Caecal leiomyoma detected by whole-body MRI in a patient with Hodgkin lymphoma: first case report.

INTRODUCTION: Hodgkin Lymphoma (HL) is one of the most curable malignant diseases. Modern treatments, like the combined radiochemotherapy and stem cell transplantation, have increased the number of malignant disease survivors. However, HL survivors are at risk of long-term effects, including the development of solid tumors. Secondary neoplasms are a major cause of late morbidity and mortality following treatment for HL. CASE REPORT: We report the case of a male patient, treated for HL by chemotherapy, who developed a large leiomyoma of the cecum one year after the treatment. A whole-body Magnetic Resonance (WBMRI) scan performed during the follow-up allowed the detection of this incidental caecal mass that was absent in a Computed Tomography (CT) scan performed immediately after the treatment. After a CT-guided biopsy, the lesion was surgically removed and the diagnosis of caecal leiomyoma was obtained. DISCUSSION: To our knowledge, this is the first case report, according to the scientific literature, of caecal leiomyoma developing after chemotherapy in a HL survivor. Leiomyoma is a rare benign tumor that usually appears as a solitary small mass with a nodular growth and a benign course. CONCLUSION: This case shows that WB-MRI allows detecting relevant incidental findings during the oncologic follow-up, avoiding both radiation exposure and contrast agent administration. Furthermore, leiomyoma should be considered in the differential diagnosis between the caecal masses with high growth rate.

Renal endometriosis mimicking complicated cysts of kidney: report of two cases.

Endometriosis is a common gynecologic disorder characterized by ectopic endometrial tissue growth outside the uterine cavity. Although usually occurring in pelvic organs, endometrial lesions may involve urinary tract. Renal endometriosis is extremely rare and it has only occasionally been reported in the past. We report two cases of patients with renal cystic lesions, incidentally found at imaging techniques during oncologic follow-up for gastric sarcoma and melanoma, initially misinterpreted as complicated haemorrhagic cysts and then histologically characterized as renal localizations of extragenital endometriosis.

Incidence of new foci of hepatocellular carcinoma after radiofrequency ablation: role of multidetector CT.

PURPOSE: The authors sought to assess the incidence of new foci of hepatocellular carcinoma (HCC) using multidetector computed tomography (MDCT) in patients treated with radiofrequency ablation (RFA). MATERIALS AND METHODS: Two readers retrospectively reviewed by consensus the follow-up MDCT studies of 125 patients (88 men and 37 women; mean age 68 years) with 141 HCCs (size 1-5.2 cm; mean 2.2 cm) treated with RFA. MDCT follow-up was performed at 1 and 3 months and every 6-12 months thereafter. Reviewers assessed: (1) the presence of new HCC foci in the same liver segment or in a different segment; (2) complete or incomplete tumour ablation; (3) tumour progression. RESULTS: A total of 113 new HCCs (size 0.7-4.8 cm; mean 1.7 cm) were detected in 69/125 (55.2%) patients (mean follow-up 30.38±19.14 months). Of these, 86 (76.1%) new HCCs were multiple (p<0.0001), and 92 (81.4%) occurred in a different segment from that of the treated HCC (p<0.0001). New HCCs were observed in the first 12 months, between 12 and 24 months and after 24 months in 31/69 (44.9%), 24/69 (34.8%) and 14/69 (20.3%) patients, respectively (p=0.175). Mean diseasefree interval was 16.1±16.31 (range 1-52) months. Complete tumour ablation was achieved in 132/141 (93.6%) treated HCCs, and tumour progression occurred in 29/141 (20.6%) cases. CONCLUSIONS: In patients with RFA-treated HCCs, MDCT follow-up revealed a high incidence of new HCCs, even after 1 year of follow-up. The new foci tended to be multiple and located in a liver segment different from that of the previously treated nodules.

Characterisation of focal liver lesions undetermined at grey-scale US: contrast-enhanced US versus 64-row MDCT and MRI with liver-specific contrast agent.

PURPOSE: The aim of this study was to assess the role of contrast-enhanced ultrasonography (CEUS) in the characterisation of focal liver lesions in comparison with multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) with liver-specific contrast agent. MATERIALS AND METHODS: One hundred and eighty-seven focal liver lesions, 91 malignant and 96 benign (mean size 3.2 cm) - proved by biopsy (n=12), histology (n=4), MDCT (n=108), MRI (n=44) MDCT/MRI (n=19) - in 159 patients were studied by CEUS. Two expert radiologists consensually evaluated the contrast-enhancement patterns at CEUS. For each lesion, they assessed: (a) nature (benign, malignant, not assessable), (b) specific diagnosis and (c) need for further radiological evaluation. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CEUS were calculated. RESULTS: A total of 167/187 (89.3%) lesions were correctly assessed as benign or malignant at CEUS, whereas 14/187 (7.5%) lesions remained undetermined and 6/187 (3.2%) were incorrectly assessed. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CEUS were, respectively, 89%, 89.6%, 89%, 89.6% and 89.3%. The need for further radiological evaluation decreased to 46/187 (24.6%) lesions after CEUS (p<0.001). CONCLUSIONS: In selected cases, CEUS can be considered an effective alternative to MDCT and MRI and reduce the need for further radiological workup.

Videofluorography swallow study of patients with systemic sclerosis.

PURPOSE: This study was undertaken to evaluate the role of the videofluorographic (VFG) swallow study in patients with systemic sclerosis. MATERIALS AND METHODS: Over a 23-month period, 45 women (mean age 58 years, range 27-76 years) with a known diagnosis of systemic sclerosis and a history of dysphagia underwent a dynamic and morphological study of the oral, pharyngeal and oesophageal phases of swallowing with videofluorography. All examinations were performed with a remote-controlled digital C-arm device with 16-in image intensifier, 0.6- to 1.2-mm focal spot range and maximum tube voltage of 150 kVp in fluorography and 120 kVp in fluoroscopy. Cineradiographic sequences were acquired for the swallow study with 12 images per second and matrix 512 x 512 after the ingestion of boluses of high-density (250% weight/volume) barium. The evaluation of oesophageal peristalsis was documented with digital cineradiographic sequences with six images per second in the upright and supine positions during the swallowing of barium (60% weight/volume), and the water siphon test was performed with the patient in the supine position to evaluate the presence of gastro-oesophageal reflux disease (GORD). All patients subsequently underwent laryngoscopy, endoscopy and pH monitoring, and the data thus obtained were processed and compared. RESULTS: The VFG swallow study identified alterations of epiglottal tilting associated with intraswallowing laryngeal penetration in 26 patients (57.8%), pooling of contrast agent in the valleculae and pyriform sinuses in 23 (51.1%) and radiographic signs of nonspecific hypertrophy of the lingual and/or palatine tonsils in 18 (40%). The study of the oesophageal phase revealed the presence of altered peristalsis in all patients, and in particular, 36 patients (80%) showed signs of atony. Altered oesophageal clearing mechanisms were evident in all 45 patients, sliding hiatus hernia in 43 (93%) and GORD in 44 (97%). CONCLUSIONS: Our study demonstrated that in patients with systemic sclerosis, there is no primary alteration of the oral or pharyngeal phase of swallowing. In addition, alterations of epiglottal tilting associated with laryngeal penetration of contrast agent were found to be secondary to chronic GORD. Indeed, in 40% of patients, radiographic signs were found that indicated nonspecific hypertrophy of the lingual tonsil and/or palatine tonsils and nonspecific signs of chronic pharyngeal inflammation, and GORD was identified in 93% of patients, which in 40% of cases extended to the proximal third of the oesophagus. The data obtained were confirmed in 85% of cases with pH monitoring and in all cases with laryngoscopy.

Prevalence of myocardial bridging and correlation with coronary atherosclerosis studied with 64-slice CT coronary angiography.

PURPOSE: This study aimed to assess the prevalence and characteristics of myocardial bridging in patients who underwent multislice computed tomography coronary angiography (MSCT-CA) and to evaluate the correlation between bridged coronary segments and atherosclerosis. MATERIALS AND METHODS: A total of 277 patients (mean age 60+/-11 years) we consecutively examined with 64-slice MSCT-CA for suspected or known coronary atherosclerosis were retrospectively reviewed for myocardial bridging. Segments proximal and distal to the bridging were evaluated for atherosclerotic plaque, as were the remaining coronary segments. RESULTS: Myocardial bridging was present in 82 patients (30%, mean age 59+/-12). Bridges were of variable length (<1 cm 58%; 1-2 cm 32%; >2 cm 10%) and depth (superficial 69%, intramyocardial 31%) and frequently localised in the mid-distal segment of the left anterior descending artery (95%). Myocardial bridging cannot be considered a significant risk factor for coronary atherosclerosis (odds ratio 0.49) compared with traditional cardiovascular risk factors. Coronary segments proximal to the bridge showed no atherosclerotic disease (33%), positive remodelling (27%), <50% stenosis (20%) or >50% stenosis (20%). We identified 12 noncalcified, 32 mixed and 17 calcified plaques. The distal segments were significantly less affected (p<0.0001). CONCLUSIONS: MSCT-CA is a reliable, noninvasive method that is able to depict myocardial bridging and associated atherosclerotic plaque in the proximal segments.

A rare case of pedunculated bronchial hemangioma.

We describe a rare case of pedunculated endobronchial hemangioma observed in a 60-years-old patient complaining of chronic productive cough and accessional dyspnea which had been progressively worsening over 20 years. The lesion was first noticed at fiberoptic bronchoscopy; then computed tomography scan was performed and integrated with tridimensional reconstruction techniques. Pathology showed the picture of a vascular neoplasm, compatible with capillary hemangioma. The lesion was submitted to laser-assisted endoscopic removal in order to relieve the obstruction, leading to remission of symptoms.

Utility of post mortem computed tomography in clivus fracture diagnosis. Case illustration and literature review.

Clivus fractures are usually associated with head blunt trauma due to traffic accident and falls. A 23 - year-old man died immediately after a smash-up while he was stopping on his motorcycle. Post-mortem Computed tomography (PMCT), performed before autopsy, revealed a complex basilar skull base fractures associated with brainstem and cranio-vertebral junction injuries, improving the diagnostic performance of conventional autopsy. Imaging data were re-assessable and PMCT offers the possibility to perform multiplanar and volume rendered reconstructions, increasing forensic medicine knowledge related to traumatic injuries.

Absence of the common crus in Goldenhar syndrome.

We describe an unusual labyrinthine malformation in a case of Goldenhar syndrome studied with CT and steady-state MR imaging. A single posterosuperior semicircular canal was found with no common crus formation. The malformation could not be attributed to any embryologic development. Nosologic considerations are discussed.

Bitemporal pseudohemianopia related to the "tilted disk" syndrome: CT, MR, and fundoscopic findings.

We describe a case of the "tilted-disk" syndrome in a patient with a bitemporal field depression (a pseudohemianopia). CT and MR imaging showed thinning and prolapse of the nasal sectors of the posterior walls of the globes and flattening of the temporal portion of the globes.

MR dacryocystography: comparison with dacryocystography and CT dacryocystography.

BACKGROUND AND PURPOSE: Several techniques have been used to image the nasolacrimal system, providing functional (dacryoscintigraphy) or morphologic (dacryocystography, CT dacryocystography [CTD]) information. Using gadopentetate dimeglumine-diluted solution injected into the lacrimal canaliculus or instilled into the conjunctival sac, we compared the sensitivity of MR dacryocystography (MRD) with that of CTD. METHODS: Eleven healthy volunteers and 25 patients affected by primary epiphora (21 patients) or postsurgical recurrent epiphora (four patients) underwent MRD after the topical administration of contrast media or cannulation of the lacrimal canaliculus. The MR imaging findings were compared with irrigation and CTD data. All patients underwent surgical treatment (dacryocystorhinostomy), which served as a standard of reference for confirming the MRD findings. RESULTS: The topical administration of contrast-enhanced saline solution and the injection of contrast-enhanced saline solution after cannulation were always well tolerated. In healthy volunteers, outflow of contrast media was always revealed by MRD. Eight (32%) of 25 patients with epiphora had stenosis proximal to the lacrimal sac revealed by MRD, whereas 17 (68%) of 25 showed a dilated lacrimal sac and nasolacrimal duct stenosis, as confirmed by surgical findings. The findings of MRD after the topical administration of contrast medium and MRD after cannulation of the lacrimal canaliculus were comparable with irrigation or CTD data for all patients except one. CONCLUSION: In patients with epiphora, MR imaging performed after the topical administration of diluted contrast material can reveal stenosis of the lacrimal apparatus and can be added to the standard orbital imaging protocol when lacrimal system involvement is suspected.

Static magnetic fields generated by a 0.5 T MRI unit affects in vitro expression of activation markers and interleukin release in human peripheral blood mononuclear cells (PBMC).

PURPOSE: To investigate the effects of the static magnetic field (SMF) generated by a 0.5 T superconducting MRI unit on in vitro activation marker expression and interleukin release in human peripheral blood mononuclear cell (PBMC) samples from healthy volunteers. MATERIALS AND METHODS: PBMC samples were split into two groups: exposed and sham-exposed under isothermal conditions. PBMC were exposed for 2 h at 24 degrees C to the SMF of a 0.5 T superconducting MRI unit. Immediately after exposure, both samples were cultured for 24 h at 37 degrees C with or without mitogenic stimulation by phytohaemagglutinin (PHA). PBMC were examined for expression of CD25, CD69 and CD71 by immunofluorescence analysis and supernatants were assayed to quantify IFN-gamma, TNF-alpha and IL-4 by ELISA. RESULTS: The 0.5 T SMF produced, after 24 h of culture, a reduced expression of CD69 from PBMC in vitro, that was enhanced after PHA stimulation. An increased release of IFN-gamma and IL-4 was also found, which was reduced after PHA stimulation. The release of TNF-alpha, IL-6 and IL-10 was not modified. CONCLUSIONS: The SMF generated by a 0.5 T superconducting MRI unit modified in vitro activation marker expression and interleukin release from human PBMC.

Image quality control in breast ultrasound.

Sonography is well suited for breast studies. Adequate equipment is needed to acquire high quality images because several technical factors influence ultrasound images. Thus, the use of high frequency dynamic scanning probes, the ultrasound beam focusing corrected for the near field, the adjustment of the gain and image contrast may all interfere with ultrasound beam reflection and scattering, determined by the heterogeneity of the gland parenchyma. In the last few years, a line of ultrasound equipment dedicated to this kind of application has been developed with 'small parts' transducers and frequencies ranging 10-13 MHz. These units can improve the evaluation of superficial structures and provide diagnostic results that conventional equipment cannot achieve. The higher the quality, the more a sonographic image corresponds to real anatomy. This capability depends on the different kinds of system resolution. Axial spatial resolution is the capability to resolve discrete structures along the beam axis. Pulse length is inversely proportional to frequency and thus, the higher the transducer frequency, the better the axial resolution. However, the increase in frequency reduces the depth of penetration of the ultrasound beam. The spectrum of frequencies emitted by the crystal has been recently modified in order to obtain a good trade-off between the beam resolution and its penetration. Indeed, the development of the multifrequency technology allowed to improve the near field resolution while retaining a good penetration into the distant field. Furthermore, the use of compound ceramics with a broad bandwidth helps Doppler analysis because flow studies are optimized by low frequencies, whereas two-dimensional morphologic imaging is optimized by high frequencies. Lateral spatial resolution is the capability to resolve discrete structures perpendicular or lateral to the beam axis. This parameter strictly depends on the size of the ultrasound beam section and it is optimal only in the focal area. Therefore, it improves with narrow beams. Several transducers are available in breast sonography, but the most adequate one is currently the annular transducer. The equipment should be able to detect even slight differences in acoustic impedance between the several breast tissues. This may be obtained by optimizing the dynamic range and the pre- and postprocessing setting. Apart from equipment, two other technical factors should be optimized to obtain high quality images, namely beam intensity and gain curve. A new Doppler technique has been recently introduced: power Doppler, which allows the demonstration of breast nodule vascularization with higher sensitivity than color Doppler. Finally, a rigorous examination technique is required to obtain high quality images. In the last few years, several quality assurance programs have been introduced. Dedicated phantoms are generally used. Recently, computer systems have been also developed.

Monitoring treatment response with color and power Doppler.

Color and power Doppler are now widely used to monitor treatment response because of the latest technologic advances and of the increasing use of echo-enhancing agents. The assessment of treatment response is based on the amount of necrosis obtained and changes in local vascularization indicate a successful treatment. To date, clinical experiences have mainly concerned the treatment of hepatocellular carcinomas, hyperfunctioning nodules of the thyroid and parathyroid glands and the neoadjuvant chemotherapy of breast cancer. Aim of this review is to describe the role and potentials of color and power Doppler in this field. Hepatocellular carcinomas are currently treated with surgery or percutaneous ethanol injection and/or chemoembolization. Treatment response can be monitored with color Doppler: after a successful treatment, color signals are no longer detectable on color Doppler images. Conversely, the presence of arterial signals indicates persistent viable tumor. Unfortunately, color Doppler is limited when the hepatocellular carcinoma is hypovascular, small or deep. Echo-enhancing agents may help overcome these limitations, although spiral computed tomography or dynamic magnetic resonance imaging cannot be replaced yet in the definitive assessment of tumor necrosis. Color and power Doppler are well-established tools in the study of functioning thyroid and parathyroid adenomas after percutaneous ethanol injection. Echo-enhancing agents may improve Doppler sensitivity in the detection of residual viable tissue. Other interesting applications of color and power Doppler in this field are secondary hyperparathyroidism and hyperfunctioning thyreopathies (Graves' disease) treated with mercaptoimidazole. The evaluation of systolic flow velocity in the inferior thyroid artery is more reliable than the quantitative analysis of color signals in monitoring treatment response in Graves' disease. In our experience, systolic velocity in the inferior thyroid artery decreased from 150-250 to 60-80 cm/s after medical therapy. Finally, Doppler studies have provided good results in the follow-up of breast cancers after neoadjuvant therapy. In our experience on 18 patients treated with local parenteral repeated administration of antiblastic drugs, sonography showed no more signals within the lesion in 16 patients at the end of therapy. In the remaining two cases with persistent tumor at ultrasound, some color spots were still present and histopathology confirmed residual tumor cells. In conclusion, the results of color and power Doppler are encouraging. Thus, we believe that Doppler will be increasingly used in monitoring treatment response.

Color Doppler measurement of blood flow in the inferior thyroid artery in patients with autoimmune thyroid diseases.

PURPOSE: The aim of the study is to find out whether the measurement of peak systolic velocity in the inferior thyroid artery (ITA) is a valuable parameter to differentiate autoimmune thyroid diseases (hyper-, normo- or hypofunctional) and to evaluate the efficacy of medical treatment. MATERIAL AND METHODS: The ITA of 31 patients (eight with Graves' disease, 23 with subclinical hypothyroidism) was examined with color Doppler and pulsed Doppler. The final diagnosis was obtained by cytology and by hormonal and antibodies assays. The patients were monitorized by ultrasound for a period of 8 months. RESULTS: In all the patients with Graves' disease the peak systolic velocity was always over 150 cm/s, while in other autoimmune thyroiditis the peak systolic velocity was within the normal range, and never exceeding 65 cm/s. In the first group, the measurement taken in the ITA showed also the efficacy of the pharmacological treatment earlier and more reliably than the color Doppler pattern obtained in the parenchyma. CONCLUSIONS: The color Doppler measurement of the ITA seems to be a promising technique with low-cost and easy approach. In our experience, the color Doppler of the ITA could have a clinical role in the differential diagnosis of diffuse thyroid diseases and in the follow-up of the Graves' disease during medical treatment.

Perfusion MRI in normal and abnormal pituitary gland. A preliminary study.

Perfusion MRI (magnetic resonance imaging) of the pituitary gland was performed in 20 healthy volunteers and 63 patients with various lesions involving the pituitary gland. All patients underwent sequential contrast-enhanced MRI using spoiled gradient recalled sequences with high temporal resolution (7 seconds). Four pituitary areas (pituitary stalk, posterior lobe, postero-superior, and antero-inferior adenohypophysis) were tested with a selected region of interest. Maximal contrast percentual variation was calculated. The timing of enhancement in normal patients matched perfectly with normal pituitary vascularization. Abnormal timing in pathological condition was investigated.

[Diffuse liver diseases: possibility or limitations of echography?]. / Le epatopatie diffuse: possibilità o limite dell'ecografia?

Reports on echography as a diagnostic tool in diffused liver diseases are quite numerous in the literature. As it is shown by the analysis of such reports there is no general agreement as far as including echography into the diagnostic protocol of liver diseases is concerned. Reliability of echography for the assessment of fat liver is quite ascertained, while its role in the diagnosis of acute and chronic hepatitis is still quite controversial. On the basis of personal experience, percent incidence of the most relevant echographic features is checked retrospectively and their diagnostic reliability is evaluated. The role of echography in the follow-up of sclerotic liver diseases is discussed as far as the evaluation of parenchymal structure, of associated features and of complications is concerned. Echographic data should always be completed by clinical data, laboratory tests and histological examination, during diagnosis and follow-up of patients with liver diseases.

[Diagnostic problems in the echographic demonstration of appendiceal mucocele. Description of a case]. / Problemi diagnostici nell'accertamento ecografico del mucocele appendicolare. Descrizione di un caso.

The ultrasound diagnosis of appendicular mucocele may sometimes present problems in relation to its differentiation from other space-occupying intra or extra-peritoneal lesions. An observed case is described in which the echographic pattern of the mass suggested other diagnostic possibilities.

[Biological effects of ultrasonics used in diagnosis. Experimental studies on the incorporation of tritiated thymidine into rat hepatocytes]. / Effetti biologici degli ultrasuoni impiegati a scopo diagnostico. Ricerche sperimentali sull'incorporazione di timidina tritiata in epatociti di ratto.

In order to evaluate the possible effects of diagnostically employed ultrasounds on DNA turnover, 35 Wistar strain rats were subjected to an ultrasonic frequency band of 2.25 MHz for exposure times varying from 10 to 500 seconds. Upon administration of thymidine tritiate, it was observed that capacity to absorb the substance remained largely normal in those rats exposed for up to 40 seconds, but was diminished where longer exposure times were employed.

[Does CDDP have radiosensitizing properties in the treatment of solid tumors in advanced stage?]. / Ha il CDDP proprietà radiosensibilizzanti nel trattamento di tumori solidi in stadio avanzato?

Various experimental and clinical studies have signalled the radiosensitizing properties of CDDP (Cis-dichloro diammine platinum). Twenty eight patients with advanced solid tumours were included in a pilot study incorporating classic fraction (2.00 Gy X 5 weeks) radiotherapy and weekly doses of 30 g/sq.m CDDP. A complete response was obtained in 21 patients with 11 of them NED at a mean follow-up period of 4-16 months. The toxicity of the treatment was low and no kidney damage or ototoxicity was encountered. The results obtained by the combined treatment are encouraging but a correct assessment will require a randomised trial on a bigger patient sample.