Anna Maria De Gaetano

Delayed MR imaging of hepatocellular carcinoma enhanced by Gadobenate Dimeglumine (Gd-BOPTA).

The purpose of this study was to determine the efficacy of gadobenate dimeglumine (Gd‐BOPTA)‐enhanced magnetic resonance (MR) imaging for evaluation of hepatocellular carcinoma HCC. MR images were obtained in 14 patients with 31 HCC nodules as a part of a phase III clinical trial. T1‐ and T2‐weighted images were obtained before and after iv administration of 0.1 mmol/kg of Gd‐BOPTA. Two blinded readers evaluated pre‐ and delayed postcontrast images separately for detection of tumor nodules. Quantitative measurements of signal‐to‐noise (SNR) and tumor/liver contrast‐to‐noise (CNR) ratios were also performed. A signal/intensity ratio was calculated. Tumor enhancement was correlated with histologic findings. Consensus agreement of precontrast T1‐ and T2‐weighted images revealed 23/31 HCC nodules in 14 patients; postcontrast T1‐weighted images demonstrated 24/31 HCC nodules in the same number of patients. Combining both pre‐ and postcontrast images, 27/31 lesions were detected. Four patients had four well‐differentiated HCC nodules detected only on postcontrast images, while three well‐differentiated lesions in two patients were only seen on precontrast images. Quantitative evaluation showed an SNR ratio increase in both liver parenchyma and HCC nodules, as well as a significant increase in the absolute CNR ratio on postcontrast T1‐weighted gradient‐recalled images (P < 0.05). Well‐differentiated HCC lesions showed a greater enhancement than poorly differentiated HCC lesions. J. Magn. Reson. Imaging 1999;9:704–710.

Role of PET/CT in the functional imaging of endocrine pancreatic tumors

Endocrine pancreatic tumors (EPTs) are a heterogeneous group of neoplasms with variable clinical and biological features and prognosis, ranging from very slow-growing tumors to highly aggressive and very malignant ones. As other neuroendocrine tumors, EPTs are characterized by the presence of neuroamine uptake mechanisms and/or peptide receptors at the cell membrane and these features constitute the basis of the clinical use of specific radiolabeled ligands, both for imaging and therapy. The more widespread use of hybrid machines, i.e., positron emission tomography/computed tomography (PET/CT), allows to perform imaging with high resolution and high diagnostic accuracy especially for small lesions, and to correlate anatomic location with function. The recent WHO recommendations for classification and prognostic factors help the selection of tracers likely to show a positive image on PET; therefore, tracers exploiting specific metabolic patterns (18F-DOPA and 11C-5-HTP) or specific receptor expression (68Ga-DOTA-peptides) are suited to well-differentiated tumors, while the use of 18F-FDG is preferred for poorly-differentiated neoplasms with high proliferative activity and loss of neuroendocrine features. In differentiated EPTs, 11C-5-HTP performs better than 18F-DOPA even though its use is hampered by its complex production and limited availability and experience; 68Ga-peptides are indicated for all type of gastroenteropancreatic (GEP) neuroendocrine tumors, regardless of their functional activity. In addition, 68Ga-DOTA-peptides play a distinctive role in planning peptide receptor radionuclide therapy.

imaging of peritoneal carcinomatosis with FDG PET-CT: diagnostic patterns, case examples and pitfalls

Early diagnosis of peritoneal spread in malignant disease is essential to prevent unnecessary laparotomies and to select the patients in whom complete cytoreduction is feasible. Although anatomic imaging is the mainstay for evaluating peritoneal seeding, small neoplastic implants can be difficult to detect with CT and MR imaging. FDG PET-CT has the potential to improve detection of peritoneal metastases as lesion conspicuity is high at PET due to low background activity and fused PET-CT offers the combined benefits of anatomic and functional imaging. Correlation of uptake modalities with the pathogenesis of intraperitoneal spread of malignancies, provides a rational system of analysis and is essential to define disease. Distinct patterns appear to predict the presence of either nodular or diffuse peritoneal pathology. Main pitfalls are related to normal physiologic activity in bowel loops and blood vessels or focal retained activity in ureters and urinary bladder. PET-CT is most suitable in patients with high tumor markers and negative or uncertain conventional imaging data and in selecting patients for complete cytoreduction. FDG PET-CT adds to conventional imaging in the detection and staging of peritoneal carcinomatosis and is a useful diagnostic tool in monitoring response to therapy and in long term follow-up.

USEFULNESS OF THE COMBINATION OF ULTRASONOGRAPHY AND 99MTC-SESTAMIBI SCINTIGRAPHY IN THE PREOPERATIVE EVALUATION OF UREMIC SECONDARY HYPERPARATHYROIDISM

The usefulness of the combination of technetium‐99m‐methoxyisobutylisonitrile (99mTc‐MIBI) parathyroid scintigraphy and ultrasonography to detect parathyroid glands (PTGs) in secondary hyperparathyroidism (SHPT) is still controversial.

The accuracy of voiding urosonography in detecting vesico-ureteral reflux: a summary of existing data

Abstract. The primary objective of this review was to assess the diagnostic accuracy of voiding urosonography (VUS) in detecting reflux (VUR). As a secondary objective, the reported technical suggestions and diagnostic mistakes were shown to improve the examination protocol and provide the most accurate results. Using a Medline Database search, the published articles comparing the grey-scale (GS) or colour-Doppler (CD) VUS with voiding cystourethrography (VCUG) as the gold standard were selected. Articles were excluded when data were not sufficient to construct 2×2 tables or when the gold standard was different from VCUG. For the analyses of diagnostic accuracy values, 95% confidence intervals were given. Agreements in the results of GSVUS and VCUG and in those of CDVUS and VCUG were determined by Kappa statistics. GSVUS and CDVUS were compared for diagnostic accuracy by the McNemar test. Results showed that the range of GSVUS sensitivity and specificity in detecting VUR was 69%–100% and 86%–97%, respectively. The agreement between GSVUS and VCUG diagnoses ranged from 90% to 97% (K score range 0.61–0.92; P<0.001). The range of CDVUS sensitivity and specificity in detecting VUR was 93%–100% and 86%–93%, respectively. The agreement between CDVUS and VCUG diagnoses ranged from 89% to 96% (K score range 0.77–0.91; P<0.001). One study comparing both VUS modalities with VCUG in the same group of patients, showed that the diagnostic accuracy of CDVUS was significantly higher than that of GSVUS (96% versus 90% of cases correctly classified; McNemar chi squared =4; P<0.05). Conclusion: the existing data indicate that false-negative voiding urosonographic diagnoses (8%–31%) and underestimated reflux grading cases using the same technique are related to anatomical conditions, patient cooperation and contrast medium administration. False-positive (3%–14%) and overestimated reflux grading cases using voiding urosonography could be correctly assessed cases. The intermittent nature of vesico-ureteral reflux is better detected by a technique employing a prolonged observation time, such as voiding urosonography. This might question the current role of voiding cystourethrography in the investigation of reflux.

Clinical applications of 18 F-FDG PET in the management of hepatobiliary and pancreatic tumors

The assessment of hepatobiliary and pancreatic tumors is commonly achieved by ultrasound, computed tomography (CT), and magnetic resonance. The 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) detects increased glucose metabolism associated with neoplastic lesions, provides high accuracy in most cancer imaging applications and is now widely used in clinical practice. However, PET is not always useful and accurate knowledge of appropriate indications is essential for a proper clinical management. 18F-FDG is transported into cells and phosphorylated by the enzyme hexokinase to 18F-FDG-6-phosphate, which cannot proceed down the glycolytic pathway and therefore is accumulated in the malignant tissue. PET allows accurate quantification of FDG uptake in tissue, and previous studies have demonstrated that standardized uptake values provide highly reproducible parameters of tumor glucose use (Weber et al., J Nucl Med 40:1771–1777, 1999). The recent development and diffusion of hybrid PET–CT scanners allows functional and anatomic data to be obtained in a single examination, improving lesion localization and resulting in significant diagnostic improvement (Wahl, J Nucl Med 45:82S–95S, 2004). Moreover, CT can be performed diagnostically with the use of intravenous and oral contrast and simultaneous PET–contrast-enhanced CT scanning appears to be an efficient method in cancer evaluation. However, in most centers, a low-dose CT is routinely performed without contrast media infusion.Proper patient preparation, scanning protocol, combined assessment of PET and CT data, and the evaluation of conventional imaging findings are essential to define disease and to avoid diagnostic pitfalls. The role of PET and PET–CT in malignancies of the liver, biliary tract, and pancreas is here reviewed; normal patterns, representative cases, and common pitfalls are also presented.

Imaging of gynecologic malignancies with FDG PET-CT: case examples, physiolocic activity, and pitfalls

The utilization of 2-[fluorine 18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in combination with computed tomography (CT) in the assessment of gynecologic malignancies has been rapidly growing in recent years; however, its role in clinical practice has yet to be established. A number of pitfalls are commonly encountered, including normal physiologic activity in bowel loops and blood vessels, or focal retained activity in ureters and urinary bladder. Increased uptake has also been reported in many benign pelvic processes and in premenopausal patients; endometrial activity changes cyclically, whereas increased ovarian uptake may be functional. FDG PET–CT has an emerging role in staging nodal disease and in the evaluation of local recurrence or peritoneal spread of gynecologic malignancies and is also useful in monitoring response to therapy and in long-term follow-up. FDG PET–CT is most suitable in patients with high tumor markers and negative or uncertain conventional imaging data. Patient preparation, proper scanning protocol, combined assessment of PET and CT data, and the evaluation of conventional imaging findings are essential to define disease and to avoid diagnostic pitfalls.

A phase II study of sunitinib in advanced hepatocellular carcinoma

BACKGROUND In 2007, sorafenib was the first drug able to improve overall survival in patients with advanced hepatocellular carcinoma. AIM In 2005 we designed a phase II study to assess safety and efficacy of sunitinib. METHODS This is a single arm, open-label, single-centre phase II trial. Eligibility criteria were advanced hepatocellular carcinoma; no prior chemotherapy, performance status 0-1; and Child≤B8. The treatment schedule was 50mg each day orally, 4 weeks on, 2 weeks off. RESULTS Between 10/2007 and 10/2010, 34 patients were enrolled. A significant worsening of liver functional reserve after sunitinib was observed. Grade 3/4 adverse effects occurred in 80% of patients and included fatigue (47%), nausea (15%), liver failure (15%), encephalopathy (12%) and upper gastrointestinal bleeding (12%). Six patients (18%) died within 60 days of enrolment. A partial response was observed in 4 patients (12%). Median time to tumour progression was 2.8 months and median overall survival was 5.8 months. CONCLUSION A dose of 50mg/d induces a high rate of severe adverse events. Toxicity remains a key concern also at the dose of 37.5mg/d. However, sunitinib is able to induce a prolonged response in some patients. Positron Emission Tomography/Computed Tomography scans may select good responders.

Radiofrequency ablation plus drug-eluting beads transcatheter arterial chemoembolization for the treatment of single large hepatocellular carcinoma

BACKGROUND Our aim was to evaluate the effectiveness of the single-step combined therapy with radiofrequency ablation and drug-eluting beads transarterial chemoembolization in single hepatocellular carcinoma (HCC) larger than 3cm. Secondary aim was to compare the results with those obtained in a matched population treated with drug-eluting beads transarterial chemoembolization alone. METHODS 40 consecutive cirrhotic patients with single HCC were prospectively enrolled and treated. Twenty-three patients had tumours between 3 and 5cm (Group A), and 17 larger than 5cm (Group B). Twenty cirrhotic patients with single HCC treated only with chemoembolization formed the control group. RESULTS Complete response at 1 month was achieved in 32/40 tumours (80%). During follow-up, complete response was maintained in 25 patients (25/40, 62.5%), and this rate was higher in Group A (69.6% vs 53%, p=0.008). The group treated with combined therapy showed a significantly lower 2-year recurrence (48.1% vs 78.2%, p<0.001) and significantly higher survival (91.1% vs 60.6%, p=0.004) than the group treated with chemoembolization alone. CONCLUSIONS Balloon-occluded-radiofrequency ablation plus drug-eluting beads transarterial chemoembolization is an effective treatment of HCC larger than 3cm not amenable to surgical resection, providing better results than transarterial chemoembolization alone. The best results are achieved in tumours up to 5cm.

Ultrasound Patterns of Parathyroid Glands in Chronic Hemodialysis Patients with Secondary Hyperparathyroidism

Background: The role ofparathyroid glands (PTG) ultrasonography (US) in hemodialysis patients with secondary hyperparathyroidism (SHPT) is still controversial. The present study aimed at evaluating the relationship between US findings and SHPT degree as well as therapeutic outcome. Methods: Twenty hemodialysis patients with moderate SHPT and 15 with severe SHPT underwent US to assess the PTG number, maximum longitudinal diameter (MLD), structural (1 – hypoechoic, 2 – slight heterogeneous, 3 – high heterogeneous, 4 – nodular) and vascular patterns (1 – slight, 2 – medium and 3 – high). Results: PTG number, MLD and US patterns were correlated with iPTH levels. MLD of patients with moderate or severe SHPT was 7.2 ± 2.3 and 15 ± 5.1 mm (p < 0.001). Most patients with moderate SHPT showed a single PTG with an MLD <9 mm associated with 1–2 structural and vascular pattern, whereas patients with severe SHPT exhibited more than one PTG with MLD >9 mm and 3–4 structural and vascular patterns. Thirteen patients were responders to treatment and 22 nonresponders. In nonresponders, a higher number of PTG was observed as well as higher echostructural and vascular patterns. In 14 patients who underwent parathyroidectomy, no differences were found between PTG US MLD and pathology diameter. All PTG with evidence of 3–4 structural and vascular score at ultrasound showed nodular hyperplasia at pathological examination. Conclusions: The adopted classification of US findings is correlated with SHPT degree and therapeutic outcome and might be an adjunctive predictive method useful to assess the SHPT severity and to plan the therapeutic strategy.