Bilateral testicular adrenal rest tissue in congenital adrenal hyperplasia: US and MR features.

We describe magnetic resonance (MR) and ultrasonography (US) features of bilateral testicular adrenal rest tissue in a 20-yr-old man with congenital adrenal hyperplasia (CAH). Scrotal ultrasonology detected bilateral homogeneous hypoechoic lesions with well-defined margins and without evidence of sound attenuation. MR is useful in defining the size of lesions, because the contrast resolution is better than with sonography and allows an accurate definition of the extent of disease. This case suggests that US evaluation should be included in periodical follow-up of patients with CAH, while MR may be used in the case of rapid increase in the size of the testicular mass.

Longitudinal evaluation of prostate-specific antigen levels in a case-control study.

BACKGROUND: Over the last period--late 1970 to early 1990--the incidence of prostate carcinoma has nearly doubled, even though many more patients die with prostate cancer rather than of it. This finding, together with the slow growth of this tumor and the absence of a controlled trial, makes early diagnosis for this pathology quite questionable. On the other hand, it is well known that prostatic carcinoma is curable as long as it is intracapsular and that there is an ever increasing encouragement for early detection in all diseases. Since prostatic pathology increases its incidence as age advances, the first step in early diagnosis is to be able to discriminate between healthy, benign prostatic hyperplasia and cancer cases with a well-accepted and easily understandable method. The problem is to find the best method to do it. METHODS: We measured serum prostate-specific antigen (PSA) levels in 435 men participating in an epidemiological study, at first in 1987 and again in 1992. Men with PSA levels above 4 ng/ml (in 1992) were invited to undergo other diagnostic tests (digital rectal examination, transrectal ultrasonography, biopsy) in sequence on the basis of the results of the previous tests. The pathological findings from biopsies were the reference test to determine the presence or absence of prostate cancer (2.5% of the population). RESULTS: We divided PSA concentrations into three categories, according to the most used cutoffs ( < 4, 4-10, > 10 ng/ml); in the meantime, we took into account the change rate in PSA concentration in time, defined as delta PSA. By the comparison between PSA categories and delta PSA, we found out that the first one does not discriminate between benign and malignant pathologies, while the use of delta PSA strongly discriminates them (p < 0.001). CONCLUSION: On the basis of our results, we think that delta PSA might be the best parameter to indicate the presence of prostate cancer cases in an asymptomatic population.

[CT-guided transthoracic needle aspiration of solitary lung lesions. Personal experience in 118 cases]. / Citoaspirazione transtoracica con guida TC di lesioni polmonari singole. Esperienza personale in 118 casi.

Fast-scan CT is widely and frequently used to guide fine-needle aspiration biopsy (FNAB) of questionable lung nodules. To investigate technical problems, complications, diagnostic accuracy and indications of this technique, the findings were reviewed relative to 118 patients with negative transbronchial biopsy and sputum cytology who underwent CT-guided FNAB of solitary lung lesions. Over a 25-month period, 73 men and 45 women underwent CT-guided FNAB of lung lesions. The CT unit was a GE 9800; 22-gauge 7/9-cm spinal needles were used in most cases, while 22-G 15-cm Chiba needles were used in 6 cases. In 114 patients one FNAB was performed, 4 patients only requiring the maneuver to be repeated. Regarding the malignant nature of the lesions, there were 70 true positive, 36 true negative, 12 false negative and no false positive cytologic findings; sensitivity was 85.36%, specificity and positive predictive value were 100%, negative predictive value was 75% and diagnostic accuracy 89.83%. Only minor complications occurred: 5 cases of hemophtoe, 7 of peripheral bleeding, 4 of chest pain, 4 vagal reactions and 10 cases of pneumothorax, only one of them requiring drainage. In our experience, only one pass per patient is required and the presence of the cytopathologist is unnecessary, since in most of our cases (114/118) the diagnosis was made at the first FNAB performed by the radiologist. CT allowed the lesions to be approached easily and precisely, which is useful especially in small, peripheral or hilar, nodules missed or poorly defined by radiology. To conclude, CT-guided transthoracic FNAB can be suggested as the method of choice to diagnose lung lesions which are difficult to puncture endoscopically because of size or location, and in suspected metastases. Moreover, FNAB can be used as second-line method in the lesions where endoscopic biopsy cannot be performed or whose findings are negative.

An unusual false-positive scan in a patient with pericardial effusion.

Uptake of I-131 in the pericardial area is described in an asymptomatic patient who underwent total body scan for recurrent papillary thyroid cancer. Ultrasonography demonstrated a small pericardial effusion that persisted after I-thyroxine therapy was reinstituted. Two I-131 therapeutic doses were given, and follow-up total body scans were performed during the next 6 years. Although tracer accumulation in the neck was eliminated and the serum thyroglobulin level was not elevated, I-131 uptake persisted in pericardial effusion. Despite diligent study, no neoplastic, infectious, or autoimmune etiology could be demonstrated, and we thus classified it as idiopathic pericardial effusion. This phenomenon should be considered when interpreting I-131 scans that show I-131 uptake in the region of the heart.

[Splenic abscesses. Their percutaneous treatment and the role of the interventional radiologist]. / Ascessi splenici. Trattamento percutaneo e ruolo del radiologo interventista.

Percutaneous abscess drainage is not as common in the spleen as in other anatomical sites, probably because of an uncontrollable fear of bleeding. Five cases of intrasplenic abscess drainage are presented. A double-way 12/14-F vanSonnenberg catheter was percutaneously inserted under CT guidance in four patients and under US guidance in one patient. Orthogonal scout CT views were useful to check the correct positioning of the drainage. In three patients the maneuver was successful, with no recurrence at follow-up at 12, 16 and 24 months, respectively. In one patient with a splenic abscess due to iatrogenic ischemic necrosis, the drainage allowed delayed surgery after relief of symptoms. Another patient died of sepsis five days after multiple well-functioning drainages. No early or late complications occurred. Bleeding was never observed in our series and there are no recent literature reports on this complication. Whenever it occurs, bleeding can be treated with selective embolization. In our experience, the percutaneous drainage of splenic abscesses, performed by the radiologist, should be considered the treatment of choice in these cases.

[The role of the absolute value and "density" of the prostate-specific antigen estimated echographically in the selection of patients to undergo a biopsy in suspected prostatic carcinoma. A comparison between PSA, palpation and echography in 95 patients undergoing echo-guided endorectal prostatic biopsy]. / Ruolo del valore assoluto e della "densità" dell'antigene prostatico specifico, valutata ecograficamente, nella selezione dei pazienti da sottoporre a biopsia nel sospetto di carcinoma prostatico. Confronto tra PSA, palpazione ed ecografia in 95 pazienti sottoposti a biopsia prostatica endorettale ecoguidata.

We retrospectively reviewed the findings relative to 95 patients with known prostate specific antigen (PSA) values who had undergone digital rectal examination, transrectal US and US-guided biopsy for suspected prostate carcinoma. Histology (48 adenocarcinomas, 26 BPHs, 12 inflammations and 9 negatives) was compared with results from rectal examination, prostate US, PSA values and "density" (PSA/prostatic volume, as measured with US). PSA values < 4 ng/ml exhibited 90% negative predictive value and PSA > 10 ng/ml 70.8% positive predictive value. In the intermediate range (4-9.9 ng/ml) the positive predictive value of PSA was 44.4% and its negative predictive value was 55.5%. PSA density did not affect predictive values in the two groups with PSA < 4 and > 10 ng/ml, while in the intermediate 4-9.9 ng/ml group, positive predictive value raised to 62.5% and negative predictive value to 81.8%, thus increasing the specificity of PSA values and US findings. Our results suggest that PSA should be the examination of choice in the patients with prostatic disease. Follow-up with PSA dosage after one year may be suggested when PSA < 4 ng/ml. PSA density can be helpful in patients with PSA values ranging 4-9.9 ng/ml; biopsy should be performed when the index > 0.15, while follow-up at 6 months should be performed when the index < 0.15. PSA values > 10 ng/ml require further evaluation with rectal examinations, prostate US and US-guided biopsy. Random biopsies are suggested when PSA values are > 20 ng/ml.

Cystic renal tumors: US and CT findings.

Cystic renal tumors represent a variety of lesions in which both solid and liquid components coexist. These lesions may be either benign or malignant and include the multilocular cystic nephroma (MCN), the renal cell carcinoma (RCC), and the papillary adenocarcinoma (PAC). The MCN is a rare neoplasm formed of multiple loculated cystic masses divided by septa. The tumor is benign, although there are some rare reports of malignant cases. The RCC and the PAC may appear with cystic patterns. This is rather uncommon for the RCC, which inside has a unilocular or multilocular cystic appearance, if the necrotic component is large. PAC is an infrequent renal tumor, which has a greater tendency to appear as a large mass with a unilocular large cystic space. The ultrasonography (US) and computed tomographic (CT) features of 27 cystic tumors are presented. Both US and CT allowed the recognition of the cystic components, the septa, and the vegetations. The two imaging techniques made it possible to distinguish the tumors into "unilocular" and "multilocular" masses: the former correspond to RCC and PAC, the latter to MCN and RCC. CT added some information on calcified or partially calcified tumors. CT more than US enabled the differentiation between the malignant RCC and the benign MCN for which conservative surgery may be indicated. The two techniques did not allow the differentiation between RCC and PAC, which has different prognostic behavior.

[Ultrasonic diagnosis in the study of primary hyperparathyroidism]. / L'ecotomografia nello studio dell'iperparatiroidismo primitivo.

Ultrasonography (US) of parathyroid glands was performed in 56 patients with clinic and/or laboratory findings diagnostic or strongly suggesting a primary hyperparathyroidism. In 42 cases CT and in 8 US-guided fine needle biopsy (FNB) were performed. Surgical or autoptic confirmation was obtained in 34 patients. In controlled cases US yielded an overall sensibility of 88.46%, specificity of 95.14% and accuracy of 94.58% in identifying enlarged parathyroid glands. Doubtful US findings can be due to atypical pattern or site and associated thyroid pathology: in these cases, also in our experience, US-guided FNB can be usefully employed. US was more accurate than CT in detecting small size glands. In our opinion CT is mandatory only in negative US and/or scintigraphic cases. According to some clinical and surgical problems US may have a localizing or diagnostic role.

Sonographically guided fine-needle aspiration biopsy of adrenal masses.

Percutaneous fine-needle aspiration biopsy of solid adrenal masses was performed under real-time sonographic guidance in 18 patients. Cellular material was aspirated in all cases. Cytologic examinations were correct in 11 metastatic deposits, three primary adrenal adenocarcinomas, and one pheochromocytoma. One subsequently proven primary adenocarcinoma was not diagnosed. In two cases of adenoma, normal adrenal cells were aspirated. Percutaneous aspiration of adrenal masses is recommended when the precise nature of the lesions is clinically required. The simplicity and speed of fine-needle aspiration biopsy under sonographic control and its high diagnostic accuracy and safety suggest its use as a routine procedure in the management of patients with adrenal masses well depicted by sonography.