Antonio Corvino

Contrast-Enhanced Ultrasound in the Characterization of Complex Cystic Focal Liver Lesions

Complex cystic focal liver lesions (FLLs) found at non-contrast ultrasound (US) may turn out to be malignant. In this prospective, monocentric study we investigated the value of contrast-enhanced US (CEUS) in the differential diagnosis of complex cystic FLLs. In the past 3 years, all patients with complex cystic FLLs unclassifiable at US underwent CEUS with low-transmit insonation power. We evaluated 36 consecutive patients with 61 FLLs (1-6/patient, mean = 2). The diameter of the lesions ranged from 1.1 to 7.9 cm (mean = 3.9 cm). Sixteen patients had an extrahepatic malignancy. There were 42 malignant lesions and 19 benign lesions. No lesion had a certain diagnosis at conventional US, whereas 16 FLLs were classified as probable (benign or malignant) and 45 as uncertain. CEUS correctly categorized 95% of the malignant cases. CEUS was not able to differentiate the biliary cystadenoma from its malignant counterpart and misdiagnosed two abscesses. Complete non-enhancement throughout three phases or sustained enhancement in the portal/late phase was exhibited in most benign complex cystic FLLs, except for 1 (of the 3) cystadenomas and in 2 (of the 4) abscesses. On the other hand, all malignant lesions presented a contrast washout with a hypo-enhancing appearance. CEUS may provide added diagnostic value in all complex cystic FLLs found uncertain at conventional US, potentially avoiding the use of more invasive and expensive imaging modalities.

Synchronous mucinous colonic adenocarcinoma and multiple small intestinal adenocarcinomas: report of a case and review of literature

With the wide use of diagnostic imaging modalities, multiple primary malignancies frequently occur; different associations of malignancies have been reported. We describe the case of a primary mucinous adenocarcinoma of large bowel synchronous with three primary poorly differentiated adenocarcinomas of ileum. This type of association has not been described yet; since computed tomography increasingly is proving to be highly accurate in detection of colon cancer, this technique is recommended in such patients.

Rectal melanoma presenting as a solitary complex cystic liver lesion: role of contrast-specific low-MI real-time ultrasound imaging

Cystic hepatic metastases arising from malignant melanoma are extremely rare, with the few such cases reported in the literature to date describing indeterminate imaging findings, being focused more on computed tomography. To the best of our knowledge, there is no prior report describing contrast-enhanced ultrasound findings of a solitary cystic liver metastasis from a primary rectal melanoma. We herein describe a case of a 41-year-old patient with a rectal melanoma, in whom the first manifestation of disease was a solitary complex cystic liver metastasis incidentally detected by ultrasound. On admission, our patient was free of specific symptoms and his laboratory test was normal. In this setting, contrast-enhanced ultrasound showed some distinctive features that helped us to make the correct diagnosis, confirmed subsequently by FNAC examination, thus allowing to provide the correct management for our patient. Although cystic metastases are rare, knowledge of CEUS imaging findings will be invaluable for radiologists and other medical subspecialties that may face such cases in the future in helping to provide adequate management for affected patients.RiassuntoMetastasi epatiche di tipo cistico secondarie a melanoma maligno sono estremamente rare; ad oggi, i pochi casi riportati in letteratura descrivono reperti di imaging aspecifici, focalizzandosi quasi esclusivamente sul ruolo della Tomografia Computerizzata. Per quanto a nostra conoscenza, non ci sono precedenti lavori in letteratura che descrivano reperti eco-contrastografici di casi di metastasi cistiche solitarie epatiche a partenza da melanomi primitivamente rettali. Di seguito, descriviamo il caso di un paziente di 41 anni con melanoma rettale, nel quale la prima manifestazione clinica di malattia è stato il riscontro diagnostico di una lesione epatica cistica complex di natura metastatica, rilevata incidentalmente ad un esame ecografico di routine. Al momento del ricovero, il paziente era asintomatico e con profilo laboratoristico nella norma. In questo caso, l’eco-contrastografia ha mostrato caratteristiche semeiologiche peculiari che hanno permesso una corretta diagnosi presuntiva, confermata successivamente da un esame FNAC, consentendo un corretto management del paziente. Sebbene le metastasi cistiche rappresentino un’eventualità rara, riconoscerne i reperti CEUS è indispensabile sia per i radiologi sia per qualunque altro specialista che possa trovarsi ad affrontare tali casi in futuro, fornendo loro un valido strumento per la corretta gestione di questo tipo di pazienti.

Endovascular occlusion of pulmonary arteriovenous malformations with the ArtVentive Endoluminal Occlusion System

Pulmonary arteriovenous malformations (PAVMs) are vascular anomalies of the lung and carry the risk of cerebral thromboembolism, brain abscess, or pulmonary hemorrhage. We describe a 64-year-old male with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) who presented with a five-year history of progressive effort dyspnea and a PAVM in the right upper lobe successfully treated by transcatheter embolization of feeding arteries using a new occlusion device, the ArtVentive Endoluminal Occlusion System™.

Hepatic inflammatory pseudotumor: educational value of an incorrect diagnosis at contrast-enhanced ultrasound

Hepatic inflammatory pseudotumor (IPT) is a rare lesion that is frequently confused with malignant tumors. According to the latest guidelines on contrast-enhanced ultrasound, hypoenhancement of solid lesions in the portal and late phases corresponds to the wash-out phenomenon that characterizes malignancies. IPT may show rapid arterial enhancement and portal or late phase hypoenhancement, falsely suggesting malignancy. We report a case of a diagnostic error in which a multifocal IPT was misdiagnosed as hepatic metastases. The IPT developed after an endoscopic retrograde cholangiography was investigated by close follow-up with CEUS and contrast-enhanced CT.

Simultaneous non-functioning neuroendocrine carcinoma of the pancreas and extra-hepatic cholangiocarcinoma. A case of early diagnosis and favorable post-surgical outcome.

CONTEXT Thanks to the wide use of diagnostic imaging modalities, multiple primary malignancies are being diagnosed more frequently and different associations of malignancies have been reported in this setting. CASE REPORT In this paper, we describe the case of a patient with non-functioning well-differentiated neuroendocrine carcinoma of the head of the pancreas associated with extra-hepatic cholangiocarcinoma, in which an early diagnosis using magnetic resonance imaging allowed a good outcome. CONCLUSION The simultaneous association of neuroendocrine pancreatic tumors and cholangiocarcinoma has not yet been described; however, this association should be considered and, due to the high contrast of magnetic resonance imaging, this technique is recommended in such patient in order to reach an accurate diagnosis.

Diagnostic Performance and Confidence of Contrast-Enhanced Ultrasound in the Differential Diagnosis of Cystic and Cysticlike Liver Lesions

OBJECTIVE The aims of this study were to assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) in the characterization of atypical cystic and cysticlike focal liver lesions in comparison with conventional US and to determine whether the use of CEUS can reduce the need for further diagnostic workup. SUBJECTS AND METHODS In a 3-year period 48 patients with 50 atypical cystic and cysticlike lesions found at conventional US underwent CEUS. Diagnostic confirmation was obtained in cytohistopathologic examinations, with other imaging modalities, and in follow-up. Overall, there were 24 cystic lesions and 26 cysticlike solid lesions, specifically 32 benign and 18 malignant lesions. The conventional US and CEUS images and cine loops were reviewed by two blinded readers independently. Sensitivity, specificity, area under the ROC curve (Az), and interobserver agreement were calculated. RESULTS Diagnostic performance improved after review of CEUS examinations by both readers (conventional US Az = 0.781 vs 0.972; CEUS Az = 0.734 vs 0.957). Interreader agreement increased, although slightly (conventional US weighted κ = 0.894; CEUS weighted κ = 0.953). In terms of differential diagnosis, the occurrence of correctly characterized lesions increased after CEUS for both readers (reader 1, 62% to 98%; reader 2, 56% to 96%). CONCLUSION The development of low-acoustic-power CEUS has made it possible to identify several imaging features of cystic and cysticlike focal liver lesions that, in association with history and clinical findings, may help to correctly characterize them. Our data indicate the usefulness of CEUS in the evaluation of patients with these lesions.

Diagnostic Imaging of Patients with Pancreato-Biliary Diseases: Comparison between Ultrasound, Computed Tomography and Magnetic Resonance

Diagnostic Imaging of Patients with Pancreato-Biliary Diseases: Comparison between Ultrasound, Computed Tomography and Magnetic Resonance The aim of this study was to directly compare the results of MR cholangio-pancreatography (MRCP) with those of ultrasound (US) and multi-slice computed tomography (MSCT) in patients with pancreatico-biliary diseases. A total of 110 patients (62 M, 48 F), ranging in age from 22 to 89 years, was studied before surgery (n=99) or after cholecystectomy (n=11) for lithiasis. MRCP was performed in all patients while US was acquired in 55 patients and MSCT was performed in 76 patients. Histology (n=34), biopsy (n=38), endoscopic retrograde cholangio-pancreatography (ERCP) (n=28) and/or clinical-imaging follow-up (n=10) data were considered as standard of reference. Patient population was divided in three groups; Group 1 (n=55) consisted of a comparison between MRCP and US in biliary tract diseases; Group 2 (n=37) consisted of a comparison between MRCP and MSCT in biliary tract diseases; Group 3 (n=40) consisted of a comparison between MRCP and MSCT in pancreatic masses. A regional imaging qualitative evaluation of biliary and pancreatic duct system (gallbladder and cystic duct, intra- and extra-hepatic ducts, main pancreatic duct) was performed.

Duodenal Involvement by Breast Cancer

A54-year old woman presented to the emergency department with abdominal pain, intermittent vomiting, and mild jaundice for the past few weeks. Her past medical history included invasive ducto-tubular carcinoma of the right breast treated with wide local excision and axillar node sampling, followed by adjuvant radiation and hormonal therapy. A contrast-enhanced CT scan showed a concentric wall thickening with severe luminal stenosis of the second duodenum, added to thickened ampulla with (a)