Local and distant recurrences -- a comparative study on conservative and radical surgery for breast cancer.

The treatment of breast cancer has evolved over the past 40 years. Followed by radiotherapy, conservative surgical procedures are options increasingly more preferred by surgeons and patients. This paper aims to highlight comparative aspects of local and distant recurrence in patients who had radical or conservative surgery for breast cancer. We performed a retrospective study between January, 2005 - July 2013, that included 477 breast cancer patients from the Regional Institute of Oncology Iasi, who were evaluated by imaging in the Radiology Clinic,Hospital "St. Spiridon", Iasi. We included in the study patients in curable stages 0, I and II; 248 (52 %) patients had radical surgery and 229 (48 %) patients had conservative surgery. We used the ultrasound scan, mammography, CT and MRI, that allowed diagnosis, pretherapeutic staging and diagnosing of the loco-regional and distant recurrences. Local and distant recurrences were higher in patients with conservative surgery(86 recurrences), than in patients who had radical surgery (55 recurrences). Local recurrences are more common in younger individuals and in patients treated with conservative surgery and radiotherapy, than in patients with radical mastectomy.The most common metastases are located in the bone, liver and lung.

SCORING IN ACUTE PANCREATITIS: WHEN IMAGING IS APPROPRIATE?.

Acute pancreatitis (AP) is a frequent presentation to the emergency departments with a rising incidence and a great variability in clinical severity and outcome. The aim of this review is to offer a succinct presentation on acute pancreatitis scoring systems and the use of different imaging methods in severity prediction: Ranson criteria, Glasgow criteria, Hong Kong Score, Acute Physiology and Chronic Health Evaluation II (APACHE II), computed tomography scoring systems, Bedside Index of Severity in Acute Pancreatitis (BISAP) score, Panc 3, Japanese Severity Score (JSS), Harmless Acute Pancreatitis Score (HAPS), Pancreatitis Outcome Prediction (POP), Sequential Organ Failure Assessment (SOFA). This article also describes the Revised Atlanta Classification of AP (2012) and the correlation with computed tomography.

BILATERAL BREAST CANCER: DIAGNOSIS AND PROGNOSIS.

AIM: To assess bilateral breast cancer patients, initially diagnosed with stage II unilateral breast cancer. MATERIAL AND METHODS: 113 patients with stage 0-II breast cancer diagnosed between 1983 and 2011 were assessed. Of these, 8 patients had bilateral breast cancer: 7 patients with metachronous bilateral breast cancer and 1 patient with synchronous breast cancer. Breast ultrasound, mammography, computed tomography and magnetic resonance imaging were used to diagnose recurrence, loco regional and distant metastasis. RESULTS: Age at diagnosis ranged from 37 to 59 years, with a maximum age incidence in the 4th decade (age between: 31-40 years). The average time interval between the two breast cancers was 8.125 years. The most common histological type was invasive ductal carcinoma. All eight patients with bilateral breast cancer had at least one type of recurrence/metastasis, mostly in the liver, and statistically the pleuropulmonary and liver metastases were the most frequent causes of death. CONCLUSIONS: Patients in the 4th decade diagnosed with unilateral breast cancer are at risk of developing bilateral breast cancer. In metachronous breast cancer, the time interval between the detection of the second breast cancer and death is directly proportional to the time interval between the two breast cancers. TASTASES, DEATH.

PANCREATIC CANCER CT IMAGING: COMPARISON WITH SURGERY.

AIM: To establish the best protocol for pancreatic computer tomography and criteria for staging (mainly for vascular invasion). MATERIAL AND METHODS: Our research included 49 consecutive patients with pancreatic cancer examined at the Iasi "Sf. Spiridon" Hospital between January and December 2014 with a Siemens 16 Emotion CT unit. CT protocol included no enhanced CT and pancreatic phase of the superior abdomen, portal venous phase of the abdomen and pelvis. RESULTS AND DISCUSSION: The study patients were stratified into 5 age groups and the most frequently affected by pancreatic cancer were the patients aged 60 to 79 years. For T staging the extension in the per pancreatic fat tissue, into surrounding organs (5 patients had extension in other organs) and vessels was evaluated. We determined the degree of contact between the tumor and the artery, thrombosis and deformity of the veins and we have found 8 resettable lesions, 28 tumors in stage T3 and 13 pancreatic cancers in stage T4. Thirty-three patients had lymphadenopathies and 31 of them had distant metastases. CONCLUSIONS: Our study proved that computed tomography is a good method of examination for pancreatic cancer when the right imaging protocol is used; during the pancreatic phase the arteries and the tumor are well depicted, liver metastases are best evaluated during the portal venous phase. The best criterion for arterial invasion is tumor contiguity with more than half of vessel circumference, and for vein invasion deformity or thrombosis. Comparison with surgical staging was o good backup for the radiologist and depicted several differences with imaging staging, more often understating than over staging.

Histiocytic sarcoma associated with Hodgkin's disease.

Histiocytic sarcoma is a rare malignant neoplasm. It is well-known the association of Langerhans' cell histiocytosis with Hodgkin's disease but only few cases of histiocytic sarcoma associated with Hodgkin's disease was reported. We present the case of 20-years-old female patient with Hodgkin's disease with a sternal tumor mass which was diagnosed as histiocytic sarcoma. The diagnostic was established immunohistochemically, using a large battery of antibodies (S-100, CD 68, CD 34, CD 15, CD 30, Vim, NFAP) and by electron microscopy which revealed the lack of the Birbeck granules in the malignant proliferated histiocytes.

CAUSES OF DEATH IN PATIENTS WITH STAGE 0-II BREAST CANCER.

AIM: To analyze the main causes of death in patients with stage 0-II breast cancer who undergo breast conserving surgery or radical mastectomy, and to establish the role of imaging surveillance protocols following breast cancer treatment. MATERIAL AND METHODS: We conducted a retrospective medical record review between January 2005 and December 2012, when breast cancer was the primary cause of death for 113 inpatients. All patients were admitted to the Oncology Clinic of the Iasi Regional Cancer Institute (IRCI), Romania. Patients were stratified by clinical stage 0, I and II, of which 33 (29.2%) patients were managed by breast conservation therapy and 80 (70.8%) underwent radical mastectomy. From the patient medical records all diagnostic imaging studies performed (ultrasound, radiography and computed tomography) were identified and analyzed according to a standard protocol for imaging the postoperative breast. RESULTS: Bone, liver, lung, lymph nodes and local-regional recurrence were the most common sites for metastasis, while the most frequent cause of death were metastases to the liver, pleura, lung and brain. The time interval between recurrence and death ranged from 0-24 years among patients with one type of metastasis, and decreased to 0-3 years since the last recurrence for patients with multiple metastases. CONCLUSIONS: The current imaging protocol for monitoring the postoperative breast could be optimized to improve the prognosis and quality of life in patients with stage 0-II breast cancer.

BREAST INFECTIONS: DIAGNOSIS WITH ULTRASOUND AND MAMMOGRAPHY.

AIM: Evaluation of ultrasonographic and mammographic pattern, etiology and risk factors of breast infections. MATERIAL AND METHODS: Our study included a group of 66 female patients aged 16 to 71 years, examined by ultrasound and mammography in several medical imaging services in Iasi in the interval 2008-2014; ultrasound was performed in all 66 patients and mammography in 22. RESULTS: In our study breast infections occurred mostly during breastfeeding and the most frequent causative agent was Staphylococcus aureus; ultrasound established the correct diagnosis in 63 cases and detected one or more of the following aspects in case of breast infections: edema of the fatty tissue, hypoechoic areas in the breast tissue, dilated ducts, or fluid collections. Mammography was not necessary in puerperal mastitis and was performed only in women over 40 years old; in most cases we had encountered a focal asymmetric density which had low specificity for the diagnosis of mastitis or breast abscess. CONCLUSIONS: Our study proved that ultrasound is a valuable method for the diagnosis of mastitis, especially when an abscess is suspected and established a correct diagnosis in most cases; the abscesses appear as inhomogeneous fluid collections, with poorly defined margins, posterior acoustic enhancement, no Doppler signal inside, sometimes associated with enlarged axillary lymph nodes. Mammography was not helpful for the diagnosis.

Subcutaneous metastasis--the first sign of hepatocellular carcinoma in chronic virus C hepatitis patient--Case report.

Hepatocellular carcinomas make up 90% of primary liver cancers. The association between the hepatic carcinoma and virus B and C infection has been already proven. Hepatocellular carcinoma develops, in most cases, on a background of cirrhosis and rarely in hepatitis. The case we have chosen to report distinguishes itself due to the unusual extra-hepatic metastatic location of a hepatocellular carcinoma in a patient with Chronic HCV hepatitis.

[Multiple perforated, poorly differentiated carcinomas of the small bowel]. / Carcinoame slab diferentiate sincrone perforate de intestin subtire.

The small bowel malignant tumors represent a rare pathology; in their diagnosis an important role is played by the clinical suspicion in front of non-specific symptoms. However, the therapeutic decision must not be delayed by excessive explorations, but it should be permanently adapted to the patient's condition; the operative exploration has the advantage of making an accurate diagnosis. The authors present the case of a patient admitted in emergency with the suspicion of a generalized peritonitis from a perforated peptic ulcer and who was subsequently diagnosed with multiple perforated small bowel malignant tumors. The patient's history offers data that could be interpreted in the context of the intraoperative diagnosis. This is the first reported case of multiple perforated poorly differentiated carcinomas of the small intestines.

[A case of stromal gastric tumor-uncommon clinical and pathological entity]. / Un caz de tumora stromala gastrica--raritate clinica si histopatologica.

Stromal gastric tumors represents an uncommon entity with difficult diagnosis, both preoperative and pathological. We present the case of a patient admitted for abdominal pain, with palpable tumor in epigastrium and right hypochondrium; abdominal echography, barium enema and abdominal CT-scan were not able to precise the involved organ. Operative exploration found at the level of horizontal portion of the stomach a solid tumor, which was resected, with good subsequent evolution. Pathologic diagnosis was stromal gastric tumor. We present latest news concerning diagnosis, prognostic and treatment for this type of tumor.

Computerized calculation of breast density: our experience from Arcadia Medical Imaging Center.

THE AIM OF THIS STUDY: To implement a spatial fuzzy C-means algorithm for image segmentation and breast tissue density quantification and compare it with BI-RADS breast density classes determined by radiologists. MATERIAL AND METHODS: The analysis was based on 206 mammograms performed in 111 women with various breast abnormalities. Digitized mammographic films were independently double read by radiologists certified in breast diagnosis, followed by consensus with arbitration agreement (radiological ground truth). Reporting was done using the BI-RADS mammography lexicon. Using an algorithm based on a combination of spatial fuzzy C-means clustering and binary thresholding, percent mammographic density was computed in digitized mammograms. The BI-RADS breast density readings were compared with percent breast density measurements determined by computer algorithm. RESULTS: The algorithm was found to match the BI-RADS density classification in 90% of the cases, with an excellent agreement (kappa = 0.88) between the radiological ground truth versus the algorithm breast tissue density estimates. CONCLUSIONS: Our study proposed an algorithm that can be applied both to digitized and digital mammograms, which proved to be effective in breast density estimates. The method can accurately determine the percentage density removing the human observer variability. The proposed method showed an excellent agreement with radiological ground truth.

Multifactorial analysis of local and lymph node recurrences after conservative or radical surgery for stage 0-II breast cancer.

AIM: Multifactorial analysis of local and lymph node recurrences in stage 0-II breast cancer treated by conservative or radical surgery. MATERIAL AND METHODS: In the interval January 1, 2005-July 31, 2013, 477 breast cancer patients were assessed by imaging techniques at the Radiology Clinic of Iasi "Sf. Spiridon" Hospital and Radiology Service of the Iasi Regional Cancer Institute. Of these 229 (48%) patients underwent conservative surgery and 248 (52%) patients radical surgery. RESULTS: Local recurrences were 2.8 times more frequent in conservatively vs. radically treated patients, and lymph node recurrences 2 times more frequent in patients treated conservatively. Breast tumors larger than 3 cm in diameter were at higher risk for local and distant recurrence in lymph nodes. CONCLUSIONS: Assessment in patients with local and lymph nodes recurrences of the relative risk for developing other types of recurrences (bone, pleuro pulmonary, liver, brain metastases) indicated that these are a risk factor for other types of recurrences, influencing the prognosis of patients. Local recurrences showed a higher relative risk for other types of recurrences than nodal recurrences.

Hemangioma of the parotid gland: case report.

Hemangiomas account for half of the parotid gland tumors occurring in children. After a rapid increase in the first months of life, some of them gradually regress (until complete disappearance) in a period of several years. Hemangiomas that do not regress over time, grow in size (possibly within a short period of time) or develop complications such as intralesional acute bleeding or thrombosis require aggressive therapy: intralesional corticosteroid injection, sclerotherapy. radiation therapy, laser photocoagulation. embolization, or surgical removal. We present the case of a 12-year-old boy with hemangioma of the left parotid gland diagnosed by CT scan, angio-CT with 3D reconstruction and angiography successfully treated by superselective intraarterial embolization with acrylic glue followed after 4 days by left superficial parotidectomy with facial nerve preservation.

Unmasking a young adult migratory deep venous thrombosis--case report.

Venous thromboembolism is a known complication of cancer which impacts on patient mortality and quality of life. The primary site of cancer is an important risk factor, with highest rates observed in patients with brain, pancreas, gastric, kidney, ovary and lung cancers. The extent of metastatic spread further adds to the risk. In this article, we present the case of a young patient who was diagnosed with an aggressive form of pancreatic neoplasm with secondary determinations, without any previous digestive symptoms, with the occasion of a recurrent and migratory deep venous thrombosis (DVT).

Ectopic adrenocorticotropic hormone syndrome caused by a carcinoid tumor of the thymus. A case report.

Ectopic ACTH secretion accounts for less that 10% of all causes of endogenous Cushing's syndrome. Carcinoids are rare thymic tumors, and when associated with ACTH hypersecretion display local or distant aggressive behavior. A 32-year-old woman was admitted to the Endocrinology Unit for obesity, moon face, facial hirsutism, hyperpigmentation, and secondary amenorrhea. Laboratory test confirmed the hypercortisolism and excess ACTH, while dexamethasone suppressive test was negative. Thorax computed tomography (CT) showed an antero-superior mediastinal tumor invading the pericardium and left mediastinal pleura. A complete resection through median sternotomy of the tumor, pericardium and left mediastinal pleura was performed. After a one-year symptom-free period, hypercortisolism recurred, confirmed by laboratory findings. Although no signs of local recurrence were seen on thorax CT, left internal mammary lymph nodes involvement and vertebral body metastases at C7 and LI were found. Refractory electrolyte disturbances could not be corrected resulting in severe cardiac arrhythmia and death from cardiac arrest. The reported case draws attention on the aggressiveness of ACTH-secralso due to the refractory electrolyte disturbances with fatal outcome.

[Image-guided diagnostic percutaneous puncture biopsy]. / Punctia percutana diagnostica ghidata radio-imagistic.

Percutaneous aspiration and biopsy have an increasing diagnostic role. Ultrasound and CT are the imaging methods most frequently used for guiding, but fluoroscopy and MRI are also considered. The paper reviews the indications, contraindications, method of ultrasound-guided and CT-guided punctures, and the results of needle aspiration and biopsy for cerebral, head and neck, thoracic, abdominal and musculoskeletal lesions.

[Torsion and infarction of an accessory liver lobe]. / Lob hepatic accesoriu torsionat si infarctat.

Anatomical abnormalities of the liver are extremely rare. We report a case of a 32 year old female who has admitted with acute epigastric pain and vomiting. Physical exam revealed a mobile mass in right middle abdominal quadrant. Ultrasound and contrast--enhanced CT demonstrated a heterogeneous vascular left mass. Small bowel enema shows left jejunal loops displacement. Surgical findings: twisted, congested swelling, attached by a long pedicle to the liver's third segment. Histological examination showed recent hepatic infarction.

[Thermo-necrosis in nonresectable colorectal hepatic malignant tumors. Preliminary results]. / Termonecroza metastazelor hepatice nerezecabile de origine colorectala cu vapori de apa sub presiune. Rezultate preliminare.

MATERIAL AND METHOD: We report the 19 months followup results after thermo-necrosis with steam water of non-resectable colorectal liver metastases. The studied group included 24 (18 men + 6 women) cases, aged 39-85 (mean age = 61), that were subjected to thermo-necrosis procedure between 2004-2006. Thermo-necrosis was performed per primam (1 case with non-resectable primary tumor), or either synchronous (8 cases) or at up to 53 months (15 cases) after primary tumor resection, and implied delivering of 6.7 - 87 kiloJoules to targeted lesions (for a median of 5 targets per patient liver). Concomitant with thermo-necrosis, in 8 cases some metastatic lesions were also resected (for tumor mass reduction). Followup consisted in echographic, CT, clinical and laboratory evaluation each 1-2 month. RESULTS: The thermo-necrosis procedure was completed within 3 to 20 (median = 10) minutes, and no peri-operatory deaths or complication were recorded. After procedure, the treated lesions either shrunken or were stationary under imaging explorations; increasing images marked the time to tumor progression. Tumor progression was recorded in 12 cases, time to tumor progression ranging from 1 to 14 (median = 5) months; the follow up time for the remaining 12 cases ranging 3 - 18 (median = 8) months. Nine cases died at 6-15 (median = 9) months after thermo-necrosis; for the remaining 15 cases the followup time ranged 4-19 (median= 10) months. One year survival was 61%; median survival (50%) time was 9 months. CONCLUSIONS: Thermo-necrosis with steam water of non-resectable colorectal liver metastases associate low invasiveness, good compliance, and time interval for tumor progression and survival comparable or better than other thermo-necrosis techniques, representing a promising palliative therapy in secondary liver cancer.

[MRI in the differential diagnosis of liver focal lesions]. / Irm în diagnosticul leziunilor focale hepatice.

51 patients with focal liver abnormalities at ultrasound were examined by MRI. The cases with liver metastasis of known origin submitted for staging and cholangiocarcinomas of the external bile ducts or gall bladder with liver invasion were not included in the study. Most of the examinations were performed for suspected hepatocarcinoma. MRI studies, using 2D T1 and T2 weighted FSE sequences and T1 weighted 3D SPGRE contrast enhanced sequences were able to differentiate between different kinds of benign lesions e.g. large hemangiomas or FNH or even complicated hydatic cysts from hepatocarcinoma.

[Pancreatic metastases. A case report--solitary pancreatic metastasis from a clear cell renal cell carcinoma]. / Metastaza pancreatica unica de la un carcinom renal cu celule clare prezentare de caz.

Three years after right nephrectomy for stage II (T2N0) clear cell carcinoma, a 51-year old man presented with upper digestive tract bleeding. Endoscopic examination revealed a duodenal mass. Imaging modalities showed the lesion in the head of the pancreas, with duodenal wall invasion, and raise the question of a pancreatic metastasis. The anatomopathology result of the resection specimen confirms the imaging diagnosis.