Synovial sarcoma: CT imaging of a rare primary malignant tumour of the thorax.

PURPOSE: This paper presents computed tomography (CT) features of three patients with primary synovial sarcoma of the lung (PSSL) who came to our attention and underwent surgery; reviews of the literature on this rare thoracic tumour are also presented. MATERIALS AND METHODS: The patients, all men, with a mean age of 58 years, underwent clinical and radiological re-evaluation after receiving a histological diagnosis. None of the patients had multifocal disease or other concomitant neoplasms. All patients had undergone both chest X-rays and computed tomography, and two had also been studied with positron emission tomography (PET)-CT. Two patients underwent surgical removal of the tumour, whereas the third initially underwent surgery (following an incorrect diagnosis) and then thoracoscopic biopsy of the pleural lesions that subsequently arose. RESULTS: In each case, chest X-rays showed changes, with the presence of pulmonary masses noted in all patients. In one patient, pleural effusion was also visible. CT scans showed parenchymal masses that were largely of a colliquative nature (in two out of three patients). Ipsilateral pleural effusion was present in two patients, associated in one with solid nodules within the pleura. Mediastinal lymphadenopathy, which was not radiologically significant, was present in only one patient. The two patients who also underwent PET-CT examination showed pathological tracer uptake confined to the lesion site without other thoracoabdominal or musculoskeletal localisations. CT-guided biopsy, performed in one patient only, was positive for mesenchymal tumour. In the two patients who underwent surgery, a definitive diagnosis of monophasic synovial sarcoma of the lung was made. The diagnosis of monophasic synovial sarcoma in the third patient was confirmed using thoracoscopic biopsy DISCUSSION: Both in the cases described and in those identified in the literature review, standard chest X-rays mainly showed a parenchymal mass of pleural origin with either irregular or well-defined margins. CT characteristics are more definite, with evidence of a mass with regular and sharply defined margins, occasionally polycyclic, with inhomogeneous density due to the presence of colliquative areas within the tumour. CONCLUSIONS: Although PSSL is a rare tumour, a pulmonary mass of inhomogeneous density, associated with pleural effusion but without lymphadenopathy, detected in an asymptomatic or poorly symptomatic patient, should lead to PSSL being considered in the differential diagnosis, provided that metastases from the more common synovial sarcomas of the musculoskeletal system have been excluded.

High-resolution CT of nontuberculous mycobacteria pulmonary infection in immunocompetent, non-HIV-positive patients.

PURPOSE: The objective of this study was to demonstrate that nontuberculous mycobacteria (NTM) pulmonary infections are not so infrequent and that the diagnosis may be suggested on the basis of the high-resolution computed tomography (HRCT) pattern alone. MATERIALS AND METHODS: We retrospectively reviewed HRCT scans of 29 patients (9 men, 18 women; mean age 63 years, range 38-88 years) with positive culture from bronchial wash. Mycobacterium avium complex (MAC) was present in all (with the exception of one in whom the NTM was indistinct). In six patients, MAC was associated with M. chelonae, M. kansasii, M. fortuitum or M. xenopi. In one of these patients, MAC was associated with both M. fortuitum and M. chelonae. All patients had had nonspecific symptoms of pulmonary infection for a time ranging from 6 months to 12 years. Previous tuberculous infection was present in five patients (18.5%). Eleven patients had other pulmonary diseases (40.8%), and 12 had associated systemic diseases (44.4%). RESULTS: HRCT findings were apical fibrotic scarring (n=8; 29.6%), consolidations (n=16; 59.2%), single/multiple nodules >1 cm (n=8, multiple; 29.6%), cavitations (n=7; 25.9%), ground glass appearance (n=3; 11.1%), reticular/reticulonodular pattern (n=6; 22.2%), bronchiectasis (n=25; 92.5%), centrilobular nodules (tree in bud) (n=24; 88.8%), air trapping (n=8; 29.6%), lymphadenopathy >1 cm, also with calcification (n=13, 3 with calcification; 48.1%) and pleural effusion (n=2; 7.4%). In 3/7 patients with nodules >1 cm and with cavitations, the "feeding bronchus sign" (a patent bronchus running into a cavitation) was present. Lesions were in the upper lobes in 23 (85.1%), middle lobe/lingula in 25 (92.5%) and lower lobes in 18 (66.6%) patients. The findings were diffuse in 13 (48.1%) cases and patchy in 17 (62.9%). CONCLUSIONS: HRCT findings are essential for the diagnosis of NTM pulmonary infection. The presence of bronchiectasis, cavitary nodules with feeding bronchus sign and tree-in-bud nodules in the middle lobe and lingula are suggestive of NTM infection, thus assisting the physician in the diagnostic workup of these patients.

Mucinous cystadenoma of the pancreas as a cause of acute pancreatitis.

Acute pancreatitis is only rarely the first presentation of a cystic neoplasm of the pancreas. Mucinous cystadenomas have not been reported to be a cause of acute pancreatitis; however, we present two cases of mucinous cystadenoma of the pancreas which have caused acute pancreatitis. Both patients (female) presented acute abdominal pain, with serum amylase elevation and ultrasound scan (US) and computed tomography (CT) evidence of moderate pancreatitis, which resolved with medical treatment; fluid collection in the distal pancreas had been misinterpreted as a pseudocyst. There was no history of alcohol abuse or gallstone disease. After distal pancreatectomy the diagnosis of mucinous cystadenoma was confirmed; in one case a large pseudocyst was associated with this diagnosis. Pre-operative differential diagnosis between inflammatory and neoplastic cysts is difficult, especially when the patient's first presentation is due to an episode of acute pancreatitis. A neoplastic cyst should be considered when acute pancreatitis attacks occur in non-alcoholic women, who do not have gallstone disease.

[High-resolution x-ray computed tomography in the study of the pulmonary parenchyma. Personal experience]. / Tomodensitométrie en haute résolution dans l'étude du parenchyme pulmonaire. Expérience personnelle.

High-resolution CT (HRCT) scans were performed on 156 patients, using a bone-reconstruction algorithm, 1.5 mm sections at 4 cm intervals from apex to base of the lungs and a 512 x 512 matrix. The patients either appeared to have a pathologic condition on chest film, or they presented positive clinical symptoms--i.e., cough, dyspnea, fever--and questionable/negative chest films. Since HRCT is capable of showing the secondary lobule, we employed it to study both its anatomy and the alterations that can modify its normal morphology--i.e., thickening of interlobular septa, reticular pattern, nodular pattern, high-density areas, sub-pleural lines, honeycomb pattern. HRCT findings in secondary lobules, airways, and pleura were examined. They were: lymphangitic spread of carcinoma, pulmonary fibrosis, sarcoidosis, pneumoconiosis, interstitial edema, inflammatory disorders, bronchiectasis, emphysema, and bullae. Even though some limitations still exist due to the non-specificity of HRCT findings, the latter is the best method currently available to recognize and locate interstitial conditions and, sometimes, to make a diagnosis--e.g., of lymphangitic spread of carcinoma, interstitial edema, fibrosis, emphysema, bronchiectasis. Moreover, HRCT can accurately locate pathologic areas for lung biopsy and can be used instead of chest radiographs in the follow-up.

Tracheal and main bronchial diverticula: the role of CT.

PURPOSE: This paper describes an asymptomatic and rarely diagnosed entity without a clear correlation with respiratory disease identified in 1%-2% of cases at spiral computed tomography (CT). MATERIALS AND METHODS: We retrospectively reviewed the CT features of air collections contiguous to the tracheal or main bronchial wall and communicating with the airway in 16 patients undergoing CT for other reasons. Four patients were also studied by virtual bronchoscopy and three by actual bronchoscopy. RESULTS: Thirteen of the 16 patients had a single diverticulum, whereas the remaining three had multiple diverticula. Only one patient had a bronchial diverticulum. The most frequent site was the right posterolateral wall of the trachea at the level of the second or third thoracic vertebral body. In 2/3 of patients, chronic obstructive pulmonary disease was not documented. CONCLUSIONS: CT was the most effective method for evaluating the presence and features of diverticula. A correlation between tracheobronchial diverticula and chronic respiratory disease was documented in 5/16 patients, whereas no respiratory disorder was identified in the remaining 11. Although chronic inflammatory tracheobronchial changes and increased endoluminal pressure may be important causes, we hypothesise that other, as yet unknown, aetiopathological factors could exist.

Organizing pneumonia: typical and atypical HRCT patterns.

Organizing pneumonia (OP) is a clinical-pathological entity that, if idiopathic, makes part of the idiopathic interstitial pneumonias classification of the American Thoracic Society/European Respiratory Society (ATS/ERS) of 2002 (50% of the cases, called cryptogenic organizing pneumonia, or COP). In the remaining 50% it is secondary, representing one modality of response of the lung to various forms of injury. Typical computed tomography (CT) pattern has been widely described and consists of peripheral parenchymal consolidations with air bronchogram with or without surrounding ground-glass-like opacities. The purpose of this article is to describe the less frequent imaging pattern of this disease represented by single or multiple focal lesions (nodules or masses that place diagnostic problems with malignancy), bronchocentric pattern (parenchymal consolidations with peribronchovascular distribution), atoll sign (central area of ground-glass-like density and peripheral area of consolidation), nodular lesions (poorly defined micronodular pattern), linear and band-like opacities (subpleural linear opacities that can have disposition parallel or perpendicular in relation to the pleura), perilobular pattern (thickening of the interlobular septa with reticular pattern) and progressive fibrotic pattern (irregular thickening of the interlobular septa with associated ground-glass-like appearance and consolidations).

[High-definition computed tomography in the study of the pulmonary parenchyma. The author's own experience]. / Tomografia computerizzata ad alta definizione nello studio del parenchima polmonare. Esperienza personale.

High-resolution CT (HRCT) scans were performed on 156 patients, using a bone-reconstruction algorithm, 1.5 collimation at 4 cm intervals from apex to base of the lungs and a 512 x 512 matrix. The patients appeared to have a pathologic condition on chest film, or else they presented positive clinical symptoms--i.e., cough, dyspnea, fever--and questionable/negative chest films. Since HRCT is capable of showing the secondary lobule, we employed it to study both its anatomy and the alterations that can modify its normal morphology--i.e., thickening of interlobular septa, reticular pattern, nodular pattern, high-density areas, sub-pleural lines, honeycomb pattern. HRCT findings in secondary lobules, airways, and pleura were examined. They were: lymphangitic spread of carcinoma, pulmonary fibrosis, sarcoidosis, pneumoconiosis, interstitial edema, phlogosis, bronchiectasis, emphysema, and bullae. Even though some limitations still exist due to the aspecificity of HRCT findings, the latter is the best method currently available to recognize and locate interstitial conditions and, sometimes, to make a diagnosis--e.g., of lymphangitic spread of carcinoma, interstitial edema, fibrosis, emphysema, bronchiectasis. Moreover, HRCT can accurately locate pathologic areas for lung biopsy and can be used instead of chest radiographs in the follow-up.

[Bronchiolo-alveolar carcinoma in a solitary site. The computed tomographic characteristics]. / Carcinoma bronchiolo-alveolare a unica localizzazione. Caratteristiche con tomografia computerizzata.

Bronchioloalveolar carcinoma is a peripheral, well-differentiated neoplasm arising beyond a recognizable bronchus, with a tendency to spread to the peripheral air spaces using the lung structure as stroma. This tumor has better prognosis than other lung neoplasms if it is diagnosed early (stage I). For this reason, the CT scans of 16 patients (all of them asymptomatic, only 2 smokers) were reviewed to assess CT capabilities. The cytologic diagnosis was made with CT-guided fine-needle aspiration biopsy in 4 patients (surgical confirmation followed); the histologic diagnosis was made in 12 patients after surgery. CT findings included the peripheral (14 cases) or subpleural (2 cases; 12.5%) location, irregular margins forming a star-like pattern (2 cases; 12.5%), pseudocavitation (13 cases; 81%), heterogeneous attenuation (11 cases; 69%), pleural tags (14 cases; 87.5%) and air bronchogram (2 cases; 12.5%). These CT findings, if compared with the same number of CT scans in patients with adenocarcinoma and squamous cell carcinoma, are present in 70% of patients (11/16) and, although not highly specific (specificity: 36%), they are typical enough to suggest the diagnosis.

[Pleural and parenchymal lung diseases from asbestos exposure. CT diagnosis]. / Alterazioni pleuro-parenchimali da esposizione all'asbesto. Diagnosi con Tomografia Computerizzata.

INTRODUCTION: We report the CT findings of parenchymal and pleural diseases in a group of patients with a history of asbestos exposure, excluding lung cancer (which is not typical in this subjects) and asbestosis (which is a parenchymal fibrosis). MATERIAL AND METHODS: We retrospectively reviewed a series of CT examinations (conventional, helical and high resolution scans) of 21 patients examined from 1995 to 1999. They had pleural plaques (10), round atelectasis (2) and malignant pleural mesothelioma (9). All patients had a history of direct or indirect asbestos exposure, except one with malignant pleural mesothelioma. We evaluated the following CT findings: nodular, plaque or uniform pleural thickening; pleural calcifications; pleural thickening less or greater than 1 cm; pleural margins (regular, polycyclic, spiculated); localization (uni/bilateral hemithorax); distribution (upper, medium or lower region); pulmonary, mediastinal and diaphragmatic involvement; fissural involvement; pleural effusion; lymph node enlargement; lung mass with the comet-tail sign; lung volume (normal, reduced, increased). RESULTS: Pleural plaques were always bilateral and less than 1 cm thick, with calcifications in 80% of the cases. Margins were always regular, polycyclic in 40% of the patients and never irregular. The pulmonary pleura in the mid-chest was involved in cell cases the diaphragmatic pleura in the 50% of the cases and the upper and lower regions in 60% and 80% of the patients, respectively. Round atelectasis (3 cases in 2 patients) was always shown as a parenchymal mass in the lower lobes, posteriorly or posteromedially, with adjacent pleural thickening; its diameter ranged 4.4-6 cm and there was the comet-tail sign. In malignant pleural mesothelioma we always found pleural effusion, with unilateral pleural effusion being the only sign in 2 patients. Other findings were pleural nodules (77.7%), with spiculated (22.2%) and polycyclic (77.7%) margins, more than 1 cm in diameter. The disease was always unilateral. The parenchymal pleural was involved in 77.7% of the cases while the mediastinal and diaphagmatic pleura were involved in 44.4% of the patients. Fissural involvement was demonstrated in 66.6% of the patients. Lymph nodes were enlarged in 66.6% of the cases. The volume of the affected hemithorax was increased (22.2%), decreased (44.4%) or normal (33.3%). DISCUSSION AND CONCLUSIONS: The presence of pleural plaques is a specific sign of asbestos exposure. Round atelectasis may also indicate asbestos exposure, but it can be found in many diseases with pleural inflammation, such as tuberculous effusion, trauma, pulmonary infarct, congestive heart failure, coronary artery bypass. The CT patterns of these two diseases are typical and no other finding is necessary to confirm the diagnosis. CT-guided needle biopsy is needed only if the round atelectasis has an atypical appearance on CT images, that is without the comet-tail sign. Malignant pleural mesothelioma is strongly associated with previous occupational exposure and presents typical CT findings only in an advanced stage (irregular and nodular pleural thickening, pleural effusion, mediastinal and pulmonary contraction for tumor encasement, parenchymal and lymph node metastases), but the differential diagnosis with pleural metastatic disease can be difficult. CT plays an important role in tumor assessment but biopsy is necessary for lesion characterization.

[Inverted axis scans in the study of the lumbo-sacral passage with computed tomography]. / Scansioni con asse inverso nello studio dello spazio di passaggio lombo-sacrale con Tomografia Computerizzata.

In the CT study of the lumbosacral spine, the disk spaces must be scanned along a plane which parallels the relative intervertebral disk perfectly. However, the lumbosacral space often happens to be too oblique--i.e., over the possible inclination of the gantry (usually: +/- 25 degrees). Thus, the somatic planes of the spine overlap. Therefore, in a series of 1,800 patients, the lumbosacral space was studied with the gantry inclined in the opposite direction to that in conventional scans, with the maximum angle allowed by our unit (-25 degrees). The incidence of negative findings for disk conditions was 7% (versus 13.5% with conventional CT). In both the negative and the positive cases, inversion CT scans were diagnostic in 594 patients (468 with disk herniation)--i.e., in 33% of cases.

[Pulmonary tuberculosis in non-immunocompromised patients. Current radiologic features]. / La tubercolosi polmonare nei pazienti non immunodepressi. Attuali aspetti radiologici.

Sixty-four non-immunocompromised and adult patients with proved tuberculosis were examined. Twenty-three of them had bacteriologic confirmation with sputum examination, 7 with biopsy, 8 with bronchoscopy and bronchial lavage, 3 with pleural effusion examination and 3 with specific ex-juvantibus therapy. Fifteen patients had positive Mantoux skin tests. Thirty-nine patients had primary and 25 postprimary tuberculosis. All patients underwent chest radiography and 37 underwent also CT scans of the chest. The radiographic findings in primary tuberculosis were: 33 parenchymal consolidation patterns (in 24 patients), more frequent in the upper (20/33) than in the lower (13/33) lobes, with cavitations in 16 cases; 2 miliary patterns; 4 atelectasis cases; 4 intrathoracic adenopathies and 11 pleural effusions. The radiographic findings in postprimary tuberculosis were: 32 parenchymal consolidation patterns (in 19 patients), more frequent in the upper (27/32) than in the lower (5/32) lobes, with cavitations in 7 cases; 2 tuberculomas; 1 miliary pattern; 1 atelectasis; 5 pleural effusions and 1 pericardial effusion. Thus, we can conclude that in our series both primary and postprimary tuberculosis appear mostly as upper lobe consolidation, with cavitations especially in the primary form, often with pleural effusion and sometimes with intrathoracic adenopathies. Primary tuberculosis is most frequent in adult men. Finally, lower lobe consolidations or less typical radiographic patterns are observed, e.g., atelectasis, adenopathies or pleural effusion with no parenchymal changes, which can mimic other diseases and thus delay the diagnosis.

[Radiography and computerized tomography of the thorax in lung small cell tumors. Diagnostic possibilities]. / Radiografia e tomografia computerizzata del torace nel tumore a piccole cellule. Possibilità diagnostiche.

Small cell lung cancer (SCLC) is a highly malignant tumor which is nearly always metastatic at diagnosis and generally staged as a localized or diffuse disease. The authors compared the capabilities and the advantages of CT with those of chest films in the diagnosis, staging and follow-up of this type of cancer in 54 patients (52 men and 2 women, mean age: 62 years, range: 45 to 79 years). All the patients were submitted to the same examinations 3 months (18 patients), 6 months (6 patients), 9 months (6 patients) and 12 months (2 patients) after radiochemotherapy. Median survival time was 13 months (range: 6-20 months). On staging, radiography showed mediastinal masses (63%), bronchial narrowing (57%), hilar masses (45%), atelectasis (37%), pleural effusion (29%), pericardial thickening and/or effusion (22%), multiple (20%) or single (16%) peripheral masses and tracheal narrowing (2%). CT was more sensitive, chiefly in depicting mediastinal masses (34 cases demonstrated by CT vs 12 by chest films), bronchial narrowing (38 vs 0) and pericardial involvement (12 vs 0); after CT, 12 patients with localized disease on chest films were diagnosed as having diffuse disease. Complete response after therapy, i.e., the total disappearance of all signs and symptoms of disease for 30 days at least, was depicted by CT in 16 patients and by chest films in 9 patients. Partial response-i.e., disease decrease by 50% or more, with no new lesions, for 30 days at least--was depicted by CT in 16 patients and by chest films in 4 patients. Finally, no response or disease progression was depicted by CT in 10 patients and by chest films in 9 patients. To conclude, the presence of mediastinal and hilar masses, with bronchial narrowing, atelectasis, pleural/pericardial involvement, sometimes with a peripheral mass, are strongly suggestive of small cell lung cancer. CT was more sensitive than chest films in the staging of localized and diffuse disease, but it failed nevertheless to improve significantly the diagnosis, prognosis and follow-up of SCLC relative to chest films (p = 0.34).

[Thoracic radiography and high resolution computerized tomography in the diagnosis of pulmonary disorders caused by amiodarone]. / Radiografia del torace e Tomografia computerizzata ad alta risoluzione nella diagnosi delle alterazioni polmonari da amiodarone.

To assess the radiographic patterns of amiodarone-induced pulmonary toxicity, the chest films (32) and HRCT scans (16) were reviewed of 14 patients into amiodarone protocols for 3 months to 6.5 years (average: 40.5 months). All patients were symptomatic and presented with shortness of breath, a general malaise, a fever. The radiographic findings included: intersurface signs, defined as irregular interfaces between parenchyma, bronchi, vessels and visceral pleura, indicating interstitial abnormalities (HRCT: 8 = 50%); septal thickening (Kerley's lines) (chest film: 32 = 100%; HRCT: 6 = 37%); reticular opacities (chest film: 24 = 75%; HRCT: 6 = 37%); peribronchial cuffing (chest film: 2 = 6%; HRCT: 0); interstitial nodules (chest film: 12 = 37%; HRCT: 4 = 25%); alveolar nodules (chest film: 16 = 50%; HRCT: 12 = 75%); consolidations (chest film: 20 = 62%; HRCT: 12 = 75%); parenchymal masses (chest film: 2 = 6%; HRCT: 2 = 12%); fibrosis (chest film: 24 = 75%; HRCT: 16 = 100%); reduced lung volume (chest film: 14 = 43%; HRCT: 4 = 25%); pleural effusion and/or thickening (chest film: 4 = 12%; HRCT: 4 = 25%). The lesions were always localized in the lower lobes and often also in the upper lobes (chest film: 12 = 37%; HRCT: 14 = 87%); in the latter site the lesions were smaller. HRCT showed the peripheral site of the lesions. Amiodarone discontinuation and corticosteroids administration improved the radiographic patterns in 2 patients and attenuated the symptoms, with disappearance of alveolar nodules, in 11 patients. In contrast, clinical symptoms progressed and the radiographic pattern worsened in one patient. Both chest films (Kerley's lines, reticular, interstitial and alveolar opacities without cuffing and pleural effusion or clear fibrosis) and HRCT (fibrosis associated with alveolar opacities) showed sufficiently typical patterns of amiodarone-induced pulmonary toxicity, especially when associated with pleural thickening.

[Slow-resolution pneumonia: radiologic and tomodensitometric features]. / Polmoniti con risoluzione lenta: aspetti radiologici e tomodensitometrici.

To assess the radiologic findings of unresolving pneumonias (radiologic signs not normalized at the end of the fourth week of antibiotic therapy), the radiologic (192) and CT examinations (33) of 50 patients were reviewed, for a total of 64 pulmonary parenchymal lesions. These lesions presented as masses (3; 4.6%), parenchymal thickenings with aerial bronchogram (41; 63.7%), sometimes escavated (4; 10%), alveolar ground glass alterations (4; 6.2%), more frequent on the right side (49; 73%), mostly in the upper lobe (21; 32.8%). Pleural effusion was demonstrated in 16 patients (32%) and lymphadenopathies were shown in 8 patients (8%). When possible, the responsible germ was isolated with microbiological expectoration test (14; 35.3%), bronchoscopy associated with bronchoalveolar lavage (7; 37.5%) and needle biopsy in the mass (2; 5%). The germs were Candida (9), haemophilus influentiae (1), Klebsiella (1), pneumococcus (1), Pseudomonas (3), Staphylococcus aureus (4), streptococcus alpha hemoliticus (6). There are no typical radiologic and CT findings for the described lesions in different-patients and different germs can produce the same changes. Therefore, pulmonary inflammations must be followed to their complete resolution, to rule out the chance of a neoplastic process (obstructive pneumonia). The first radiologic control must be made at least 15 days after the beginning of therapy for the anatomo-pathologic processes of recovery to show radiographically. CT can be fundamental in the differential diagnosis with neoplasm, in unresolving pneumonia, to study the tracheobronchial tree, to study lymphadenopathies and to guide needle biopsy.

[Calcification of the basal nuclei in hypoparathyroidism. The computed and magnetic resonance tomographic aspects]. / Calcificazione dei nuclei della base nell'ipoparatiroidismo. Aspetti con tomografia computerizzata e con risonanza magnetica.

Six female patients with hypoparathyroidism (2 idiopathic and 4 postoperative cases following total thyroidectomy) were examined with brain CT scans; 4 of them underwent MR exams too. Two patients presented with no symptoms, 4 exhibited extrapyramidal syndrome, tetany, fainting seizures or ischemic attacks and only 2 presented with abnormal calcium-phosphorus balance. CT showed calcifications of the basal nuclei in 5 patients. The caudate nucleus was always affected (100%). The calcifications were in the putamen, globus pallidus and thalamus in 4 cases (80%), in the dentate nuclei, centrum semiovale and cerebral cortex in 2 cases (40%) and in the mesencephalic gray matter in 1 case (20%). In one case only CT failed to detect the abnormalities, which were nevertheless depicted by MRI. In the other 3 patients who underwent MRI, CT findings were confirmed as low-signal areas on SE T1- and T2-weighted MR scans where the calcifications were present, but areas of increased signal intensity were also evident on SE T2-weighted images; in one patient, low-signal areas were surrounded by a ring of increased signal intensity on SE T1-weighted scans. Low-signal areas reflect an early stage of calcium deposition; on the other hand, high-signal areas are probably caused by proteins and mucopolysaccharides or by liquid pools secondary to endothelial membrane incompetence. CT better defined the site and extent of the calcifications which may be found in both idiopathic and postoperative hypoparathyroidism, in symptomatic or asymptomatic patients. On the other hand, MRI seems to be capable of depicting the various stages of calcium deposition on the basis of the presence of reduced or increased SE T2 signal intensity.

[Evaluation of tracheobronchial lesions with spiral CT: comparison between virtual endoscopy and bronchoscopy]. / Valutzione delle lesioni tracheo-bronchiali con TC spirale: Confronto tra endoscopia virtuale e broncoscopia.

INTRODUCTION: The aim of this study is to describe the scanning parameters for virtual bronchoscopy in the evaluation of the tracheobronchial tree and to compare the results of this examination with the endoscopic findings. MATERIAL AND METHODS: 27 patients with tracheobronchial neoplasms suspected at preliminary clinical and chest film findings or postoperative follow-up for malignant disease were evaluated with spiral CT of the chest and bronchoscopy. Virtual endoscopy was performed on the pulmonary volume involved by the lesion, using narrow axial images (thickness 2 mm, table index 3 mm, reconstruction index 1 mm.) so as to obtain MPR, MIP and 3D reconstructions with 3D Endo Vew program (Philips Medical System, Eindhoven, Holland). We compared these reconstructions and the findings the normal spiral CT scanning with the corresponding endoscopic examinations. RESULTS: In all patients we were able to study the lobar and segmental bronchi in all patients and in 2 we also evaluated the subsegmental bronchi. 25 lesions in 23 patients were shown by virtual endoscopy (8 occlusions, 8 stenosis, 5 compressions, 3 flogosis with endobronchial mucus, 1 bronchocele) and in 4 patients the examinations were negative. The bronchoscopy was negative in 4 patients and positive in 23 patients with 25 lesions, but we had agreement in 23/27 patients (85,1%). In 2 patients virtual endoscopy showed the lesions in a different bronchus compared to bronchoscopy. In one patient we interpreted the obstruction as neoplastic instead of mucus inside the bronchi and in the last patient bronchoscopy was not performed due to his old age and the virtual endoscopy showed total obstruction of a segmental bronchus. DISCUSSION AND CONCLUSIONS: The results show that virtual endoscopy can study the tracheobronchial tree as far as the segmental bronchi, and sometimes also the subsegmental bronchi and the bronchi below a closed obstruction. In addition, it can evaluate the extraluminal location of the lesions. For these reasons virtual endoscopy provides a road map for bronchoscopy as a guide for transbronchial biopsy and for endobronchial treatment planning. The limitation of this technique is its inability to evaluate the mucosal surface and distinguish flogosis from neoplastic lesions by biopsy. It can be used however in the postoperative follow-up both for cancer and transplant, when immediate biopsy is not necessary.

Serum tumor markers and cyst fluid analysis are useful for the diagnosis of pancreatic cystic tumors.

BACKGROUND: This study was performed to evaluate the utility of serum and cyst fluid analysis for enzymes (amylase and lipase) and tumor markers (carcinoembryonic antigen, CA 19-9, CA 125, and CA 72-4) in the differential diagnosis of cystic pancreatic lesions. METHODS: Serum and cyst fluid were obtained from 48 patients with pancreatic cysts (21 pseudocysts, 14 mucinous cystic neoplasms, 6 ductal carcinomas, and 7 serous cystadenomas), observed between 1989 and 1994. RESULTS: Serum CA 19-9 levels were significantly higher in ductal carcinomas (all > 100 U/mL) and mucinous cystic neoplasms (P < 0.05). CA 72-4 cyst fluid levels were significantly higher in mucinous cystic tumors (P < 0.005), with 95% specificity and 80% sensitivity in detecting mucinous or malignant cysts. A combined assay of serum CA 19-9 and cyst fluid CA 72-4 correctly identified 19 of 20 (pre-) malignant lesions (95%), with only 1 false-positive result (3.6%). Cytology showed a sensitivity of 48% and specificity of 100%. CONCLUSIONS: Any pancreatic cyst with high serum CA 19-9 values, positive cytology, or high CA 72-4 in the fluid should be considered for resection.

[Ultrasonography and computerized tomography in the diagnosis of gallbladder carcinoma]. / Ecografia e tomografia computerizzata nella diagnosi del carcinoma della colecisti.

The US and CT images of 40 surgical patients with histologically proved gallbladder carcinoma were retrospectively reviewed. The radiologic diagnosis was correct in 22 patients (55%). Gallbladder carcinoma patterns were: an intraluminal mass (type I) (7 patients, 17.5%), focal or diffuse wall thickening (type II) (5 patients, 12.5%) a mass replacing the gallbladder (type III) (10 patients, 25%). In 5 patients with type I or II gallbladder carcinoma, US and CT diagnosis was made easier by the presence of associated findings--i.e., liver infiltration and/or metastases, lymphadenopathy, dilated intrahepatic ducts, ascites. In 7 patients a gallbladder carcinoma was suspected in the presence of a small intraluminal mass (6 cases) or of focal wall thickening (1 case), with no stones and with dilated intrahepatic biliary ducts. In the extant 18 patients (45%) the radiologic diagnosis was: polyps (6 cases), stones with cholecystitis (11 cases) and empyema (1 case). US is the examination of choice in the diagnosis of gallbladder and biliary ducts conditions, but several diagnostic problems may arise in the differentiation from polyps and acute inflammatory disease. CT better demonstrates gastrointestinal tract invasion and lymphadenopathy, which can be a valuable finding for treatment planning.

[Role of computerized tomography in the densitometric assessment of lithiasis of the gallbladder]. / Ruolo della tomografia computerizzata nella valutazione densitometrica della litiasi della colecisti.

Radiolucent gallstones frequently contain significant calcium deposits. Their detection is important to select the patients to submit to medical gallstone dissolution. Since CT facilitates the identification of calcifications undetected at conventional radiologic procedures, 60 patients were studied with CT. All of them had US confirmation of cholelithiasis and in the whole of cases an X-ray examination of the right upper abdominal quadrant was performed (for the identification of radiopaque stones), together with oral cholecystography (to evaluate gallbladder function). CT attenuation values of the stones were measured and the patients subsequently divided into 2 groups; the threshold value was 50 HU: below it, the stones were considered hypo- or isodense (group I); above it, they were considered hyperdense (group II). Later on, 28 patients (14 from group I and 14 from group II) were selected for chemical dissolution with ursodeoxycholic acid over a 1-year period. US examinations were performed at 6 and 12 months. Seventy per cent of the patients in group I responded to treatment (50% with complete stone dissolution and 20% with partial dissolution), whereas no patient in group II had complete dissolution and only 30% had partial response.

[Comparative study of traditional radiology, echography and computerized tomography in chest pathology]. / Studio comparativo tra radiologia tradizionale, ecografia e tomografia computerizzata in patologia toracica.

The authors have examined 57 cases of thoracic pathology by conventional radiology, ultrasounds and computed tomography (CT). The conventional radiology remains the test of first choice; the ultrasounds proved sometimes useful to distinguish between solid and cystic lesions while CT is the method in the evaluation of the extension.