Effective and ovarian dose in PA conventional and rotational 3D hysterosalpingography examinations.

The purpose of this study was to compare effective and ovarian doses (E and OD, respectively) in hysterosalpingography (HSG) examinations performed with conventional posterioanterior (PA) projections and rotational 3D (3D) techniques. 29 HSG examinations (11 conventional and 18 3D), were performed using a digital C-arm angiographic system. In the conventional technique, we used posterioanterior (PA) instead of an anterioposterior (AP) projection normally used according to the international literature. All information concerning exposure conditions for each patient, were recorded. Thermoluminescent dosimeters (TLDs) were attached on the skin of each patient over the ovaries. In conventional HSGs, average values were for Dose Area Product (DAP) 0.41 Gycm(2), for Effective Dose (E) 0.15 mSv and for Ovarian Dose (OD) 0.24 mGy. In 3D-HSGs, they were 14.4 Gycm(2), 2.29 mSv and 3.96 mGy correspondingly. Patient doses in 3D-HSGs are of the same order of magnitude with those reported in the literature for conventional technique. However, they are larger compared to the conventional HSG performed with the technique we use in this specific X-ray system. E and OD are much lower with our technique where PA projection and the specific C-arm system are used in comparison with the corresponding values published in the literature for the conventional technique where the AP projection is used.

Treatment of Budd-Chiari syndrome by transjugular intrahepatic portosystemic shunt.

Patients with Budd-Chiari syndrome may require therapy with portal decompressive surgery. Transjugular intrahepatic portosystemic shunt has recently emerged as a new treatment alternative to surgical shunting, but reported literature is scarce and its long-term outcome is to be evaluated. The aim of our study was to present two patients with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt. Two female patients with acute and subacute Budd-Chiari syndrome respectively, uncontrolled by medical therapy, were referred for transjugular intrahepatic portosystemic shunting. Both patients had refractory ascites, while one had hepatic insufficiency. Hepatic vein thrombosis was without definitive etiology in one patient and due to essential thrombocytosis in the other. Transjugular intrahepatic portosystemic shunt was successfully created in both patients; in one a transcaval approach was performed. Bare stents were used in one, while in the other a polytetrafluoroethylene-covered stent-graft. Technical success was 100% with no complications. Ascites resolved in both patients and liver function improved. The first patient remains asymptomatic with good shunt patency 6 months after intervention. The second patient is symptom-free two years after the shunt creation, despite stent occlusion. She remains asymptomatic due to hepatic vein collateral development. In patients with acute or subacute Budd-Chiari syndrome uncontrolled by medical therapy, transjugular intrahepatic portosystemic shunt is highly effective with no complications and an associated mid-term clinical success.

Transarterial embolization of giant liver hemangiomas associated with Kasabach-Merritt syndrome: a case report.

Of 22 patients with symptomatic giant liver hemangiomas referred for embolization, two females (52 and 74 years) had Kasabach-Merritt syndrome (KMS). Hematocrit values were observed to be 33% and 29%, platelets 4000 and 5400/mm(3), and fibrinogen 98 and 77 mg/dl, respectively. Lesion diameters were 7 and 14 cm, respectively. Hepatic angiography revealed excessive vascular lakes typical of cavernous hemangiomas. Microspheres of 40-300 microm were superselectively injected under fluoroscopic guidance until cessation of flow. Coil packing of the feeding hepatic artery was additionally used in one patient. The procedure was uneventful in both. Partial restoration of platelet count was observed immediately; fibrinogen levels and platelets were restored completely in one patient and partially in the other, without remissions at 2-year follow-up.

Long-term outcome of a hepatocellular carcinoma 7(1/2) years after surgery and repeated radiofrequency ablation: case report and review of the literature.

An interesting case is presented of a 78-year-old patient with cirrhosis who was managed with combined treatment (surgery and radiofrequency (RF) ablation) for hepatocellular carcinoma (HCC) and has survived for 7(1/2) years. Elevation of the alpha-FP (alpha-fetoprotein) levels was noted 2 years after surgery. CT demonstrated two lesions: one central at the remaining right liver lobe, and the other at the excision site. Biopsy of the lesions confirmed the diagnosis of HCC for both of them. RF ablation of these two lesions was performed in one session with technical success. Four and a half years after the first RF ablation a new recurrence was demonstrated at the CT follow-up control. RF ablation was again applied successfully. The imaging findings and the therapeutic percutaneous management of this patient along with the natural course of HCC and its recurrence are discussed, and the literature concerning risk factors is reviewed.

Hysterography -- new techniques.

For many years hysterosalpingography has provided images of the lumen of the fallopian tubes and the uterine cavity that were not available by other diagnostic modalities. In our days the development of new imaging and endoscopic techniques has limited its indications. In this paper we will discuss the current use of hysterosalpingography and the new techniques that have been developed such as sonohysterography.

Virtual bronchoscopy versus thin section computed tomography in evaluation of moderate and low grade stenoses: receiver operating characteristic curve analysis.

PURPOSE: To evaluate the impact of virtual bronchoscopy, under proper threshold settings, on observer level of confidence in the assessment of bronchial abnormalities producing stenoses < or = 75% compared to interpretation of thin section computed tomography (CT) images. MATERIAL AND METHODS: Sixty-five patients with fiberoptic bronchoscopy positive for tracheobronchial abnormalities were evaluated in a blinded observer study using a commercially available virtual endoscopy software package. The findings of virtual endoscopy were compared with those of fiberoptic bronchoscopy using receiver operating characteristic curves (ROCs) and other statistical tools. RESULTS: A total of 102 lesions were identified by fiberoptic bronchoscopy, with 44 of these producing bronchial stenoses < or = 75%. Concerning the latter lesions, for virtual bronchoscopy the areas under the ROCs were 0.93 and 0.96 for the two observers, respectively, while for thin section CT the corresponding values were 0.86 and 0.88; the differences observed were statistically significant. Contrary to thin section CT, virtual bronchoscopy did not show statistically significant differences from fiberoptic bronchoscopy regarding estimation of degree of stenosis. CONCLUSION: Virtual bronchoscopy under proper threshold settings has a statistically significant impact on observer performance where moderate and low-grade bronchial stenoses are concerned and gives an estimate of the degree of stenosis more precisely than thin section CT.

Cervical spine ROM measurements: optimizing the testing protocol by using a 3D ultrasound-based motion analysis system.

The aim of this study was to evaluate the intra- and inter-examiner reliability and validity of neck range of motion (ROM) measurements. Thirty-five healthy subjects were assessed in all neck movements from two initial positions, sitting and standing, actively (open and closed eyes) and passively by using a 3D ultrasound-based motion analysis device (Zebris). Three tests were employed to assess intra-examiner reliability and two examiners used for the inter-examiner reliability. X-rays in neck flexion and extension were used to validate the Zebris system. The standing position yielded higher intraclass correlation coefficient (ICC) values (>0.86) with less error [smallest detectable difference (SDD)<13.8%] than sitting (ICC>0.79, SDD<14%). Passive assessment of neck ROM presented better reproducibility than active assessment with open or closed eyes in both positions. The inter-examiner reliability was moderate (ICC=0.43-0.68). The correlation between the Zebris system and X-rays was high in both flexion and extension movements. The results showed that the most reliable protocol for assessment of neck ROM is a passive measurement in the standing position. The measurements were well validiated against X-rays and the experience of the investigators must be considered before any comparison among studies is employed.

Cerebral metastases of malignant melanoma: contemporary treatment modalities and survival outcome.

The aim of our study was to analyze prognostic factors, effect of treatment and survival outcome of a contemporary cohort of melanoma patients with cerebral metastases and eventually propose new recommendations regarding therapy. Sixty four patients with melanoma brain metastases were treated in our department within a 15-year period. We performed a retrospective analysis of their survival with respect to the type of treatment instituted. Four groups were formed according to treatment: Group A patients treated with surgery followed by radiotherapy; group B temozolomide as first-line treatment and radiotherapy after cerebral disease progression; group C radiotherapy alone; group D supportive care only. Patients* characteristics influenced the selection of treatment modality: Group A (7.8%) patients with a single brain metastasis (p=0.001) and controlled extra-cranial disease (p<0.0001), while Group D (21.8%) patients with ulcerated primary lesions (p=0.010) and uncontrolled extra-cranial disease (p<0.0001). Only group B (26.6%) and C (43.7%) patients with similar characteristics including more than one brain lesion. Median overall survival was 3 months. In univariate analysis, median survival for groups A, B, C and D was 12, 5, 3 and 2 months, respectively (p<0.0001). The survival difference between the surgery and non-surgery groups was statistically significant (p=0.0011). Patients treated with supportive care had the worse prognosis (p<0.0001). A survival benefit for patients receiving first-line treatment with temozolomide, as compared to those receiving radiotherapy alone was noted (p=0.0267). In multivariate survival analysis, the number of brain lesions (p=0.0138), the absence of uncontrolled extra-cranial disease (p=0.00221) and the type of treatment for the cerebral disease (p=0.0053) remained significant independent survival predictors. Patients' characteristics remain a critical factor for treatment selection. The number of brain metastases, the extent of disease and the type of treatment represent independent survival predictors. Melanoma patients with a single brain metastasis and controlled extra-cranial disease gain a survival benefit, if surgically treated. Including temozolomide in the first-line treatment of melanoma patients with brain metastases who would have been treated with radiotherapy alone, might present a promising future direction affecting the length of survival.

Cirrhosis-related intrathoracic disease. Imaging features in 1038 patients.

BACKGROUND/AIMS: To describe imaging features of cirrhosis-related intrathoracic disease. METHODOLOGY: Chest CTs of 1038 cirrhotic patients (mean age 53 yrs; range, 17-79) were evaluated for: bronchoarterial ratio (BAR), arteriovenous malformations, interstitial opacities, emphysema, and pleural effusions. Lymphangiography, pulmonary angiography, cardiac ultrasound and scintigraphy were selectively performed. RESULTS: Mean BAR was 0.83+/-0.19. In two patients with hepatopulmonary syndrome (HPS), mean BAR was 0.55. HRCT detected interstitial lung opacities in 15 patients. Signs of fibrosis were seen in 7 (only two associated to biliary cirrhosis) and interstitial edema in 8. Accurate pattern recognition was achieved in 10/15 cases (66.6%). Of the 93 patients with emphysema only one had documented alpha1-AT deficiency (1.08%). Multiple type 1 vascular dilatations were visualized in two patients with HPS. Hepatic hydrothorax was present in 49 patients (4.72%); right-sided in 34 (69.4%), bilateral in 9 (18.4%) and left-sided in 6 (12.2%). Hepatic chylothorax was confirmed in 3 patients. Lymphangiography demonstrated the site of leakage and the engorged thoracic duct. CONCLUSIONS: CT can identify intrathoracic pathology associated with liver disease. Decreased BAR is highly specific for HPS. However, a multimodality approach is necessary to depict cases of liver origin.

Iliac artery angioplasty : technique and results.

Percutaneous angioplasty is widely used for the treatment of iliac artery occlusive disease. Access to the ipsi-lateral, or less commonly contralateral, common femoral artery is obtained under local anaesthesia; the lesion is crossed with a guidewire and dilated with an angioplasty balloon catheter. This technique yields excellent immediate results with very few complications. Stent placement is used in lesions not amenable to balloon angioplasty, in complications, and recurrences. Evidence suggests that balloon angioplasty is the procedure of choice for iliac artery occlusive lesions. Stent placement should be reserved for angioplasty failures. However, primary stent placement is indicated in total occlusions. Lesion morphology is an important determinant of immediate success and long-term patency. TASC lesions type A and B are best treated with angioplasty and stenting, while TASC lesions type C and D show better results with surgical treatment. The development of new stent designs may expand the indications of the percutaneous treatment.

Effects of superselective embolization for renal vascular injuries on renal parenchyma and function.

AIM: Our objective was to evaluate the outcome of superselective embolization used for treatment of renal vascular injuries on renal parenchyma and renal function. MATERIALS AND METHODS: Between January 1999 and December 2001, 6 consecutive patients (five males, one female, mean age 45 years) underwent embolization to treat bleeding from renal vascular injuries, resulting from iatrogenic interventions (4) and blunt abdominal trauma (2). Five patients had increased serum creatinine. Angiography depicted a pseudoaneurysm (PA) in three, PA with arteriovenous fistula (AVF) in one, and active extravasation in two patients. Superselective catheterization was achieved using a 5-F catheter in three, and coaxial microcatheter in the remaining three cases. All lesions were successfully embolized with 0.035" or 0.018" coils. RESULTS: Bleeding was ceased in all patients and did not recur. Mean post-embolization parenchymal ischemic area was 11.7% (range: 0-30%). Imaging follow-up (mean: 12 months, range: 5-23) showed that mean parenchymal infarcted area was 6% (range: 0-15%). Serum creatinine level was normal in all patients one week after the procedure and at the latest follow-up. CONCLUSION: Superselective embolization resulted in permanent cessation of bleeding. Serious parenchymal infarction was prevented and serum creatinine level returned to the pre-bleeding values. Embolization should be considered as the treatment of choice in this patient population.

Threshold selection in virtual bronchoscopy: phantom study and clinical implications.

PURPOSE: To investigate the effect of the threshold selection on the apparent diameter of a virtual bronchus and the virtual wall morphology and to examine the parameters that can affect the selection of the appropriate threshold for virtual bronchoscopy with single slice computed tomography. MATERIAL AND METHODS: A bronchial phantom containing plastic tubes simulating the airways of the tracheobronchial tree was constructed. The diameters of the virtual images of these tubes were measured using various thresholds for two different materials surrounding the tubes: air and water. These measurements were correlated with the density in HU of the walls. Furthermore, data from 20 virtual bronchoscopies in patients were retrospectively analyzed in the same way. RESULTS: The diameter of a virtual bronchus is strongly affected by the selected threshold. The appropriate threshold for accurate diameter representation depends on the density of the bronchial wall. CONCLUSION: Our results suggest that in clinical practice a single threshold value cannot be used for imaging all segments of the tracheobronchial tree. While a value of -520 is appropriate for the trachea and lobar segments, values down to -720 could be needed on the level of segmental and subsegmental bronchi. At these levels, a threshold value about 65 HU more negative than the value where the artificial holes appear on the virtual bronchial walls could be used.

Endovascular repair of abdominal aortic aneurysm in renal transplantation.

Successful endovascular correction of a 12-cm abdominal aortic aneurysm (AAA) is described in a 76-year-old man with a functional pelvic renal transplant and 18-month follow-up. Endovascular treatment is a safe alternative to surgery for AAA correction in the elderly post-transplantation patient since it does not require flow interruption during the procedure.

Percutaneous CT-guided drainage of splenic abscess.

OBJECTIVE: The objective of our study was to determine the current role of percutaneous CT-guided drainage as an alternative to surgical treatment of splenic abscesses. CONCLUSION: Splenic abscess is an uncommon entity that can be treated percutaneously. CT-guided drainage of splenic abscess seems to be a safe and effective alternative to surgery, allowing preservation of the spleen.

Chondrosarcoma of the larynx: treatment with radiotherapy.

The case of a 50-year-old man with chondrosarcoma of the larynx treated with radiotherapy is reported. The patient presented with hoarseness and dyspnea. He underwent computed tomography (CT), which demonstrated a soft tissue mass of the larynx. Direct laryngoscopy with biopsy established the diagnosis of chondrosarcoma. Although experience with radiotherapy in these cases has been lacking in the literature, it was considered and eventually used, as radical surgery would result in severe cosmetic and functional impairment. Radiation therapy alone resulted in long-term remission of the tumour for more than 3 years. The patient has been followed up using CT and direct laryngoscopy for early detection of recurrence or metastases.

Malignant melanoma metastatic to the gastrointestinal tract.

A retrospective study of 385 melanoma patients was performed, with the goal of evaluating the clinical characteristics, the role of imaging and the impact of treatment on patients with gastrointestinal (GI) metastases. Eighteen patients (4.7%) had GI tract metastases. In 50% the primary lesion was on the lower extremities (P< 0.01), while 61.1% had nodular melanomas (P < 0.01). Imaging and/or endoscopy were undertaken in 72.2% of the patients, yielding positive results in all. Eight patients underwent curative surgery, two received no treatment, while the remaining eight patients had chemotherapy or immunochemotherapy. Long-term palliation was offered to 87.5% of the surgical patients compared with 50% of the patients treated medically. Median survival in the patients treated with surgery was 47.5 months compared with 5.8 months in the medical group (P < 0.01). GI tract metastases were more common in patients with nodular melanoma of the lower extremities. To our knowledge, this is the first study correlating the primary lesion's characteristics with the development of GI tract metastases. Imaging is effective in the diagnosis of GI tract involvement. Melanoma patients with GI tract metastases can benefit from palliation by surgical resection. Survival is improved when such patients are treated with curative surgery.

Malignant fibrous histiocytoma of the trunk metastatic to the liver: treatment with transcatheter intrahepatic chemoembolization.

We report a patient with symptomatic liver metastases as the sole site of recurrence of a previously resected malignant fibrous histiocytoma of the trunk. We treated the patient with two sessions of transcatheter chemoembolization. Tumor regression was achieved, and the patient remained free of symptoms 23 months after the diagnosis of liver involvement, when he died of acute myocardial infarction. To our knowledge, this is the only case of transcatheter chemoembolization of liver metastases from soft-tissue sarcoma reported in the literature. Although it is a single case, it shows that this method may be a promising therapy for this grave disease.