High dose irradiation after pleurectomy/decortication or biopsy for pleural mesothelioma treatment.

PURPOSE: The role played by radiation therapy after pleurectomy/decortication or surgical biopsy in malignant pleural mesothelioma is uncertain. We treated patients with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy in an attempt to keep lung toxicity to a minimum. The present study reports the feasibility and toxicity of this approach. MATERIAL AND METHODS: Between 2008 and 2012, 36 patients with malignant pleural mesothelioma underwent accelerated hypofractionated radiotherapy to the hemithorax after pleurectomy/decortication (19 patients) or biopsy (17 patients). The prescription dose was 25Gy in five fractions over 5 consecutive days. RESULTS: We observed three patients with G3 pneumonitis, five cases of grade 2 dyspnea and six cases of grade 2 cough. The median follow-up was 37 months (range: 3-54 months). The median overall survival for patients who underwent pleurectomy/decortication followed by radiotherapy was 21.6 months [95% confidence interval (95% CI): 15.5-24.1] compared to 19.4 months for patients not submitted to surgery. CONCLUSION: Treatment of intact lung with pleural intensity-modulated arc irradiation in malignant pleural mesothelioma patients with malignant pleural mesothelioma proved safe and feasible, with an acceptable rate of pneumonitis. Survival rates were encouraging for both biopsy-only and pleurectomy/decortication groups. We are currently conducting a phase II dose escalation trial in a similar patient setting to prospectively evaluate the impact of radiotherapy on toxicity, disease-free survival and overall survival.

[Anatomic and radiological observations of th bifid mandibular condyle]. / Osservazioni anatomiche e radiologiche sul condilo mandibolare bifido.

PURPOSE: To determine the morphology and the frequency of bifid mandibular condyle (BMC) in anatomic material and to study its diagnosis in living persons. MATERIAL AND METHODS: The morphology and the frequency of BMC were studied on a sample of 210 intact mandibular condyles belonging to a collection of 200 dry male adult skulls held by the Institute of Anatomy of University of Bologna. Diagnostic imaging was verified retrospectively on 6 cases of BMC observed in living subject. RESULTS: In the anatomic material, we found 29/210 mandibular condyles with the articular surface simply parted in two (13.80%) and 1 condyle consisting of two separate articular heads (0.47%) at different levels and without the neck. Therefore BMC with separate neck is very rare. In living persons diagnosis was established by radiology using orthopantomography and demonstrated 2 cases of bilateral BMC (one dysplasic and the other traumatic) and 4 of unilateral BMC. DISCUSSION AND CONCLUSIONS: We believe that primitive BMC is a consequence of a dysplasic process of the condyle cartilage at the early stages of its development, while secondary traumatic BMC is caused by bone remodelling after articular trauma or repeated microtraumas from malocclusion. In dysplasic BMC, as evidenced by the observation made on a living subject, a distinction should be made between the complete type in which the accessory articular head is separate from the principal head, at a different level and with its own separate neck, and the other, incomplete types. Orthopantomography, which proved to be a valid diagnostic tool, must be integrated with CT and MR if surgery is planned.

Role of color Doppler ultrasonography in the preoperative staging of pancreatic cancer.

We describe our experience with color Doppler ultrasonography (CDU) in the preoperative staging of pancreatic cancer and, particularly, in detecting the involvement of the portal-mesenteric trunk (PMT). Of the 54 patients studied, 43 (79.6%) underwent surgery and 11 (20.4%) did not because of evident infiltration of the PMT. Of the 43 patients operated on, the CDU study was normal in 8 cases (18.6%), abnormal in 33 (76.7%), and not possible in the remaining 2 cases (4.7%). Results of the CDU were confirmed intraoperatively in 39 cases (diagnostic accuracy, 95.1%). In only two cases (4.9%) did the CDU not show involvement of the PMT, which was, instead, demonstrated by intraoperative ultrasonography (false negatives). Of the 11 nonoperated patients, all showed morphological alterations at CDU, while only 7 showed hematic flow changes. The sensitivity of CDU was 94.2% and the specificity 100%. The positive predictive value was 100%; the negative predictive value, 75%. The results indicate that CDU may be the first imaging technique for preoperative assessment of PMT involvement in pancreatic cancer.

Transdermal nitroglycerin in cirrhosis. A 24-hour echo-Doppler study of splanchnic hemodynamics.

BACKGROUND/AIMS: The present study was aimed to evaluate the 24-hour effect of transdermal nitroglycerin on splanchnic hemodynamics in cirrhotic patients. METHODS: Hemodynamic parameters (blood velocity and resistance indexes) were determined by means of pulsed echo-Doppler, a non-invasive method which proved to be useful to evaluate the effects of drugs on splanchnic vessels. Nine patients with biopsy-proven liver cirrhosis were studied. They were kept on a standard diet divided into 3 meals served at 8, 12 a.m. and 6 p.m. Echo-Doppler measurements were determined for 2 consecutive days at 7, 8, 9, 12 a.m, 1, 3, 6, 7, 9, 12 p.m. and again at 7 a.m. A transdermal nitroglycerin tape, capable of releasing 15 mg of the drug in 24 h, was applied to the skin of the chest at 7 a.m. of the second day. RESULTS: After nitroglycerin mean portal blood velocity and flow significantly decreased by 18 and 22%. Similarly superior mesenteric artery velocity decreased, while resistance indexes increased. ANOVA analysis showed a significant effect of the drug on superior mesenteric artery and portal flow, while the effect on hepatic artery flow and renal indexes were low. CONCLUSIONS: This study shows that nitroglycerin, given as transdermal long-acting system, significantly influences portal hemodynamics in liver cirrhosis. Its use, favoured by easy administration, may be proposed for long-term clinical studies to test its efficacy in preventing gastrointestinal bleeding.

[The correlation between morphology, electrolytic content and risk factors in breast cysts]. / Correlazione tra morfologia, contenuto elettrolitico e fattori di rischio nelle cisti mammarie.

Many studies on the biochemical composition of the liquid aspirated from breast cysts have identified three types of cysts: type I (apocrine) cysts, with a high concentration of K+ and low levels of Na+ and C1-; type II (transudate) cysts, with an electrolytic content similar to that of plasma and high Na+ levels and, finally, type III cysts, with intermediate characteristics. The literature data appear to indicate that the women with type I cysts are at higher risk for breast cancer. The authors report the results of a study carried out on 143 women from October, 1991, through October, 1994, in the Radiology Department of the University of Bologna, to investigate the correlations between some risk factors for breast cancer, the characteristics of cyst fluid and the morphology of the cysts after pneumocystography. Of 186 cysts, 104 (55.9%) were type I, 49 (26.4%) were type II, and 33 (17.7%) were type III. Among the risk factors we considered, only the premenopausal state (41 to 45 years of age) exhibited a statistically significant correlation with the presence of type I cysts. The morphological study of the cysts after pneumocystography showed a surprisingly high correlation between the honeycomb pattern and type I cysts. The constant correlation between cyst morphology and electrolytic content may allow the easy identification of the subgroups of patients eligible for a closer follow-up.

Functional hepatic flow and Doppler-assessed total hepatic flow in control subjects and in patients with cirrhosis.

Functional hepatic flow and total hepatic flow were determined by non-invasive techniques in 32 patients with cirrhosis and in 32 paired control subjects. Functional hepatic flow was measured by the hepatic clearance of D-sorbitol, while total hepatic flow was determined by pulsed echo-Doppler, as the sum of portal and hepatic arterial blood flow. Functional hepatic flow was significantly reduced in patients with cirrhosis (927 +/- 314 vs. 1287 +/- 315; p < 0.0001), while total hepatic flow was slightly increased (1511 +/- 540 vs. 1261 +/- 321 in controls; p = 0.028). In control subjects functional hepatic flow significantly correlated with total hepatic flow (r = 0.823; p < 0.001), while no correlation was observed in cirrhosis. Functional hepatic flow and the difference between total hepatic flow and functional hepatic flow significantly correlated with the Child-Pugh score in patients with cirrhosis. The data obtained in control subjects support the measurement of functional hepatic flow and total hepatic flow by non-invasive techniques. The finding that in cirrhosis functional hepatic flow is significantly decreased, while Doppler-assessed total hepatic flow is preserved or even increased, confirms that a relevant part of blood flowing through the liver is diverted by intrahepatic shunts. The simultaneous assessment of these two parameters by non-invasive techniques may be proposed as a reliable tool for the study of functional shunting of cirrhosis.

[Transrectal ultrasonography in the study of recurrences in patients surgically treated for rectal neoplasms]. / Studio mediante ecografia transrettale delle recidive nei pazienti operati per neoplasia rettale.

The value of transrectal US is known in the preoperative staging of rectal cancer but remains debated in the follow-up of the patients submitted to anterior resection or local therapy. The authors report their experience with the postoperative follow-up of 80 patients submitted to 125 transrectal US exams to study method reliability. The results were 9 true positive, 2 false positive, 113 true negative and 1 false negative cases, with 90% sensitivity, 98.3% specificity and 97.6% accuracy rates. Positive predictive value was 81.8% and negative predictive values was 99.1%. Twelve patients were submitted also to MRI which correctly diagnosed one false negative result of transrectal US. Twenty-one patients were examined also with transrectal Doppler and color-Doppler US: in rectal cancer recurrences the peak velocity of hemorrhoid vascular flow was higher than in non-recurrent patients. On the basis of our results, transrectal US deserves to be included in the postoperative follow-up of the patients submitted to anterior resection or to local therapy for rectal cancer. Moreover, according to our preliminary findings, Doppler and color-Doppler US can improve transrectal US reliability in detecting local recurrences.

[High-resolution computed tomography in the study of congenital cystic adenomatoid malformation of the lung]. / La tomografia computerizzata ad alta risoluzione nello studio della malformazione congenita adenomatoide cistica del polmone.

Congenital cystic adenomatoid malformation of the lung is a rare condition requiring an early diagnosis and the accurate assessment of its site and extent since it can be surgically treated with excellent prognosis. This study enrolled 12 patients with suspected congenital cystic adenomatoid malformation examined with high-resolution CT (HRCT) under general anesthesia and after pulmonary hyperinsufflation, to investigate HRCT capabilities in the pathological and topographic characterization of the lesion. In 11 patients HRCT showed features suggestive of cystic adenomatoid malformation and histology confirmed the diagnosis (type I in 9 cases and type II in 2 cases). In contrast, in 1 case of extralobar pulmonary sequestration, only pathology could exclude an associated cystic adenomatoid malformation type III. In all patients HRCT assessed lesion site and extent accurately: the lesions involved only one lobe in 7 patients, whereas in the other 5 more lobes were involved, unilaterally (3/5) or bilaterally (2/5). Associated lesions were found in 6 patients (2 intralobar pulmonary sequestrations, 1 rhabdomyosarcoma, 3 pulmonary inflammations). HRCT allowed the finest anatomic structures to be identified and made it possible to acquire images without movement or reflected dysventilation, which meant better disease assessment and more correct treatment planning. In conclusion, the authors suggest HRCT in the study of cystic adenomatoid malformations and for all lung conditions in the pediatric age.

[Endorectal echography as a guide to the surgical approach to tumors of the median-lower rectum]. / L'ecografia endorettale quale guida all'approccio chirurgico dei tumori del retto medio-inferiore.

There is no difference in the late results of destructive and conservative surgery in the treatment of rectal cancers, provided that preoperative staging is correct. Thirty-two patients with medium-low rectal cancer underwent endorectal US to evaluate local cancer spread; the aim was allow the correct surgical treatment to be carried out. US findings were compared with pathology: US diagnostic reliability was 93.75%, with 1 case of understaging (T2 as T1) and 1 case of overstaging (T2 as T3). Endorectal US, thanks to its high reliability, is therefore of basic importance because it allows the best local therapy to be chosen and risk margin to be determined. Moreover, US correctly evaluates the degree of parietal infiltration and local spread, thus helping preserve a more or less wide resection margin during destructive surgery. Therefore, endorectal US stands out as a basic research method in the correct preoperative staging of medium-low rectal cancers according to T, thus allowing a rational surgical approach and helping avoid not only unnecessary destructive surgery but also local recurrences.

[Role fo ultrasound in the study of latero-cervical metastases]. / Ruolo dell'ecografia nello studio delle metastasi laterocervicali.

In patients undergoing radiotherapy (RT) for malignant neoplasies of the head and neck the availability of a diagnostic method permitting frequent, easy checkups of the latero-cervical lymph nodes would be extremely useful. This is especially so because clinical examination is often hindered by the post-actinic fibrosis of the tissues. Among the methods presently available for this purpose (CAT, NMR, lymphoscintigraphy, xerography, ultrasound) echotomography appears to be the most indicated as it is least invasive, can easily be repeated and is not difficult to perform. The refining of ultrasound techniques would, as reported in the literature, make it possible today to evaluate the effects of RT on latero-cervical metastases both during and some time after treatment. The authors, therefore evaluated the advantages and limitations of the method examining 33 patients undergoing RT for latero-cervical metastases due to head and neck carcinoma. Each patient underwent ultrasound examination prior to, during and at the end of the RT treatment cycle. Once treatment had been terminated 18 underwent latero-cervical neck dissection. Upon termination of the radiation treatment three distinct types of ultrasound behaviour were identified: complete response; partial response; minimal or negligible response. For those patients undergoing surgery this response was compared to lymph node chain histology while, for the others, it was compared to the ultrasound findings of subsequent examinations. The results obtained appear to indicate that a systematic scheduling of ultrasound checkups offers a reliable evaluation of how metastatic adenopathies respond to RT. At times such response can only be completed several months after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Subungual keratoacanthoma: a variant of verrucous squamous cell carcinoma of the skin.

A case of so-called subungual keratoacanthoma is reported. Clinically and morphologically, this lesion is similar to a verrucous carcinoma of the skin. It is possible that subungual keratoacanthoma and carcinoma cuniculatum (verrucous carcinoma) are different aspects of the same entity.

[Echotomography of pathological masses of the mediastinum. Indications and limits]. / L'ecotomografia nella patologia espansiva del mediastino. Indicazioni e limiti.

The authors refer to the application of sonography in the evaluation of mediastinal masses. In this pathology, sonography is useful if neither air nor bone tissue are present between the transducer and the mass. Sector scans are obtained through the transgiugular line, the intercostal spaces, the hepatic and splenic windows, the sternal notch. The diagnostic value is due to the possibility to define the solid or liquid content of the investigated masses.

[Mammary focal scleroelastotic lesion (author's transl)]. / La scleroelastosi focale mammaria.

Mammary focal scleroelastotic lesions are a newly recognized entity, with mammographic and macroscopic features simulating an infiltrating carcinoma but with benign microscopic features. The authors report two cases of this mammary lesion.