsy CT and to investigate the final clinical impact of cyto-histologic results. MATERIALS AND METHODS: A prospective study was carried out on 128 CT-guided transthoracic biopsies performed in 119 subjects with a solitary pulmonary nodule to assess the diagnostic accuracy of the method. The cyto-histologic diagnosis was then compared to the previous radiologic and CT diagnosis and to clinical outcome, to define the reliability of the previous CT diagnosis and the clinical impact of lung biopsy in relation to its risk. For each needle biopsy, the lesion site, diameter and depth, the number of punctures and needle size were related to the complications, their latency and treatment. The cyto-histologic diagnosis was compared with the results of the macro- and microscopic examination of the surgical specimens in the surgical patients (no. 44). RESULTS: As for the drawbacks of our approach, 40 patients (31%) developed pneumothorax which required thoracic drainage in 10% of cases. A self-resolving, clinically asymptomatic blood effusion was observed around the lesion site or adjacent to the needle path in 21 patients. All the complications were only related to the number of needle punctures and to perilesional emphysema. 113 of 128 (88%) needle biopsies of isolated pulmonary nodules were diagnostic, with 88 malignant and 25 benign lesions. All malignant diagnoses had surgical (42 cases) of follow-up confirmation. No false positives were observed in our series but we had 4 false negatives; specificity was 100%, sensitivity 95%, PPV 100% and NPV 84% and overall diagnostic accuracy 96%. The CT diagnosis of malignancy was correct in 68% of cases and we had 16 false positives and 20 false negatives. Thus, CT had 77% sensitivity and 36% specificity in malignant characterization and particularly in identifying benign lesions (9 of 25 cases). The results of biopsy had an unquestionable impact on diagnosis and treatment in 44% of patients: the previous CT diagnosis was modified in 32% and treatment planning changed accordingly. In the other 14 patients whose CT diagnosis was correct (4 lymphomas, 3 small cell carcinomas, 3 mesotheliomas, 4 benign lesions), biopsy was the cornerstone of subsequent treatment planning. CONCLUSIONS: CT-guided thoracic biopsy, allowing an accurate histologic diagnosis, is confirmed as a safe procedure with a strong impact on the diagnostic protocol of the solitary pulmonary nodule.

[Computerized tomography and magnetic resonance in the diagnosis of recurrent rectal neoplasms: comparison of reliability and errors of both methods]. / Tomografia computerizzata e Risonanza Magnetica nella diagnosi di recidiva delle neoplasie del retto: affidabilità ed errori delle due metodiche a confronto.

Our work was aimed at assessing the accuracy of CT and MRI in the early identification of postoperative recurrences of rectosigmoid cancer, quantifying false positive and false negative ratios and questionable findings. A homogeneous series of 50 patients submitted to surgery for primary rectosigmoid carcinoma was studied with both CT and MRI and followed-up for up to 2 years: local recurrences were observed in 15 patients (30%) which occurred within the first year of surgery in 67% of cases and were in extraluminal site in 86% of cases. CT appeared to be a reliable and highly sensitive screening method, with 82% sensitivity: only 2 false negatives were observed, which were nevertheless followed-up because CT had yielded questionable, and not negative, findings. In contrast, CT had only 78% specificity, being unable to differentiate fibrosis, displaced normal structures and recurrences in 7 cases; its positive predictive value (PPV) was 66%, with 89% negative predictive value (NPV) and 80% accuracy. MRI had a complementary role to CT, because of its capabilities in discriminating all the questionable CT cases and in identifying all CT false positives, thanks to its higher specificity (100%). MRI had 74% sensitivity, which was lower than that of CT; MRI yielded 2 false negatives which, however, had been previously diagnosed with CT. MRI had 100% PPV, 89% NPV and 92% accuracy. Therefore, for the early detection of rectal cancer recurrences, the following diagnostic protocol is suggested: CT should be performed first, as a screening method, within 2-4 months of surgery, and repeated every 6-8 months during the first 2 years-together with CEA values monitoring. MRI should be reserved to the patients in whom CT findings were positive, questionable, or in disagreement with clinical symptoms and/or with increasing CEA values. If MRI fails to solve the diagnostic doubt, a CT-guided biopsy of the mass should be performed.