A case of intermittent lumbar pain radiating to the right shoulder in a 76-year-old woman.

Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma, occurring most frequently in the deep soft tissues of the extremities, and it is most frequently seen in elderly patients. A primary MFH of the diaphragm is very rare, and to the best of our knowledge, a multi-phased spiral CT appearance of this tumour has not been previously reported. In this report, we describe the clinical and multi-phase CT features of a primary MFH of the diaphragm.

Radiofrequency thermal ablation of small tumors in transplanted kidneys: an evolving nephron-sparing option.

Small tumors in transplanted kidneys are rarely detected during follow-up. With surgical treatment, it is sometimes challenging to preserve the graft and its function. Image-guided ablation techniques have been recently reported as effective in treating these tumors. Herein three cases of radiofrequency (RF) thermal ablation in transplanted kidneys are reviewed and compared with cases in the literature. There were no major complications seen, the mean change in serum creatinine level was no greater than 0.1 mg/dL, and complete ablation was sustained on imaging studies at 3, 18, and 62 months follow-up. RF ablation can be considered a safe, function-preserving, and effective evolving therapeutic option for small tumors in transplanted kidneys.

A case of epigastric pain in the ED: late mechanical complication after vertical banded gastroplasty.

A 50-year-old woman presented to our emergency department complaining of recurrent epigastric stabbing pain on eating of 1 month duration. She had a history of morbid obesity treated 13 years before with laparoscopic vertical banded gastroplasty (VBG). Diagnosis was made by radiology, after upper gastrointestinal series and abdominal unenhanced computed tomography. These demonstrated intragastric band migration, with outlet stenosis of narrowed stomach. Vertical banded gastroplasty is a miniinvasive approach that gives the benefits of shorter hospital stay, less postoperative pain, and quicker functional recovery. However, many complications are known and require recognition to be appropriately treated. In our case, the history and clinical presentation led to a high suspicion of intraabdominal pathology due to postoperative complication. Radiologic upper gastrointestinal investigation and computed tomography findings were then decisive to detect the intragastric band migration.

Acute abdomen as an unusual presentation of hepatic PEComa. A case report.

Perivascular epithelioid cell (PEC) tumors (or PEComas) are myomelanocytic lesions defined by coexpression of melanocytic and muscle markers, suggesting dual differentiation. They are rare mesenchymal tumors and include subtypes with distinct clinical features: angiomyolipoma, lymphangioleiomyomatosis, and clear cell "sugar" tumors of the lung, pancreas and uterus. Consequent upon the World Health Organization's recognition of PEC-derived tumors as a distinct entity, an increasing number of reports has documented PEComas arising at various anatomical locations. Clear cell myomelanocytic tumors of the falciform ligament/ligamentum teres (CCMTs) represent a rare variant of the PEComas. These hepatic PEComas, different from angiomyolipoma of the liver, pose a clinical, radiological and morphological diagnostic challenge. Because of their rarity, the clinical features and biological behavior of these tumors have yet to be established. We experienced our first case of CCMT in a 36-year-old woman who presented to our emergency department with a 3-day history of abdominal discomfort and progressive growth of an epigastric bulk. Intralesional hemorrhage was causing abdominal distension, which progressed to acute abdomen soon after. The hemoglobin concentration was 9.9 g/dL. Liver laboratory tests showed slight elevation of AST, ALT and gamma-GT. The alpha-fetoprotein level was not elevated. The radiological images showed a hemorrhagic mass with some bizarre features in left hepatic lobe, immediately adjacent to the ligamentum teres and falciform ligament. The patient underwent a left hepatic lobectomy. The diagnosis of CCMT was based on histological and immunohistochemical staining. The postoperative course was uneventful. The patient received no adjuvant treatment and is currently, 34 months after surgery, alive and disease free. In this report we describe a peculiar and hitherto undescribed clinical presentation of this tumor and its further course. Moreover, we discuss previously undescribed diagnostic imaging. We recommend that all unusual carcinomas and mesenchymal tumors of the liver should be tested for HMB-45: when positive, there is a high likelihood of PEComa.

Clinical implications and added costs of incidental findings in an early detection study of lung cancer by using low-dose spiral computed tomography.

INTRODUCTION: To prospectively evaluate the frequency and spectrum of incidental findings (IF) in a 5-year lung cancer screening program with low-dose spiral computed tomography (CT) and to estimate the additional costs of their imaging workup incurred from subsequent radiologic follow-up evaluation. MATERIALS AND METHODS: A total of 519 asymptomatic volunteers were enrolled. All IFs were reported and were considered clinically relevant if they required further evaluations or with clinical implications if they required more than one additional diagnostic test for characterization or medical and/or surgical intervention. RESULTS: IFs were commonly found (59.2%, 307/519 participants at baseline and 5.3% per year at 5-year follow-up [123 participants of 2341 LDsCT exams performed during follow-up], with an overall rate of 26.3%). IFs were categorized as previously unknown clinically relevant in 52 (10.0%) individuals at baseline. Of these, 36 (6.9%) individuals had IFs with clinical implications (10 clinically relevant, of which 6 had clinical implications, detected during the subsequent 5-year follow-up). The most common recommendations were for additional imaging of the thyroid and kidneys. Additional imaging was mainly performed by ultrasound (43/68 [63.2%]). Subsequent surgical intervention resulted from these findings in 7 (1.5%) subjects. Six malignancies were diagnosed (rate, 0.2% per year). Costs of subsequent radiologic follow-up studies were calculated as €4644.56 [U.S. $6575.04] at baseline and €1052.30 [U.S. $1489.69] at 5-year follow-up (average added costs per participant €8.95 [U.S. $12.67] and €2.25 [U.S. $3.19], respectively). CONCLUSIONS: Low-dose spiral CT commonly detects IFs. Some of these require further investigations to assess their clinical relevance. Although such IFs add little clinical benefit to the screening intervention, moderate incremental costs are incurred based on additional radiologic procedures generated during short-term follow-up, given the potential for positive effects on patient care.

Accuracy of 64-row multidetector CT in the diagnosis of surgically treated acute abdomen.

OBJECTIVE: To assess the accuracy of 64-row computed tomography (CT) in the differential diagnosis of acute abdomen in the emergency department. MATERIALS AND METHODS: Prospective analysis of 181 patients with surgically treated acute abdomen. RESULTS: In 158/181 cases, CT was totally concordant with surgical repertoire. Partial concordance was found in 15 cases. Overall sensitivity was 87.3% when only cases of complete concordance were considered, 95.6% if also partial concordance cases were included. CONCLUSION: CT showed high reliability in the differential diagnosis of acute abdomen surgically treated, although associated conditions can sometimes be missed.

Second Italian consensus conference on malignant pleural mesothelioma: state of the art and recommendations.

Malignant pleural mesothelioma (MPM) is a relevant public health issue. A large amount of data indicate a relationship between mesothelioma and asbestos exposure. MPM incidence has considerably and constantly increased over the past two decades in industrialized countries and is expected to peak in 2010-2020. In Italy, the standardized incidence rate in 2008 was 3.6 and 1.3 per 100,000 in men and women respectively, with wide differences from one region to another. The approach to this disease remains difficult and complex in terms of pathogenic mechanism, diagnosis, staging and treatment thus an optimal strategy has not yet been clearly defined. The Second Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Turin (Italy) on November 24-25, 2011: recommendations on MPM management for public health institutions, clinicians and patients are presented in this report.

Imaging of benign solitary fibrous tumor of the pleura: a pictorial essay.

Solitary fibrous tumor of the pleura (SFTP) is a mesenchymal tumor that tends to involve the pleura, and is also described in other thoracic and extrathoracic sites. SFTP usually presents as a peripheral mass abutting the pleural surface, to which it is attached by a broad base or by a pedicle that allows it to be mobile. SFTPs exist in benign and malignant forms. A precise pre-operative diagnosis can be arrived at with a cutting-needle biopsy, although most cases are diagnosed with postoperative histology and immunohistochemical analysis. In this pictorial essay, we review a large series of cases, with emphasis on the radiographic appearance of these lesions and their findings from computed tomography, magnetic resonance imaging, ultrasonography and positron emission tomography.

Percutaneous RF thermal ablation of renal tumors: is US guidance really less favorable than other imaging guidance techniques?

The purpose of this study was to compare our experience with ultrasound (US)-guided percutaneous radiofrequency thermal ablation (RFA) of renal tumors with results of CT-guided and MRI-guided series in the current literature. Of 90 consecutive renal tumors treated with RFA in 71 patients, 87 lesions were ablated under US guidance. We performed a retrospective analysis of clinical outcome and safety. Results were then compared to published case series where CT and MRI guidances were used exclusively. In our series we had a major complication rate of 4.6%, whereas in CT- and MRI-based series it was 0-12% (mean, 2.2%) and 0-8.3% (mean, 4.1%), respectively. During follow-up (1-68 months; mean, 24 months) technical effectiveness was 89.7%, while it was between 89.5% and 96% in CT-guided series and between 91.7% and 100% in MRI-guided series. The size of successfully treated lesions (28 mm) was lower than that of partially-ablated lesions (36 mm; p = 0.004) and only central lesion location proved to be a negative prognostic factor (p = 0.009); in CT-guided series, positive prognostic factors were exophytic growth and size

Radiofrequency ablation of colorectal liver metastases: small size favorably predicts technique effectiveness and survival.

The objective of this study was to analyze long-term results of radiofrequency thermal ablation (RFA) for colorectal metastases (MTS), in order to evaluate predictors for adverse events, technique effectiveness, and survival. One hundred ninety-nine nonresectable MTS (0.5-8 cm; mean, 2.9 cm) in 122 patients underwent a total of 166 RFA sessions, percutaneously or during surgery. The technique was "simple" or "combined" with vascular occlusion. The mean follow-up time was 24.2 months. Complications, technique effectiveness, and survival rates were statistically analyzed. Adverse events occurred in 8.1% of lesions (major complication rate: 1.1%), 7.1% with simple and 16.7% with combined technique (p = 0.15). Early complete response was obtained in 151 lesions (81.2%), but 49 lesions (26.3%) recurred locally after a mean of 10.4 months. Sustained complete ablation was achieved in 66.7% of lesions < or = 3 cm versus 33.3% of lesions > 3 cm (p < 0.0001). Survival rates at 1, 3, and 5 years were 91%, 54%, and 33%, respectively, from the diagnosis of MTS and 79%, 38%, and 22%, respectively, from RFA. Mean survival time from RFA was 31.5 months, 36.2 in patients with main MTS < or = 3 cm and 23.2 in those with at least one lesion > 3 cm (p = 0.006). We conclude that "simple" RFA is safe and successful for MTS < or = 3 cm, contributing to prolong survival when patients can be completely treated.

Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome.

OBJECTIVES: To assess the potential of bedside lung ultrasound to diagnose the radiologic alveolar-interstitial syndrome (AIS) in patients admitted to an emergency medicine unit and to estimate the occurrence of ultrasound pattern of diffuse and multiple comet tail artifacts in diseases involving lung interstitium. METHODS: The ultrasonic feature of multiple and diffuse comet tail artifacts B line was investigated in each of 300 consecutive patients within 48 hours after admission to our emergency medicine unit. Sonographic examination was performed at bedside in a supine position. Eight anterolateral ultrasound chest intercostal scans were obtained for each patient. RESULTS: The artifact showed a sensitivity of 85.7% and a specificity of 97.7% in recognition of radiologic AIS. Corresponding figures in the identification of a disease involving lung interstitium were 85.3% and 96.8%. CONCLUSION: Comet tail artifact B line is a lung ultrasound sign reasonably accurate for diagnosing AIS at bedside.

Digital chest radiography system with amorphous selenium flat-panel detectors: Qualitative and dosimetric comparison with a dedicated film-screen system.

PURPOSE: To compare the quality and radiation dose of a conventional film-screen system and a digital system with amorphous selenium detectors in the study of the chest, by verifying overall performance and exposure levels for the main chest structures in patients of different sizes. MATERIALS AND METHODS: An analogic system (Chest-Changer, Dupont, Day-light model 1000) and a digital system (Directray Rad 1000C, Hologic) were tested on a total of 1000 patients randomly assigned to one of two groups of 500 subjects. The patients were further subdivided according to BMI (Body Mass Index). Image quality was determined by two chest radiologists who evaluated eight anatomical structures. The entrance surface dose (skin-dose), calculated based on the exposure parameters, was taken as the patient dose. RESULTS: Mean dose delivered was very similar for both techniques in the PA view (0.28 mGy), but it was greater in the LL projections obtained with the digital system (1.20 mGy versus 0.83 mGy). The highest overall scores were assigned to 43% and 23.2% analogic radiograms and 64% and 70.2% digital radiograms, for the PA and LL projections respectively. The scores assigned to the various anatomical structures confirmed the better performance of the digital system in almost all of the regions considered. CONCLUSIONS: The mean quality of radiograms is definitely higher with the digital system, in particular in the LL projections, where the higher patient doses are counterbalanced by fewer repeated scans. The greater level of exposure in the digital system appears nonetheless tolerable on account of the greater informativeness and therefore diagnostic gain and also considering the possibilities for improving the system.

CT findings in primary pulmonary lymphomas.

PURPOSE: To describe the CT findings of pathologically confirmed primary pulmonary lymphomas. MATERIALS AND METHODS: The CT examinations of 11 patients with pathologically proven primary pulmonary lymphoma (9 BALT lymphomas and 2 non-BALT lymphomas) were retrospectively reviewed by three radiologists. Evaluated findings included morphology (consolidation, mass, nodule), number and distribution of lesions. Other CT findings such as air bronchogram, lymphadenopathy, atelectasis and pleural effusion were also assessed. RESULTS: Pulmonary lesions were depicted as airspace consolidation (pneumonia-like) in 5 patients (45%), tumour-like rounded opacity in 4 (36%), and nodules in 4 (36%). Multiple and bilateral lung lesions were seen in 3 patients (27%). Air bronchogram was present in 7 patients (63%), lymphadenopathy in 3 (27%), atelectasis in 4 (36%) and pleural effusion in only 1 (9%). CONCLUSIONS: Our results agree with previous studies regarding lesion patterns and their relative frequency. A smaller number of nodules and multiple lesions were found compared with some previous studies. The most frequent pattern was airspace consolidation.

Low dose CT in early lung cancer diagnosis: Prevalence data.

PURPOSE: Lung cancer has a high mortality rate and its prognosis largely depends on early detection. We report the prevalence data of the study on early detection of lung cancer with low-dose spiral CT underway at our hospital. MATERIALS AND METHODS: Since the beginning of 2001, 519 asymptomatic volunteers have undergone annual blood tests, sputum tests, urinalyses and low-dose spiral CT. The inclusion criteria were age (=/> 55 years old), a history of cigarette smoking and a negative history for previous neoplastic disease. The diagnostic workup varied depending on the size and CT features of the nodules detected. RESULTS: At baseline, the CT scan detected nodules > 5 mm in 22% of subjects; the nodules were single in 42 and multiple in 71. In 53% of cases the findings were completely negative, while in 122 (23.4%) nodules with a diameter < 5 mm were detected. Six cases of lung cancer were identified, of which four were stage I, one stage was IIIB and one was stage IV with adrenal metastases. CONCLUSIONS: Our preliminary data on spiral CT as a potential new diagnostic tool for lung cancer screening, although less promising than the Japanese and ELCAP results, confirm the feasibility of the technique. Additional validation is, however, required.

[MEN 1 and 2: the role of diagnostic imaging].

PURPOSE: To report the results of a retrospective study on the use of the different imaging methods in the diagnosis of type 1 and type 2 multiple endocrine neoplasias, and to provide an overall evaluation of the diagnostic yield of the various examinations performed correlating the results with the surgical findings. MATERIALS AND METHODS: The study was conducted by reviewing the data of 12 patients, of whom four with MEN1 and eight with MEN2, assessed with different imaging modalities. In the patients with MEN1 the examinations revealed 4 parathyroid hyperplasias, 4 gastro-pancreatic endocrine-secreting lesions, one hypophyseal adenoma, one bronchial carcinoid and two bilateral adrenal hyperplasias. In the patients with MEN2 the examinations revealed 6 medullary thyroid carcinomas (MTC), 4 pheochromocytomas and 3 parathyroid hyperplasias. RESULTS: In MEN1 the parathyroid hyperplasias were diagnosed by scintigraphy in all four cases, whereas neck ultrasound was positive in only two cases. The gastro-pancreatic endocrine-secreting lesions were demonstrated in all four patients with CT and endoscopic ultrasound (two patients also underwent scintigraphy with octreotide, which was positive). In only one patient with MEN1 did the chest X-ray detect a bronchial carcinoma, confirmed by CT. CT also enabled identification of a single hypophyseal adenoma. The patients with MEN2 were divided into two groups: one consisting of asymptomatic patients undergoing screening following positive genetic testing and one of symptomatic patients. In the first group the imaging examinations diagnosed one MTC and three pheochromocytomas; all patients in the second group had MTC (detected by positive ultrasound and scintigraphy examinations). DISCUSSION AND CONCLUSIONS: Given the rarity of this condition we believe that the only statistically important finding in our series concerns the sensitivity of the imaging examinations performed in that, with adequate clinical and laboratory data, the possible problem of false positive results is exceptional. The role of diagnostic imaging in the management of patients with MEN1 and 2 is twofold: identification of the target organs of lesions suspected on the basis of clinical and laboratory findings to enable adequate medical and/or surgical treatment; staging of malignant lesions to enable correct surgical planning. In particular, our study once again highlights the diagnostic efficacy of CT for the diagnosis of pheochromocytomas and of the combination of biopsy plus ultrasound and ultrasound plus scintigraphy for the diagnosis of MTC in MEN 2. As for MEN1 spiral CT was found to have good sensitivity (66%) in localising endocrine neoplasias of the gastrointestinal tract; endoscopic ultrasound on the other hand revealed good diagnostic efficacy, showing constantly positive findings. Finally, in both pathologies we believe that the assessment of parathyroid conditions to be mainly a matter for nuclear medicine.

Intermittent maximal androgen blockade in patients with metastatic prostate cancer: an EORTC feasibility study.

OBJECTIVES: In preparation of an intercontinental Phase III trial comparing continuous maximal androgen blockade (MAB) to intermittent androgen suppression (IAS) in untreated metastatic prostate cancer, a feasibility study on IAS was accomplished. METHODS: 107 patients (median follow-up 92 weeks) were treated with MAB until a PSA nadir was reached. Nadir was defined as PSA below 20 ng/ml corresponding to PSA reduction by at least 80% of baseline value. Criteria for restarting treatment was PSA >20 ng/ml and PSA > nadir + 50%. Trials aim was to assess the likelihood that 80% of patients would reach a first nadir and that 80% of these would also reach a second nadir. RESULTS: 51.4% of patients had some degree of pain at entry, 27.1% had >15 hot spots, 23.7% demonstrated obstruction. Only 17.8% had normal potency, 56.1% were totally impotent. One to seven cycles of treatment were given. 76.6% of patients reached a 1st nadir after a median of 19 weeks of treatment, 84.1% of these started the 2nd cycle and 71% of them reached a 2nd nadir after a median of 13.6 weeks. Median time off-treatment was 14.3 and 16.0 weeks corresponding to 38.4% and 48.5% of the duration of each cycle. A similar proportion of patients was reported to be potent during follow-up compared to baseline. 32.7% of patients died during follow-up, 82.9% of prostate cancer. CONCLUSION: Around 75% of the patients achieved a nadir at each cycle. The concept of IAS seems to be feasible and warrants further investigation.