Diagnostic accuracy of radionuclide imaging using 131I nor-cholesterol or meta-iodobenzylguanidine in patients with hypersecreting or non-hypersecreting adrenal tumours.

The aim of this retrospective study was to evaluate the diagnostic accuracy of nor-cholesterol and meta-iodobenzylguanidine radionuclide imaging in two separate groups of patients with adrenal tumours to characterize lesions as adenoma or pheochromocytoma. We studied 75 patients (22 male and 53 female, mean age 47 +/- 15 years) with hypersecreting (n = 32) or non-hypersecreting (n = 43) unilateral adrenal tumours detected by computerized tomography or magnetic resonance scans. 131I nor-cholesterol adrenal scintigraphy was performed in 41 patients. Meta-[131I]iodobenzylguanidine (131I-MIBG) imaging was acquired in the other 34 patients. Pathology examinations (n = 58) or computerized tomography follow-up studies (n = 17) were obtained. Adrenal lesions were represented by 44 adenomas, four cysts, one myelolipoma, one pseudotumour, one ganglioneuroma, 16 pheochromocytomas, three carcinomas, four metastases and one sarcoma. Radionuclide studies were qualitatively evaluated and the corresponding results were classified as true positive, true negative, false positive and false negative. Diagnostic sensitivity, specificity and accuracy as well as positive and negative predictive values were calculated. The diagnostic values of nor-cholesterol scintigraphy in identifying adrenal adenomas were sensitivity 100%, specificity 71%, accuracy 95%, positive predictive value 94% and negative predictive value 100%; of note, two false positive cases were observed represented by a pheochromocytoma and a myelolipoma. The diagnostic values of MIBG scintigraphy in recognizing pheochromocytoma were sensitivity 100%, specificity 95%, accuracy 97%, positive predictive value 94% and negative predictive value 100%; only one false positive case occurred consisting of a carcinoma. It is concluded that, in the large majority of cases, adrenal scintigraphy using nor-cholesterol or MIBG is able to characterize specific lesions such as adenoma and pheochromocytoma, respectively. These findings show relevant clinical impact, particularly in patients with non-hypersecreting adrenal lasions. Radiotracer selection depends on clinical patient history and department availability; since benign adenomas are the most common cause of non-hypersecreting tumours, nor-cholesterol should be the first choice followed by MIBG if nor-cholesterol shows normal images. However, rare as well as unusual findings may be observed; nor-cholesterol uptake may occasionally be also found in non-adenoma tumours such as myelolipoma and pheochromocytoma. Similarly, MIBG accumulation may occur not only in lesions arising from medullary chromaffin tissue, but also rarely in cortical adrenal carcinoma.

The diagnostic role of radionuclide imaging in evaluation of patients with nonhypersecreting adrenal masses.

UNLABELLED: The aim of this study was to evaluate the role of radionuclide imaging in the characterization of nonhypersecreting adrenal masses. METHODS: A total of 54 patients (19 men, 35 women; mean age, 50 +/- 16 y) with nonhypersecreting unilateral adrenal tumors that had been originally detected on CT or MRI underwent adrenal scintigraphy using different radiotracers. None of the patients showed specific symptoms of adrenal hypersecretion. Screening tests for excess cortical and medullary products showed normal adrenal hormone levels. Radionuclide studies (n = 73) included (131)I-norcholesterol (n = 24), (131)I-metaiodobenzylguanidine (MIBG) (n = 23), and (18)F-FDG PET (n = 26) scans. RESULTS: Histology after surgery (n = 31) or adrenal biopsy (n = 23) was obtained. Adrenal lesions were represented by 19 adenomas, 4 cysts, 1 myelolipoma, 1 neurinoma, 2 ganglioneuromas, 5 pheochromocytomas, 4 pseudotumors, 6 carcinomas, 2 sarcomas, and 10 metastases (size range, 1.5- to 5-cm diameter; mean, 4.9 +/- 3.1 cm). For norcholesterol imaging, diagnostic sensitivity, specificity, and accuracy were 100%, 71%, and 92%, respectively; the positive predictive value (PPV) of the norcholesterol scan to characterize an adrenal mass as an adenoma was 89%, whereas the corresponding negative predictive value (NPV) to rule out this type of tumor was 100%. For MIBG imaging, diagnostic sensitivity, specificity, and accuracy were 100%, 94%, and 96%, respectively; the PPV of the MIBG scan to characterize an adrenal mass as a medullary chromaffin tissue tumor was 83%, whereas the corresponding NPV to rule out this type of tumor was 100%. For FDG PET, diagnostic sensitivity, specificity, and accuracy were 100%, 100%, and 100%, respectively; the PPV of FDG PET to characterize an adrenal mass as a malignant tumor was 100%, whereas the corresponding NPV to rule it out was 100%. Furthermore, in 7 patients with malignant adrenal tumors, FDG whole-body scanning revealed extra-adrenal tumor sites (n = 29), allowing an accurate diagnosis of the disease's stage using a single-imaging technique. CONCLUSION: In patients with nonhypersecreting adrenal masses, radionuclide adrenal imaging, using specific radiopharmaceuticals such as norcholesterol, MIBG, and FDG, may provide significant functional information for tissue characterization. Norcholesterol and MIBG scans are able to detect benign tumors such as adenoma and pheochromocytoma, respectively. Conversely, FDG PET allows for recognition of malignant adrenal lesions. Therefore, adrenal scintigraphy is recommended for tumor diagnosis and, hence, for appropriate treatment planning, particularly when CT or MRI findings are inconclusive for lesion characterization.

Assessment of scanner performance and normalization of estimated relaxation rate values.

The purpose of this study was to develop and test a method for the assessment of Magnetic Resonance (MR) scanner performance suitable for routine brain MR studies and for normalization of calculated relaxation times. We hypothesized that regular monitoring of machine performance changes could provide a helpful normalization tool for calculating tissue MR parameters, thus contributing to support their use for longitudinal and comparative studies of both normal and diseased tissues. The method is based on the acquisition of phantom images during routine brain studies with standard spin-echo sequences. MR phantom and brain tissue parameters were used to assess the influence of machine related changes on relaxation parameter estimates. Experimental results showed that scanner performance may affect relaxation rate estimates. Phantom and in vivo results indicate that the correction method yields a reduction in variability of estimated phantom R1 values up to 29% and of R1 for different brain structures up to 17%. These findings support the validity of using brain coil phantoms for routine system monitoring and correction of tissue relaxation rates.

Levovist-enhanced Doppler sonography versus spiral computed tomography to evaluate response to percutaneous ethanol injection in hepatocellular carcinoma.

The aim of the current study was to compare Levovist-enhanced power Doppler (PD) imaging with contrast-enhanced spiral computed tomography (CT) in the evaluation of intratumoral vascularity of hepatocellular carcinomas at diagnosis and after percutaneous ethanol injection (PEI). Nineteen patients with hepatocellular carcinoma (HCC) underwent PD with and without Levovist and spiral CT at diagnosis and 1 month after PEI treatment. Compared to spiral CT at baseline evaluation, the PD showed intratumoral vascularity in 36.8% of the cases; this percentage reached 78.9% after Levovist enhancement. One month after PEI, only 5 out of 19 treated HCCs appeared as hypodense areas at CT and showed no contrast enhancement. Only 3 of the 14 patients with a positive spiral CT scan were positive at the PD performed without the Levovist administration (sensitivity, 21.4%). The use of contrast-enhanced ultrasonography led to detection of residual signal in six other HCCs treated by ethanol injection (sensitivity, 64.2%). We confirm that spiral CT is the most sensitive and accurate technique in evaluating the effect of ethanol injection in HCC. It correctly identifies most cases of treatment failure as enhanced areas within the lesion. The lower rate of detection of tumoral vascularity by Doppler sonography was significantly increased by Levovist. The evidence of residual vascularity within HCC at Levovist Doppler sonography allows the targeting of additional ethanol injections.

[3D spiral computerized tomography in the reconstructive treatment of malignant maxillofacial tumors]. / Tomografia Computerizzata spirale con elaborazioni tridimensionali di superficie nel trattamento ricostruttivo dei tumori maligni del massiccio facciale.

PURPOSE: To investigate the role of Helical CT and the usefulness of three-dimensional (3D) imaging for preoperative planning and follow-up of reconstructive maxillofacial surgery with alloplastic material in neoplastic disease involving this region. MATERIAL AND METHODS: From 1996 to 1999 eleven patients were examined with Helical CT and 3D images for planning of maxillofacial plastic and reconstructive surgery for advanced cancer of this anatomically complex region. A 3D-modulated titanium mesh (100%) or micronets was used to rebuild the anterior surface of maxillary bone and the orbital floor. The mesh was cut to the appropriate size and shape and curved where necessary. Within the residual sinusal cavity a siliconed filling was used surmounting an acrylic prosthesis with dental arch to rebuild the palate. A rehydrated bovine pericardium was affixed and moduled on the borders in two cases only. Three-dimensionally reconstructed CT images were obtained preoperatively and at least 6 months postoperatively in all patients. The images were generated on a computer workstation using the shaded surface display (SSD) software with threshold values ranging 425 to 630 HU, and a more closed window for the imaging of titanium mesh/bone interface in the postsurgical follow-up. RESULTS: We always obtained an excellent complete spatial depiction of maxillofacial region both before and after surgery, with no artefacts so important as to affect the 3D reconstruction process and the image quality. Together with the head-neck surgical team we could work for preoperative planning through CT scans by different 3D points of view. The 3D reconstructed follow-up scans showed good filling of the defect in the area where the titanium mesh had been used. Then efficacious bone modelling and good biocompatibility of the alloplastic material were seen in all patients, with no inflammatory reactions. CONCLUSIONS: Titanium is a well-known material, which is widely used for cranioplasty. It is a radiolucent, nonferrous metal of low atomic number that allows very clear CT and MR images to be obtained. Further Ti features are strength, biocompatibility and easy handling. 3D Helical CT scan has proved to be the most complete and accurate imaging technique for reconstructive plastic surgery with alloplastic material in advanced maxillofacial cancer, also considering the anatomic and functional complexity of this area. The prospect is provided to identify virtual 3D presurgical ablation planes. These may allow the surgeon to improve plastic reconstruction and shorten intervention time.

Imaging of adrenal tumors using FDG PET: comparison of benign and malignant lesions.

OBJECTIVE: The aim of this study was to differentiate benign from malignant adrenal tumors using positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in patients with unilateral adrenal masses originally detected by CT or MR imaging. CONCLUSION: PET imaging with FDG can metabolically characterize adrenal masses. Abnormally increased FDG uptake in adrenal malignancies allows one to differentiate these abnormalities from benign lesions. Whole-body PET can also reveal extraadrenal tumor sites in patients with malignant tumors, using a single imaging technique for accurate disease staging.

Scintimammography with 99mTc-MDP: experience of the National Cancer Institute of Naples.

The role of scintimammography with 99mTc-MDP was investigated in patients with mammographic or clinical evidence of breast lesions, suspicious for malignancy, in our Department at the National Cancer Institute of Naples. The end-point of the study was to assess the uselfulness of this test in diagnosing or ruling out breast cancer in more than 2000 women. Scintimammography results were compared with those of mammography and ultrasound and categorized according to histological findings. Overall sensitivity was 92%, specificity was 90%, and accuracy 91%. Sensitivity was affected by the lesions exceeding 12 mm and specificity by sclerotic and/or hyaline or myxoid fibroadenomas, which may be positive. The major advantages of scintimammography appeared in the study of calcifications without a mass and of the indirect mammographic signs of breast cancer, such as distortion and asymmetry. Scintimammography with 99mTc-MDP is a reliable, safe and highly cost-effective procedure to diagnose or to rule out breast cancer, after mammography and ultrasound have yielded questionable results.

[Magnetic resonance in the study of suprarenal neoplasms. Qualitative and quantitative analysis of signal intensity]. / La Risonanza Magnetica nello studio delle neoplasie surrenaliche. Analisi qualitativa e quantitativa dell'intensità del segnale.

INTRODUCTION: Magnetic Resonance Imaging (MRI) has been proposed as the diagnostic technique of choice to characterize adrenal tumors. However, the results of the current studies are controversial. MATERIAL AND METHODS: Forty-nine patients with unilateral adrenal masses were submitted to MRI for lesion characterization on the basis of MR signal intensity. Cytology and/or histology demonstrated 14 pheochromocytomas (pheos), 11 adenomas, 3 cysts, 2 myelolipomas, 4 carcinomas, 3 metastases and 1 fibrosarcoma; a clinical diagnosis of adenoma was made in the remaining 11 patients. MR studies were performed using spin-echo (SE) sequences with T1 (TR/TE = 600/17 ms) and T2 (TR/TE = 2000/15-90 ms) weighting. T1-weighted images were also acquired after Gadolinium-DTPA (Gd-DTPA) administration. MR studies were integrated with in- and out-of-phase (TR/TE = 100/4-6 ms) chemical-shift (CS) sequences. MR signal intensity (SI) was analyzed qualitatively and quantitatively; MR results were correlated with tumor type and hormone secretion. RESULTS: The qualitative analysis of T2 images showed high signal intensity in the majority (80%) of adrenal lesions (14 pheos, 12 adenomas, 3 cysts, 2 myelolipomas and 8 malignancies). The quantitative analysis of post-Gd-DTPA T1 images permitted to distinguish adenomas, cysts and myelolipomas from pheos and malignancies. The qualitative analysis of post-Gd-DTPA T2 and T1 images permitted to distinguish pheos and cysts from adenomas and malignancies (p < .05); however, pheos and cysts as well as adenomas and malignancies were not differentiated. MR SI was similar in secreting and nonsecreting adenomas from both a qualitative and a quantitative viewpoints. CS MRI permitted to distinguish adenomas (decreased signal intensity on out-phase relative to in-phase images) from other benign and malignant lesions (no signal change from out-phase to in-phase images). CONCLUSIONS: The qualitative analysis of MR SI on conventional T1 and T2 images does not permit to differentiate adrenal masses. The qualitative evaluation of T1 images after Gd-DTPA administration, the quantitative analysis and CS sequences are technical options improving lesion characterization.

[Hemorrhage in the Wirsung's duct caused by aneurysm of the splenic artery in chronic pancreatitis]. / Emorragia nel dotto di Wirsung da aneurismi dell'arteria splenica in corso di pancreatite cronica.

Two cases of haemorrhage from rupture of a splenic artery aneurysm into the pancreatic duct are reported. Both patients suffered from chronic pancreatitis; when haemorrhage appeared both patients experienced abdominal pain. In one patient the melaena was repetitive, in the other one--with a single episode of melaena - the endoscopy showed fresh blood near the papilla. In both patients ultrasonography and computerized tomography (CT) revealed a cystic mass in the pancreatic tail; CT scan also showed a clear contrast enhancement of these lesions after iodinated medium intravenous bolus. Coeliac arteriography confirmed the presence of two large saccular aneurysmal dilatation of the splenic artery. Both patients underwent a laparotomy: distal pancreatectomy with aneurysm resection and splenectomy were successfully performed.

[Hemorrhagic aneurysm of the celiac trunk. Diagnosis by ultrasound, CT and angiography]. / Gli aneurismi emorragici del tronco celiaco. Diagnosi con US, TC e angiografia.

The authors report their experience in the study of bleeding aneurysms of the celiac arteries. Eleven patients were examined with US, CT, and angiography (8 hepatic artery aneurysms and 3 splenic artery aneurysms). Clinical findings included digestive bleeding, upper abdominal pain, palpable pulsating masses, and jaundice. Patient history included blunt abdominal trauma, penetrating trauma due to gunshot, acute pancreatitis, recent hepatic biopsy. In all cases US showed an abdominal mass ranging in size from 2 to 10 cm. US findings included cyst-like lesions (8 cases), a lobulated solid-like lesion, and complex lesions (2 cases). Continuity of the lesion with adjacent arterial vessels was noted in 5/11 cases, and pulsing activity in 3/11 cases. US patterns, although not specific, play an important role in the diagnosis when associated to other elements such as arterial continuity, mass pulsatility, patient history, and gastrointestinal bleeding. They suggest the need for more specific imaging exams, i.e. CT and angiography, and help avoid dangerous diagnostic biopsies. CT was performed to confirm US findings in 5 cases, and detected either hypodense cystic masses, or inhomogeneous masses with arterial enhancement after bolus injection of cm. CT was used to better demonstrate the lumen, patency of the vessel, the walls of the vessel, and the parietal thrombotic component. The typical arterial enhancement was the decisive finding for the diagnosis, even though a total continuity with arterial vessels was never observed. Angiography was the method of choice for the preoperative demonstration of hepatic artery aneurysms (10 cases) and for occlusive treatment with Gianturco coils (3 cases).

[Echographic study of the inferior vena cava in abdominal neoplastic pathology. Comparison with the inferior cavography]. / Studio ecografico della vena cava inferiore nella patologia neoplastica addominale. Confronto con la cavografia inferiore.

The authors evaluated the reliability of echography in the involvement of the inferior vena cava in the abdominal tumors. 137 patients were studied with echography and 125 with inferior cavography too. All the diagnosis were confirmed with arteriography and/or CT and/or surgical findings. The reliability of the echographic method was significant, and particularly in case of emboli and tumor invasion.

[Echographic diagnosis of neuroblastoma in children]. / La diagnosi ecografica del neuroblastoma infantile.

Ultrasounds have a high diagnostic value mainly in the structural assessment of the neoplasia. They are also very useful for the evaluation of the spread. In this paper the authors analyze the criteria for a differentiated diagnosis of Wilms' tumour.

[Ultrasound in the diagnosis of Wilms' tumor]. / Gli ultrasuoni nella diagnostica del tumore di Wilms.

Ultrasound (US) play a very important role in the diagnosis of Wilms' tumour. The authors analyze the findings in 12 children affected by this neoplasia. The resolution power of 4 different diagnostic levels is also analyzed. They are: a) mass identification; b) diagnosis of the tumour nature; c) diffusion balance; d) recurrence control. The most relevant resolution power lies in the diagnosis of nature and in the recurrence control.

[Comparative study of echotomography and percutaneous transhepatic cholangiography in the diagnosis of obstructive jaundice]. / Confronto fra ecotomografia e colangiografia percutanea transepatica nella diagnosi dell'ittero ostruttivo.

The authors compare the results of sonography (US) and percutaneous transhepatic cholangiography (PTC) in the study of 48 patients with obstructive jaundice. The results obtained were correlated to various diagnostic levels and to the different causes of obstruction. The analysis of the results led the authors to believe that, in most cases, the association of both techniques is absolutely necessary in order to define the whole diagnostic picture.

Recent advances in diagnostic techniques in Caroli's disease.

Preoperative diagnosis of congenital dilatation of the intrahepatic bile ducts (Caroli's disease) is difficult. The best techniques for this diagnosis are endoscopic retrograde cholangiopancreatography, abdominal ultrasonography and computerized tomography. The authors present a case of Caroli's disease diagnosed using ultrasonography and computerized tomography. They discuss the usefulness and the real possibilities of existing techniques in the diagnosis of intra- and extrahepatic bile duct disease.