Staging of endometrial cancer with MRI: guidelines of the European Society of Urogenital Imaging.

The purpose of this study was to define guidelines for endometrial cancer staging with MRI. The technique included critical review and expert consensus of MRI protocols by the female imaging subcommittee of the European Society of Urogenital Radiology, from ten European institutions, and published literature between 1999 and 2008. The results indicated that high field MRI should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine body) of the pelvic content. High-resolution post-contrast images acquired at 2 min +/- 30 s after intravenous contrast injection are suggested to be optimal for the diagnosis of myometrial invasion. If cervical invasion is suspected, additional slice orientation perpendicular to the axis of the endocervical channel is recommended. Due to the limited sensitivity of MRI to detect lymph node metastasis without lymph node-specific contrast agents, retroperitoneal lymph node screening with pre-contrast sequences up to the level of the kidneys is optional. The likelihood of lymph node invasion and the need for staging lymphadenectomy are also indicated by high-grade histology at endometrial tissue sampling and by deep myometrial or cervical invasion detected by MRI. In conclusion, expert consensus and literature review lead to an optimized MRI protocol to stage endometrial cancer.

A paraneoplastic retroperitoneal fibrosis resistant to corticosteroids treated with tamoxifen.

Retroperitoneal fibrosis (RPF) is a rare disease characterized by an inflammatory proliferative fibrosing process occurring in the retroperitoneum, often causing urinary tract obstruction. Medical therapy is not well-defined, but glucocorticoids have been the mainstay of therapy. Recently, positive response to tamoxifen, an antiestrogen drug, has been reported among patients with RPF. We report the case of a 65-year-old male with a renal cell carcinoma in the upper pole of the right kidney showing acute renal failure due to a biopsy-confirmed RPF determining bilateral hydronephrosis. After polar resection of the right kidney, a high-dose oral steroid therapy did not modify the hydronephrosis. At 6 months, therapy with tamoxifen determined the retroperitoneal fibrotic mass regression and resolved the ureteral obstruction, that persists at the 13th month of follow-up. Tamoxifen can be considered as an effective alternative to corticosteroids and immunosuppressors in treating RPF.

Minocycline hydrochloride as a soft sclerotizing agent for symptomatic simple renal and hepatic cysts.

OBJECTIVE: To present the results of our ten-year case series in simple hepatic and renal cysts sclerosis using minocycline hydrochloride as a sclerotizing agent, evaluating the effectiveness, the safety and the feasibility of this agent for percutaneous sclerotherapy for symptomatic cysts. PATIENTS AND METHODS: We retrospectively evaluated our archives of patients treated (54 patients with 60 renal cysts, 21 patients with 24 hepatic cysts) for symptomatic abdominal cysts. These patients were treated with ultrasound guided drainage and subsequent minocycline hydrochloride instillation. In large or recurrent cysts, we repeated the treatment for the second time. The patients were evaluated at 6 and 12 months; some patients underwent later, additional examinations and we also reviewed these exams for any eventual long-term relapse. RESULTS: The percentage of sclerosis success was found to be 100% for hepatic cysts and 86% for renal cysts. We also found that minimal complications were encountered. CONCLUSIONS: Minocycline hydrochloride has proven to be an effective sclerotizing agent. In our cases, symptoms disappeared in 100% of patients with hepatic cysts and in 93% of patients with renal cysts. It is also a safe sclerotizing agent, as demonstrated by the few complications encountered. Percutaneous sclerosis with Minocycline hydrochloride is a very effective and promising nonsurgical treatment for patients with symptomatic simple cysts, and it can be performed without major complications.

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.

Radiofrequency thermal ablation (RFA) of liver tumors: percutaneous and open surgical approaches.

Radiofrequency Thermal Ablation (RFA) of liver tumors is done by percutaneous, laparoscopic and open surgical approach. Selection criteria for percutaneous or open surgical ablation of 65 hepatic lesions are here evaluated in 45 patients treated in a two-years period. Twenty-five patients were males and 20 females, ages ranged from 35 to 80 years (mean 63 years). RFA was performed in 57 procedures, ablating 14 hepatomas and 51 liver metastases. In 10 cases the treatment was repeated twice. Tumor size ranged from 0.5 cm to 8 cm, with a mean of 2.4 cm. Open surgical approach was performed in 14 cases (24.6%), seven of which were simultaneously treated for associated diseases. Percutaneous treatment was adopted in 43 cases (75.4%). A laparoscopic approach was not tempted in any case. Morbidity was 8.8%, mostly in open surgery (4 cases or 28.6%) but in one patient (2.3%) with percutaneous approach. Difference in between the two groups was statistically significant (p=0.013). Overall mortality was 2.2%: one patients deceased for myocardial infarction. The mean length of hospital stay was of 4.1 days for the percutaneous treatment group and 7.6 days for the open surgery approach. Number of the lesions did not interfere with surgical approach. Postoperative CT control showed no differences, in terms of complete ablation of the tumor, between the two groups of patients. Advantages of percutaneous approach include less invasiveness, reduced postoperative pain, shorter hospitalization, reduced costs and lower discomfort in repeating the procedure. In addition, open surgical RFA allows better cancer staging, avoidance of adjacent organ injury, accessibility to all liver areas and gives the chance to performe simultaneous organ resection. These results are encouraging in making the percutaneous approach of RFA the method of choice in these patients.

Modulation of blood circulating immune cells by radiofrequency tumor ablation.

Tumor ablation by radiofrequency (RFA) is an appealing therapeutical strategy for the treatment of liver tumors (hepatocarcinoma and metastatic lesions) to be used as valid alternative to the surgical resection that often is appropriate and feasible in only a minority of patients. RFA induces the localised and controlled disruption of the tumor by heating the tissue causing its coagulative necrosis. Such therapy results as a pathogenic "noxa" for the body, inducing a strong inflammatory response. We wanted to ascertain whether the inflammatory response induced by RFA was similar in patients with hepatocarcinoma and in patients with liver metastasis. We considered body temperature, leucocyte counts at different time points as inflammatory parameters. We observed that RFA treatment produced the inflammatory systemic effects as expected (fever, increase of neutrophils) only in the patients with liver metastasis, while no such effect could be seen in the HCC patients. On the other hand the circulating monocytes increased after RFA in both groups of patients. These preliminary results suggest that RFA tratment can exert different effects on the immune system depending the etiopathogenesis of the treated neoplastic liver lesions.

Radiofrequency thermal ablation (RFA) of liver tumors: open surgical or percutaneous approach?

RFA was used to ablate 81 liver lesions: 61 liver metastases and 20 hepatomas. An open surgical approach was adopted in 19 instances (27.5%), 12 of which were simultaneously treated for associated diseases, and percutaneous treatment was adopted in 50 instances (72.5%). The CT liver control at 6 months showed a complete necrosis in 50 lesions (66.3%). The advantages of the percutaneous approach include less invasiveness, reduced postoperative pain, shorter hospitalization, reduced costs and less discomfort in repeating the procedure. In conclusion, radiofrequency liver nodule ablation could be considered, today, as one of the promising and versatile techniques for loco-regional liver cancer control.

[Radiofrequency thermal ablation of hepatic nodules: selection criteria for percutaneous treatment]. / Termoablazione con radiofrequenza di noduli epatici: criteri di scelta del trattamento percutaneo.

Radiofrequency thermal ablation (RFA) of liver tumor is done by percutaneous, laparoscopic and open surgical approach. Selection criteria for percutaneous or open surgical ablation of 54 hepatic lesions are here evaluated in 30 consecutive patients. Open surgical approach was performed in 9 cases only, 5 of them due to concomitant treatment of associated diseases. Number and size of the lesions did not interfere with surgical approach. Postoperative CT control showed no differences in terms of complete ablation of the tumor in between the two groups of patients. Percutaneous approach of RFA is gone to be in the future the modality of choice in these patients.

[Medical therapy with mebendazole in hydatid cyst disease. A follow-up of 40 cases]. / La terapia medica con mebendazolo nella malattia cistica idatidea. Follow-up di 40 casi.

Mebendazole (50-60 mg/kg/day in 7-8 divided doses after fatty rich meals for at least 6 months) was given to 44 patients with cystic hydatid disease of the liver and other organs, about 1/3 having suffered from recurrences, even multiple, before beginning the pharmacological treatment. Fifteen patients underwent operation after a course of mebendazole, and macroscopic and histological degeneration of hydatid cysts was always documented; sixteen subjects were not operated due to their severe general and/or local conditions but ultrasound, radiologic (CT) and clinical evidence of cyst regression was obtained, and was closely comparable to that in the aforementioned group. Some of the patients (13) began the treatment only after conservative surgery. The mean real follow-up available at the moment is for 40 subjects because 2 patients did not show adequate compliance for the drug and in 2 additional cases it was withdrawn because of an increase in serum transaminases. The rate of recurrence was 7.5% and occurred in high-risk patients (multiple, bone, lung locations) who had, however, an additional and longer course of mebendazole with good results. The detachment of membranes and the increase of internal echoes, observed by means of ultrasonography, which was successfully applied to liver and soft tissue sites as well as the decrease in blood eosinophils when elevated before therapy, were observed to be the most sensitive indicators of early success in the medical treatment for hydatid disease, as far as the viability of parasite cysts was concerned.

[Adrenal gland cysts. Our experience]. / Le cisti del surrene. Nostra esperienza.

Adrenal cysts are an uncommon finding, in most cases unexpectedly discovered in the evaluation of nonspecific abdominal pain or at autopsy. Cystic adrenal masses can be classified into neoplastic and non-neoplastic aetiologies. The distinction between malignant and benign adrenal cysts can still be difficult. Cysts of neoplastic aetiology occur as a result of necrosis and cystic degeneration within both benign and malignant tumours. Non-neoplastic cysts have been conventionally divided into four categories: endothelial (45%), haemorrhagic or pseudocystic (39%), epithelial (9%) and parasitic (7%). Small adrenal cysts are clinically silent, while cysts of large size can cause displacement and compression of adjacent organs. The radiological aim is to detect the adrenal mass and CT is regarded as the best method available for this detection, although a differentiation between benign and malignant tumours can be difficult. Here we report our experience in nine patients with adrenal cysts. Abdominal pain was the dominant sign, two patients were hypertensive, one presented a palpable mass at abdominal examination and another presented oligomenorrhea with hypertrichosis, in five patients the adrenal mass was discovered unexpectedly during radiologic examination. All cysts in our patients were unilateral. All patients were examined by ultrasound and CT, one by RM, three by 75Se-Seleniumcholesterol cortical scintigraphy and two by 131I-MIBG medullary scintigraphy. In three patients a percutaneous aspiration of the cyst was performed via a posterior approach with CT or US guidance. This approach has been used for diagnostic and therapeutic purposes. Examination of aspirated cyst fluid for steroid hormones showed markedly elevated cortisol levels compared with normal plasma cortisol levels in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

[The preoperative staging of rectal neoplasms: the clinical exam and diagnostic imaging]. / Stadiazione preoperatoria delle neoplasie del retto: esame clinico e diagnostico per immagini.

The management of rectal cancer remains an important clinical problem. Although there was been great progress in surgical management, the survival of patients with locally advanced disease has not improved significantly during the past decades. Preoperative staging and evaluation of the risk of recurrence may help in the choice of operation. It is difficult for clinicians to quantify reliably with digital examination the degree of fixation of the tumor, and they usually cannot distinguish nodal metastases except in advanced cases. The more frequent overstaging of small tumors within one quadrant of the rectum is a major drawback of digital examination. Computed tomography and magnetic resonance seems to underestimate the extension of rectal tumors, but both can be helpful in selecting patients with advanced tumors for whom preoperative adjuvant treatment is being considered. Endoluminal ultrasound is superior in staging tumors confined to the rectal wall, but is not the ideal tool for staging: the results are examiner dependent, the field of vision in depth is limited, and stricturing tumors cannot be passed by the ultrasound transducer. Imaging diagnostic attendibility confirms the preeminent role of intraoperative exploration in the assessment of neoplastic diffusion in order to plan a correct surgical treatment.