A. Rotondo

Intrarectal ultrasound and computed tomography in the pre- and postoperative assessment of patients with rectal cancer

The ability of intrarectal ultrasound to recognize the local extent of disease was investigated in 23 patients with histologically proven adenocarcinoma of the lower two-thirds of the rectum before operation. Two probes, 12 cm long, working at a frequency of 3·5 and 7·5 MHz, were used. The results were compared with those of pre-operative computed tomography (CT) and with the pathological report of the resected specimens. Sonography correctly staged 20 of 23 tumours with two false negatives and one false positive, while CT correctly staged 19 of 23 tumours with two false negatives and two false positives. The results of ultrasound were found to be as accurate as those of CT; the low cost and simple use of ultrasound makes it preferable in the pre-operative assessment of the depth of invasion of rectal cancer. In addition, intrarectal ultrasound was routinely performed in 42 patients, operated on for rectal cancer by means of sphincter-saving procedures, at variable intervals in the first 2 years postoperatively. Eight local recurrences were recognized and confirmed by CT. Based on the low cost, reliability and simple use, intrarectal ultrasound is proposed as first examination for local recurrence detection in the follow-up of patients with low anterior resection for rectal cancer.

Ischemia and infarction of the small bowel and colon: spectrum of imaging findings

Mesenteric ischemia presents as an abdominal emergency due to decreased intestinal blood flow secondary to mesenteric arterial vascular hypoperfusion, occlusion, or impaired venous drainage [1]. The small bowel or colon may be involved. Distinction between intestinal ischemia and infarction sometimes is not considered adequately in the interpretative process: the ischemia may be a transient and a totally reversible event, whereas infarction may be one of the possible consequences that requires surgical or interventional management. Despite continuing advances in imaging and surgical techniques, early detection of intestinal ischemia before infarction develops remains difficult [2]. Early diagnosis is important to improve survival rates [2, 3]; in most cases of late or missed diagnosis, mortality rate from intestinal infarction is very high, from 60% to 90% [4–6]. Prognosis of an ischemic intestinal insult depends upon clinical factors, such as its acuteness, duration and severity, the presence of collateral vascular circulation, the response of the mesenteric vascular branches and intestinal wall to the injury [7], extent of intestinal involvement, and the timeliness of diagnosis and intervention. From a phase in which the intestinal vascular injury may be suspected and the imaging findings of ischemia noted, the severity of mural damage may proceed rapidly to infarction with dire consequences. Differences in bowel wall findings may be appreciable between small bowel arterial and venous infarctions [8–10]. Radiologic descriptions of intestinal ischemia and infarction reported in the literature are rich [10–13] but not pathognomonic. Currently, there is no report of a direct correlation between bowel wall findings and a confirmed diagnosis of ischemia or infarction. Most literature on this topic is characterized by nonhomogeneous material and methodology of study. Some parameters regarding the timing of imaging in which studies are performed, intravenous and/or oral contrast medium administration, dynamics of the acute vascular injury, and the different etiologies (superior or inferior venous or arterial mesenteric vessels, occlusive or nonocclusive event) are sometimes difficult to summarize in a comparative classification. However, diagnostic imaging may play a pivotal role in the detection of the degree and severity of intestinal ischemia and assessment for evidence of infarction. In the following sections, imaging findings (wall thickness and enhancement, caliber of intestinal loops, presence of air-fluid levels, intestinal peristalsis, mesenteric arterial and venous vessel viabilities, mural and/or portal/mesenteric pneumatosis) from different method of study (abdominal plain film, sonography [US], and computed tomography [CT]) will be correlated to various phases of intestinal changes from ischemia and infarction due to mesenteric vessels hypoperfusion or occlusion based on experience in our institutions.

Low back pain and sciatica: treatment with intradiscal-intraforaminal O(2)-O (3) injection. Our experience.

PurposeThis paper describes discolysis by intradiscal, periganglionic and periradicular oxygen-ozone (O2-O3) injection, a minimally invasive percutaneous technique for the treatment of lumbar disk herniation.Materials and methodsFrom June 2000 to December 2006, we performed O2-O3 chemonucleolysis procedures in 2,900 patients affected by lumbar disk herniation. Patients were selected on the basis of clinical, psychological, neurological and neuroradiological criteria. Exclusion criteria were extruded hernia and/or free disc fragments, hyperalgesic-paralysing sciatica and progressive neurological impairment of the affected limb. All percutaneous treatments were performed under computed tomography (CT) guidance. All patients were evaluated after 1 month, and those showing only partial success were scheduled for a second treatment session.ResultsResults were evaluated with the modified MacNab classification, the visual analogue scale and the Oswestry Disability Index at 6 and 12 months. Success rates were 75%–80% for soft disc herniation, 70% for multiple-disc herniations and 55% for failed back surgery syndrome. None of the patients suffered early or late neurological or infectious complications.ConclusionsAccording to our data, minimally invasive percutaneous treatment by intradiscal, periradicular or periganglionic O2-O3 infiltration is a valuable and competitive technique that provides excellent results at low cost and without complications.RiassuntoObiettivoIllustrare la tecnica mini-invasiva percutanea di infiltrazione di ossigeno-ozono (chemiodiscolisi con miscela di O2-O3) intradiscale, perigangliare e periradicolare per il trattamento delle ernie del disco lombari.Materiali e metodiDal giugno 2000 al dicembre 2006 sono state eseguite 2900 procedure di infiltrazione di O2-O3 in pazienti affetti da ernia discale lombare. Tutti i pazienti sono stati selezionati secondo criteri clinici, psicologici, neurologici e neuroradiologici. I criteri di esclusione sono stati: ernia discale espulsa e/o frammento erniario libero, grave deficit motorio dell’arto e/o disturbi sfinterici, sciatalgia iperalgica, deficit neurologico progressivo dell’arto interessato. La tecnica percutanea è stata sempre eseguita sotto guida TC. Tutti i pazienti sono stati valutati a distanza di un mese dal primo trattamento e sottoposti a un secondo trattamento percutaneo in caso di successo parziale.RisultatiI risultati sono stati valutati secondo la scala di “Mac Nab modificata”, secondo la “Visual Analogyc Scale” (VAS) e “Oswestry Disability Scale” (ODS) a sei e dodici mesi con un successo variabile tra il 75% e l’80% per le ernie discali molli; 70% per le ernie discali multiple e 55% per la sindrome da fallimento chirurgico (FBSS). Non è stata riportata nessuna complicanza neurologica o infettiva nel breve o lungo follow-up.ConclusioniSecondo la nostra casistica, il trattamento percutaneo mini-invasivo con infiltrazione di O2-O3 intradiscale e periradicolare risulta essere un’alternativa valida e competitiva rispetto alle altre tecniche percutanee garantendo un ottimo risultato terapeutico in termini percentuali, a basso costo, facilmente ripetibile e in assenza di complicanze.

Lipomatous lesions of the head and neck region: imaging findings in comparison with histological type

PurposeAim of the study is to demonstrate the main role of magnetic resonance imaging in the identification and characterization of lipomatous lesions of the head and neck.Materials and methodsCT and MRI findings of 78 patients (43 male, 35 female) aged 12–80 (mean 47.5) years surgically treated for lipomatous lesions of the head and neck region between January 1995 and June 2005 were retrospectively analysed and correlated with the histological results.ResultsOn CT images, lipomas and fibrolipomas appeared as smooth (38/50 cases) or lobulated (12/50 cases) well-defined masses associated with moderate displacement of surrounding tissues; tumours had high signal intensity on MR T1-weighted images, with relative decreasing signal on T2-weighted images. Infiltrating lipomas appeared as expansile ill-defined masses with heterogeneous signal. Angiolipomas showed a characteristic contrast enhancement on both CT and MRI. In one case of sialolipoma, the lesion appeared markedly heterogeneous in signal. MR and CT images of Madelung’s disease showed multiple symmetrical lipomatous masses involving the neck region. Intraosseous fatty lesions appeared as well-defined hypodense masses sometimes associated with cortical expansion and disruption.ConclusionsBoth CT and MRI exams are useful for detecting lipomatous lesions. MRI, however, is more accurate in the evaluation of their extent and in the characterisation of uncommon lipomatous lesions of the head and neck, and intravenous administration of gadolinium better depicts the margins of the tumour and its vascularisation.RiassuntoObiettivoLo scopo del lavoro è dimostrare il ruolo primario della risonanza magnetica nell’identificazione e nella caratterizzazione dei lipomi della regione testa-collo.Materiali e metodiGli esami di tomografia computerizzata e risonanza magnetica di 78 pazienti (43 M, 35 F) di età compresa tra i 12 e gli 80 anni (media: 47,5), sottoposti ad intervento chirurgico per l’asportazione di lipomi del distretto testa-collo tra gennaio 1995 e giugno del 2005, sono stati valutati retrospettivamente e correlati successivamente ai risultati dellesame istologico.RisultatiNelle immagini di tomografia computerizzata i lipomi ed i fibrolipomi appaiono come masse ben definite con margini lisci (38/50 casi) o lobulati (12/50 casi) associate, con modesta dislocazione dei tessuti circostanti; le lesioni appaiono iperintense nelle immagini di risonanza magnetica ottenute con sequenze T1-pesate con riduzione proporzionale del segnale nelle immagini T2-pesate. I lipomi infiltranti appaiono come masse espansive scarsamente definite e dotate di segnale eterogeneo. Le immagini di tomografia computerizzata e di risonanza magnetica della malattia di Madelung mostrano lesioni multiple e simmetriche nel distretto testa-collo. Le lesioni intraossee appaiono come aree ipodense ben definite talora associate ad espansione e distruzione della corticale.ConclusioniLa tomografia computerizzata e la risonanza magnetica sono entrambe utili per la diagnosi dei lipomi; la risonanza magnetica, tuttavia, costituisce la tecnica più leaccurata nella valutazione della loro estensione e nella caratterizzazione delle lesioni rare del distretto testa-collo. La somministrazione intravenosa di mezzo di contrasto definisce con maggiore dettaglio i margini del tumore ed il suo pattern di vascolarizzazione.

Intestinal pneumatosis in adults: diagnostic and prognostic value

Intestinal pneumatosis (IP) has been traditionally associated with intestinal infarction and poor outcome in adults; recent studies have questioned its clinical value. To assess its diagnostic and prognostic significance, we have retrospectively evaluated 102 patients correlating the CT finding of gastrointestinal parietal gas with clinical data and outcome. Fifty-three patients (52%) had surgical evidence of intestinal infarction. In the remaining patients, a variety of lesions were found including intestinal obstruction, cancer, volvulus, ulcer, hernia, trauma, Crohns disease, diverticulitis, and iatrogenic causes. We observed the presence of portal vein gas (PVG) associated to IP in 25.5% of cases. In patients having both IP and PVG, intestinal infarction was observed in 69.2% of cases. In our series, overall mortality was 30.4% (31/102), and when PVG was present, it rose to 50% (13/26). In our study, IP has been observed in a broad range of lesions with very different prognosis, the most frequent of which was intestinal infarction. When associated to PVG, there was a much higher prevalence of intestinal infarct, and the prognosis was definitively worse.

Water enema transvaginal ultrasound for local staging of stenotic rectal carcinoma.

AbstractBackground: To increase the value of ultrasound in the staging of stenotic rectal carcinoma. Methods: Water enema transvaginal ultrasound (WE-TVUS) was performed in 21 consecutive female patients with severely stenotic rectal tumor (adenocarcinoma histologically proved) who were selected on the basis of clinical and double-contrast barium enema study. All patients underwent surgery, and histopathologic correlation was possible. Results: Rectal tumors were well demonstrated in all cases, and a good correlation between perirectal neoplastic infiltration, and lymph node involvement at WE-TVUS and histologic data were observed. Compared with histologic results, WE-TVUS correctly staged 19 of 21 tumors (overall accuracy = 90%); one case was understaged (T4 as T3) and one case was overstaged (T3 as T4). In the detection of lymph node involvement, the sensitivity was 50% and specificity was 78%. Conclusion: WE-TVUS is a potentially valuable technique for defining the local extension of severely stenotic rectal tumors in women.

Influenza A virus: radiological and clinical findings of patients hospitalised for pandemic H1N1 influenza.

PurposeThis paper describes the radiological and clinical findings identified in a group of patients with H1N1 influenza.Materials and methodsBetween May and mid-November 2009, 3,649 patients with suspected H1N1 influenza presented to our hospital. Our study population comprised 167 (91 male, 76 female patients, age range 11 months to 82 years; mean age 29 years) out of 1,896 patients with throat swab positive for H1N1 and clinical and laboratory findings indicative of viral influenza. All 167 patients were studied by chest X-ray (CXR), and 20 patients with positive CXR and worsening clinical condition also underwent computed tomography (CT). The following findings were evaluated on both modalities: interstitial reticulation (IR), nodules (N), ground-glass opacities (GGO), consolidations (CONS), bacterial superinfection and pulmonary complications.ResultsNinety of 167 patients had positive CXR results. Abnormalities identified on CXR, variously combined and distributed, were as follows: 53 IR, 5 N, 13 GGO, 50 CONS; the predominant combination was represented by six GGO with CONS. Of the 20 CXR-positive cases also studied by CT, 17 showed pathological findings. The abnormalities identified on CT, variously combined and distributed, were as follows: 14 IR, 2 N, 5 GGO; the predominant combination was 10 GGO with CONS. Despite the differences between the two modalities, the principle radiological findings of bacterial superinfection were tree-in-bud pattern, consolidation with air bronchogram, and pleural and pericardial effusion. Fifteen of the 20 patients studied by both CXR and chest CT showed respiratory complications with bilateral and diffuse CONS on CXR and CT. Six of 15 died: 4/6 of acute respiratory distress syndrome and 2/6 of multiple organ failure.ConclusionsOur study describes the radiological and clinical characteristics of a large population of patients affected by H1N1 influenza. CXR and chest CT identified the site and extent of the pulmonary lesions and documented signs of bacterial superinfection and pulmonary complications.RiassuntoObiettivoLo scopo di questo lavoro è stato quello di definire il quadro radiologico e clinico di un gruppo di pazienti con influenza H1N1.Materiali e metodiUn totale di 3649 pazienti con sospetta H1N1 si sono presentati al nostro presidio ospedaliero tra maggio 2009 e metà novembre 2009. Centosessantasette su 1896 casi risultati positivi al tampone faringeo per H1N1 (91 M, 76 F, range età 11 mesi-82 anni, età media 29 anni), con alterazioni clinico-laboratoristiche di influenza virale, hanno costituito la popolazione del nostro studio. Tutti i 167 pazienti hanno eseguito radiografia (Rx) del torace; per le più gravi condizioni cliniche, 20 casi positivi alla Rx del torace hanno effettuato tomografia computerizzata (TC) del torace. Abbiamo identificato in ambedue le metodiche: reticolazione interstiziale (RI), noduli (N), opacità ground glass (OGG), consolidamenti (CM), segni di sovrainfezione batterica e complicanze.RisultatiNovanta su 167 casi mostravano reperti radiografici positivi. Le lesioni polmonari identificate alla Rx, variamente associate e distribuite, sono state: 53 RI, 5 N, 13 OGG, 50 CM; 6 OGG con CM rappresentavano l’associazione predominante. Dei 20 pazienti positivi alla Rx del torace e sottoposti ad esame TC, 17 mostravano reperti TC positivi. Le lesioni polmonari identificate alla TC, variamente associate e distribuite, sono state: 14 RI, 2 N, 5 OGG; 10 OGG con CM rappresentavano l’associazione predominante. Sebbene differentemente identificati in Rx e TC, i segni di sovrainfezione batterica più frequenti sono stati tree-in-bud, CM con broncogramma aereo, versamento pleurico e pericardico. Dei 20 pazienti studiati con Rx e TC, 15 hanno presentato complicanze respiratorie con un quadro Rx e TC di OGG e CM diffusi e bilaterali. Sei/15 sono deceduti: 4/6 per acute respiratory distress syndrome (ARDS), 2/6 per multiple organ failure (MOF).ConclusioniIl nostro studio ha delineato le caratteristiche radiologiche e cliniche di un’ampia popolazione di pazienti con influenza H1N1. La Rx e la TC del torace hanno identificato sede ed estensione delle lesioni polmonari, documentando i segni di sovrainfezione batterica e le complicanze polmonari.

Involvement of Proteasome and Macrophages M2 in the Protection Afforded by Telmisartan against the Acute Myocardial Infarction in Zucker Diabetic Fatty Rats with Metabolic Syndrome

This study investigated the involvement of proteasome and macrophages M2 in the protection afforded by telmisartan against the acute myocardial infarction in Zucker diabetic fatty (ZDF) rats with metabolic syndrome. ZDF rats were treated for three weeks with telmisartan at doses of 7 and 12 mg/kg/day. After treatment, rats were subjected to a 25 min occlusion of the left descending coronary artery followed by 2 h reperfusion (I/R). At the end of the I/R period, biochemical, immunohistochemical, and echocardiographic evaluations were done. Telmisartan treatment (7 mg/kg and 12 mg/kg) reduced the myocardial infarct size, the expression of proteasome subunits 20S and 26S, and the protein ubiquitin within the heart. The compound has led to an increased M2 macrophage phenotype within the cardiac specimens and a modification of the cardiac cytokine and chemokine profile. This was functionally translated in improved cardiac performance as evidenced by echography after 2 h reperfusion. 7 mg/kg/day telmisartan was sufficient to improve the left ventricular ejection fraction LVEF of the rat heart recorded after I/R (e.g., vehicle 38 ± 2.2%; telmisartan 54 ± 2.7%) and was sufficient to improve the diastolic function and the myocardial performance index up to values of 0.6 ± 0.01 measured after I/R.

Intermittent pericardial bleeding from cardiac trauma: computed tomography findings.

1558-2027 2011 Italian Federation of Cardiology almost 200 ml of blood in the cavity. Because the patient was haemodynamically stable, an emergency multidetector-row computed tomography (MDCT) scan was requested. Total body MDCT with a 60 s delay after intravenous contrast injection (Fig. 1a, c) showed multiple traumatic consolidations in lung, pleural effusion and an enlarged and hyperdense thymus. No bone lesions were observed. The pericardium was empty and no contrast extravasation was present. All ultrasound abdominal findings were also confirmed. At a scan 105 s later (Fig. 1b, d), a marked pericardial enhancement and enlargement emerged (arrows), suggesting sudden acute bleeding from a cardiac lesion. After MDCT, 120 ml of blood was drained from the pericardium again. Surgical exploration (Fig. 2) showed congested and haemorrhagic lung and thymus. Pericardial opening revealed blood in the cavity and only a tiny clot on the surface of the right atrium auricula covering a small wall lesion. As the clot was removed, bleeding restarted. The lesion was sutured, and no other surgical procedure