Factors predicting complete necrosis rate after ultrasound-guided percutaneous laser thermoablation of small hepatocellular carcinoma tumors in cirrhotic patients: a multivariate analysis.

PURPOSE: To assess factors affecting the effectiveness of percutaneous laser ablation (PLA) under ultrasound (US) guidance in terms of complete ablation achievement. MATERIAL AND METHODS: The clinical records of 86 hepatocellular carcinoma (HCC) tumors (mean diameter 23.7 mm) in 60 cirrhotic patients (mean age 68.3 years; 36 males; 57 HCV+; 53 Child's class A, seven Child's class B) treated by means of PLA were reviewed. PLA was performed with a continuous-wave Nd:YAG laser by a single operator who positioned two to four 300-microm optic fibers advanced in 21-gauge needles into target lesions under US guidance. Triphasic computed tomography (CT) studies were used to verify treatment effectiveness 1 month after PLA completion. The association between characteristics of the lesion and outcome (complete or incomplete ablation) was evaluated by logistic regression, taking into account the following predictive factors: tumor size, pattern of growth (infiltrating or not) at imaging, location, first diagnosis of HCC (naïve tumors vs. non-naïve tumors), number of sessions (1/ > 1), total delivered energy, and years of treatment in 2001-2002 (first period) vs. 2003-2004 (second period). RESULTS: Complete ablation was obtained in 62 nodules (72%). Statistically significant predictors of incomplete ablation after the first PLA course at both univariate and multivariate analysis included: infiltrating growth pattern (odds ratio (OR) 12.3, P<0.002), non-naïve tumors (OR 8.7, P<0.001), and first period of treatment (OR 10.3, P<0.002). CONCLUSION: The effectiveness of US-guided PLA for HCC tumors < or =4 cm turned out to be negatively affected by both operator-related (the beginning of the operator's experience with the technique) and tumor-related factors (non-naïve, infiltrating HCC tumors).

[Cystic dilatation of the seminal vesicles: which diagnostic approach?]. / Dilatazione cistica delle vescichette seminali: quale l'iter diagnostico?

PURPOSE: We investigated the frequency, clinical features, diagnostic course and therapy of congenital and acquired seminal vesicle cysts. MATERIAL AND METHODS: Seven vesicular cysts were found in adult subjects in 1995-1996. All diagnoses were made with suprapubic and transrectal US, CT and MRI. Vesiculo-deferentography was never used for diagnosis. Patient age and symptoms, cyst site, structure and dysembryogenetic associations were considered for diagnosis. RESULTS: All the patients were adult and all but one fertile. Age ranges were IV (43%), III and V (28.5%) decades. The cyst was congenital in 5 patients, associated with other dysplasias in 60% of them, and acquired in 2 patients. 57% of patients had urogenital symptoms and 2 patients (28.5%) had no clinical signs. US was performed for fertility tests in one patient. The left gland was always and exclusively involved; its size ranged 3.2 to 5.8 cm and its shape was characteristic only in 2 acquired cysts. DISCUSSION: Both abdominal and rectal US examinations were always performed and always reliably showed cyst site, origin, size and components. CT confirmed local findings and was also used to study the abdomen assessing renal presence and function. MRI permitted the best anatomical study with the multiplanar demonstration of the relationships between small pelvis structures. CONCLUSIONS: Congenital cysts and acquired distension of the seminal vesicles are uncommon findings also because they are difficult to diagnose. Diagnostic imaging reliably differentiates vesicular cysts from other cystic collections in that region, providing enough information to distinguish acquired from congenital forms, the former curable with drug treatment and the latter requiring more invasive therapy. Relative to site prevalence (100% in the left gland), we do not know if this was an aleatory finding or it indicated an actual congenital predisposition. US yields the indispensable diagnostic findings, but MRI should be always performed to ensure diagnosis, to study the abdomen and to plan possible surgery.

[Doppler color ultrasonography with contrast media in the study of eye and orbit neoplasms]. / L'eco color Doppler con mdc nello studio delle neoplasie dell'occhio e dell'orbita.

We investigated the diagnostic efficacy of the i.v. administration of a sonography (US) contrast agent to study eye and orbit tumors at different stages. We administered Levovist (Schering), an air microbubble stabilized by fatty acid, which is specific for angiographic indications. Baseline color Doppler US was performed on 24 selected patients and tumor vascularization patterns were classified into three classes. Color Doppler signal enhancement was assessed after contrast agent administration and the signal-to-noise ratio (SNR) was improved in 70% of cases, which helped identify vascular patterns and improved flowmetric accuracy. The Doppler effect was also improved and vascular signal was always enhanced. The SNR was improved also by the postcontrast detection of small vessels missed on baseline scans. Doppler signal enhancement was proportional to precontrast vascularization and depended on tumor size, with poor results in lesions < 5 mm. In contrast, vascular signal spots with increased postcontrast echogenicity sometimes caused excessive noise affecting the results. No correlation was found between signal enhancement and lesion histotype or between signal and lesion site. Treated lesions exhibited poorer contrast agent enhancement. The examination technique must be accurate and the various parameters set optimally, especially the velocity scale, gain and filtration; the unit must feature adequate recording capabilities (mm/s). To conclude, we believe that the routine use of i.v. US contrast agents will play a major role in improving diagnostic imaging in oculistics also thanks to the lack of untoward reactions and to the ease of contrast agent preparation.

[Clinico-radiologic considerations on "stress fractures" of the leg]. / Considerazioni clinico-radiologiche sulle "fratture da stress" dell'arto inferiore.

Stress fractures are ubiquitary and most often caused by the subject's activities. In the past they occurred mostly in recruits, but today they are frequent in sportsmen. Stress fractures most frequently occur in the lower limbs, especially in the distal leg. We reviewed 32 injuries observed January, 1993, to June, 1995, and found that 25% of them had been misdiagnosed as stress fractures: in the cases where the diagnosis was correct, fatigue fractures (32%) were less frequent than insufficiency fractures (68%) and occurred in young subjects (mean age: 24 years), usually sportsmen (2/3 of cases). Insufficiency fractures may occur in people aged 8 to 81 years (mean: 61 years) and in subjects with metabolic disorders (45.5%). Considering the injury biomechanics and the patient history and symptoms, these lesions appear a rather uncommon event, whose radiologic diagnosis must be confirmed by clinical findings, since radiology mostly (81.6% of cases) showed only the repair process, rather than the fracture itself. The radiologic patterns were classified into three groups: the fracture margin was not shown in 70% of cases (group I), where however intraperiosteal reaction and/or soft tissue effusion were found; bone fracture was shown in 3 cases (group II) and fracture sequels in 4 (group III), where bone thickening (3 cases) or abnormal consolidation (1 case) was found. There are several synonyms of "stress fracture" and confusion is increased because stress lines and other not necessarily abnormal signs such as Park or Harris lines, reinforcement or calcification lines, are often grouped together with stress fractures. Only accurate clinical examination and laboratory findings permit to distinguish fatigue from insufficiency stress fractures and the latter are also very difficult to differentiate from pathologic fractures. The differentiation of fatigue from insufficiency fractures, originally made by English speaking authors, may be confusing because the definition "pathologic fractures" should be reserved only to focal injuries while in the past it included also insufficiency fractures. Thus, only (bone) fatigue injuries in patients exercising intensely and constantly should be considered stress fractures. Conventional radiography is an indispensable tool and MRI is used in selected cases where the former method is negative and in the patients needing early mobility to go back to work. If radiographic findings are questionable for metastases, nuclear medicine is the method of choice and CT and/or MRI may be indicated as second-line diagnostic imaging tools.