The Italian multi-centre project on evaluation of MRI and other imaging modalities in early detection of breast cancer in subjects at high genetic risk.

This report presents the preliminary results of the first phase (21 months) of a multi-centre, non-randomised, prospective study, aimed at evaluating the effectiveness of contrast-enhanced magnetic resonance imaging (MRI), X-ray mammography (XM) and ultrasound (US) in early diagnosis of breast cancer (BC) in subjects at high genetic risk. This Italian national trial (coordinated by the Istituto Superiore di Sanità, Rome) so far recruited 105 women (mean age 46.0 years; median age 51.0; age range 25-77 years), who were either proven BRCA1 or BRCA2 mutation carriers or had a 1 in 2 probability of being carriers (40/105 with a previous personal history of BC). Eight cases of breast carcinomas were detected in the trial (mean age 55.3 years, median age 52.5; age range 35-70 years; five with previous personal history of BC). All trial-detected BC cases (8/8) were identified by MRI, while XM and US correctly classified only one. MRI had one false positive case, XM and US none. Seven "MRI-only" detected cancers (4 invasive, 3 in situ) occurred in both pre- (n = 2) and post-menopausal (n = 5) women. With respect to the current XM screening programmes addressed to women in the age range 50-69 years, the global incidence of BC in the trial (7.6%) was over ten-fold higher. The cost per "MRI-only" detected cancer in this particular category of subjects at high genetic risk was substantially lower than that of an XM-detected cancer in the general women population. These preliminary results confirmed that MRI is a very useful tool to screen subjects at high genetic risk for breast carcinoma, not only in pre-, but also in post-menopausal age, with a low probability of false positive cases.

Celiac plexus block: injectate spread and pain relief in patients with regional anatomic distortions.

BACKGROUND: The success of the neurolytic celiac plexus block, despite different approaches and methods used, depends on adequate spread of the injectate in the celiac area. This retrospective study was conducted to evaluate the patterns of alcohol spread and pain relief in patients with cancer or therapy-related anatomic distortion of the celiac area. METHODS: From 177 cancer patients who underwent computed tomography (CT)-guided single-needle neurolytic celiac plexus block via an anterior approach, a radiologist, blind to the aim of the study, retrospectively selected 105 patients with abnormal anatomy of the celiac area as judged by CT images obtained before the block. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Results were expressed as the number of quadrants into which contrast spread, ie., four, three, two, or one quadrants with contrast. The patterns of contrast spread according to the number of quadrants with anatomic distortion were analyzed. Patient assessment by visual analog scale was reviewed to evaluate the degree of pain relief. Pain relief 30 days after block was considered long-lasting. Pain relief at 30 days after block was analyzed according to the number of quadrants with contrast. RESULTS: Overall, four, three, two, and one quadrants with contrast were observed in 9 (8%), 21 (20%), 49 (47%), and 26 (25%) patients, respectively. An inverse correlation was observed between the number of quadrants with anatomic distortion and the number of quadrants with contrast (P < 0.001). Long-lasting pain relief was noticed in nine of nine patients (100%; 95% confidence interval, 66-100) with contrast in four-quadrants, and in 10 of 21 patients (48%; 95% confidence interval, 26-70) with contrast in 3 quadrants (P < 0.01). None of the 75 patients with contrast in two quadrants or one quadrant experienced long-lasting pain relief. CONCLUSIONS: These findings suggest that, using the single-needle anterior approach, the neurolytic spread in the celiac area is highly hampered by the regional anatomic alterations. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia, and that this picture may be obtained in a very limited fraction of patients with regional anatomic alterations.

[The presentation of a picture archiving and communication system (PACS) and the initial experiences with its use]. / Presentazione di un sistema di archiviazione e di trasmissione delle immagini ("Picture Archiving and Communication System"--PACS) e prime esperienze applicative.

INTRODUCTION: The use of computers has yielded new diagnostic techniques (US, CT, MRI and computed radiography) that can successfully replace conventional film in data acquisition, image display and image interpretation. Thanks to the Picture Archiving and Communication System (PACS), we can now manage the whole of diagnostic data because the images are acquired, coupled to the patient data stored in the Radiology Information System (RIS), sent to display workstations and finally sent to the archives. PURPOSE: To present the configuration and functions of a new PACS used in radiology and nuclear medicine departments and to evaluate its efficacy one year after implementation. Particular attention is paid to the objective difficulties radiologists found in approaching the system. RESULTS: Secretarial work reduction and a more rational archiving organization are two of the advantages of automation. PACS permits rapid image display, retrieval nd archiving for both scientific and statistical purposes; however, its correct use is hindered by a series of problems, namely: a) reluctance to use PACS by many members of the medical staff, due to the complexity of its procedures; b) lack of panoramicity on the display monitor in multi-image examinations and c) underuse of viewing workstations in several wards of our institution due to lack of know-how. CONCLUSIONS: Although the use of PACS has improved the workload management in our departments, the system still needs to be customized to the radiologist to optimize its use. Workstations must be user-friendly, with simultaneous display of more images. On the other hand, radiologists need to expand their knowledge of new techniques, thus modifying obsolete working procedures.

Central venous catheter-related thrombosis in clinically asymptomatic oncologic patients: a phlebographic study.

Fifty-seven oncologic patients with short- or long-term central venous catheters (CVCs) and without clinical signs of axillary-subclavian thrombosis were evaluated phlebographically. Different degrees of incomplete thrombosis were found in 26 patients (45.5%) and complete thrombosis, clinically silent, was found in six patients (10.5%). A fibrin sleeve around the CVC was radiologically demonstrated in 45 (78%) patients, 21 of them (46%) with negative standard venogram. Only in four patients there was no evidence of fibrin sleeve or parietal thrombosis. There were no significant differences between patients with long-term and short-term CVCs. We conclude that parietal thrombosis of the axillary-subclavian veins is a frequent event, even if there is no clinical evidence of flow obstruction and we confirm in vivo that a fibrin coating of the CVCs is present in the majority of the cases.

Antithrombin III deficiency as a risk factor for catheter-related central vein thrombosis in cancer patients.

The fibrin sleeve of venous catheters (VC) and parietal thrombi represent frequent and dangerous side-effects of central venous catheterization (CVC), due to the risk of embolism. Reduced levels of coagulation clotting factors inhibitors (such as Antithrombin III) are known to be associated with increased thrombogenic risk. The aim of this study was to evaluate the role of Antithrombin III (AT III) deficiency as a risk factor for thrombosis in cancer patients undergoing CVC. The study groups included patients with a reduced AT III activity (< 70%, 20 consecutive patients) and with normal AT III values (> 70%, 20 randomly selected patients), requiring a VC for chemotherapy and/or total parenteral nutrition. The study protocol included evaluation of Hb, PLTs, PT (INR), aPTT, Fibrinogen and AT III at days 0, 1, 3 and 8 after CVC and upon VC removal. Peripheral and pullout phlebographies were performed in all patients on catheter withdrawal. A quantitative scale was developed to evaluate both VC and parietal thrombus degree in each catheter-containing venous segment (subclavian, innominate, superior vena cava); the sum of the mean values was defined as overall thrombus. The average VC dwelling time was similar in both groups. There were no significant differences in Hb, PLTs, PT (INR), aPTT, Fibrinogen and in the remaining parameters of the study between the two groups. The group with AT III deficiency presented a higher degree of both parietal (p < 0.05) and overall thrombus (p < 0.02). Data showed a higher severity of CVC-related thrombosis in patients with AT III deficiency than in the control group. Further studies are needed to evaluate whether the therapeutically-induced normalization of AT III levels can reduce the thrombosis degree.

[Urinary calculi in an intestinal loop used for ureteral substitution. A case report]. / Calcolosi urinaria in ansa intestinale utilizzata per sostituzione ureterale. Osservazione di un caso.

The authors report the case of large urinary calculi formed inside the ileal conduit diversion in a patient who underwent radical surgery for an ovarian carcinoma involving the right ureter. Two ureter stents were left to ensure drainage and were endoscopically removed after six months. Renal function and ureteral canalization were normal. However, because of a knot in the proximal end of stents, a piece 5 cm-long-was left inside the diversion. After six months the patient developed recurrent renal colics: plain abdomen X-ray and urography showed a large urinary stone around the stents fragment and several smaller stones nearby. They all were removed surgically. The pathogenesis of such complications was considered: even though the slow flux of urine in the diversion, the abnormal mucus production from the ileal mucosa and the excessive and chronic bicarbonate loss played an important role in the developing of urinary calculi, the authors believe that in this case the main responsible for the stone formation was the foreign body in the urinary diversion.

[Splenectomy in cytoreductive surgery in ovarian cancer]. / La splenectomia nella chirurgia citoriduttiva del carcinoma ovarico.

During the course of surgery for the treatment of ovarian cancer, splenectomy is rarely performed since this tumour rarely infiltrates the parenchyma although it spreads around the spleen. Surgery is significant if surgical efforts successfully reduce tumour volume to less than one centimetre in diameter. Perisplenic involvement is frequent, even if not always massive and infiltrating, in relation both to biological aggressiveness and clinical and instrumental diagnostic delay. Between January '81 and December '91 a total of 16 splenectomies were performed during the course of surgery relating to 311 (5.1%) patients suffering from mullerian ovarian carcinoma at the 3rd and 4th stage. Of these, 7 were performed during the first operation and 9 during the course of a second-look. The mean age of patients was 56 with a range of 33-71 years. Massive hilar infiltration was found in 14 cases, in 7 together with contemporary capsular infiltration. Parenchymal infiltration was present in 3 cases; one splenectomy was performed following an iatrogenic complication during the mobilization of the left colic flexure, necessary for the creation of the colon-rectal anastomosis. Splenectomy was always well tolerated in an overall assessment of surgery and was without severe local complications. The most frequent complications were pleural (7/16) with reactive effusion and bronchopulmonary with basal dystelectasia (3 cases) and bronchopneumonic foci (4 cases). A silent hematoma in a splenic site was revealed using ultrasonography in 3 cases but resolved spontaneously without requiring drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

[Radiologic characteristics of the thorax during therapy with interleukin-2]. / Aspetti radiologici del torace durante terapia con interleukina-2.

Interleukin-2 is a glycoprotein physiologically produced by human lymphocytes which is capable of mediating some still unknown immunologic reactions. In vitro, interleukin-2 was seen to induce a lytic reaction against tumor cells through the activation of a cytolytic system of natural killer cells. If administered to man in heavy doses, it causes a clinical response in the treatment of metastases from melanoma and renal cell carcinoma in 20-40% of cases. However, the clinical use of the drug, in therapeutic doses, is prevented by the occurrence of several side-effects, the major one being increased permeability of alveolar vessels with capillary leak and interstitial pulmonary edema (Vascular Leak Syndrome in the English literature). Thus, this work was aimed at evaluating chest radiographs during interleukin-2 treatment to detect, in the pulmonary district, the early stages of the vascular leak syndrome--i.e., pulmonary edema, pleural and pericardial effusions. Forty-three patients had been treated for metastases from renal cell carcinoma and melanoma November 1989 through September 1991: standard chest radiographs demonstrated 26 cases (60%) of pulmonary edema, 14 cases (32%) of bilateral pleural effusions and 12 cases (27%) of pericardial effusions. Daily chest films of the patients undergoing interleukin-2 therapy allowed the early stage of the vascular leak syndrome to be depicted, thus enabling the physician to use the highest tolerated doses and eventually to stop infusion before marked respiratory distress develops.

[Role of computerized tomography in the TNM staging of laryngeal and hypopharyngeal neoplasms]. / Ruolo della tomografia computerizzata nella stadiazione TNM delle neoplasie laringee ed ipofaringee.

70 patients with squamous cell carcinoma of larynx and hypopharynx were examined by computed tomography; the TNM staging of tumors by CT, by endoscopy and by surgical operation was reviewed. CT proved to be reliable both to recognize the presence of neoplasms, with the exception of those very superficial, and their deep spreading to pre-epiglottic and para-laryngeal spaces, to the soft tissues of the neck and to the cartilages. Therefore CT is the examination of choice in laryngeal neoplasms staging, because it precisely completes the clinical and endoscopical informations.

[Computerized tomography in acetabular fractures]. / La tomografia computerizzata (TC) nelle fratture dell'acetabolo.

The paper deals with sixteen cases of acetabular fractures studied with CT. After a short description of the normal CT findings, the different kind of fractures are reported. The usefulness of CT examination in evaluating acetabular fractures and their complications is confirmed both in conservative treatment and surgical approach.

[Computerized tomography in cerebellar atrophy]. / La tomografia computerizzata nelle atrofie cerebellari.

Among 5680 patients who had CT cranial scans at the Radiological Service of the Hospital of Pordenone we selected by their histories and clinical findings and CT images 31 patients showing the signs of a cerebellar atrophic process. We compared CT scans with clinical symptoms; we found a correlation in 71% among CT abnormalities and clinical findings; in 22.5% CT showed an infratentorial atrophy, but clinical symptoms were absent; in 6.5% the CT scans were normal, although was present a cerebellar syndrome. We conclude that CT is an important and significative method in the diagnosis of posterior fossa degeneration, taking so the place of pneumoencephalography.