Contrast echocardiography for pulmonary arteriovenous malformations screening: does any bubble matter?

AIMS: To evaluate diagnostic accuracy of contrast echocardiography (CE) as compared with CT, for the screening of pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia (HHT); to evaluate the clinical significance of semi-quantitative analysis of a shunt on CE. METHODS AND RESULTS: A blinded prospective study was conducted in 190 consecutive subjects at risk of HHT who underwent screening for PAVMs, including clinical evaluation, pulse oximetry, standard and CE, and chest multirow CT without contrast medium. A semi-quantitative analysis of the shunt size was performed according to the contrast echo opacification of the left-sided chambers: Grade 0, no bubbles; 1, occasional filling with <20 bubbles; 2, moderate filling; 3, complete opacification. The first 100 patients were compared with 100 controls. A total of 119 (63%) patients had positive CE (32.2% Grade 1, 13.1% Grade 2, 11% Grade 3, 6.3% with patent foramen ovale). The overall diagnostic performance of CE was sensitivity 1.00, specificity 0.49, positive predictive value (PPV) 0.32, negative predictive value (NPV) 1.00. The PPV for the different grades was 0.00 for Grade 1, 0.56 for Grade 2, 1.00 for Grade 3; the NPV of Grade 0 was 1.00. A significant correlation was found between the CE grading and the number of PAVM, and complications (P < 0.0001). CONCLUSION: CE is an extremely sensitive procedure for the detection of PAVMs with substantial clinical impact.

Doppler ultrasonographic grading of hepatic vascular malformations in hereditary hemorrhagic telangiectasia -- results of extensive screening.

AIMS: In previous studies, the prevalence of hepatic vascular malformations (VMs) in a large Italian family with hereditary hemorrhagic telangiectasia (HHT) was examined by Doppler ultrasonography (US) as screening technique, and the relevant Doppler US findings were described and classified. Thereafter, Doppler US has been routinely used to screen HHT families for liver involvement. Hepatic VMs were evaluated and classified on the basis of Doppler US findings. METHODS: Three hundred and forty-six subjects belonging to 64 pedigrees were checked for the presence of signs of HHT. All of them underwent abdominal Doppler US screening for hepatic VMs. Vascular abnormalities were classified as minimal if the hepatic artery was dilated in extrahepatic tract only and measured > 6 mm; as moderate if the hepatic artery was dilated in both intra and extrahepatic tract; and as severe if complex changes of the arterial hepatic branches were associated with hepatic and/or portal vein dilatation. Furthermore, Doppler parameters, both qualitative (flow direction, turbulence) and quantitative (peak flow velocity and resistivity index in hepatic artery, mean velocity in portal vein, diastolic peak flow velocity in hepatic veins), were entered into our VM classification. RESULTS: HHT was found in 222 subjects, with hepatic VMs detected by Doppler US in 92 (41.4 %) (24 males, 68 females, mean age 52.2). Hepatic VMs were minimal in 11 subjects, moderate in 70, and severe in 11. CONCLUSIONS: On the basis of our proposed grading, hepatic VMs can be easily classified in subjects with HHT by Doppler US. Depending on the degree of hepatic vascular derangement, appropriate programs for follow up and/or therapy can be designed.

[The dynamic computed tomography of small hepatocarcinomas treated by US-guided percutaneous ethanol injections. The short- and long-term follow-up aspects]. / Tomografia computerizzata dinamica di piccoli epatocarcinomi trattati con iniezione percutanea ecoguidata di etanolo. Aspetti nel follow-up a breve e a lungo termine.

Dynamic CT studies with an automatic injector of iodinated contrast medium were performed in 22 patients affected with 29 hepatocellular carcinomas (HCCs) (phi: 0.8-4.5 cm) before and after treatment with percutaneous ethanol injection (PEI) and during the follow-up period, every 6-9 months. Before PEI, most of the HCCs showed contrast enhancement on CT scans. Treatment was suspended when US-guided fine-needle biopsy demonstrated the absence of malignant cells and when the lesions were unenhanced on dynamic CT scans. Dynamic CT detected 21 HCCs (72.4%) before PEI and 24 HCCs (82.8%) after PEI and during the follow-up period. After PEI, 14 HCCs exhibited a thin and hyperdense peripheral rim on dynamic CT scans. Nine of these lesions, with long-term follow-up (12-31 months), have a smaller diameter than the primary lesion; 6 patients have no HCC recurrence. The authors conclude that dynamic CT is useful for evaluating the effectiveness of PEI in the treatment of HCCs; moreover, their personal experience suggests that the finding of a thin and hyperdense peripheral rim cannot always be related to viable cancerous tissue.

[Radical nephrectomy in renal carcinoma: surprising and unusual clinical and diagnostic features and prognostic factors in 20 consecutive cases]. / Nefrectomia radicale nel carcinoma renale: sorprendenti ed inconsueti aspetti clinici e diagnostici e fattori prognostici in 20 casi consecutivi.

The Authors reports the recent experience on renal carcinoma. The clinical beginning and the diagnostic consequences are emphasized.

[Bone metastasis of hepatocarcinoma. Review of the literature, radiologic pictures and personal caseload]. / Metastasi ossee di epatocarcinomi. Revisione della letteratura, quadri radiologici e casistica personale.

Prognosis of patients affected with hepatocellular carcinoma (HCC) has been improved by the modern imaging techniques allowing an early diagnosis and by the value of the therapeutic protocols employed. Staging has also become more and more important. Bone metastases from HCC are reportedly rare. The authors observed a 5.5% incidence in 90 cases of hepatocarcinoma. The metastases were demonstrated by radiography, CT, and nuclear scintigraphy, in patients with skeletal pain. The plain film appearance of skeletal metastases from HCC was osteolytic in all cases; no surrounding sclerosis was seen. CT scans demonstrated the destructive nature of these lesions, which were associated with bulky soft-tissue masses. Metastases exhibited increased radiotracer (99mTc-MDP) uptake at bone scintigraphy. The authors believe that bone scintigraphy should be included in the staging protocols of the HCCs which need a potentially curative therapy.

A family with hereditary intracerebral cavernous angiomas.

There are a very few reports in literature of inherited intracerebral cavernous angiomas. The majority of them are Mexican-American families. In some of the reported families autosomal dominant transmission is suggested. We report a family in which three members of three consecutive generations were proven to have multiple intracerebral cavernous malformations, without involvement of skin, eyes, or other viscera. An autosomal dominant mode of inheritance is clearly suggested.

[The efficacy of echography in the diagnosis of gallbladder carcinoma]. / Utilità dell'ecografia nella diagnosi del carcinoma della colecisti.

The preoperative diagnosis of carcinoma of the gallbladder is very difficult because the clinical manifestations of this disease are nonspecific and often indistinguishable from those of cholecystitis. Radiography, including oral cholecystograms and i.v. cholangiograms, give aspecific findings. Ultrasound scans were performed on 13 gallbladder carcinomas: only "massive" cancer was diagnosed correctly, because sonography does not offer specific patterns for "infiltrating" and "fungating" carcinomas.