Bilateral renal hemorrhage in an anticoagulated patient: A rare case of Wunderlich syndrome.

We describe a rare case of Wunderlich syndrome with bilateral renal hemorrhage in a patient under anticoagulant therapy for atrial fibrillation. An 84-year-old woman came to our department complaining of acute bilateral flank pain. Clinical and laboratory examinations revealed a condition of hypovolemic shock. An abdominal contrast-enhanced CT scan detected the presence of a bilateral hemorrhage affecting the peri- and para-renal spaces. Planning an appropriate management strategy considering the anticoagulated treatment required a multidisciplinary approach in the case of the Wunderlich syndrome diagnosis.

Pneumomediastinum: a rare complication in COVID-19 patients.

A 62-year-old man with COVID-19 had PS for fever, coughing, and breathlessness. Two days after therapy, the patient's clinical condition worsened. X-ray and CT showed pneumomediastinum, emphysema and pneumothorax. The patient was intubated and subjected to conservative therapy. The patient was discharged after about 20 days. Radiological imaging plays a key role in the proper diagnosis and treatment of COVID-19 patients with related complications.

Lung Cancer and Radiological Imaging.

BACKGROUND: Lung cancer is the neoplasm with the highest prevalence and mortality rates in the world. Most patients with lung cancer that are symptomatic have hemoptysis, coughing, shortness of breath, chest pain and persistent infections. Less than 10% of patients are asymptomatic when the tumor is detected as an incidental finding. OBJECTIVE: The present expert review aims to describe the use of radiological imaging modalities for the diagnosis of lung cancer. METHODS: Some papers were selected from the international literature, by using mainly Pubmed as a source. RESULTS: Chest x-ray (CXR) is the first investigation performed during the workup of suspected lung cancer. In the absence of a rib erosion, CXR cannot distinguish between benign and malignant masses, therefore computed tomography (CT) with contrast enhancement should be performed in order to obtain a correct staging. Magnetic resonance imaging of the chest is considered a secondary approach as the respiratory movement affects the overall results. CONCLUSION: Radiological imaging is essential for the management of patients affected by lung cancer.

Ground glass pulmonary nodules: their significance in oncology patients and the role of computer tomography and 18F-fluorodeoxyglucose positron emission tomography.

OBJECTIVE: to determine the clinical significance of ground glass pulmonary nodules, either pure (GGNs) or mixed with the presence of solid component (MPNs), in patients with known pulmonary or extra-thoracic malignancies and to evaluate the role of computed tomography (CT) and positron emission tomography (PET)/CT in their diagnosis and follow-up. METHODS: A total of 130 nodules in 68 patients were revealed: 119 GGNs and 11 MPNs. GGN lesions were found in 58 patients, MPNs in eight, and in two cases, both. The median diameter of the nodules was 7 mm (3-30 mm). Moreover, 27 patients, who had a pars-solid >5 mm in the GGN or a pure GGN with a diameter > 5 mm, underwent FDG PET/CT. The median follow-up with CT was >3 years. RESULTS: The comparison between the first and the last positive CT scan showed that GGNs and/or MPNs remained unchanged for a median period of 18 months (range 11-48 months) in 53 patients, they disappeared after a median of 3.5 months (range 2-11 months) in 12 and increased in diameter after a median period of 17 months (range 12-67 months) in 3. In particular of these latter patients, two had malignant lesions. Only three patients with a single nodule showed a significant uptake of FDG at PET/CT. CONCLUSION: in the evaluation of GGNs and MNPs, CT examinations performed after 3 months often showed some changes, mainly with respect to nodules disappearing. PET/CT often plays no role but it can exclude malignancy at the end of staging. Finally, in patients with known pulmonary or extra-thoracic malignancies showing GGNs or MPNs, a 3-year CT follow up is justified, due to the slow growth rate of these lesions.

Conflicting or complementary role of computed tomography (CT) and positron emission tomography (PET)/CT in the assessment of thymic cancer and thymoma: our experience and literature review.

BACKGROUND: To evaluate the role of computed tomography (CT) and positron emission tomography (PET)/CT in patients with thymic cancer and thymoma at initial staging. METHODS: We retrospectively reviewed CT and PET/CT scans of 26 patients with a thymic cancer (n = 9) or thymoma (n = 17). Chest CT findings documented were qualitative and quantitative. Both qualitative and semiquantitative data were recovered by PET/CT. The comparisons among histological entities, outcome, and qualitative data from CT and PET/CT were made by non-parametric analysis. RESULTS: PET/CT resulted positive in 15/17 patients with thymoma. CT was available in 5/9 (56%) patients with thymic cancer and in 3/17 with thymoma. All quantitative CT parameters were significantly higher in patients with thymic cancer than thymoma (maximum axial diameter: 45 vs. 20 mm, maximum longitudinal diameter: 69 vs. 21 mm and volume: 77.91 vs. 4.52 mL; all P < 0.05). Conversely, only metabolic tumor volume (MTV) and total lesion glycolysis were significantly different in patients with thymic cancer than thymoma (126.53 vs. 6.03 cm3 and 246.05 vs. 20.32, respectively; both P < 0.05). After a median follow-up time of 17.45 months, four recurrences of disease occurred: three in patients with thymic cancer and one with a type B2 thymoma. CT volume in patients with recurrent disease was 102.19 mL versus a median value of 62.5 mL in six disease-free patients. MTV was higher in the recurrent than disease-free patient subset (143.3 vs. 81.13 cm(3)), although not statistically significant (P = 0.075). CONCLUSION: Our preliminary results demonstrated that both morphological and metabolic volume could be useful from a diagnostic and prognostic point of view in thymic cancer and thymoma patients. A large multi-center clinical trial experience for confirming the findings of this study seems mandatory.

Indeterminate lung nodules in cancer patients: pretest probability of malignancy and the role of 18F-FDG PET/CT.

OBJECTIVE: The purpose of this study was to determine likelihood of malignancy for indeterminate lung nodules identified on CT comparing two standardized models with (18)F-FDG PET/CT. MATERIALS AND METHODS: Fifty-nine cancer patients with indeterminate lung nodules (solid tumors; diameter, ≥5 mm) on CT had FDG PET/CT for lesion characterization. Mayo Clinic and Veterans Affairs Cooperative Study models of likelihood of malignancy were applied to solitary pulmonary nodules. High probability of malignancy was assigned a priori for multiple nodules. Low (<5%), intermediate (5-60%), and high (>60%) pretest malignancy probabilities were analyzed separately. Patients were reclassified with PET/CT. Histopathology or 2-year imaging follow-up established diagnosis. Outcome-based reclassification differences were defined as net reclassification improvement. A null hypothesis of asymptotic test was applied. RESULTS: Thirty-one patients had histology-proven malignancy. PET/CT was true-positive in 24 and true-negative in 25 cases. Negative predictive value was 78% and positive predictive value was 89%. On the basis of the Mayo Clinic model (n=31), 18 patients had low, 12 had intermediate, and one had high pretest likelihood; on the basis of the Veterans Affairs model (n=26), 5 patients had low, 20 had intermediate, and one had high pretest likelihood. Because of multiple lung nodules, 28 patients were classified as having high malignancy risk. PET/CT showed 32 negative and 27 positive scans. Net reclassification improvements respectively were 0.95 and 1.6 for Mayo Clinic and Veterans Affairs models (both p<0.0001). Fourteen of 31 (45.2%) and 12 of 26 (46.2%) patients with low and intermediate pretest likelihood, respectively, had positive findings on PET/CT for the Mayo Clinic and Veterans Affairs models, respectively. Of 15 patients with high pretest likelihood and negative findings on PET/CT, 13 (86.7%) did not have lung malignancy. CONCLUSION: PET/CT improves stratification of cancer patients with indeterminate pulmonary nodules. A substantial number of patients considered at low and intermediate pretest likelihood of malignancy with histology-proven lung malignancy showed abnormal PET/CT findings.

Indeterminate pulmonary nodules on CT images in breast cancer patient: the additional value of 18F-FDG PET/CT.

AIM: To assess the potential role of 18F-Fluorodeoxiglucose (FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) in characterizing indeterminate lung nodules detected at CT scan in patients previously treated for a breast cancer (BC). MATERIALS AND METHODS: Twenty-nine consecutive BC patients (28 females, mean age 65 ± 12 years) with evidence of indeterminate lung nodules at contrast-enhanced CT (CECT) scan (lesions with axial diameter ≥8 mm) were retrospectively analysed: all patients underwent 18F-FDG PET/CT within a mean 2 ± 1 months from CECT imaging. PET/CT was considered positive in the presence of abnormal FDG uptake in the pulmonary nodules and/or in other organs. The nature of lung nodules was defined at histopathology and/or imaging follow-up. RESULTS: Fourteen (48%) patients showed negative and 15 (52%) positive PET/CT scan in the lungs: of these 15 patients, 7 (47%) had pathologic FDG-uptake in lungs only, whereas 8 (53%) showed abnormal FDG-uptake also in sites different from lungs. At histology and/or imaging follow-up, five (17%) patients were considered positive for BC lung metastases while in seven (24%) a second cancer was diagnosed. In this subset of patients, the sensitivity and specificity for FDG PET/CT in revealing lung lesions were 17% and 100%, respectively, for nodules <8 mm in diameter, and 77% and 85%, respectively, for nodules with diameter ≥8 mm. The therapeutic planning was changed to surgery in seven patients, chemotherapy in one patient and continued hormonal therapy in five. The inclusion of PET/CT in the diagnostic algorithm of the evaluated patients helped avoid unnecessary over-treatment in 12 of 29 patients. CONCLUSION: FDG PET/CT appears useful in characterizing indeterminate lung nodules found at CECT scan in BC patients, with a sensitivity that is proportional to nodule size. In addition, PET/CT helped in avoiding over-treatment in a significant proportion of patients.

Early bone marrow metastasis detection: the additional value of FDG-PET/CT vs. CT imaging.

OBJECTIVE: To assess the addition value of ¹8F-Fluorodeoxyglucose (FDG) PET/computed tomography (FDG-PET/CT) vs. CT in detecting early metastatic deposits in bone marrow (BM). METHODS: From January 2009 to December 2010, 198 consecutive patients (88 male, 110 female; median age: 64 years) were retrospectively examined. All patients underwent ¹8F-FDG-PET/CT for disease evaluation: 65 for lung cancer, 66 for breast cancer, 57 for lymphoma and 10 for multiple myeloma. All scans were reviewed by a radiologist and a specialist in nuclear medicine for the identification of bone lesions. The presence of BM metastases was confirmed by biopsy, sequential PET/CT scan or magnetic resonance imaging when available. A patient-based analysis was performed. RESULTS: Investigating the presence of skeletal metastasis, 94 (48%) patients had positive and 104 (52%) negative CT scan whereas 110 (56%) had positive and 88 (44%) negative FDG-PET/CT scan (P<0.001). The two imaging modalities were concordant in 178 (90%) patients for bone lesions; on the contrary 20 (10%) patients had discordant results (P<0.001). In 21 out of 178 concordant patients BM lesions were identified both in CT and FDG-PET, whereas nine out of the 20 discordant patients showed BM involvement at PET/CT only. Overall, PET/CT was able to identify 30 (15%) patients with BM lesions. In these latter patients, the maximum standardized uptake value (SUVmax) for BM metastases was 7.9±4.5 (range: 3.1-19.0), resulting slightly higher in patients with negative than positive CT scan (8.3±5.1 vs. 7.8±4.3, respectively; P=0.79). CONCLUSIONS: FDG-PET/CT resulted more accurate than CT in early detection of BM metastases. The FDG-PET/CT images improve the staging of about 15% of our study population. PET/CT detected BM lesions mainly on the basis of their increased metabolic activity rather than on anatomical alterations. Moreover, it provided an accurate identification of tumour viability that was useful for treatment planning and follow-up.

[Treatment of liver metastases from colorectal carcinoma: our experience]. / Trattamento delle metastasi epatiche da carcinoma colorettale: nostra esperienza.

The latest hepatic surgical strategies enable liver resections to be performed on a larger number of patients, improving the survival rate. Moreover, the contribution of radiological techniques and chemotherapy to surgery has led to the multidisciplinary management of patients suffering from liver metastases, involving surgeons, radiologists and oncologists. If surgical treatment is not considered curative, it is appropriate to advise alternative strategies in order to down-stage the disease and make it resectable.