Recurrent hepatocellular carcinoma and non-classic adreno-genital syndrome.

OBJECTIVE: Hepatocellular carcinoma (HCC) is one of the most common fatal cancer in the world and androgens are among the possible etiological factors. Congenital adrenal hyperplasia (CAH) is a group of inherited diseases caused by enzyme failure in the steroid biosynthesis of the adrenal cortex, resulting in an augmented 17-hydroxyprogesterone, androstenedione and testosterone production. While the occurrence of testicular adrenal rest tumors and adrenocortical tumors in congenital adrenal hyperplasia is well described in the literature, no data on HCC occurrence are available. CASE PRESENTATION: A 35-years-old Italian man of Caucasian origin, affected by non-classic CAH due to partial 21-hydroxylase deficiency came to observation for revaluation of his adrenal picture. Besides common hormonal and biochemical analysis, an abdomen Magnetic Resonance Imaging was performed, resulting in an 18 mm large nodular lesion between liver segments VII and VIII. Radiological reports matched with an increased serum α-fetoprotein level. A surgical removal of the lesion was performed. After that, several recurrences of the lesion, which was consequently treated by radiofrequency ablation, occurred. Every recurrence was accompanied by an increase in testosterone and steroid hormone binding globulin serum levels. CONCLUSIONS: Our report suggests the need for screening of liver lesions in males affected by this syndrome.

Neoadjuvant concurrent radiochemotherapy in locally advanced (IIIA-IIIB) non-small-cell lung cancer: long-term results according to downstaging.

BACKGROUND: To report the efficacy of induction treatment (IT) protocol with concurrent radiochemotherapy in locally advanced non-small-cell lung cancer (NSCLC), and to analyze downstaging as a surrogate end point. PATIENTS AND METHODS: Patients with histo- or cytologically confirmed stage IIIA or IIIB NSCLC were treated according to an IT protocol followed by surgery. Downstaging was assessed for all resected patients. RESULTS: In the period between February 1992 and July 2000, 92 patients were enrolled in the study (57 IIIA, 35 IIIB). Response was observed in 63 patients; 56 patients underwent radical resection. Patients downstaged to stage 0-I (DS 0-I) showed a statistically significant improved disease-free survival (26.2 months pStage 0-I versus 11.2 months pStage II-III; P=0.0116) and overall survival (median 32.5 months pStage 0-I versus 18.3 months pStage II-III; P=0.025). Patients with DS 0-I had a significantly lower probability (P=0.0353) of developing distant metastases estimated in 0.2963 odds ratio. CONCLUSION: Neoadjuvant radiochemotherapy is feasible with good pathological DS results. Pathological downstaging was confirmed to have high predictive value. Its use is suggested in the short-term evaluation of induction protocols efficacy in locally advanced NSCLC.

Congenital absence of the portal vein associated with focal nodular hyperplasia in the liver in an adult woman: imaging and review of the literature.

We present a new case of congenital absence of the portal vein and focal nodular hyperplasia in the liver without additional congenital anomalies. Ultrasound, computed tomography, magnetic resonance imaging, and angiography depicted the splenic vein and the superior mesenteric vein joining and entering into the inferior vena cava without passing through the liver. The features of this patient and the 30 previously reported cases are reviewed.

Ten year experience with induction therapy in locally advanced non-small cell lung cancer (NSCLC): is clinical re-staging predictive of pathological staging?

OBJECTIVE: To verify if in our experience with 'induction therapy' in non-small cell lung cancer (NSCLC) the clinical re-staging is really predictive of pathological staging. MATERIALS AND METHODS: From January 1990 to February 2000, 136 patients with locally advanced NSCLC underwent a protocol of induction therapy according to three different treatment plans: Carboplatin + radiotherapy--study A; Cisplatin + 5-Fluorouracil + radiotherapy--study B; Gemcitabine + radiotherapy--study C. RESULTS: Clinical re-staging showed in the patients enrolled in study A a clinical Complete Response rate (cCR) of 2.3%; a clinical Partial Response rate (cPR) of 50%; a clinical Stable Disease (cSD) rate of 44.3%; a clinical Disease Progression (cDP) rate of 3.4%. In study B, cCR was 0%; cPR: 71.4%; cSD 10.7%; cDP: 17.9%. In study C, cCR was 0%; cPR: 23.5%; cSD: 11.8%; cDP: 64.7%. After clinical re-staging, 76 patients (47 group A; 23 group B; 6 group C) were judged to be resectable and underwent a surgical operation. Pathological staging showed no tumour in eight patients (10.5%; 8/76) (three in study A, four in study B, one in study C) and microscopic neoplastic remnants in seven (9.2%; 7/76). Thirty-nine patients were pN0. Overall downstaging rate in the operated patients was 51%. No precise correlation was found among clinical re-staging and pathological staging. We had two cCRs and eight pCRs, and all of these pCRs had been re-staged as cPR except in one case (cSD). In seven cases, where only microscopic remnants have been found, six had been clinically restaged as cPR and one as cSD. CONCLUSIONS: Our experience confirmed how often the clinical re-staging data are unreal. Accordingly surgery should be indicated in any case where an induction therapy has been administered, if it is reasonably possible.

Amebic abscess of urachal remnants.

We report a rare case of amebic abscess of the urachus, mimicking an urachal neoplasm: no previous reports of amebic infection of the urachus were found in the literature. The challenges of the differential diagnosis between urachal abscess and carcinomas based both on clinical and radiological data are discussed.

[Evaluation of the "N" factor in nonsmall cell lung cancer. Correlation between computerized tomography and pathologic anatomy]. / Valutazione del fattore "N" nel carcinoma polmonare non a piccole cellule. Correlazione tra Tomografia Computerizzata e anatomia patologica.

PURPOSE: To evaluate the role of CT in identifying other morphological signs of metastatic lymph node involvement from non small cell bronchogenic carcinoma. This is done to improve N staging, a critical step in this disease. In fact, since diameter is the only criterion used to distinguish normal form abnormal lymph nodes, medistinal CT only has 80% diagnostic accuracy. MATERIAL AND METHODS: 137 patients with known or suspected lung cancer were examined with Helical CT during early and late arterial phases (2 min delay, 3 mm thickness, 5 mm interslice gap) to depict node characteristics. Mediastinal lymph nodes, located according to the American Thoracic Society mapping, were considered normal when they were not visible or, if visible, less than 1 cm in diameter and of homogeneous density; lymph nodes over 1 cm in diameter and homogeneous density were considered reactive. A lymph node was considered metastatic when, independent of size, the following signs were found: central hypodensity; hyperdense thin/thick rim, with nodules within; hyperdense strands or diffuse hyperdensity in perinodal adipose tissue. The tumor site was also considered. RESULTS: Seventy patients were excluded because they were inoperable. Sixty-five of the remaining 67 patients were operated on, 1 underwent mediastinoscopy and another one mediastinoscopy followed by surgery. Based on the above CT signs, 46 patients were staged as N0, 61 as N1 and 15 as N2. In 44/46 N0 patients there was agreement between anatomical and pathologic findings; 3 of the 44 patients had lymph nodes over 1 cm in diameter and with homogeneous density. Micrometastases to mediastinal lymph nodes (N2) were found at histology in 2/46 patients (CT false negatives). In the 6 N1 and the 15 N2 patients there was complete agreement between anatomical and pathologic findings; in particular, 9 N2 patients had lymph nodes less than 1 cm in diameter with signs of metastasis and 4 had lymph nodes over 1 cm in diameter with signs of metastasis and 2 had lymph nodes either over or less than 1 cm. In all N2 patients the tumor histotype and the mediastinal location were also considered relative to the lesion site. DISCUSSION: A closer correlation was found with node morphology and density than with size. Indeed, CT sensitivity, specificity and diagnostic accuracy were 97, 100 and 97%, respectively, for the former versus 52, 93 and 77% for the latter. Adenocarcinoma was the predominant histotype (70.5%) in N2 patients. Metastases to node region 4 were predominant in right upper lobe carcinomas while node region 5 was predominant in left upper lobe lesions. CONCLUSIONS: Other criteria can be associated with size to improve CT diagnostic accuracy in N staging. Technique optimization plays a major role particularly in the late, thin slice, examination phase.

Lymph node imaging: from conventional radiology to diagnostic imaging.

From Herophilus, Aristotle in the 3rd century BC, Aselli, Pecquet, Mascagni to Jossifow and Rouviere the lymphatic system was investigated. Kinmonth and Wallace were the first to study it with lymphangiography. Mediastinal lymph nodes were poorly visualized in high contrast radiography before the seventies; subsequently with the high voltage technique, xerography and signs from mediastinal lines they were better identified. However these procedures were replaced by CT, with which even lymph nodes less than 0.5 cm in size, are recognized. The differentiation between normal and pathologic lymph nodes is based on dimensional, morphologic and densitometric criteria. CT is able to identify typical patterns of inflammatory, systemic and metastatic lymph nodes. On lymphography a great number of signs as gross and dense dotting, foaming, chipping and lacunae are identified, which allow the differentiation of inflammatory, systemic and metastatic patterns. On sonography some nodal characteristics are evidenced as the round shape, hypoechogenicity, absence of hyperechoic medullary line. CT has replaced lymphangiography in the study of abdominal lymph nodes.

Combined diagnostic imaging of mediastinal lymphadenopathy in lung cancer.

The identification and characterization of lymphadenopathies is one of the fascinating challenges of modern diagnostic imaging. At present, the real problem is the distinction between normal and pathologic signs. For twenty years, the differentiation was based on the dimensional criterion, namely a short axis < 1 cm, however it was shown to be inadequate. After an overview of the anatomy, ATS classification, the role of N factor in lung cancer (60% of N0 patients survive at 5 years) while only 20% of N2 patients survive), the new signs evidenced on CT are analyzed and interpreted. With thin section, late phase CT, a retrospective study and a perspective study were carried out on densitometric changes in lymph nodes correlated with histology findings. The role of intranodal hypodensity, peripheral rim and adipose tissue was stressed. The results of these studies were concordant with histology findings and confirmed the better accuracy in staging and the impact on survival of extranodal spread detected, based on radiologic criteria.

Diagnostic imaging of pulmonary tuberculosis.

Pulmonary tuberculosis in its primary and postprimary form is a widespread disease. Radiologic and CT findings in the acute phase of the disease, its many different aspects, as well as the alterations observed following the outcomes of tuberculosis at the parenchymal and pleural level, are examined.

Technical trends in functional radiology of the lung.

In functional radiology of the lung, the depiction of subtle details of circulatory and bronchial anatomy, is very important. At present, the evolution of the radiographic techniques allows to overcome the difficulty in imaging, essentially related to the marked difference in density of chest structures, producing radiographs optimized to the concomitant representation of the parenchyma and higher absorption structures. Main quality factors related to radiation beam optimization on one hand and to imaging systems on the other hand, are considered with an analysis of the evolution of methods and techniques of thoracic radiology.

[Pulmonary thromboembolism and diagnostic imaging: integration of techniques and methods]. / Tromboembolia polmonare e diagnostica per immagini: integrazione di tecniche e metodiche.

Thromboembolism is presently the third most frequent cardiovascular disease, with an incidence of deep venous thrombosis of 800,000 cases a year in the USA. The clinical diagnosis of the condition is difficult and noninvasive procedures are poorly reliable, which makes the diagnosis and treatment of deep venous thrombosis appropriate in the patient with clinically suspected pulmonary embolism. Color-Doppler US is now replacing phlebography in the diagnosis of deep venous thrombosis. Proximal deep venous thrombosis is always at high risk for embolism (50%). Isolated calf thrombi may spread into proximal veins and thus cause severe embolism. Therefore, the early detection of thrombus site and extent and a timely treatment before embolism are of the utmost importance. Color-Doppler US is a noninvasive technique which can show deep venous thrombosis with 95% sensitivity in the proximal and 55% sensitivity in the distal districts in asymptomatic patients. This examination must be used not only to confirm a diagnostic suspicion of deep venous thrombosis, but also to screen high-risk patient and to monitor distal thrombosis. In the secondary prophylaxis of pulmonary embolism, the radiologist must perform a mechanical interruption of inferior vena cava by positioning a caval filter. Caval filters can be temporary or definitive; standard indications for caval filter positioning are a contraindication to anticoagulant therapy and the onset of pulmonary embolism in spite of anticoagulant drugs. A further indication is the presence of floating thrombi in the femoroiliac-caval trunk. Multidisciplinary groups including the hematologist, the radiologist and the clinician should plan the diagnostic and therapeutic approach and participate in the decision-making process. In our department, from January, 1992, to June, 1995, sixty-five caval filters were positioned in 62 patients selected out of 260 candidates. Three complications only were observed; one patient had recurrent pulmonary embolism and three patient had caval thrombosis spreading beyond the filter. In 198 patients in whom no caval filter was implanted, pulmonary embolism did not recur. At present, the role of the radiologist is markedly changing, especially in the management of this condition. On the one hand, radiologists must diagnose thromboembolism as a whole and not only its pulmonary evidence; on the other hand, they play a major operational and interventional role in the treatment of thromboembolism patients.

Epidemiology, pathophysiology and natural history of venous thromboembolism.

Venous thromboembolism is a relevant social and health care problem for its high incidence, pulmonary embolism-related mortality, and long-term sequels which may be disabling. In the United States, there are at least 100,000 deaths per year from pulmonary embolism, found in over 10% non selected autopsy findings. The use of noninvasive diagnostic procedures has improved our knowledge on venous thromboembolism, with reference to surgery in particular. Deep vein thrombosis represents one of most common postoperative complications. Fatal pulmonary embolism is observed at least in one over thousand operated patients. From data of literature and in the authors' experience, the incidence of pulmonary embolism is decreasing in last years. Deep vein thrombosis is caused by several factors associated with Virchow's triad. Its evolution is site-related. While deep vein thrombosis of the calf can be considered a "benign" pathological condition for the incidence and severity of the embolic complication, as well as for the long-term outcomes, when the proximal venous trunks are involved, it is related to a high incidence of severe pulmonary embolism and relevant postphlebitic sequels. Pulmonary embolism is often the first manifestation of thromboembolism. Mobilization of thrombi is easier in the first phases, when they do not adhere as yet to the venous wall. Of 52 consecutive cases of pulmonary embolism, 21% occurred in the absence of signs or symptoms of deep vein thrombosis. In rare cases, thrombosis may be massive with total block of venous return flow and onset of ischemia. These forms have a severe prognosis apart from the embolic complication.

Chest radiograph in pulmonary embolism.

Chest radiograph plays a major role in patients with suspected pulmonary embolism because it frequently allows the visualization of the radiologic signs of pulmonary embolism without or with infarct while at the same time the presence of other diseases which mimic it, can be detected. Combined with other investigations this finding allows the precise diagnosis of a higher number of diseases while other diagnostic exams can be selected. Numerous radiologic signs are visualized. They involve the vascularization, the parenchyma, the pleura and diaphragms. They allow to distinguish between embolism with infarct from embolism without infarct. They require a global interpretation to attribute a diagnostic role to chest radiograph. This should be carefully performed to represent a valid support to the diagnostic approach.

Multidisciplinary approach to venous thromboembolism.

Venous thromboembolism shows a high incidence and a significant mortality. Even if valid methods are available, thromboembolism is underdiagnosed. There are a number of diagnostic difficulties. They concern the time of the diagnostic suspicion, the patient selection for the various procedures and their combination. These difficulties may be overcome by team work where specialists of different disciplines (surgeons, internists, experts in nuclear medicine, radiologists) integrate their competence to attain the established objectives. The integration results in "synergism", namely an added value greater than the sum of competences of the team components. Thus, an operational unit active 24 hours over 24 must be formed to diagnose and treat the largest number of cases of thromboembolism. To establish the clinical suspicion of thromboembolism is the first indispensable step for patient selection. Thromboembolism should be investigated in all patients with chest pain, dyspnea and tachypnea in the absence of preexisting cardiorespiratory disease. The team should evaluate the impact of signs and symptoms to establish a definitive clinical probability which can direct towards the suitable, least invasive imaging procedure. Perfusion scanning, when highly suggestive or normal, is conclusive. However in 70% of cases it is indeterminate. Thus it should be combined with other procedures and with the clinical assessment. In practice, many dubious cases remain unsolved. The team work represents an organizational response to this diagnostic and therapeutic inadequacy. The real change in strategy which has revolutionized the diagnosis of thromboembolism was the widespread use of color Doppler US in the diagnosis of deep vein thrombosis. Since pulmonary embolism as well as deep vein thrombosis are treated with the same therapy, it is adequate to document the thrombosis also in the absence of a definitive demonstration of embolism. The old-fashioned approach should be reversed and the investigation should be centered on the assessment of deep vein thrombosis: site, emboligenic potential, floating extremity and extension. The integration of the clinical assessment, scanning finding and color Doppler US lowers by about 20% the number of indeterminate cases and indicates the patients for whom pulmonary spiral CT or pulmonary angiography is required. In all patients with cardiorespiratory insufficiency still unsolved after the combination of noninvasive exams, pulmonary angiography or spiral CT is mandatory because of the high risk for death. The remaining ones can be followed with serial color Doppler US exams. The cost/benefit ratio shows that the noninvasive strategy is the least expensive, the least hazardous and the most effective. At present, effective therapies are available for thromboembolism. Standard heparin and low molecular weight heparin fractions, fibrinolytic agents, surgery and recently caval filters are playing a major role in secondary prophylaxis of pulmonary embolism. The therapeutic approach is conditioned by various factors: the features of thrombosis, the presence and entity of pulmonary embolism, the patient cardiorespiratory condition, possible contraindications for anticoagulant and fibrinolytic agents. The presence of such a number of variables makes the use of a therapeutic algorithm, difficult. In this phase, based on our experience we believe that the present solution lies in the activity of an operational team of experts who establish the treatment to be performed.

Digitization of radiologic images.

Information technology is at present an integrating part of the department of radiology. The applications to radiology involve the new imaging procedures as CT and MRI as well as exams which to-date are performed with analog methods. Besides off-line digital conversion of images by video camera or scanner, on-line systems are available with which conventional images are directly converted to digital images. Digital radiography using photostimulable phosphors is based on the capability of barium fluorohaldeide plates to emit light when stimulated by a laser beam. Digital spot fluorography is a dedicated system which enables the digital acquisition of dynamic images. The diffusion and evolution of digital systems dedicated to conventional exams will permit in a near future a fully digital radiology department.

[Lung transplantation: the physiopathological considerations and imaging diagnosis problems]. / Trapianto del polmone: considerazioni fisiopatologiche e problematiche di diagnostica per immagini.

In the last years, lung transplantation has become a widely accepted treatment for the patients suffering from end-stage chronic lung disease. This study was aimed at investigating the role of diagnostic imaging techniques before and after lung transplantation, in the light of the physiopathological changes occurring in transplanted lungs. Our study included 4 patients (3 men and 1 woman, age range: 33-58 years): 3 of them underwent single lung transplantation and one double lung transplantation. All the operations were successful. Chest radiographs and HRCT showed the main early and late complications that occurred after transplantation. In the early postoperative period, the reperfusion syndrome was observed in 2 patients and acute rejection in the 3 patients submitted to single lung transplantation. In the late postoperative period, chronic rejection occurred in the patient submitted to left lung transplantation. None of our patients presented any infection or such airway complications as bronchial dehiscence or strictures. Both literature data and our personal experience show that preoperative diagnostic imaging allows the assessment of lung conditions, which helps choose the better side for transplantation. Moreover, lung size must be studied to match the donor's lung to the recipient's chest. In the postoperative period, both early and late complications must be investigated, all of them characterized by aspecific radiologic findings. Currently, time plays a major diagnostic role but we hope that more accurate interpretation of radiologic findings will improve the clinical assessment of lung transplant recipients.

[Congenital anomalies of the inferior vena cava: role of imaging]. / Anomalie congenite della vena cava inferiore. Ruolo dell'imaging.

In recent years, clinics and radiology of congenital anomalies of the inferior vena cava have increased in importance in planning abdominal surgery, liver or kidney transplantation, or new interventional or diagnostic procedures such as the positioning of inferior vena cava filters to prevent pulmonary embolism, varicocel sclerotherapy and renal venous sampling. In the past, the radiologic assessment of these rare anomalies was performed only with angiography, which remains the most accurate diagnostic method. Today, besides angiography, less invasive examinations can be performed, e.g., US, CT and MRI, with MRA. In the last two years, 5 patients with inferior vena cava anomalies were examined: 3 had double inferior vena cava and 2 azygos continuation. All of them were submitted to US, CT, MRI and MRA and 3 patients underwent also angiography, two of them with double puncture. US can suggest the diagnosis but may be limited by technical factors and in the assessment of the whole inferior vena cava. Enhanced CT can depict anomaly extent, but uses contrast agents and ionizing radiations. Angiography better depicts craniocaudal spread and collateral networks but is an invasive procedure and sometimes needs a double puncture (double inferior vena cava). MRI, with MRA, yields the same information as the other modalities, but without contrast agents or ionizing radiations. The development of velocity encoded sequences will probably make this technique the method of choice in the study of inferior vena cava anomalies. Our study was aimed at reviewing the embryo-genesis of inferior vena cava anomalies and to assess the relative importance of different diagnostic procedures in the diagnosis and staging of these anomalies.

The reasoned combined modality imaging of rectal anatomy.

An accurate analysis of the rectal anatomy and of its "setting" is carried out. The various anatomical structures are defined by the available imaging procedures to supply information on a reasoned combined modality imaging of rectal anatomy.