Drug-induced interstitial lung disease during cancer therapies: expert opinion on diagnosis and treatment.

BACKGROUND: Drug-induced interstitial lung disease (DIILD) is a form of interstitial lung disease resulting from exposure to drugs causing inflammation and possibly interstitial fibrosis. Antineoplastic drugs are the primary cause of DIILD, accounting for 23%-51% of cases, with bleomycin, everolimus, erlotinib, trastuzumab-deruxtecan and immune checkpoint inhibitors being the most common causative agents. DIILD can be difficult to identify and manage, and there are currently no specific guidelines on the diagnosis and treatment of DIILD caused by anticancer drugs. OBJECTIVE: To develop recommendations for the diagnosis and management of DIILD in cancer patients. METHODS: Based on the published literature and their clinical expertise, a multidisciplinary group of experts in Italy developed recommendations stratified by DIILD severity, based on the Common Terminology Criteria for Adverse Events. RESULTS: The recommendations highlight the importance of multidisciplinary interaction in the diagnosis and management of DIILD. Important components of the diagnostic process are physical examination and careful patient history-taking, measurement of vital signs (particularly respiratory rate and arterial oxygen saturation), relevant laboratory tests, respiratory function testing with spirometry and diffusing capacity of the lung for carbon monoxide and computed tomography/imaging. Because the clinical and radiological signs of DIILD are often similar to those of pneumonias or interstitial lung diseases, differential diagnosis is important, including microbial and serological testing to exclude or confirm infectious causes. In most cases, management of DIILD requires the discontinuation of the antineoplastic agent and the administration of short-term steroids. Steroid tapering must be undertaken slowly to prevent reactivation of DIILD. Patients with severe and very severe (grade 3 and 4) DIILD will require hospitalisation and often need oxygen and non-invasive ventilation. Decisions about invasive ventilation should take into account the patient's cancer prognosis. CONCLUSIONS: These recommendations provide a structured step-by-step diagnostic and therapeutic approach for each grade of suspected cancer-related DIILD.

Strategies to tackle RAS-mutated metastatic colorectal cancer.

The RAS oncogene is among the most commonly mutated in cancer. RAS mutations are identified in about half of patients diagnosed with metastatic colorectal cancer (mCRC), conferring poor prognosis and lack of response to anti-epidermal growth factor receptor (EGFR) antibodies. In the last decades, several investigational attempts failed in directly targeting RAS mutations, thus RAS was historically regarded as 'undruggable'. Recently, novel specific KRASG12C inhibitors showed promising results in different solid tumors, including mCRC, renewing interest in this biomarker as a target. In this review, we discuss different strategies of RAS targeting in mCRC, according to literature data in both clinical and preclinical settings. We recognized five main strategies focusing on those more promising: direct RAS targeting, targeting the mitogen-activated protein kinase (MAPK) pathway, harnessing RAS through immunotherapy combinations, RAS targeting through metabolic pathways, and finally other miscellaneous approaches. Direct KRASG12C inhibition is emerging as the most promising strategy in mCRC as well as in other solid malignancies. However, despite good disease control rates, tumor response and duration of response are still limited in mCRC. At this regard, combinational approaches with anti-epidermal growth factor receptor drugs or checkpoint inhibitors have been proposed to enhance treatment efficacy, based on encouraging results achieved in preclinical studies. Besides, concomitant therapies increasing metabolic stress are currently under evaluation and expected to also provide remarkable results in RAS codon mutations apart from KRASG12C. In conclusion, based on hereby reported efforts of translational research, RAS mutations should no longer be regarded as 'undruggable' and future avenues are now opening for translation in the clinic in mCRC.

Ulipristal Acetate Efficacy in a Patient with Symptomatic Fibroid and Concomitant Pulmonary Embolism.

Ulipristal acetate (UPA) is an effective drug for the treatment of symptomatic uterine fibroids. The drug is highly effective in controlling bleeding control and in the recovery of anemia. Here, we report the case of a woman with severe menorrhagia due to a uterine fibroid and with concomitant pulmonary embolism, a serious life-threatening condition. UPA was shown to be effective in reducing fibroid volume and controlling symptoms, without worsening the underlying embolic disease. No adverse events were observed, and the patient has completely recovered.

Outcomes and Risk Factors for Complications of Laser Ablation for Thyroid Nodules: A Multicenter Study on 1531 Patients.

BACKGROUND: Image-guided laser ablation therapy (LAT) of benign thyroid nodules demonstrated favorable results in randomized trials with fixed modalities of treatment. The aim of this retrospective multicenter study was to assess the effectiveness, tolerability, and complications of LAT in a large consecutive series of patients from centers using this technique in their routine clinical activity. PATIENTS: Clinical records of 1534 consecutive laser-treated nodules in 1531 patients from eight Italian thyroid referral centers were assessed. Inclusion criteria were as follows: solid or mixed nodules with fluid component up to 40%; benign cytological findings; and normal thyroid function. METHODS: LAT was performed with a fixed-power protocol, whereas the number of applicators and illumination times were different according to target size. From one to three illuminations with pullback technique and with a total energy delivery based on the nodule volume were performed during the same session. Patients were evaluated during LAT, within 30 days, and 12 months after the procedure. RESULTS: Total number of treatments was 1837; 1280 (83%) of nodules had a single LAT session. Mean nodule volume decreased from 27 ± 24 mL at baseline to 8 ± 8 mL 12 months after treatment (P < .001). Mean nodule volume reduction was 72% ± 11% (range 48%-96%). This figure was significantly greater in mixed nodules (79% ± 7%; range 70%-92%) because they were drained immediately before laser illumination. Symptoms improved from 49% to 10% of cases (P < .001) and evidence of cosmetic signs from 86% to 8% of cases (P < .001). Seventeen complications (0.9%) were registered. Eight patients (0.5%) experienced transitory voice changes that completely resolved at the ear-nose-throat examination within 2-84 days. Nine minor complications (0.5%) were reported. No changes in thyroid function or autoimmunity were observed. CONCLUSIONS: Real practice confirmed LAT as a clinically effective, reproducible, and rapid outpatient procedure. Treatments were well tolerated and risk of major complications was very low.

Does iodine concentration affect the diagnostic efficacy of biphasic spiral CT in patients with hepatocellular carcinoma?

BACKGROUND: We investigated the effect of iodinated contrast medium concentration on increased neoplastic lesion enhancement and its direct relation to diagnostic efficacy in biphasic spiral computed tomography for detection of hepatocellular carcinoma. METHODS: A pilot, single-center, randomized, double-blind, crossover, comparative study was performed and included 22 participants. Each patient underwent two separate biphasic contrast-enhanced spiral computed tomographic examinations. Scans were performed with iomeprol containing 400 (iomeprol 400) or 300 (iomeprol 300) mg of iodine per milliliter (Iomeron, Bracco Imaging SpA, Milan, Italy) with a 2- to 12-day window scan; patients were given an equal total dose of 45 g of iodine at a fixed injection rate of 4 mL/s. Comparison included assessment of quantitative and qualitative parameters. RESULTS: Lesion density and lesion-to-liver contrast increased more markedly with the higher concentration of contrast medium during the arterial phase (p = 0.0016 and 0.0005, respectively). There was no significant difference in any parameter between the two concentrations during the portal phase. Number of lesions detected during the arterial phase increased from 37 with iomeprol 300 to 42 with iomeprol 400; in the portal phase, the respective numbers were 34 and 36. CONCLUSION: Even though a small number of patients was examined, our study suggests that, in patients with cirrhosis, an increased concentration of iodine improves liver-to-lesion contrast and may improve the detection of hepatocellular carcinoma.

Intraarterial chemotherapy with polyoxyethylated castor oil free paclitaxel, incorporated in albumin nanoparticles (ABI-007): Phase I study of patients with squamous cell carcinoma of the head and neck and anal canal: preliminary evidence of clinical activity.

BACKGROUND: This study was designed to determine the feasibility, maximum tolerated dose, and toxicities of intraarterial administration of paclitaxel-albumin nanoparticles in patients with advanced head and neck and recurrent anal canal squamous cell carcinoma. Antitumor activity also was assessed. METHODS: Forty-three patients (31 with advanced head and neck and 12 with recurrent anal canal squamous cell carcinoma) were treated intraarterially with ABI-007 every 4 weeks for 3 cycles. In total, 120 treatment cycles were completed, 86 in patients with head and neck carcinoma (median, 3 cycles; range, 1-4) and 34 in patients with anal canal carcinoma (median, 3 cycles; range, 1-4). ABI-007 was compared preliminarily with Taxol for in vitro cytostatic activity. Increasing dose levels from 120 to 300 mg/m2 were studied in 18 patients. Pharmacokinetic profiles after intraarterial administration were obtained in a restricted number of patients. RESULTS: The dose-limiting toxicity of ABI-007 was myelosuppression consisting of Grade 4 neutropenia in 3 patients. Nonhematologic toxicities included total alopecia (30 patients), gastrointestinal toxicity (3 patients, Grade 2), skin toxicity (5 patients, Grade 2), neurologic toxicity (4 patients, Grade 2) ocular toxicity (1 patient, Grade 2), flu-like syndrome (7 patients, Grade 2; 1 patient, Grade 3). In total, 120 transfemoral, percutaneous catheterization procedure-related complications occurred only during catheterization of the neck vessels in 3 patients (2 TIA, 1 hemiparesis) and resolved spontaneously. CONCLUSIONS: Intraarterial administration of ABI-007 by percutaneous catheterization does not require premedication, is easy and reproducible, and has acceptable toxicity. The maximum tolerated dose in a single administration was 270 mg/m2. Most dose levels showed considerable antitumor activity (42 assessable patients with 80.9% complete response and partial response). The recommended Phase II dose is 230 mg/m2 every 3 weeks.

[Percutaneous implant of Denver peritoneovenous shunt: a new opportunity for the interventional radiologist]. / L'impianto percutaneo dello shunt peritoneo-venoso di Denver: Una nuova opportunità per il radiologo interventista.

PURPOSE: The study is aimed at presenting our experience in the implant of Denver peritoneovenous shunts. Medical treatment-resistant ascites, either neoplastic or related to hepatic failure, is highly symptomatic and its treatment is indicated in order to improve patients' quality of life. One of the most efficient methods of treatment consists in implanting a peritoneovenous shunt. The availability of this device and its percutaneous implantation provide Interventional Radiologists with the possibility of expanding their repertoire. MATERIAL AND METHODS: Thirteen shunts were implanted in 12 patients, 10 with neoplastic ascites and 2 with hepatic failure-related ascites. In 1 patient a second device had to be implanted. All the procedures were performed in the Interventional Radiology Department, under local anesthesia and mild sedation. The central venous access was by the subclavian vein in 7 cases and the internal jugular vein in 6 cases. The puncture kit is consists of 2 needles, 1 for venous puncture and 1 for peritoneal puncture, 2 angiographic J-guide wires, 2 peel-away introducers, and a chamber containing the double valve-pump connected with both the venous and the peritoneal catheters. The whole device is placed subcutaneously thus allowing fluids to flow from the peritoneum to the vein either spontaneously, if intra-abdominal pressure exceeds 3cm of water, or by manual compression exerted on the pump itself. RESULTS: All implants were successfully performed. One transient complication occurred consisting in a mild inflammatory reaction along the subcutaneous catheter route, which promptly solved by antibiotic therapy. So far a total of 1773 catheter/days have been accumulated. 7/10 of the neoplastic patients died from progressive disease after 915 catheter/days (median 120, range 30-180). In a cirrhotic patient the first shunt occluded after 430 days due to hemoperitoneum caused by hepatic biopsy: it was removed and a new one implanted. Five shunts are in now use, with a follow-up of 30, 48, 70, 120 and 160 days each. DISCUSSION: The implanting technique was well tolerated by all patients and it could be performed under local anesthesia. The central vein puncture was easy for both accesses but the introducer diameter (12F) and the possibility of clavicle pinch-off induced us to use the internal jugular approach in the last six cases, which provided a reduced risk of pneumothorax and a better catheter track. In the patients with neoplastic ascites we observed neither disease dissemination nor changes in the patients' changed related to the shunt. Our results show that the implant of Denver venous-peritoneal shunts is a relatively easy procedure, which can be performed by Interventional Radiologists on a regular basis.

Stereotactic breast biopsy: en bloc excision of microcalcifications with a large-bore cannula device.

OBJECTIVE: Breast calcifications pose a significant diagnostic and procedural dilemma. We evaluated en bloc stereotactic excision of indeterminate and suggestive microcalcifications for histologic diagnosis using a large-bore cannula biopsy device. MATERIALS AND METHODS: We retrospectively reviewed 61 groups of microcalcifications removed with a large-bore cannula biopsy device from 59 patients (age range, 35-72 years old). The cannula diameter was 20 mm in 47 cases, 15 mm in nine cases, and 10 mm in five cases. The median lesion diameter was 6.6 mm (range, 4-17 mm). The procedure was performed by radiologists in an outpatient setting, with patients undergoing local anesthesia. All patients with a diagnosis of malignancy underwent surgery. RESULTS: In all instances, microcalcifications were removed in a single pass, in a single intact tissue specimen, through a maximum skin incision of 2 cm (0.8 inch). Twenty-five malignancies, 34 benign lesions, and two cases of lobular carcinoma in situ were identified. Sixteen malignancies were noninvasive and nine were invasive. No residual tumor was found at surgery in six of the 18 cases with involved margins and in five of the seven cases with uninvolved margins. One case of lobular carcinoma in situ with involvement of the margins additionally showed ductal carcinoma in situ at surgery. CONCLUSION: Mammographically identified microcalcifications are excised en bloc with the large-bore cannula biopsy device, providing a stereotactically localized tissue sample that is comparable with that obtained with open surgical biopsy and allows evaluation of the margins. This surgical radiologic procedure may represent a valid alternative, in selected patients, to conventional surgical biopsy after radiologic localization.

First clinical experience with a high-capacity implantable infusion pump for continuous intravenous chemotherapy.

PURPOSE: To evaluate the efficiency of a new high-capacity pump for systemic venous chemotherapy and to verify the quality of implantation by interventional radiology staff. METHODS: A total of 47 infusion pumps with a 60-ml reservoir and variable flow rates (2, 6, 8, or 12 ml/24 hr) were implanted by radiologists in 46 patients with solid tumor metastases requiring treatment with a single, continuously infused cytostatic agent. The reservoir was refilled transcutaneously, usually once weekly. The flow accuracy of the pump was assessed from actual drug delivery recorded on 34 patients over a minimum observation period of 180 days. RESULTS: No early complications occurred in any of the 47 implants in 46 patients. A total of 12 (25.53%) complications occurred between 3 and 24 months after implantation. Seven (14.90%) of these were due to the external design of the pump, while five (10.63%) were related to the central venous catheter. In the 34 patients available for pump evaluation (follow-up of at least 180 days), the system was used for a total of 14,191 days (range 180-911 days, mean 417.38 days), giving an overall complication rate of 0.84 per 1000 days of operation. The mean flow rate accuracy was 90.26%. CONCLUSION: The new implantable pump showed good flow rate accuracy and reliable operation. The pump-related complications were related to its external design and have now been corrected by appropriate modifications. From a radiologic and surgical viewpoint, the venous implantation procedure is identical to that of conventional vascular access devices and can be performed by radiologists familiar with these techniques. The current limitations lie in the high cost of the pump and, for certain drugs, the short time between refills.

[Diagnosis of non-palpable lesions of the breast with stereotactic excisional biopsy with cannula. Advanced Breast Biopsy Instrumentation (ABBI) with fine diameter of 20 mm]. / Diagnosi delle lesioni non palpabili della mammella mediante la biopsia escissionale stereotassica con cannula. Advanced Breast Biopsy Instrumentation (ABBI) con diametro fino a 20 mm.

PURPOSE: To evaluate the advisability of use by interventional radiologists of the ABBI system for stereotactic biopsy in the diagnosis of mammographically detected nonpalpable breast lesions considered suspicious for cancer. MATERIAL AND METHODS: Breast biopsy with the ABBI cannula, available in various diameters, was offered to 61 patients who gave their informed consent and was performed in 36. Reasons for exclusion were insufficient thickness of the compressed breast (37.5%), the lesion site (50%) and the failure to detect the lesion with stereotactic mammography (12.5%). The procedure was carried out under local anesthesia in an outpatient setting. Fifteen nodules, 15 groups of microcalcifications and 6 nodules with calcifications were excised. The diameter of the ABBI cannula used was 20 mm in 32 cases and 15 mm in four cases. RESULTS: A definitive histological diagnosis was obtained in all cases, with the identification of 20 neoplasms (56%) and 16 benign lesions (44%). The lesions margins were involved in 14 cases of malignancy. All the patients with a diagnosis of malignancy underwent surgery. No residual tumor was found in five cases. The mean diameter of the lesions removed was 11-12 mm. The only complications were two late hematomas which were drained by simple percutaneous aspiration. The procedure was well tolerated by all patients except one who experienced a vagal attack due to emotional stress. CONCLUSIONS: Stereotactic breast biopsy with an ABBI surgical cannula can be carried out autonomously by interventional radiologists, safely and with diagnostic accuracy.

Stereotactic excisional breast biopsy performed by interventional radiologists using the advanced breast biopsy instrumentation system.

The Advanced Breast Biopsy Instrumentation (ABBI) system, which uses surgical cannulas up to 20 mm in diameter, is an alternative to conventional surgical biopsy for the diagnosis of non-palpable breast lesions. Since the need for radiological skill outweighs the surgical content of the technique, we evaluated the feasibility of complete management of the procedure by interventional radiologists. 35 of the 111 patients originally scheduled for the procedure were excluded, three because the lesion could not be visualized and 32 because of insufficient thickness of the compressed breast. The procedure had to be abandoned in one case due to a technical failure. 77 stereotactic excisional breast biopsy procedures were performed using the ABBI system in 75 patients with suspicious non-palpable mammographic lesions. The procedure was carried out under local anaesthesia in the radiology department, using a dedicated Lorad (R) radiographic system. 31 (40%) masses without calcifications, 11 (14%) masses with calcifications and 35 (46%) clusters of microcalcifications without tumour mass were sampled. 43 (56%) benign lesions and 34 (44%) malignant lesions were diagnosed. The overall mean diameter of the lesions was 8.7 mm (range 3-22 mm). All 34 patients with malignancies and lobular carcinoma in situ subsequently underwent surgery, the results of which are reported. Three (4%) haematomas were detected and aspirated percutaneously. Two technical problems occurred: an ABBI cannula malfunction, and a computer failure of the digital imaging system during the procedure. The average procedure time was 80 min and the cost of each procedure was 2,800,000 Italian lire (1555 US$). It is concluded that tissue sampling with the ABBI system can be performed entirely by radiologists without significant problems. The procedure was well tolerated by all patients. The quality of the biopsy specimen was identical to that of a surgical specimen but with the advantages of stereotactic precision for localization of the lesion.

Hepatocellular carcinoma in patients who undergo liver transplantation: sensitivity of CT with iodized oil.

PURPOSE: To evaluate the diagnostic efficacy of computed tomography (CT) after hepatic intraarterial injection of iodized oil in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Forty patients who underwent CT with iodized oil before orthotopic liver transplantation (OLT) were evaluated prospectively. All patients underwent digital subtraction angiography and injection of iodized oil during chemoembolization. CT during arterial portography (CTAP) was performed in 34 patients. The number of neoplastic nodules was assessed in explanted livers and compared with the radiologic results. RESULTS: Sixty-six HCC nodules were present in the explanted livers. CT with iodized oil enabled correct diagnosis in 38 of 66 lesions (58%), and the results were false-positive in two lesions (3%). Digital subtraction angiography had a sensitivity of 67% (44 of 66 nodules) and CTAP had a sensitivity of 85% (45 of 53 nodules). Four (6%) false-positive diagnoses were made at digital subtraction angiography and three (6%) at CTAP. The diagnostic efficacy of CT with iodized oil was significantly related to lesion diameter greater than 2 cm (P < .0001) and hypervascularity (P < .0001). CONCLUSION: CT with iodized oil failed to provide any substantial information in the pre-OLT staging of HCC: It was inaccurate for small HCC nodules (<2 cm) and intrahepatic metastases. Its sensitivity matched that of digital subtraction angiography and was statistically significantly inferior to that of CTAP.

[Diagnostic imaging of liver metastasis]. / Diagnostica per immagini delle metastasi epatiche.

The early diagnosis and monitoring of hepatic metastases are now achieved by different imaging modalities, some using ionizing radiations (computed tomography and angiography), some based on other energy sources (sonography and magnetic resonance), but all coming within the radiological area, which offers concrete possibilities of integration and the necessary organization. These modalities are sometimes used only for percutaneous histological samplings with minimal invasiveness. The progress in hepatic resective surgery and the possibility of orthotopic liver transplantation for some neoplastic histotypes, together with the alternatives provided by interventional radiology, have brought a continuous updating of the specialist' interest in the morphological and functional definition of hepatic metastatic disease, with the specific aim of choosing the best therapeutic strategy. Hepatic metastases have the greatest impact on the survival of patients with gastrointestinal neoplasms, especially colonic adenocarcinoma. Intraoperative sonography and CT arterial portography currently provide greatest diagnostic sensitivity in terms of spatial resolution but cannot be considered as methods of choice, the former for obvious reasons and the latter because of its invasiveness and complexity. The alternatives are to be sought in spiral CT and the new MR sequences which can undoubtedly provide a decisive improvement in the diagnostic standards currently available. Profoundly changed, but no less important, is the role of angiography, which still provides the anatomical support for hepatic surgery and the means for alternative treatments, such as chemoembolization and continuous infusional chemotherapy.

Long-term infusion in cancer chemotherapy with the Groshong catheter via the inferior vena cava.

AIMS AND BACKGROUND: Vascular access through a vein draining into the superior vena cava is commonly used for long-term infusion of drugs inr cancer chemotherapy; prolonged cannulation of the inferior vena cava is generally considered as having an excessively high complication rate. METHODS: Prolonged cisplatin infusion via the inferior vena cava by means of a Groshong catheter was evaluated in 20 consecutive patients with thoracic malignancies showing evidence of superior vena cava infiltration or obstruction. RESULTS: We achieved 1,291 catheter days for our survey with a mean duration of vascular access of 64.5 days per patient and a mean duration of infusion time of 40 days. There were 2 complications, a catheter obstruction after a 7-day rest period and an ileo-femoral thrombosis 6 days after catheter placement. CONCLUSIONS: Our experience compared favourably with the results obtained by long-term central venous access via the supraumbilical route, and demonstrated the reliability and safety of this approach in cases where the superior vena cava cannulation is technically difficult or impossible.

[Transcatheter embolization in 39 cases of hyperactive arteriovenous malformation]. / Embolizzazione transcatetere in 39 casi di malformazione artero-venosa iperattiva.

Hyperdynamic arteriovenous malformations are a relevant therapeutic problem because of the complexity and variability of their presentation. The incidence of this angiodysplasia is quite low, so that only few institutions have treated more than a few patients, which certainly does not help treatment optimization. The role that transcatheter embolization has gained during the last years has fostered growing interest in this method, even though surgery remains the treatment of choice. Transcatheter embolization is a highly effective treatment, which can ensure long-lasting, although rarely definitive, hemodynamic results. The authors report their experience in 39 patients affected with hyperdynamic arteriovenous malformations. The total number of percutaneous embolization sessions was 81. In 11 patients a preoperative treatment was performed 48 hours before surgery. In all cases polyvinyl alcohol particles were used, whose diameter ranged 250-500 micron. The results, with a mean follow-up of 53 months, are reported. In the 11 patients who underwent combined surgery plus embolization treatment, conservative surgical resection was radical in 73% of cases. As for the other patients, the result was substantial in 46% of cases, partial in 27% and modest or insignificant in 27% of cases. The total incidence of major complications was 6.2%. Our experience confirms that transcatheter embolotherapy, although yielding effective long-term results, has a mostly palliative role.

Carbon dioxide digital subtraction angiography in oncological-interventional radiology.

AIMS AND BACKGROUND: The aim of this work is to demonstrate the usefulness of carbon dioxide, used as contrast agent, in special indications in vascular interventional oncological procedures. METHODS: We studied 40 patients with digital subtraction angiography enhanced with CO2 as a contrast agent. At the same time we utilized also, in all cases, jodinated contrast agent to evaluate the different opacification gradient, the different viscosity range and the different perfusion. RESULTS: The low viscosity of CO2 allows demonstration of the presence of even minimal blood losses in gastrointestinal tumors and enhances arteriovenous shunts in hepatocellular carcinoma. Carbon dioxide can also be employed to assess the patency of small-sized catheters for chemotherapy infusion which do not allow easy injection of the traditional iodinated contrast agents characterized by high viscosity. CONCLUSION: Carboangiographic study combined to digital subtraction angiography can clear some diagnostic problems and is further method to assess the outcome of angiographic interventional procedures in oncology.

US contrast enhancement with intra-arterial CO2 injection in the staging of hepatocellular carcinomas.

Liver US contrast enhancement was obtained with the intrahepatic arterial injection of CO2 in 45 hepatocellular carcinoma patients. Before digital subtraction angiography (DSA) all the patients underwent conventional US and CT of the liver; 20 patients also underwent CT during arterial portography (CTAP). Liver US contrast enhancement with CO2 exhibited the same sensitivity as DSA (92%) in demonstrating hypervascular HCCs and proved superior to the other diagnostic procedures -- 85% for CT and 78% for conventional US. DSA combined with echocarbography, with its 2D demonstration of liver anatomy, improved the correct staging of HCCs, for better treatment planning.

[Pulmonary carcinosarcoma]. / Carcinosarcoma polmonare.

Sarcomatoid carcinomas of the lung are uncommon neoplasms; the concurrent presence of malignant epithelial and sarcomatoid spindle cell components show a high malignancy. Lymph node metastases at presentation is an important prognostic factor, on the other way the most patients with sarcomatoid carcinoma of the lung usually presented at an advanced stage that needed a complementary therapy. The Authors report about one surgical case of pulmonary carcinosarcoma recently observed without lymph node metastases; the literature is reviewed and the histogenesis is discussed.

[Retroperitoneal leiomyosarcoma (case report)]. / Leiomiosarcoma retroperitoneale (Case report).

After a short introduction about the retroperitoneal tumors classification the Authors write on the management of this tumor. They present their case report: surgical treatment of retroperitoneal leiomyosarcoma. Actually the role of surgical strategy in the management of resectable retroperitoneal tumors is the most important than adjuvant therapy, even if the surgery must be very demolitive.

[Hemorrhages of the lower digestive tract: the diagnostic and therapeutic approach]. / Emorragie del tratto digestivo inferiore: approccio diagnostico e terapeutico.

The authors describe their experience with colo-rectal haemorrhage. They stress the tendency towards spontaneous arrest of such haemorrhages (92.6% of cases) as the usefulness of emergency colonoscopy in diagnosing the cause and/or site of the haemorrhagic lesion (85.7% of positive results in the present series). Therapy may be conservative (endoscopic or in the course of angiography) or surgical. Surgery is indicated in cases failing to respond to conservative therapy and in cases of unarrestable haemorrhage and usually consists in segmental resection of the portion of the intestinal tract involved.