Diagnostic imaging to detect and evaluate response to therapy in bone metastases from prostate cancer: current modalities and new horizons.

Different therapeutic options for the management of prostate cancer (PC) have been developed, and some are successful in providing crucial improvement in both survival and quality of life, especially in patients with metastatic castration-resistant PC. In this scenario, diverse combinations of radiopharmaceuticals (for targeting bone, cancer cells and receptors) and nuclear medicine modalities (e.g. bone scan, SPECT, SPECT/CT, PET and PET/CT) are now available for imaging bone metastases. Some radiopharmaceuticals are approved, currently available and used in the routine clinical setting, while others are not registered and are still under evaluation, and should therefore be considered experimental. On the other hand, radiologists have other tools, in addition to CT, that can better visualize bone localization and medullary involvement, such as multimodal MRI. In this review, the authors provide an overview of current management of advanced PC and discuss the choice of diagnostic modality for the detection of metastatic skeletal lesions in different phases of the disease. In addition to detection of bone metastases, the evaluation of response to therapy is another critical issue, since it remains one of the most important open questions that a multidisciplinary team faces when optimizing the management of PC. The authors emphasize the role of nuclear modalities that can presently be used in clinical practice, and also look at future perspectives based on relevant clinical data with novel radiopharmaceuticals.

A great enigma of the Italian Renaissance: paleopathological study on the death of Giovanni dalle Bande Nere (1498-1526) and historical relevance of a leg amputation.

BACKGROUND: The Medici project consisted in archeological and paleopathological researches on some members of the great dynasty of the Italian Renaissance. The remains of Giovanni de' Medici, so-called "dalle Bande Nere" (Forlì 1498- Mantua 1526) have not been investigated yet. The enigma of the fatal injury and leg amputation of the famous Captain excited curiosity of paleopathologists, medical scientists and Italian Society of Orthopedic and Traumatology which contributed to realize the project of exhumation and study of his skeletal remains. The aim of the study is to report the first anthropological and paleopathological results. CASE PRESENTATION: The tomb of Giovanni and his wife Maria Salviati was explored and the skeletal remains were investigated. Anthropological and paleopathological examination defined: age at death, physical constitution and activity, skeletal diseases. The bones of the leg were studied macroscopically, under stereoscopic microscope, at X-ray and CT scans to detect type of injury and level of amputation. CONCLUSIONS: The skeleton and muscular insertions of Giovanni revealed a young-adult and vigorous man, subjected to stresses of military activity since adolescence. Right tibia was amputated below the proximal half of diaphysis leaving long tibio-fibular stumps with a horizontal cut only at the lateral portion. Thus, the surgeon limited to complete the traumatic hemi-amputation. Amputation in the Sixteenth Century technically consisted in guillotine incisions below the knee using crescent shaped knife and bony saw, usually leaving a quite long tibial stump. Amputations in the Sixteenth Century were contaminated and grossly performed not providing vascular binding nor wound closure. The surgeon performed the procedure in conformity with surgical knowledge of that period.

Diffusion-weighted signal models in healthy and cancerous peripheral prostate tissues: comparison of outcomes obtained at different b-values.

PURPOSE: To evaluate the dependence on the b-values adopted of apparent diffusion coefficient (ADC), perfusion fraction (PF), slow and fast diffusion coefficient (Dslow, Dfast), corrected diffusion coefficient (D) and kurtosis (K), in healthy peripheral (HP) and peripheral cancerous (PCa) prostate tissues. MATERIALS AND METHODS: Patients who underwent multiparametric prostate MR examination were retrospectively evaluated for possible inclusion. ADC, PF, Dslow, Dfast, D, and K were estimated both in HP and PCa tissues, using three different ranges of b-values: 0-2300, 0-1800, 0-800 s/mm2 (group A, B and C, respectively). Analysis of variance (ANOVA) and receiver operating characteristic (ROC) analysis were performed, to establish differences among groups and to evaluate sensitivity and specificity of every parameter in distinguishing HP and PCa tissues when calculated with different b-values. RESULTS: In all, 57 patients were included. ANOVA showed significant differences of all parameters between group A-B vs. C, both in HP and PCa tissues. In ROC analysis K showed the best area under the curve (AUC) when calculated in groups A and B (0.87 and 0.86), while it was comparable with the ADC one in group C (both 0.82). CONCLUSION: A significant dependence on the adopted b-values of DWI parameters is shown. The best performance in distinguishing HP from PCa tissues was obtained by K, calculated using a high b-value sequence.

High-intensity focused ultrasound provides palliation for liver metastasis causing gastric outlet obstruction: case report.

BACKGROUND: Surgery is the standard of care in several oncologic diseases. However, when non-surgical candidates are not suitable for radical treatment, palliation must be achieved at least. High-intensity focused ultrasound uses ultrasound power that can be sharply focused for highly localised application, as it is a completely non-invasive procedure. Its non-invasiveness appears to be of paramount importance in critically ill patients. CASE DESCRIPTION: We describe the use of ultrasound-guided high-intensity focused ultrasound for a large liver metastasis from breast cancer causing gastric outlet obstruction in a metastatic disease. The left liver deposit did not allow the stomach to empty due to its large volume, and the patient was unable to eat properly. The tumour was metastatic, resistant to chemotherapy and had a size that contraindicated an ablation percutaneous technique. To improve the patient's quality of life, ultrasound-guided high-intensity focused ultrasound ablation seemed the only and most suitable option. Therefore, a high-intensity focused ultrasound treatment was performed, no complications occurred and the patient's general condition has improved since the early post-procedural period. Three months after treatment, two body mass index points were gained, and the lesion decreased by 72% in volume as detected through multi-detector computed tomography follow-up. DISCUSSION AND CONCLUSION: Quality of life is an unquestionable goal to achieve, and palliation must be achieved while causing as little harm as possible. In this view, debulking surgery and percutaneous ablation technique seemed not appropriate for our patient. Instead, high-intensity focused ultrasound combined several advantages, no lesion size limit and a totally non-invasive treatment. Thus, this technique proved to be a clinically successful procedure, offering better disease control and quality of life. In circumstances where other alternatives clearly seem to fail or are contraindicated, high-intensity focused ultrasound can be used and can provide benefits. We recommend its use and development in several oncologic diseases, not only for therapeutic purposes but also for the improvement of patient's quality of life.

Statistical evaluation of hemodynamic effects of regular use of sildenafil on the human corpora cavernosa.

INTRODUCTION: Sildenafil citrate is currently used on demand in the treatment of erectile failure, regardless of etiology. Nevertheless, recent data suggest a significant improvement in nocturnal penile erections in potent and impotent men taking a single dose at bedtime. The present study analyzes whether continuous use of sildenafil positively correlates with improvement of penile blood flow and treatment satisfaction referred by patients with erectile dysfunction (ED) of vascular origin. PATIENTS AND METHODS: A total of 32 patients, mean age 54, with ED of vascular etiology, were evaluated at the beginning and at the end of our study using the International Index of Erectile Function (IIEF-5) and pharmaco-penile duplex ultrasonography during basic and dynamic phases. These patients were treated with sildenafil (50 mg) twice a week for 4 months. During pharmaco-penile duplex ultrasonography, we measured basal peak flow velocity, basal acceleration of peak flow in both cavernous arteries before intracavernous (i.c.) pharmaco-stimulation, maximum peak flow velocities and end-diastolic flow velocities after i.c. stimulation. The data observed were compared with those of 10 patients with ED who voluntarily decided not to take any treatment. RESULTS AND CONCLUSIONS: In this study, basal peak flow velocity, basal acceleration, maximum peak flow velocity and IIEF-5 scores were found to significantly increase after treatment. All differences were statistically significant (p < 0.05). Only few mild adverse effects were observed. Our data suggest that the regular use of sildenafil (50 mg) improves the blood flow in cavernous arteries increasing sexual performance in patients with ED of vascular origin.

CT colonography after incomplete colonoscopy in subjects with positive faecal occult blood test.

AIM: To report our experience with computed tomography colonography (CTC) systematically performed in subjects with positive faecal occult blood test (FOBT) and an incomplete colonoscopy in the setting of a population-based screening for colorectal cancer (CRC). METHODS: From April 2006 to April 2007, 43290 individuals (age range 50-70) who adhered to the regional screening program for the prevention of CRC underwent immunochemical FOBT. FOBT was positive in 1882 subjects (4.3%). 1463 (77.7%) of these subjects underwent colonoscopy, 903 performed in a single center. Of 903 colonoscopies 65 (7.2%) were incomplete. Forty-two of these subjects underwent CTC. CTC was performed with a 16-MDCT scanner after standard bowel prep (polyethyleneglycole) in both supine and prone position. Subjects whose CTC showed polyps or masses were referred to the endoscopist for repeat colonoscopy under sedation or underwent surgery. Per-lesion and per-segment positive predictive values (PPV) were calculated. RESULTS: Twenty-one (50%) of 42 CTCs showed polyps or masses. Fifty-five of these subjects underwent a repeat colonoscopy, whereas 2 subjects underwent surgery for colonic masses of indeterminate nature. Four subjects refused further examinations. CTC correctly identified 2 colonic masses and 20 polyps. PPV for masses or polyps greater than 9 mm was of 87.5%. Per-lesion and per-segment PPV were, respectively, 83.3% and 83.3% for polyps greater or equal to 10 mm, and 77.8% and 85.7% for polyps of 6-9 mm. CONCLUSION: In the context of a screening program for CRC based on FOBT, CTC shows high per-segment and per-lesion PPV for colonic masses and polyps greater than 9 mm. Therefore, CTC has the potential to become a useful technique for evaluation of the non visualized part of the colon after incomplete colonoscopy.

Imaging of male urethra.

The male urethral imaging and pathology is not widespread in the radiology literature because this part of the urinary tract is easily studied by urologists with clinical or endoscopic examinations. Ultrasonography and MR imaging are increasingly being used in association with voiding cystourethrography and retrograde urethrography. The posterior urethra is being studied with voiding cystourethrography or voiding sonography which allows the detection of bladder neck pathology, post-surgical stenosis, and neoplasms. The functional aspects of the bladder neck and posterior urethra can be monitored continuously in patients with neuromuscular dysfunction of the bladder. The anterior urethral anatomy and pathology is commonly explored by retrograde urethrography, but recently sonourethrography and MR imaging have been proposed, distending the lumen with simple saline solution instead of iodinated contrast media. They are being used to study the urethral mucosa and the periurethral spongy tissue which can be involved in the urethral pathologies such as strictures, diverticula, trauma, and tumors. Imaging has an important role to play in the study of the diseases of the male urethra since it can detect pathology not visible on urethroscopy. The new imaging techniques in this area, such as sonography and MR, can provide adjunct information that cannot be obtained with other modalities.