Calogero Cicero

Autoimmune Pancreatitis: CT Patterns and Their Changes after Steroid Treatment

PURPOSE To retrospectively evaluate the computed tomographic (CT) patterns of autoimmune pancreatitis (AIP) and their changes after steroid therapy. MATERIALS AND METHODS Investigational review board approval was obtained, and the informed consent requirement was waived. The medical and imaging data of 21 patients (13 men, eight women; mean age, 47.5 years; age range, 25-79 years) with histopathologically proved AIP who underwent contrast material-enhanced CT at diagnosis and after steroid treatment were included in this study. Image analysis included assessment of the (a) presence or absence and type (focal or diffuse) of pancreatic parenchyma enlargement, (b) contrast enhancement of pancreatic parenchyma, (c) size of the main pancreatic duct (MPD) within the lesion and upstream, and (d) pancreatic parenchyma thickness in the head, body, and tail of the pancreas. The same criteria were applied to follow-up CT examinations, the follow-up data were compared with pretreatment data, and a paired sample t test was applied. RESULTS Pancreatic parenchyma showed focal enlargement in 14 (67%) patients and diffuse enlargement in seven (33%). Pancreatic parenchyma affected by AIP appeared hypoattenuating in 19 (90%) patients and isoattenuating in two (10%). During the portal venous phase, pancreatic parenchyma showed contrast material retention in 18 (86%) patients and contrast material washout in three (14%). The MPD was never visible within the lesion. After treatment, there was a reduction in the size of pancreatic parenchyma segments affected by AIP (P < .05). Fifteen (71%) of the 21 patients had a normal enhancement pattern in the pancreatic parenchyma, whereas the enhancement pattern remained hypovascular in six (29%). The MPD returned to its normal size within the lesion in all patients at follow-up CT. In one of the eight patients with focal forms of AIP, the upstream MPD remained dilated. CONCLUSION AIP appeared as pancreatic parenchyma enlargement, with MPD stenosis within the lesion and upstream dilatation in focal forms of AIP. After steroid treatment, there was normalization of these findings.

Solid Renal Tumors Isoenhancing to Kidneys on Contrast‐Enhanced Sonography: Differentiation From Pseudomasses

To estimate the prevalence of solid renal tumors isoenhancing to kidneys in all vascular phases on contrast‐enhanced sonography and to investigate whether they can be differentiated from pseudomasses.

Cryotherapy of Renal Lesions: Enhancement on Contrast-Enhanced Sonography on Postoperative Day 1 Does Not Imply Viable Tissue Persistence

To investigate whether persistent enhancement detected on contrast‐enhanced sonography at postoperative day 1 (early contrast‐enhanced sonography) after cryoablation of renal tumors implies the presence of residual viable tumor tissue, defined as residual enhancing tissue on reference imaging (computed tomography or magnetic resonance imaging) performed 6 months after the procedure.

Role of multislice computed tomography in the diagnosis of gene-mutation-associated pancreatitis (GMAP)

PurposeThe aim of this study was to review the computed tomography (CT) features of the pancreatic parenchyma and ducts in patients with gene-mutation-associated pancreatitis (GMAP).Materials and methodsTwenty-five patients with GMAP were included in this retrospective study. Patients were divided into two groups according to the time interval between the onset of symptoms and the first CT examination (group A ≤24 months and group B >25 months).ResultsOn qualitative image assessment, in group A patients, pancreatic duct stones were detected in 2/13 with GMAP. All stones were calcified and homogenous. Enhancement of the pancreatic parenchyma was hypovascular in 7/13 patients. In group B patients, pancreatic duct stones were detected in 12/12 with GMAP. Stones were calcified in 10/12 cases and noncalcified (protein plugs) in 2/12; in 5/10 cases, the calcified stones were heterogeneous with noncalcified central core (bull’s-eye appearance). Enhancement of the pancreatic parenchyma was hypovascular in 12/12 patients. On quantitative image assessment, in group A patients, the mean diameter of duct stones was 0.6 mm (range 0–5 mm). Mean diameter of the main duct in the pancreatic head and body/tail was 4.8 mm and 4.9 mm, respectively. In group B patients, the mean diameter of duct stones was 21.9 mm (range 2–50 mm). Mean diameter of the main duct in the pancreatic head and body/tail was 18.8 mm and 13.9 mm, respectively.Conclusions|In patients with GMAP and time interval between symptom onset and first CT scan ≤24 months (group A), CT identified normal or slightly increased parenchymal thickness and a main pancreatic duct of normal calibre and without duct stones. In contrast, in patients with GMAP and time interval between symptom onset and first CT scan >25 months (group B), it identified large-calibre duct stones with bull’s-eye appearance.RiassuntoObiettivoDescrivere le caratteristiche del parenchima pancreatico e dei dotti alla tomografia computerizzata (TC) nei pazienti con pancreatite associata a mutazione genetica (GMAP).Materiali e metodiSono stati inclusi 25 pazienti con GMAP. Nel nostro studio retrospettivo, i pazienti sono stati suddivisi in 2 gruppi in base all’intervallo di tempo intercorso tra insorgenza della sintomatologia ed esecuzione della prima indagine TC (gruppo A≤24 mesi e gruppo B>25 mesi). È stata effettuata un’analisi qualitativa delle immagini.RisultatiNel gruppo A erano presenti calcoli endoduttali in 2/13 pazienti con GMAP; tutti questi calcoli erano calcifici ed omogenei. L’impregnazione del parenchima pancreatico era ipovascolare in 7/13 pazienti con GMAP. Nel gruppo B erano presenti calcoli endoduttali in 12/12 pazienti con GMAP; in 10/12 casi i calcoli endoduttali erano calcifici, 2/12 non calcifici (plugs); in 5/10 casi i calcoli calcifici erano eterogenei con core centrale non calcifico (bull’s eye). L’impregnazione del parenchima pancreatico era ipovascolare in 12/12 pazienti con GMAP. All’analisi quantitativa delle immagini, il gruppo A presentava un diametro medio dei calcoli endoduttali di 0,6 mm (range 0–5 mm). Il diametro medio del dotto pancreatico principale nella testa e nel corpo/coda era rispettivamente di 4,8 mm e 4,9 mm nei pazienti con GMAP. Il gruppo B presentava un diametro medio dei calcoli endoduttali di 21,9 mm (range 2’50 mm). Il diametro medio del dotto pancreatico principale nella testa e nel corpo/coda era rispettivamente di 18,8 mm e 13,9 mm nei pazienti con GMAP.ConclusioniIn conclusione, la TC identifica nei pazienti con GMAP e intervallo di tempo tra insorgenza della sintomatologia e prima indagine TC≤24 mesi (gruppo A) uno spessore parenchimale normale o lievemente aumentato e un dotto pancreatico principale con calibro normale senza calcoli endoduttali. Al contrario nei pazienti con GMAP e intervallo di tempo tra insorgenza della sintomatologia e prima TC>25 mesi (gruppo B) calcoli endoduttali con grande diametro e morfologia a bull’s eye.

Multiple, Synchronous Lesions of Differing Histology Within the Same Testis: Ultrasonographic and Pathologic Correlations

OBJECTIVE To describe ultrasound (US) and pathologic findings in 11 patients with multiple, synchronous lesions of different histology within the same testis. MATERIALS AND METHODS We reviewed US and pathologic findings in 11 patients with multiple, synchronous lesions of different histology within the same testis. Lesions were classified as separate or adjacent one to another and attempt was made to predict tumor type on their US textures. Pathologic review assessed presence of normal tissue between adjacent lesions and of Germ Cell Neoplasia In Situ in surrounding parenchyma. Nine cases were from files specifically dedicated to testicular tumors and estimated prevalence was calculated. RESULTS Two nodules were seen in nine patients and 3 in remaining two. Nine had tumors of different histology; two had one malignancy and one focal benign lesion. Germ Cell Neoplasia In Situ was seen in 7/11 cases. In dedicated archives, these lesions had 1.83% prevalence. CONCLUSION Multiple focal lesions identified at imaging within the testis are not always of the same histology. This can be suspected in some cases basing on US texture. Recognition that lesions are multiple and an indication of their locations within the testis is the most important role of imaging and may help pathologists correctly sample the specimen to establish nature of each of them. Presence of multiple lesions is regarded as a contraindication to testicular sparing surgery. In two of our patients, one lesion was benign. Then, when the procedure is indicated all lesions have to be sampled and assessed by pathologists before deciding between conservative or radical technique.

Intraoperative Ultrasound in Renal Surgery

Management of renal cell carcinoma (RCC) has evolved in the middle of the last century and particularly in the last decade, and this is due to a significant improvement in surgical techniques and the arrival of new technologies that can help both during the operation and in preoperative staging. Surgery remains the definitive therapy and the means of a cure. According to the American and European Urological Association guidelines, partial nephrectomy (PN) should be offered to all patients who have T1 tumours (i.e. tumours <7 cm), and it has been found to have comparable, possibly better, survival than radical nephrectomy (RN).

Neoadjuvant sunitinib effectiveness in T4 renal clear cell carcinoma: a case report

Introduction Sunitinib therapy showed an improvement in survival of patients with metastatic renal cell carcinoma. Materials and Methods A 51-year-old man, with Eastern Cooperative Oncology Group Score (ECOG) of 0, presented at our Institute in March 2012 for macrohematuria and urinary retention. A computed tomography (CT) scan of the abdomen showed a right renal lesion. The lesion had a diameter of 15 cm and was developing towards the liver, in the absence of cleavage planes between the liver and kidney. A 12 mm finding, suspected as secondary lesion, was detected at the level of the VII hepatic segment. Neoadjuvant chemotherapy with Sunitinib was proposed. Results The patient underwent a ultrasound-guided biopsy, which confirmed the presence of Clear Cell Carcinoma. The patient began chemotherapy treatment in May 2012 according to the scheme SUNITINIB 50 mg daily for 4 weeks every 6 weeks. After four courses of treatment, according to RECIST criteria for solid tumors, 40% (9 cm vs 15 cm) regression of the primary tumor and 33% (8 mm vs 12 mm) regression of the secondary lesion were observed at a CT scan of the abdomen. In February 2013, Laparoscopic Adrenal-Sparing Radical Nephrectomy was performed. At a follow-up of 3 months, performed with a thorax and abdomen CT scans, there was a complete remission of hepatic secondary lesion and no areas of secondary localization of disease. Conclusions This case report showed the effectiveness of neoadjuvant chemotherapy with Sunitinib. The use of this chemotherapy agent can change the approach to the management of cRCC.

Bull’s-eye pattern of pancreatic-duct stones on multidetector computed tomography and gene-mutation-associated pancreatitis (GMAP)

PurposeThis study prospectively assessed whether the presence of a bull’s-eye pattern of pancreatic-duct stones on multidetector computed tomography (MDCT) correlated with gene-mutation-associated pancreatitis (GMAP) and whether other signs suggestive of GMAP can be detected with MDCT.Materials and methodsForty-seven patients with chronic calcific pancreatitis underwent genetic testing for CFTR, SPINK1 and PRSS1 mutations and an MDCT scan of the abdomen. Qualitative analysis assessed the presence or absence of pancreatic-duct stones with bull’s-eye appearance. Quantitative analysis included the number and maximum diameter of stones and the diameter of the main pancreatic duct.ResultsFifteen of 47 patients (32%) were positive for gene mutations (GMAP patients). The bull’s-eye pattern was found in 10/15 patients (67%) with GMAP and in 4/32 (12%) patients with chronic pancreatitis not associated with GMAP (NGMAP; p<0.0001). The mean diameter of duct stones was 15 mm in patients with GMAP and 10 mm in patients with NGMAP (p<0.04).ConclusionsThe presence of duct stones with a bull’s-eye pattern correlates with GMAP. Duct stones with diameter ≥15 mm are another sign suggestive of GMAP.RiassuntoObiettivoValutare prospettivamente se la presenza alla tomografia computerizzata multidetettore (TCMD) di calcoli pancreatici con pattern a “bull’s eye” si correli alla pancreatite associata a mutazione genetica (GMAP) e se vi siano altre caratteristiche TCMD suggestive nei pazienti affetti da GMAP.Materiali e metodiQuarantasette pazienti con pancreatite cronica calcifica sono stati sottoposti a test genetici per le mutazioni di CFTR, SPINK1 e PRSS1 ed esame TCMD dell’addome. L’analisi qualitativa ha riguardato la presenza o assenza di calcoli duttali pancreatici con morfologia a “bull’s eye”. L’analisi quantitativa ha incluso: numero e massimo diametro dei calcoli duttali; diametro del dotto pancreatico principale.RisultatiQuindici pazienti su 47 (32%) sono risultati positivi per la presenza di mutazioni genetiche (pazienti GMAP). Il pattern a “bull’s eye” è stato rilevato in 10/15 pazienti (67%) con GMAP e in 4/32 (12%) pazienti con pancreatite cronica non associata a mutazione genetica (NGMAP: p<0,0001). Il diametro medio dei calcoli duttali è stato di 15 mm nei pazienti con GMAP e 10 mm nei pazienti con NGMAP (p<0,04).ConclusioniLa presenza di calcoli duttali con pattern a “bull’s eye”si correla alle GMAP. Anche calcoli duttali con diametro ≥15 mm sono un segno correlato alle GMAP.

Role of multislice computed tomography in the diagnosis ofgene-mutation-associated pancreatitis (GMAP)

PurposeThe aim of this study was to review the computed tomography (CT) features of the pancreatic parenchyma and ducts in patients with gene-mutation-associated pancreatitis (GMAP).Materials and methodsTwenty-five patients with GMAP were included in this retrospective study. Patients were divided into two groups according to the time interval between the onset of symptoms and the first CT examination (group A ≤24 months and group B >25 months).ResultsOn qualitative image assessment, in group A patients, pancreatic duct stones were detected in 2/13 with GMAP. All stones were calcified and homogenous. Enhancement of the pancreatic parenchyma was hypovascular in 7/13 patients. In group B patients, pancreatic duct stones were detected in 12/12 with GMAP. Stones were calcified in 10/12 cases and noncalcified (protein plugs) in 2/12; in 5/10 cases, the calcified stones were heterogeneous with noncalcified central core (bull’s-eye appearance). Enhancement of the pancreatic parenchyma was hypovascular in 12/12 patients. On quantitative image assessment, in group A patients, the mean diameter of duct stones was 0.6 mm (range 0–5 mm). Mean diameter of the main duct in the pancreatic head and body/tail was 4.8 mm and 4.9 mm, respectively. In group B patients, the mean diameter of duct stones was 21.9 mm (range 2–50 mm). Mean diameter of the main duct in the pancreatic head and body/tail was 18.8 mm and 13.9 mm, respectively.Conclusions|In patients with GMAP and time interval between symptom onset and first CT scan ≤24 months (group A), CT identified normal or slightly increased parenchymal thickness and a main pancreatic duct of normal calibre and without duct stones. In contrast, in patients with GMAP and time interval between symptom onset and first CT scan >25 months (group B), it identified large-calibre duct stones with bull’s-eye appearance.RiassuntoObiettivoDescrivere le caratteristiche del parenchima pancreatico e dei dotti alla tomografia computerizzata (TC) nei pazienti con pancreatite associata a mutazione genetica (GMAP).Materiali e metodiSono stati inclusi 25 pazienti con GMAP. Nel nostro studio retrospettivo, i pazienti sono stati suddivisi in 2 gruppi in base all’intervallo di tempo intercorso tra insorgenza della sintomatologia ed esecuzione della prima indagine TC (gruppo A≤24 mesi e gruppo B>25 mesi). È stata effettuata un’analisi qualitativa delle immagini.RisultatiNel gruppo A erano presenti calcoli endoduttali in 2/13 pazienti con GMAP; tutti questi calcoli erano calcifici ed omogenei. L’impregnazione del parenchima pancreatico era ipovascolare in 7/13 pazienti con GMAP. Nel gruppo B erano presenti calcoli endoduttali in 12/12 pazienti con GMAP; in 10/12 casi i calcoli endoduttali erano calcifici, 2/12 non calcifici (plugs); in 5/10 casi i calcoli calcifici erano eterogenei con core centrale non calcifico (bull’s eye). L’impregnazione del parenchima pancreatico era ipovascolare in 12/12 pazienti con GMAP. All’analisi quantitativa delle immagini, il gruppo A presentava un diametro medio dei calcoli endoduttali di 0,6 mm (range 0–5 mm). Il diametro medio del dotto pancreatico principale nella testa e nel corpo/coda era rispettivamente di 4,8 mm e 4,9 mm nei pazienti con GMAP. Il gruppo B presentava un diametro medio dei calcoli endoduttali di 21,9 mm (range 2’50 mm). Il diametro medio del dotto pancreatico principale nella testa e nel corpo/coda era rispettivamente di 18,8 mm e 13,9 mm nei pazienti con GMAP.ConclusioniIn conclusione, la TC identifica nei pazienti con GMAP e intervallo di tempo tra insorgenza della sintomatologia e prima indagine TC≤24 mesi (gruppo A) uno spessore parenchimale normale o lievemente aumentato e un dotto pancreatico principale con calibro normale senza calcoli endoduttali. Al contrario nei pazienti con GMAP e intervallo di tempo tra insorgenza della sintomatologia e prima TC>25 mesi (gruppo B) calcoli endoduttali con grande diametro e morfologia a bull’s eye.

Role of multislice computed tomography in the diagnosis of gene- mutation-associated pancreatitis (GMAP) Il ruolo della TC multistrato nella diagnosi della pancreatite cronica associata a mutazione genetica (GMAP)

PurposeThe aim of this study was to review the computed tomography (CT) features of the pancreatic parenchyma and ducts in patients with gene-mutation-associated pancreatitis (GMAP).Materials and methodsTwenty-five patients with GMAP were included in this retrospective study. Patients were divided into two groups according to the time interval between the onset of symptoms and the first CT examination (group A ≤24 months and group B >25 months).ResultsOn qualitative image assessment, in group A patients, pancreatic duct stones were detected in 2/13 with GMAP. All stones were calcified and homogenous. Enhancement of the pancreatic parenchyma was hypovascular in 7/13 patients. In group B patients, pancreatic duct stones were detected in 12/12 with GMAP. Stones were calcified in 10/12 cases and noncalcified (protein plugs) in 2/12; in 5/10 cases, the calcified stones were heterogeneous with noncalcified central core (bull’s-eye appearance). Enhancement of the pancreatic parenchyma was hypovascular in 12/12 patients. On quantitative image assessment, in group A patients, the mean diameter of duct stones was 0.6 mm (range 0–5 mm). Mean diameter of the main duct in the pancreatic head and body/tail was 4.8 mm and 4.9 mm, respectively. In group B patients, the mean diameter of duct stones was 21.9 mm (range 2–50 mm). Mean diameter of the main duct in the pancreatic head and body/tail was 18.8 mm and 13.9 mm, respectively.Conclusions|In patients with GMAP and time interval between symptom onset and first CT scan ≤24 months (group A), CT identified normal or slightly increased parenchymal thickness and a main pancreatic duct of normal calibre and without duct stones. In contrast, in patients with GMAP and time interval between symptom onset and first CT scan >25 months (group B), it identified large-calibre duct stones with bull’s-eye appearance.RiassuntoObiettivoDescrivere le caratteristiche del parenchima pancreatico e dei dotti alla tomografia computerizzata (TC) nei pazienti con pancreatite associata a mutazione genetica (GMAP).Materiali e metodiSono stati inclusi 25 pazienti con GMAP. Nel nostro studio retrospettivo, i pazienti sono stati suddivisi in 2 gruppi in base all’intervallo di tempo intercorso tra insorgenza della sintomatologia ed esecuzione della prima indagine TC (gruppo A≤24 mesi e gruppo B>25 mesi). È stata effettuata un’analisi qualitativa delle immagini.RisultatiNel gruppo A erano presenti calcoli endoduttali in 2/13 pazienti con GMAP; tutti questi calcoli erano calcifici ed omogenei. L’impregnazione del parenchima pancreatico era ipovascolare in 7/13 pazienti con GMAP. Nel gruppo B erano presenti calcoli endoduttali in 12/12 pazienti con GMAP; in 10/12 casi i calcoli endoduttali erano calcifici, 2/12 non calcifici (plugs); in 5/10 casi i calcoli calcifici erano eterogenei con core centrale non calcifico (bull’s eye). L’impregnazione del parenchima pancreatico era ipovascolare in 12/12 pazienti con GMAP. All’analisi quantitativa delle immagini, il gruppo A presentava un diametro medio dei calcoli endoduttali di 0,6 mm (range 0–5 mm). Il diametro medio del dotto pancreatico principale nella testa e nel corpo/coda era rispettivamente di 4,8 mm e 4,9 mm nei pazienti con GMAP. Il gruppo B presentava un diametro medio dei calcoli endoduttali di 21,9 mm (range 2’50 mm). Il diametro medio del dotto pancreatico principale nella testa e nel corpo/coda era rispettivamente di 18,8 mm e 13,9 mm nei pazienti con GMAP.ConclusioniIn conclusione, la TC identifica nei pazienti con GMAP e intervallo di tempo tra insorgenza della sintomatologia e prima indagine TC≤24 mesi (gruppo A) uno spessore parenchimale normale o lievemente aumentato e un dotto pancreatico principale con calibro normale senza calcoli endoduttali. Al contrario nei pazienti con GMAP e intervallo di tempo tra insorgenza della sintomatologia e prima TC>25 mesi (gruppo B) calcoli endoduttali con grande diametro e morfologia a bull’s eye.