[Radiologic assessment of transpyloric spread of gastric carcinoma]. / Valutazione radiologica dell'estensione transpilorica del carcinoma gastrico.

PURPOSE: We report on our personal experience with the radiologic and CT demonstration of the traspyloric duodenal spread of gastric carcinoma, whose relative frequency and prognostic value are recent literature data. MATERIAL AND METHODS: In the last 4 years we submitted to double contrast studies of the upper gastrointestinal (GI) tract 49 gastric carcinoma patients with antrum involvement. Twenty-one cases were staged with CT performed with gastric water distension, pharmacological hypotonia and dynamic contrast agent perfusion. Finally, 41 patients underwent surgical treatment. RESULTS: Radiologic evidence of transpyloric gastric carcinoma spread was found in 6 cases; CT, performed in 5 of them, was always in agreement. Five of 6 positive cases had surgical confirmation while one lesion was unresectable. No radiologic or CT false negatives were found among the remaining 36 surgical patients. Barium studies showed irregular antral lumen narrowing, rigid, open and eccentric pyloric channel, duodenal bulb deformity and irregular thickening. CT demonstrated antrum infiltration along the two gastric curvatures and the tumor spread to the duodenal cap. CONCLUSION: Antral cancer transpyloric spread is more frequent than previously reported and its presence should not exclude a carcinomatous process. Double contrast barium studies are a valuable tool in the demonstration of this spread, showing good correlation with CT staging findings.

Hepatocellular carcinoma treated with chemoembolization: assessment with contrast-enhanced doppler ultrasonography.

PURPOSE: To report our preliminary experience concerning the use of Doppler ultrasonography (DUS) techniques after intravenous injection of the galactose-based contrast agent Levovist in the assessment of hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE). The sonographic findings are correlated with those obtained using iodized oil (Lipiodol) helical computed tomography (CT). METHODS: For 7 months we studied 28 patients with cirrhosis and HCC (a total of 43 nodules) who had undergone TACE between 18 and 30 days previously. The lesions were investigated with color Doppler ultrasonography (CDUS) and power Doppler ultrasonography (PDUS), before and after infusion of the echo-contrast agent (300 mg/ml, maximum 1 injection for each nodule, administered at constant velocity within 60-90 sec), and with helical Lipiodol-CT (0-7 days after DUS). In the retrospective analysis, special attention was given to the Doppler signals related to pulsatile intra- and perinodular flow and to the detection of new vessels after contrast agent injection. The signal intensity was graded as 0 (absent), 1 (low), 2 (medium), or 3 (high), while its distribution was classified as peripheral, central, or diffuse. Oily agent retention on CT scans was assessed as 0 (absent), I (<10%), II (<50%), III (>50%), or IV (homogeneous). These scores were awarded separately, without knowledge of the other judgments. RESULTS: An hepatic global echo-enhancing effect was identified in all cases and always lasted long enough to allow an accurate analysis of all parenchymal lesions (at least 8 min). The signal scores could be evaluated in 39 of 43 HCCs, as follows: basal CDUS: grade 0 in 17 lesions, grade 1 in 16, grade 2 in 6; contrast-enhanced CDUS: grade 0 in 12 lesions, grade 1 in 10, grade 2 in 14, grade 3 in 3; basal PDUS: grade 0 in 15 lesions, grade 1 in 13, grade 2 in 9, grade 3 in 2; contrast-enhanced PDUS: grade 0 in 11 lesions, grade 1 in 9, grade 2 in 15, grade 3 in 6. Lipiodol-CT scoring was: grade 0 in 1 lesion, grade I in 7, grade II in 11, grade III in 9, grade IV in 11. In all but one nodule the difference between CDUS and PDUS scores, compared both with each other and with nonenhanced and contrast-enhanced examinations, was never greater than one grade. CONCLUSIONS: Contrast-enhanced DUS is a simple and fast procedure allowing a valuable, constant echo-enhancing effect of sufficient duration. DUS techniques, especially contrast-enhanced PDUS, offer an effective and realistic analysis of HCC nodules treated with TACE and show more evident agreement with Lipiodol-CT findings than baseline studies.

[Multiphasic spiral computed tomography in hepatocarcinoma. An evaluation following different percutaneous ablative procedures]. / Tomografia Computerizzata spirale multifasica dell'epatocarcinoma. Valutazione dopo differenti procedure ablative percutanee.

PURPOSE: To report our personal experience with helical CT evaluation of hepatocellular carcinoma treated with various percutaneous interventional procedures. We assessed both nodular response and the spectrum of changes within normal parenchyma. MATERIAL AND METHODS: December 1996 to September 1998 we examined with helical CT 41 patients (73 nodules in all) with hepatocellular carcinoma treated with percutaneous ablation therapies: conventional ethanol injection in 18 subjects (31 nodules), one-shot ethanol injection in 3 (8 nodules), radiofrequency thermal ablation in 16 (25 nodules), and combined chemoembolization and ethanol injection in 4 (9 nodules). CT performed was 4-27 days after the last session, acquiring biphasic volumetric images in 14 patients and triphasic volumetric images in 27. A second treatment with subsequent CT study was performed for 28 lesions; 15 underwent 3 serial studies and 6 underwent 4 studies. RESULTS: Compared with pretreatment findings, the diameter was unchanged in 62% of the nodules and increased in 38%. Morphology was unchanged in 63% of the lesions while in 37% a mild deformation toward the needle path or a more regular and round shape was evident. Borders were unchanged in 37% of the cases and modified in 63%, appearing well-defined in 73% and ill-defined in 27%. The necrotic portion had a low attenuation with a nodule-to-parenchyma gradient more evident on delayed than on venous and finally arterial acquisitions; 8% of the lesions were not recognizable on unenhanced scans. Residual viable tissue was identified in 44% of the nodules and quantified as 100% in 1% of all lesions, > 75% in 3%, > 50% in 4%, > 25% in 12%, < 25% in 23%. It was located centrally in 6% of the cases, peripherally in 12%, and eccentrically in 81%, and the shape was crescent in 66% of the cases, oval in 19%, and different in 16%. During the arterial phase the residual tumor appeared hyperdense in 97% of the nodules and isodense in 3%, while during the portal phase it was hyperdense in 22%, isodense in 28% and hypodense in 50%, and during the delayed phase hypodense in 100%. For what concerns the uninvolved parenchyma, lobar atrophy was present in 4% of the nodules, segmental atrophy in 8%, and subsegmental in 16%; caval thrombosis was found in 1 patient, portal thrombosis in 4. Arterioportal fistulas were identified in 5% of the nodules and areas of transient inhomogeneous attenuation in several cases. Subsegmental biliary dilation was detected in 4% of the lesions. CONCLUSION: Multiple-phase helical CT allows optimal depiction of primitive liver nodules treated with percutaneous interventional procedures and has a central role in the assessment of tumor response. Accurate is also the evaluation of changes or complications involving the surrounding parenchyma. Regarding the ablation effect, two typical features can be identified: after total necrosis nodular volume is unchanged or increased, borders are well-defined, and density is low and homogeneous (especially in delayed phases), while after partial necrosis the diameter is not modified, margins are ill-defined, attenuation is less decreased, and peripheral tumor maintains high density in arterial phase and low density in delayed phases. As for the treatment procedure, we found that thermal ablation with radiofrequency and single-session ethanol injection cause more evident alterations within both nodule and hepatic parenchyma, while after multi-session ethanol injection changes are less dramatic and consequently more difficult to assess.