Th-17 cytokines and interstitial lung involvement in systemic sclerosis.

The two phenotypes of both limited and diffuse systemic sclerosis (SSc) have different forms of pulmonary involvement: pulmonary arterial hypertension (limited phenotype) or interstitial lung disease (ILD) (diffuse phenotype). We aimed to investigate whether Th17-related cytokines, as measured in exhaled breath condensate (EBC) and in serum were connected to ILD in diffuse SSc patients. We found that for both limited and diffuse SSc, the EBC levels of all cytokines and most of the cytokine serum levels were significantly higher in patients than in controls, while, the EBC levels of Th-17 cytokines and the serum levels of IL-10 and TNF-α were significantly higher in diffuse than in limited SSc. Moreover, the thoracic CT-scan score of ILD was significantly associated with the EBC levels of IL-1 beta and with the serum IL-23, TNF-α and IL-10 levels, whereas lung carbon monoxide diffusing capacity was negatively related to the EBC levels of IL-1 beta, IL-17 and serum IL-10. Serum IL-23 was also inversely correlated with vital capacity. In conclusion, in diffuse SSc patients our results show a clear link between Th-17 cytokines measured both in EBC and in serum with interstitial lung involvement. This highlights how important it is to target Th-17 cytokines when developing new treatments for lung fibrosis.

Can DW-MRI, with its ADC values, be a reliable predictor of biopsy outcome in patients with suspected prostate cancer?

PURPOSE: To relate the multiparametric magnetic resonance imaging (mp-MRI) of patients with suspect peripheral prostate cancer (PCa) to the results of the subsequent biopsy: in particular to explore whether DWI and ADC can predict the biopsy outcome and to investigate the relation between ADC and Gleason score (GS). MATERIALS AND METHODS: 175 consecutive patients who underwent 1.5 T mp-MRI followed by prostate biopsy were retrospectively analyzed by two independent radiologists. ADC values were measured in the peripheral suspect lesion areas (ADCSL) and in the contralateral zones (ADCNSL) obtaining ADCnorm = ADCSL/ADCNSL. Results on T2W images, DWI, ADC values, and perfusion studies were matched to their corresponding biopsy. RESULTS: Negative DWI and T2W had 100% negative predictive value (NPV). When DWI was positive, ADCSL > 0.90 × 10 > 0.90 × 10(-3) mm(2)/s (ADCnorm > 0.60) identified by the ROC curve (AUC = 0.80) corresponded to NPV = 85%. In positive biopsies, ADCSL and ADCnorm decreased significantly from GS = 6 to GS ≥ 8 with Spearman coefficient ρ = -0.40 and ROC curve AUC = 0.72. CONCLUSION: mp-MRI allows a reliable prediction of a negative biopsy through the values of DWI, T2W, and ADC. In positive biopsies, there is a moderate correlation between ADC and the various GS levels.

Interventional radiology in the treatment of early postoperative biliary complications.

PURPOSE: We sought to evaluate the feasibility and efficacy of percutaneous treatment of early postoperative biliary complications. The primary aims were to evaluate clinical and technical success and complications and perioperative mortality, and secondary aims were to evaluate treatment duration and recurrence rate. MATERIALS AND METHODS: Between March 2007 and March 2010, 75 patients (42 men and 33 women; age range, 17-88 years; mean age, 60.8 years) underwent interventional radiology procedures to treat early postoperative biliary complications of biliary and pancreatic-duodenal surgery with biliodigestive anastomosis (37.7%), laparoscopic cholecystectomy (30.6%), hepatic resection (21.1%) and several other surgical procedures (10.6%). Complications included fistulas (73%), stenoses (20%) and complete bile duct transections (7%). RESULTS: Interventional radiology achieved complete clinical success in 74 cases (85.9%) and in particular in 95.2% of fistulas, 76.5% of stenoses and 33.3% of complete bile duct transections. Mean indwelling catheter time was 34.9 days, with an average of 4.1 procedures. There were two cases of severe haemobilia (2.3%). Minor complications occurred in 7% of cases. Perioperative mortality rate was 1.2% and overall recurrence rate 6.7% (range, 1-18 months; mean, 10 months), with recurrences occurring predominantly in stenoses. All patients were retreated successfully. CONCLUSIONS: Percutaneous procedures are feasible, effective and safe for treating early postoperative biliary complications. They provide a valuable alternative to presendoscopy, which is precluded in many of these patients, and to surgery, which has higher morbidity and mortality rates.

Dynamic magnetic resonance imaging in acute pyelonephritis.

PURPOSE: This study was conducted to evaluate the role and clinical impact of dynamic magnetic resonance imaging (MRI) in the diagnosis and follow-up of acute pyelonephritis (APN). MATERIALS AND METHODS: We retrospectively reviewed 442 consecutive renal MRI examinations (279 diagnostic and 163 follow-up) performed in 285 patients (mean age 42.17 years), 35 of whom were kidney transplant recipients with a clinical suspicion of APN. RESULTS: MRI showed signal abnormalities suggestive of APN in 125/244 (51.2%) patients with native kidneys. Except for two examinations performed without paramagnetic contrast material, the inflammatory foci appeared as areas of nonenhancement: single in 39/123 cases, multiple in 84/123, unilateral in 60/84 and bilateral in 24/84. Abscesses were present in 40/123 (32.5%) positive cases. During follow-up, we observed complete normalisation of MRI signs in 86/103 patients; 17/103 (16.5%) cases evolved into fibrosis and scarring. In 15/35 (42.8%) patients with transplanted kidney, MRI was positive for APN. CONCLUSIONS: Renal MRI is an effective tool for the diagnosis and follow-up of APN both in patients not at risk and those at higher risk, such as those with a transplanted kidney. The high costs of the examination are offset by better treatment planning and early complication detection.

Radiation dose evaluations during radiological contrast studies in patients with morbid obesity.

PURPOSE: The purpose of this study was to evaluate the radiation dose to patients during radiological contrast studies performed after vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGBP) surgery in patients with morbid obesity. MATERIALS AND METHODS: Dose evaluations were performed on a sample of 39 patients (32 women and 7 men) with a mean weight of 117 kg (range 68-175 kg) and a mean body mass index (BMI) of 43.7 (range 22.2-54.9). Between the second and seventh postoperative day, patients underwent radiological follow-up after oral administration of approximately 70 ml of water-soluble iodinated contrast material (Gastrografin) and images acquired in anteroposterior, right and left oblique projections with the patient upright and then supine. Exposure conditions, dose-area product (DAP) and entrance skin dose (ESD) were recorded for each procedure. On the basis of these data, the effective dose (ED) was calculated using simulation software based on the Monte Carlo method for determining the absorbed dose to organs. To assess the optimal exposure conditions and the dose contributions of fluoroscopy and radiography, the effective dose rates were also evaluated using Plexiglas phantoms of different thickness to simulate different patient sizes. RESULTS: The phantom measurements showed a fourfold dose increase when passing from normal-sized patients to obese patients. Mean DAP value obtained from in-vivo measurements was 70 Gy cm(2) (range 17-147 Gy cm(2)), and mean effective dose was 21 mSv (range 5-45 mSv). CONCLUSIONS: When performing radiological contrast studies in patients with morbid obesity, every possible precaution should be taken to minimise patient dose. Special care should be taken to evaluate justification of the radiological procedure.

[Non invasive methods in competition for EUS (US, CE-US, CT, MRI and PET/CT): the radiologist point of view]. / metodiche non invasive in competizione con l'ecoendoscopia (US, CE-US, CT, MRI e PET/CT): il punto di vista del radiologo.

Recent technological improvements such as spiral CT, CPMR, PET-CT, US and MRI specific contrast agents have increased the accuracy of non-invasive exams performed by radiologists. US is often the first step of the examination. MRI and PET-CT are considered supplementary. At present, CT is the method of choice for the diagnosis, staging and therapeutic planning of pancreatic tumors for which a multidisciplinary approach is however mandatory.

Ectopic secretion of LH by an endocrine pancreatic tumor.

Ectopic production of biologically active glycoprotein hormones other than hCG has been reported in exceptional cases. A 61-yr-old man came to our Unit complaining of weakness, fatigue and reduced libido with erectile dysfunction. There was also a history of polycythemia, known for about 10 yr and never further investigated. The physical examination showed acne and redness of facial skin and upper chest; no other significant abnormalities were detected. Serum levels of LH were very high, whereas alpha-subunit and hCG were only slightly increased. Testosterone and 17beta-estradiol levels were increased too. Abdominal computed tomography (CT) scan revealed a large hypervascularized mass within the pancreatic tail, which was surgically removed by distal splenopancreatectomy. Diffuse immunoreactivity for LH was detected in more than 70% of the tumor cells. The alpha-subunit was also positive, while chorionic gonadotropin had only a focal reactivity. Reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern Blot analysis confirmed the synthesis of LH by the tumor. Four weeks after surgery, serum levels of LH, alpha-subunit, testosterone, hCG and 17beta-estradiol were all undetectable. The redness of facial skin and upper chest had disappeared, but libido was still reduced. At a further control, 3 months after surgery, serum levels of LH, FSH, hCG, alpha-subunit and 17beta-estradiol were all within the normal range, as well as hemoglobin concentration and the red blood cells count. Testosterone was slightly below normal, but the patient reported an increase of libido. This is an unusual case of ectopic secretion of LH from an endocrine tumor of the pancreas.

Transcatheter arterial chemoembolization in hepatocellular carcinoma. Our experience.

BACKGROUND: The results of transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) in comparison to other treatments are investigated. METHODS: 121 patients were treated in 186 sessions in our Institute from January 1991 to January 1996. RESULTS: The mean survival rates at 1 year were 41.5 and 24.4% at 2 years. The patient's survival period was significantly longer in Child A-B patients, and in those on whom multiple sessions were performed. Personal experience in chemoembolization on HCC are better when compared to the natural history of those untreated patients but worse when compared to the data reported in literature about surgery and PEI (Percutaneous Ethanol Injection). It must be made clear though the all surgery case reports do not included class C Child patients whereas PEI is not carried out on those lesions with a diameter greater than 5 cm and plurifocal ones. Our case reports, on the other hand, as most other case reports found in the literature on chemoembolization having results similar to ours, include those patients normally not included in surgical or PEI case reports; this obviously causes the worsening of the results on global patient survival. CONCLUSIONS: Our hypothesis is that in the future the first choice in non-surgical treatment will be an association of TACE and other treatments (PEI and radiofrequency) on Child A and B patients having capsulated lesions >3 cm.

[Role of endorectal ultrasonography and CT in preoperative staging of rectal cancer. Personal experience]. / Ruolo dell'ecotomografia endorettale e della TC nella stadiazione preoperatoria del cancro del retto. Esperienza personale.

We report our personal experience on endorectal US and CT in the preoperative staging of rectal carcinoma. Our series includes 64 cases (38 male and 26 female) evaluated with intrarectal sonography; 38 of these patients underwent also CT-study of the lower abdomen. Using both imaging techniques infiltration of the rectal wall and adjacent structures and lymph node involvement were studied. The results of our study refer to 58 patients who underwent endorectal US, 31 of whom studied also with CT. Referring to the T-parameter with ultrasound 41 correct diagnosis were obtained, in 13 cases the lesion was over-staged and in 4 cases understaged. The sensitivity, specificity and diagnostic accuracy was respectively 89.5%, 60% and 79.3%. With CT 23 diagnosis were correct, in 1 case the lesion was overstaged and in 7 cases understaged; sensitivity, specificity and diagnostic accuracy concerning rectal wall infiltration were respectively 72%, 83.3% and 74.2%. The evaluation of the N-parameter demonstrated low value of sensitivity with both US (15.8%) and CT (42.9%). Considering the results of our series, we feel that it is necessary to use both imaging techniques because results obtained are complementary referring to the T-parameter, although N-parameter were a little significant.

[Intraluminal ultrasonography of the biliary ducts]. / Ecografia endoluminale delle vie biliari.

We report our 4 years' experience with intraluminal US of the biliary ducts performed on 24 patients via a biliary transhepatic-duodenal drainage catheter or a surgically inserted T tube (2 cases). The final diagnosis was a malignant disease in 16 patients and a benign disease in 8 patients. We used an Intra Vascular Ultra Sound (Diasonics) unit with a 20 MHz transducer inserted into a 9 F catheter with closed tip, which in turn was pushed through the biliary ducts in a 12 F sheathed introducer which provides a safety metal guide wire in the duodenum. US examinations lasted only a few minutes and caused no additional patient discomfort; no complications followed. Intraluminal US confirmed the results of other clinical and instrumental tests in 18/24 patients and improved the diagnostic yield in assessing lesion nature and operability in 6 cases (25%). Its cost is high, but the Intra Vascular Ultra Sound includes a 3.5 MHz and a 7 MHz probes and can therefore be used for all the other US examinations needed in interventional radiology rooms and in the study of the biliary ducts. To decrease the cost, we used the Intra Vascular Ultra Sound in less than 10% of the patients treated for biliary obstruction in the same period of time, namely those with questionable diagnosis and operability. We conclude that intraluminal US of the biliary ducts is a useful tool in the centers using interventional radiology to treat many obstructive jaundice patients by a transhepatic approach.

[The diagnostic reliability of percutaneous biopsy specimens obtained under instrumental guidance using 4 different types of needles]. / Attendibilità diagnostica dei prelievi bioptici percutanei eseguiti con guida strumentale utilizzando quattro diversi tipi di aghi.

To assess if the effectiveness of biopsy sampling, whose usefulness is widely recognized, can be influenced by different cutting mechanisms, we compared four different types of needles (A, B, C, D) in 76 patients, each needle being of the same length (15 cm) and calibre (18 G) but with different tip shapes. Forty biopsy samples were obtained with each type of needle for a total of 160 samples in 76 patients; 61 samples were acquired under CT guidance and 99 under US guidance. The results were subdivided in 6 categories based on biopsy result: PI (diagnosis histotype in malignant lesions), PN (diagnosis of malignancy in neoplastic lesions), P (correct diagnosis in benign lesions), S (suspicion of neoplastic lesion), E (misdiagnosis), NI (insufficient material). The results, respectively, for each needle type are: 32.5%, 30%, 2.5%, 7.5%, 12.5% and 15% with needle A; 35%, 30%, 7.5%, 0%, 15% and 12.5% with needle B; 27.5%, 17.5%, 10%, 7.5%, 22.5% and 15% with needle C; 30%, 15%, 7.5%, 15%, 17.5% and 15% with needle D. The sensitivity and specificity for each needle type were, respectively, 84.4% and 85.29% for needle A; 86.66% and 88.57% for needle B; 70% and 73.52% for needle C; 77.41% and 79.41% for needle D. No statistically significant difference was found in the effectiveness of the four needles (chi 2); on the contrary, lesions's size can affect sampling quality.

[The reliability of echotomographic diagnosis in assessing thyroid lesions. A comparison with cytology and histology]. / Attendibilità della diagnosi ecotomografica nella valutazione delle lesioni della tiroide. Confronto con la citologia e l'istologia.

The authors report their personal experience in 160 patients affected with thyroid conditions examined with US and fine needle aspiration (FNA). Benign nodular hyperplasia, cystic-colloid nodular hyperplasia, colloid cyst, hemorrhagic cyst, adenoma, thyroiditis, follicular and malignant lesions were studied. The latter consisted of 5 papillary carcinomas, 6 follicular carcinomas, 1 medullary carcinoma, 1 Hürthle cell carcinoma, 1 lymphoma and 1 metastatic lesion. The following US patterns were observed: 69.2% of the malignant lesions were hypoechoic, 15.4% were hyperechoic and 7.7% isoechoic. Most of the malignant lesions (84.6%) had inhomogeneous echo texture; 46.1% of them exhibited peripheral microcalcifications. US diagnoses were compared with cytologic and/or histologic findings to assess US accuracy. In the surgical patients US accuracy reached 78.6% in benign lesions and 61.5% in malignant lesions. Since US alone fails to yield enough pieces of information for an accurate diagnosis to be made, especially when malignant lesions are concerned, FNA should be used, while trying to define the actual role of color-Doppler US.

[Role of ultrasonography in the assessment of lymphoma localized in the abdomen]. / Ruolo dell'ecotomografia nella valutazione delle localizzazioni addominali di linfoma.

Both prognosis and treatment of lymphomas depend strictly on both clinical staging and histologic classification. The role of US was investigated in the evaluation of patients affected with abdominal lymphoma. To this purpose, 52 patients affected with abdominal lymphoma underwent US and CT studies during staging, treatment, or follow-up. A comparison of the results of the two methods shows that the systematic use of US allows 5% of lymph nodes missed at CT to be demonstrated, together with hepatic and splenic involvement also undetected by CT. It is true, however, that the limited number of cases does not allow this result to be correlated with the histopathologic type of lymphopathy. US has also been the examination of choice to evaluate response to chemotherapy and to study suspected relapses. In the authors' opinion, US should become a complementary technique to CT in the staging of abdominal lymphomas.

[Critical evaluation of preoperative instrumental staging of rectal tumors. Research on the adequate use of US, CT and MR]. / Valutazione critica della stadiazione strumentale preoperatoria dei tumori del retto. Ricerca di un impiego adeguato di US, TC e RM.

Both traditional exams (rectal exploration, rectoscopy, barium enema, CEA) and advanced imaging (31 US, 40 CT and 11 MR) were performed for preoperative evaluation of rectal carcinoma in order to assess the accuracy of radiological imaging in the T and N staging. The results obtained have not been considered satisfactory and it is felt that US, CT and MR should not be employed routinely for rectal staging. Indeed accuracy of US, CT and MR is respectively 64%, 75% and 81% in the T evaluation and 64%, 70% and 64% in the N staging. In order to evaluate the effective usefulness of these three latter imaging techniques a double therapeutical choice was proposed. The first treatment option was suggested on the basis of traditional staging while a second choice was given considering US, TC and MR data also. Operatory findings subsequently allowed a definitive judgement on the influence of the different techniques on treatment selection. US has furnished useful data that could have allowed us to modify treatment in one case while in 5 other cases diagnostic error would have influenced treatment negatively. CT was useful in 5 cases while in 7 cases it would have influenced treatment choice negatively. MR would have been useful in one case and harmful in another. It is concluded that only patients with large neoplasms (stages T3 and T4) benefit from CT and MR staging with the exception of those cases that have tumors above the peritoneal fold or in strict relation with the sphincter structures. US was useful only in evaluating relations of neoplasms of the anterior rectal wall with nearby pelvic structures.

Percutaneous treatment (including pseudocystogastrostomy) of 74 pancreatic pseudocysts.

Percutaneous treatment of 74 pancreatic pseudocysts was performed in 70 patients. Initially, single-step fine-needle aspiration was used and had a 71% (15 of 21 patients) recurrence rate. Better results were obtained with prolonged extragastric or transgastric external drainage, performed in 43 patients (46 pseudocysts). Two patients in this series (4.7%) required urgent surgery: one for gastric wall hematoma and the other for intracystic hemorrhage. Three patients (7.0%) were lost to follow-up. The recurrence rate in the remaining 38 patients (41 pseudocysts) was 23.7% (nine of 38 patients). Since 1986, seven patients have been treated with percutaneous pseudocystogastrostomy (one also underwent external drainage and is thus included in the previous series, too) after placement of a transgastric drainage catheter, with no recurrence (follow-up, 2-26 months). It is concluded that transgastric drainage should be performed whenever the anatomic situation is favorable and that a pseudocystogastric stent should be placed in these patients whenever secretions are still abundant after 7-10 days.

[Ultrasound and CT evaluation of non-lymphomatous splenic focal lesions]. / Valutazione US e TC delle lesioni focali spleniche non linfomatose.

Differential diagnosis problems are caused by the increased, at time occasional, detection of benign and malignant spleen focal lesions in routine superior abdomen ultrasound (US). The following pathologic conditions were reported in 29 patients with focal lesions (excepted systemic diseases): 6 plain cysts, 1 cystic lymphangioma, 3 echinococcus cysts, 3 abscesses, 7 hematomas and 9 metastases. US examination and clinical data together have permitted the differentiation of cysts from solid nodules but has limits in the characterisation of lesions and in the diagnosis of abscesses. Metastases did non present specific US or CT aspects and have been correctly characterized only with aid of anamnestical data and for the coexistence of hepatic lesions. CT has proven superior specificity, compared to US, only in the diagnosis of abscesses and should thus be utilized only in selected cases.

[Percutaneous pancreato-gastrostomy in the treatment of pancreatic pseudocysts. Presentation of 2 cases]. / La pancreato-gastrostomia percutanea nel trattamento delle pseudocisti pancreatiche. Presentazione di 2 casi.

The authors describe a new method for the treatment of pancreatic pseudocysts using a personal technique: the percutaneous pseudocystogastrostomy. Under US and fluoroscopy guidance at first a percutaneous drainage is introduced in the pseudocyst using a transgastric approach. For seven days the drainage catheter is flushed with antibiotic solution (Rifocin), then under fluoroscopy and endoscopy guidance doubled pig-tail catheter is placed with its curlend ends in the lumen of the stomach and pseudocyst respectively. After 60 days the double pig-tail catheter is removed endoscopically. Two patients with pancreatic pseudocysts were treated successful by this method. No complications or recurrences were observed.