Annarita Pecchi

Gadolinium-enhanced MRI with dynamic evaluation in diagnosing the local recurrence of rectal cancer

AbstractBackground: At early stages, the diagnosis of local recurrence of rectal cancer is often difficult and magnetic resonance imaging (MRI) is currently considered the most accurate method for diagnosing recurrence. We evaluated the role of unhenhanced and gadolinium-enhanced MRI for the diagnosis of local recurrence of rectal cancer. Methods: Thirty-six patients, suspected of having a pelvic recurrence of rectal cancer, were evaluated by a high field strength MRI unit. Unenhanced spin-echo T1- and T2-weighted sequences and gadolinium-enhanced dynamic fast multiplanar spoiled gradient recalled sequences were performed in all patients. The dynamic images were re-elaborated with semiquantitative postprocessing by plotting intensity–time curves and calculating the percentage of signal increase at the end of the first postcontrast dynamic sequence. The pelvic lesions were classified as recurrent or not recurrent by applying the following diagnostic criteria: (a) morphology and signal intensity of the lesion in unenhanced sequences and (b) percentage of enhancement in dynamic enhanced sequences. Diagnosis was confirmed by computed tomography–guided needle biopsy (12 patients), surgery (four patients), clinical and imaging follow-up (20 patients). Results: The diagnosis was local recurrence in 15 patients and noncancerous lesions in 21 patients. Unenhanced MRI had 80% sensitivity and 86% specificity. Analysis of the percentage of enhancement showed 87% sensitivity and 100% specificity. Conclusion: In agreement with the literature, our results showed a high sensitivity and specificity for dynamic MRI. This technique thus can be considered an important adjunct to unenhanced MRI, especially in selected cases in which unenhanced MRI cannot rule out local recurrences. However, these results must be validated by further investigations.

Microsurgical testis-sparing surgery in small testicular masses: seven years retrospective management and results.

OBJECTIVE To retrospectively evaluate the clinical outcomes of 20 patients diagnosed with a nonpalpable or small testicular mass (2 cm) at 2 academic urological department. Testis-sparing surgery (TSS) is currently performed routinely for the management of nonpalpable testicular masses. High reliability of frozen section examination (FSE) and high-frequency ultrasound (US) and the adoption of microsurgical techniques improved safety and feasibility of this technique. METHODS From January 2004 to March 2011, 23 patients underwent microsurgical TSS. An inguinal approach was performed in 22 cases and a suprapubic incision in one bilateral case. All procedures were performed with an operating microscope, with warm ischemia in 21 cases and cold ischemia in 2 cases. Intraoperative US was performed before opening the albuginea. Mean operative time was 89 minutes. RESULTS After mass excision, FSE was performed; only 2 seminomatous tumors were identified, and the remaining masses were benign lesions. After a mean follow-up >12 months, all patients are free of disease; no hypogonadism developed. CONCLUSIONS TSS performed using an operating microscope allowed the preservation of testes for 21 patients diagnosed with small testicular and/or nonpalpable mass (<2 cm), without evidence of disease recurrence or de novo onset. This approach could be mandatory in the treatment of bilateral tumors or in solitary testis. Maintaining fertility is not the main goal of TSS because a great number of patients affected by testicular tumors are already infertile. Esthetic outcomes and sparing hormonal function are the main reasons for TSS.

Role of Magnetic Resonance Imaging in the Detection of Anastomotic Biliary Strictures After Liver Transplantation

INTRODUCTION Biliary complications after orthotopic liver transplantation (OLT) are the principal cause of morbidity and graft dysfunction, ranging in incidence from 5.8% to 30% of cases. Biliary strictures are the most frequent type of late complication. The aim of this study was to evaluate the role of magnetic resonance cholangiography (MRC) to detect biliary anastomotic strictures among patients undergone OLT with abnormal liver function tests. MATERIALS AND METHODS One hundred twenty-one of 300 patients who underwent OLT were evaluated by MRC for clinically suspected anastomotic biliary strictures. In all patients, we performed various precholangiographic sequences including T1- and T2-weighted and MRC (radial SE 2D and SS-TSE 3D). Magnetic resonance imaging findings were subdivided as absence or presence of an anastomotic stricture. Diagnostic confirmation was obtained by endoscopic retrograde cholangiography (n=32), percutaneous transhepatic cholangiography (n=21) or surgical treatment (n=18). RESULTS MRC detected 56 anastomotic biliary strictures, 53 of which were confirmed by other imaging modalities. MRC showed two false-negative cases and three false-positive cases. The sensitivity, specificity, positive and negative predictive values, and accuracy of MRC to detect biliary strictures were 96%, 96%, 95%, 97%, and 96%, respectively. CONCLUSION MRC proved to be a reliable noninvasive technique to visualize the biliary anastomosis and depict biliary strictures after OLT. MRC should be used when a biliary anastomotic stricture is suspected in an OLT patient.

Post-transplantation hepatocellular carcinoma recurrence: Patterns and relation between vascularity and differentiation degree

AIM To evaluate the relationship between hepatocellular carcinoma (HCC) vascularity and grade; to describe patterns and vascular/histopathological variations of post-transplantation recurrence. METHODS This retrospective study included 165 patients (143 men, 22 women; median age 56.8 years, range 28-70.4 years) transplanted for HCC who had a follow-up period longer than 2 mo. Pre-transplantation dynamic computed tomography or magnetic resonance examinations were retrospectively reviewed, classifying HCC imaging enhancement pattern into hypervascular and hypovascular based on presence of wash-in during arterial phase. All pathologic reports of the explanted livers were reviewed, collecting data about HCC differentiation degree. The association between imaging vascular pattern and pathological grade was estimated using the Fisher exact test. All follow-up clinical and imaging data were reviewed for evidence of recurrence. Recurrence rate was calculated and imaging features of recurrent tumor were collected, classifying early and late recurrences based on timing (< or ≥ 2 years after transplantation) and intrahepatic, extrahepatic and both intrahepatic and extrahepatic recurrences based on location. All intrahepatic recurrences were classified as hypervascular or hypovascular and the differentiation degree was collected where available. The presence of variations in imaging enhancement pattern and pathological grade between the primary tumor and the intrahepatic recurrence was evaluated and the association between imaging and histopatholgical variations was estimated by using the χ(2) test. RESULTS Of the 163 patients with imaging evidence of viable tumor, 156 (95.7%) had hypervascular and 7 (4.3%) hypovascular HCC. Among the 125 patients with evidence of viable tumor in the explanted liver, 19 (15.2%) had grade 1, 56 (44.8%) grade 2, 40 (32%) grade 3 and 4 (3.2%) grade 4 HCC, while the differentiation degree was not assessable for 6 patients (4.8%). A significant association was found between imaging vascularity and pathological grade (P = 0.035). Post-transplantation recurrence rate was 14.55% (24/165). All recurrences occurred in patients who had a hypervascular primary tumor. Three patients (12.5%) experienced late recurrence; the location of the first recurrence was extrahepatic in 14 patients (58.3%), intrahepatic in 7 patients (29.2%) and both intrahepatic and extrahepatic in 3 patients (12.5%). Two patients had a variation in imaging characteristics between the primary HCC (hypervascular) and the intrahepatic recurrent HCC (hypovascular), while 1 patient had a variation of histopathological characteristics (from moderate to poor differentiation), however no association was found between imaging and histopathological variations. CONCLUSION A correlation was found between HCC grade and vascularity; some degree of variability may exist between the primary and the recurrence imaging/histopathological characteristics, apparently not correlated.

Contrast-enhanced MRI and PET-CT in the evaluation of patients with suspected local recurrence of rectal carcinoma

PurposeThis study aimed to evaluate the role of contrastenhanced magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) in the assessment of local recurrence of rectal cancer.Materials and methodsAmong 200 patients scheduled for CT follow-up, 60 (48 low risk; 12 high risk) were selected due to CT findings suspicious for or suggestive of local recurrence. Patients underwent contrast-enhanced MRI and PET-CT within 2 weeks. Biopsy was considered the gold standard in 39 cases and follow-up at 6 and 12 months in the remaining 21.ResultsLocal recurrence was confirmed by histology in 15 cases (7 low risk; 8 high risk) and was excluded in 21 cases by long-term follow-up and in 24 by histology. Sensitivity, specificity, positive and negative predictive value and accuracy were 86.7%, 68.9%, 48.1%, 93.9% and 73.3% for contrast-enhanced MRI and 93.3%, 68.9%, 50%, 96.9% and 75% for PET-CT.ConclusionsContrast-enhanced MRI and PET-CT can help in the detection of local recurrence of rectal cancer, even though their roles in early detection remains debatable, as the value of these techniques in current surveillance protocols is still to be defined.RiassuntoObiettivoScopo del presente lavoro è stato valutare i risultati di risonanza magnetica (RM) e tomografia ad emissione di positroni (PET)-tomografia computerizzata (TC) nella diagnosi di recidiva locale di carcinoma rettale.Materiali e metodiNel gruppo di 200 pazienti sottoposti a follow-up con TC dopo trattamento chirurgico di carcinoma rettale sono stati selezionati 60 pazienti (48 basso rischio; 12 alto rischio) con quadro TC di sospetta o di probabile recidiva locale che sono quindi sono stati sottoposti, entro 2 settimane, a RM con mezzo di contrasto paramagnetico e a PET-TC. La conferma diagnostica è stata ottenuta in 39 casi con esame istologico e con follow-up a 6 e 12 mesi nei restanti 21 casi.RisultatiLa presenza di recidiva è stata evidenziata dalla biopsia in 15 casi (7 basso rischio, 8 alto rischio) ed esclusa in 21 casi dal follow-up e in 24 dall’istologia. Sensibilità, specificità, valore predittivo positivo (VPP), valore predittivo negativo (VPN) ed accuratezza diagnostica sono risultati rispettivamente: 86,7%, 68,9%, 48,1%, 93,9% e 73,3% per la RM; 93,3%, 68,9%, 50%, 96,9% e 75% per la PET-CT.ConclusioniLa RM e la PET-TC possono contribuire alla detection di recidiva, anche se il loro ruolo nella diagnosi precoce rimane dibattuto dato che l’utilità di tali metodiche nei correnti protocolli di sorveglianza è tuttora da definire.

Role of magnetic resonance cholangiography in biliary complications of orthotopic liver transplantation

PurposeThe aim of this study was to evaluate the role of magnetic resonance cholangiography (MRC) in the detection of biliary complications following orthotopic liver transplantation (OLT).Materials and methodsSeventy-eight transplant patients with clinically suspected biliary complications were evaluated with 1.5-T magnetic resonance imaging (MRI) using a surface coil. All patients were imaged with the following sequences: axial T1-weighted and axial and coronal T2-weighted, 2D spin echo (SE) breath-hold radial cholangiography, and coronal 3D single-shot turbo spin echo (SS-TSE) with respiratory triggering. Patients with negative MRI underwent clinical and sonographic followup. When biliary complications were present, diagnostic confirmation was obtained by endoscopic retrograde cholangiopancreatography (ERCP) (n=13), percutaneous transhepatic cholangiography (PTC) (n=20), ultrasonography (n=10) or computed tomography (CT) (n=2). In 11 cases, surgical confirmation was also obtained.ResultsMRC detected biliary complications in 44/78 patients, in particular, 42 biliary strictures (37 anastomotic and five intrahepatic), 40 of which were confirmed by other imaging modalities. In 25/37 cases of anastomotic stricture, preanastomotic dilatation of the biliary tract was also demonstrated. Other MRC-detected biliary complications were biliary sludge (n=4), biloma (n=5), and biliary stones (n=3). In four cases, PTC revealed biliary complications that had not been detected with MRC (false negative results). In two cases, MRC showed unconfirmed strictures of the intrahepatic ducts and biliodigestive anastomosis (false positive results). The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy of MRC were 93.5%, 94.4%, 96.7%, 89.5% and 93.9%, respectively.ConclusionsOur results confirm that MRC is a reliable technique for depicting biliary anastomoses and detecting biliary complications after OLT. The high diagnostic accuracy of MRC indicates that this examination should be routinely employed in all OLT patients with clinically suspected biliary complications.RiassuntoObiettivoScopo del nostro lavoro è stato valutare il ruolo della colangio-risonanza magnetica (RM) nell’identificazione delle complicanze biliari nel paziente sottoposto a trapianto ortotopico di fegato (OLT).Materiali e metodiSettantotto pazienti sottoposti a OLT con sospetto clinico di complicanza biliare sono stati sottoposti a studio RM del fegato mediante magnete a 1,5 T con bobina di superficie. In tutti i pazienti sono state eseguite sequenze assiale T1 pesate, assiali e coronali T2 pesate, sequenza colangiografica radiale 2D-spin echo (SE) in apnea e sequenza 3D-turbo spin echo (TSE) single shot (SS) sul piano coronale triggerata con il respiro. Quando l’esame RM è risultato negativo i pazienti sono stati sottoposti a follow-up clinico-ecografico. Le complicanze identificate all’esame RM sono state confermate mediante colangiografia retrogada endoscopica (13 casi), colangiografia percutanea transepatica (20 casi), ecografia (10 casi), tomografia computerizzata (TC) (2 casi). In 11 casi si è avuta anche conferma chirurgica.RisultatiIn 44/78 pazienti l’esame RM ha evidenziato una complicanza chirurgica, in particolare 42 stenosi biliari (37 anastomotiche e 5 intraepatiche), 40 delle quali confermate dalle altre metodiche. In 25/37 casi di stenosi dell’anastomosi la RM ha evidenziato anche la presenza di dilatazione della via biliare pre-anastomotica. Le altre complicanze biliari identificate alla colangio-RM sono state: fango e detriti biliari (4 casi), bilomi (5 casi) e calcoli biliari (3 casi). In 4 casi la colangiografia trans epatica ha mostrato la presenza di complicanze biliari non individuate alla RM. In 2 casi la RM ha evidenziato stenosi intraepatiche e dell’anastomosi bilio-digestiva non confermate dalle altre metodiche. Sensibilità, specificità, valore predittivo positivo e negativo della colangio-RM sono stati: 93,5%, 94,4%, 96,7%, 89,5% and 93,9%.ConclusioniI nostri risultati hanno confermato che la colangio-RM è una metodica ottimale per la visualizzazione della sede di anastomosi e per identificare eventuali complicanze biliari nel paziente sottoposto a OLT. Sulla base dell’accuratezza diagnostica riscontrata la colangio-RM dovrebbe essere considerata metodica di impiego routinario nel paziente trapiantato con sospetto clinico di complicanza biliare.

Radiologic imaging of the transplanted bowel

BackgroundThe radiologic evaluation of the transplanted bowel is largely unknown and rather complex because it involves several techniques that depend on indications and times that have not been fully defined.MethodsFrom December 2000 to November 2002 in the Section of Radiology I of the University of Modena and Reggio Emilia (Modena, Italy), 11 patients with transplanted bowel were studied with different methods: traditional radiologic evaluation with contrast agent (all patients), evaluation of transit time with radiopaque markers (five patients), ultrasonographic (US) evaluation of the intestinal wall and Doppler US of the vascular axes (five patients), computed tomographic (CT) evaluation (all patients), and magnetic resonance (MR) evaluation of the bowel and the vascular axes (five patients). Traditional contrast examination enabled evaluation of the gastroesophageal transit and cardia functionality; anatomy and integrity of the anastomoses (proximal and distal); time of gastric emptying; morphology, tone, and kinesis of the transplanted small bowel loops and time of global transit. The study of transit with radiopaque markers was carried out in five patients to define the time of transit through the entire transplanted bowel, confirm recovery of intestinal motility, and identify possible abnormalities. The US examination was carried out in five patients to evaluate the morphology, thickness, and echo structural features of the intestinal loops. Color Doppler was performed to visualize the superior mesenteric artery and a wall arteriole of the sampled loop. CT examination was performed 2 to 4 weeks after surgery to evaluate the anatomy of the transplanted organs, arterial and venous anastomoses in case of complications identified with other methods or suspected, and periodically in the follow-up of patients who underwent transplantation due to Gardner syndrome. The protocol for MR evaluation of the bowel included coronal single-shot fast spin-echo T2-weighted sequences, axial and/or sagittal single-shot fast spin-echo T2-weighted sequences, coronal fast multiplanar spoiled gradient-echo (FMP- SPGR) sequences, coronal FMPSPGR sequences with and without administration of intravenous paramagnetic contrast agent, and axial or sagittal FMPSPGR fat-saturated sequences performed after dynamic gadolinium administration.Results and conclusionThe study of transit with radiopaque markers was useful in patients with chronic intestinal pseudo-obstruction because it identified recovery and normalization of motility. Traditional contrast examination of the gastrointestinal tract continues to play an important role in transplanted patients because it is a simple examination that allows evaluation of the graft anatomy and recovery of motility of the residual native bowel and the transplanted loops. Moreover, it plays a crucial role in early detection of major postoperative complications such as intestinal obstruction, perforation, fistulas, and anastomotic complications (stenosis and dehiscence). CT examination is crucial for the detection of fluid collections, abscesses, and fistulas because it can serve as a guide of drainage and during follow-up of patients with Gardner syndrome can be used to investigate all possible sites in which desmoids might arise in addition to their relation to the graft. Because patients with transplanted bowel are generally rather a young population of reproductive age and because of technologic advances, MR may represent an effective method that does not use ionizing radiation and can therefore substitute for traditional radiologic evaluation. US represents a quick examination technique that is easily available and well tolerated by patients, and it has a role to play in the follow-up of transplanted patients and in the identification of major postoperative complications. However, its role in monitoring possible rejection remains to be defined with studies on wider and more representative samples.

Skeletal and cranio-facial signs in Gorlin syndrome from ancient Egypt to the modern age: sphenoid asymmetry in a patient with a novel PTCH1 mutation.

Gorlin syndrome is an autosomal dominant disorder linked to PTCH1 mutation, identified by a collection of clinical and radiologic signs. We describe the case of a family in which father and son fulfilled clear cut diagnostic criteria for Gorlin syndrome including multiple basal cell carcinomas, keratocystic odontogenic tumors, atypical skeletal anomalies and a novel PTCH1 germline mutation (c.1041delAA). Craniofacial and other skeletal anomalies displayed at 3D and helical CT scan were: macrocephaly, positional plagiocephaly, skull base and sphenoid asymmetry, bifidity of multiple ribs and giant multilocular odontogenic jaw cysts. Extensive multilamellar calcifications were found in falx cerebri, tentorium, falx cerebelli and in the atlanto-occipital ligament. The inclusion of bifid ribs as a novel major criteri may be useful for the recognition and characterization of misdiagnosed cases.

Banked Depopulated Vena Caval Homograft A New Strategy to Restore Caval Continuity

This study reports one case of primary inferior vena cava (IVC) leiomyosarcoma. A 67-year-old woman was referred to the authors’ clinic for evaluation. She presented complaining of epigastric and right upper abdominal quadrant pain. Contrast-enhanced abdominal computed tomography scan revealed a 5.2 × 6.4 cm heterogeneously enhancing mass involving the anteromedial aspect of the IVC, below the renal vein (segment I), deforming the duodenum. There was a partial intraluminal extension in the IVC. Laparotomic resection was performed, with total en bloc excision of the lower IVC tumor. The caval continuity was restored with concomitant interposition of a banked depopulated vena cava homograft. Histological findings showed leiomyosarcoma originating from IVC. The postoperative course was uneventful: Neither recurrence nor metastasis was evident at 4 years postsurgery.

Role of intraoperative ultrasonography for pancreatic schwannoma.

Pancreatic schwannoma is a rare neoplasm arising from sympathetic or parasympathetic fibers. Its histological origin is related to neoplastic transformation of the Schwann cells. Worldwide, only 40 cases are described [1,2]. Pancreatic schwannoma may be preoperatively diagnosed by combination of clinical picture and radiological images, particularly through CT-scan and MRI [3,4]. Often, benign pancreatic schwannoma occurs without von Recklinghausen’s disease, thus pre-operative diagnosis becomes very difficult. The best recommended surgical treatment consists in a simple enucleation. Among all cases reported, only four patients underwent nodule enucleation due to several concerns about true diagnosis of the lesion and nodule relationship with vascular structures [5,6]. Intraoperative ultrasonography (US) may provide an optimal contribution to detect lesion features and relationship with vascular structures, particularly with splenic artery and vein, and also with wirsung duct. Therefore, intraoperative-US picture can address to perform a simple enucleation instead a major pancreatic resection or vice versa. In this case, splenic vein involvement was pre-operatively showed by CT-scan andMRI. Intraoperatively, we performed US-Doppler to obtain a better assessment of the lesion relationship with splenic vein and its flow (Fig. 1). The lesion measured 2.5 cm; it was localized in the pancreatic