Carlo Fugazzola

Microwave tumors ablation: principles, clinical applications and review of preliminary experiences.

Local ablative techniques have been developed to enable local control of unresectable tumors. Ablation has been performed with several modalities including ethanol ablation, laser ablation, cryoablation, and radiofrequency ablation. Microwave technology is a new thermal ablation technique for different types of tumors, providing all the benefits of radiofrequency and substantial advantages. Microwave ablation has been applied to liver, lung, kidney and more rarely to bone, pancreas and adrenal glands. Preliminary works show that microwave ablation may be a viable alternative to other ablation techniques in selected patients. However further studies are necessary to confirm short- and long-term effectiveness of the methods and to compare it with other ablative techniques, especially RF.

Congenital absence of portal vein with nodular regenerative hyperplasia of the liver

Abstract. Congenital absence of the portal vein is a very rare anomaly. The intestinal and splenic venous drainage bypasses the liver and drain into the inferior vena cava (IVC). Two cases of such anomaly are described. Both cases were investigated by US coupled with echo-colour Doppler examination, CT and MR imaging, followed by digital subtraction angiography (DSA) and liver biopsy. In the first case the splenic and superior mesenteric vein formed a venous trunk which emptied directly into the IVC; in the second case, the splanchnic blood flowed into a dilated hepatofugal inferior mesenteric vein which connected to the left internal iliac vein. In both cases nodular regenerative hyperplasia of the liver was present, presumably due to an abnormal hepatic cell response to the absent portal flow. The particular contribution of MR imaging to the diagnosis of both vascular abnormalities and liver parenchyma derangement and its advantages over the other diagnostic techniques is emphasized. The clinical and radiological features of 17 previously reported cases are reviewed.

The pseudocapsule in hepatocellular carcinoma: correlation between dynamic MR imaging and pathology

Abstract. Nodular hepatocellular carcinoma (HCC) is characterized by the presence of a pseudocapsule (constructed usually from connective fibrous tissue) that appears hypointense on T1- and T2-weighted spin-echo (SE) and gradient-echo (GE) MR imaging sequences without a contrast medium. The presence of vascular structures inside the tumor, which are verified by histological exam, affects enhancement of the PC after administrating the contrast medium: The impregnation is more evident in the dynamic study but also persists on the delayed T1-weighted SE images. The accuracy of MR in detecting the pseudocapsule of HCC and contrast enhancement of the pseudocapsule during dynamic studies were evaluated and related to pathological findings. Thirty-seven HCC were examined in 33 patients and afterwards resected. In capsulated nodules, besides usual hematoxylin, eosin, and trichrome stainings, histochemical and immunohistochemical methods were performed. On a 1.5-T MR unit, T1- and T2-weighted SE and GE FLASH 2D sequences after intravenous injection of Gd-DTPA (dynamic study) were used. In a later phase, T1-weighted SE sequences were repeated. Histologically, the pseudocapsule (thickness 0.2–6 mm) was present in 26 of 37 nodules (70 %). The dynamic study was the most suitable technique to show the pseudocapsule, which was recognized in 80.7 % (21 of 26 nodules). In 5 of 26 cases, the pseudocapsule, not demonstrated by MR, was thinner than 0.4 mm. In 16 of 21 cases, in the early portal phase (30–60 s), the pseudocapsule had an early enhancement, which was more evident later; in 5 of 21 cases the enhancement was observed only in the late portal phase (1–2 min). At histological examination, 14 of 16 pseudocapsules with early enhancement showed a more prominent vasculature than those with enhancement in the equilibrium phase. Magnetic resonance was a reliable tool in demonstrating the pseudocapsule of HCC. The histological examination demonstrated a good correlation between the enhancement behavior and the vessel number of the pseudocapsule.

Follow-up of collagen meniscus implants by MRI.

PurposeThe purpose of our study was to evaluate the usefulness of magnetic resonance imaging (MRI) in the follow-up of patients treated with collagen meniscus implant (CMI) and to identify MRI patterns suitable for defining its evolution.Materials and methodsBetween March 2001 and June 2003, CMI was performed on 40 patients (27 men and 13 women, age 23–58 years, median 41 years) affected by irreparable medial meniscal lesions. All patients underwent MRI follow-up at 6 months and 1 year and 16 patients 2 years after the operation; 12 patients underwent second-look arthroscopy with implant biopsy. All MRI examinations were performed with a 1.5-T unit using GE T2*, spin-echo (SE) T1, and FatSat fast spin-echo (FSE) DP and T2-weighted sequences, with different orientations. At 24 months, MR arthrography was also performed. Implant evolution was assessed on the basis of MRI direct and indirect criteria. Direct criteria were morphology and signal intensity of the collagen meniscus/residual meniscus complex. Based on these characteristics, three pattern were identified and classified from 1 to 3, where a higher score corresponded to characteristics approaching those of the normal meniscus. Indirect criteria were chondral surface and subchondral bone marrow oedema at implant site and associated synovial pathology.ResultsMRI follow-up at 6 months showed CMI shape and size to be normal (type 3) in 35/40 patients and type 2 in 5/40 patients. CMI signal intensity was type 1 in 32/40 patients and type 2 in 8/40. An interface between prosthetic and native meniscus was identified in 27/40 patients. Chondral lesions were present in 3/40 cases and subchondral bone marrow oedema in 8/40 cases. Reactive synovial effusion was seen in 2/40 patients. MRI follow-up at 12 months showed CMI shape and size to be normal (type 3) in 33/40 patients and type 2 in 7/40. Signal intensity was type 1 in 14/40 patients and type 2 in 26/40 patients. The interface was seen in 19/40 patients. The associated chondral lesions were unchanged, whereas subchondral bone marrow oedema was present in 3/40 patients. No synovial reaction was detected. At 24 months, CMI size was type 3 in 9/16 patients, type 2 in 6/16, and type 1 in one patient in whom the implant could not be identified, as it had been totally resorbed. CMI signal intensity was type 2 in 11/15 and type 3 in 4/16. The interface was identified in seven patients. MR arthrography depicted two additional chondral lesions and enabled correct grading of all lesions. Subchondral bone marrow oedema was present in two patients only.ConclusionsMRI enables morphological and structural changes of CMI to be monitored over time. Follow-up can be extended beyond 2 years, until the CMI has stabilised and subchondral bone marrow oedema has completely resolved. In the single case with a poor CMI outcome, no related direct or indirect signs were identified.RiassuntoObiettivoScopo del nostro lavoro è valutare l’utilità della RM nel follow-up di pazienti sottoposti ad impianto di menisco collagenico bovino (CMI) e individuare patterns RM idonei a definirne l’evoluzione.Materiali e metodiQuaranta pazienti, 27 maschi e 13 femmine (di età compresa tra 23 e 58 anni, età mediana: 41 anni), sottoposti a impianto di menisco protesico mediale per via artroscopica, hanno eseguito follow-up con RM a 6 mesi e a 1 anno e solo 16 pazienti a 2 anni dall’intervento; in 12 casi è stato eseguito second look artroscopico con prelievo bioptico dell’impianto. Le indagini RM sono state eseguite con tomografo da 1,5 T, il protocollo di studio prevedeva sequenze Ge T2*, SE T1 e FSE FATSAT DP/T2 variamente orientate in tutti i controlli, a 24 mesi si eseguiva anche esame artro-RM. Per la valutazione dell’evoluzione dell’impianto all’indagine RM sono stati considerati criteri diretti: le dimensioni e l’intensità di segnale del complesso menisco collagenico-menisco residuo (in base a queste caratteristiche abbiamo individuato tre tipi di patterns che abbiamo classificato da 1 a 3, con valore tanto più alto quanto più queste si avvicinano alle caratteristiche del menisco normale) e criteri indiretti: superfici condrali e spongiosa ossea sottocondrale in sede di impianto e patologia sinoviale associata.RisultatiNel controllo RM a 6 mesi in 35/40 pazienti le dimensioni del CMI erano di tipo 3, in 5/40 di tipo 2. L’intensità di segnale del CMI era di tipo 1 in 32/40 pazienti, di tipo 2 in 8/40. L’interfaccia menisco protesico-menisco nativo era identificabile in 27/40 pazienti. In 3/40 casi è stata evidenziata patologia condrale e in 8/40 casi sofferenza dell’osso subcondrale. In 2/40 pazienti vi era versamento reattivo sinoviale. Nel controllo a 12 mesi la morfologia e le dimensioni dell’impianto erano normali (tipo 3) in 33/40 pazienti, mentre erano di tipo 2 in 7/40. L’intensità di segnale del complesso era di tipo 1 in 14/40 pazienti, di tipo 2 in 26/40 pazienti. L’interfaccia era presente 19/40 pazienti. Le lesioni condrali associate mantenevano aspetto invariato, mentre la sofferenza della spongiosa ossea subcondrale era presente solo in 3/40 pazienti. Non vi era alcuna reazione sinoviale. Nel controllo a 24 mesi in 9/16 pazienti le dimensioni del CMI erano di tipo 3, in 6/16 di tipo 2; in 1 pazienti l’impianto non risultava identificabile, totalmente riassorbito (tipo 1). In 11/15 pazienti l’intensità di segnale del CMI era di tipo 2, mentre in 4/15 era sovrapponibile al menisco normale, di tipo 3. In 7 pazienti l’interfaccia risultava riconoscibile. Con artro-RM è stato possibile rilevare 2 nuovi casi di patologia condrale e definire il corretto grading di tutte le lesioni; solo in 2 pazienti vi era sofferenza della spongiosa ossea subcondrale.ConclusioniLa RM consente di monitorare nel tempo le variazioni morfologiche e strutturali del CMI, riteniamo che il follow-up possa essere prolungato altre i 2 anni, fino alla “stabilizzazione” del CMI e alla completa risoluzione delle aree di edema della spongiosa ossea subcondrale. Nell’unico caso di evoluzione sfavorevole del CMI non si sono individuati segni diretti o indiretti correlabili.

Comparative study of jaws with multislice computed tomography and cone-beam computed tomography

PurposeThe aim of this study was to compare the dosimetric and diagnostic performance of multislice computed tomography (MSCT) and cone-beam computed tomography (CBCT) in the study of the dental arches.Materials and methodsEffective dose and dose to the main organs of the head and neck were evaluated by means of thermoluminescent dosimeters (TLDs) placed in an Alderson Rando anthropomorphic phantom and using a standard CBCT protocol and an optimised MSCT protocol. Five patients with occlusal plane ranging from 54 cm to 59 cm who needed close follow-up (range 1–3 months) underwent both examinations. Image quality obtained with CBCT and MSCT was evaluated.ResultsEffective dose and dose to the main organs of the head and neck were higher for MSCT than for CBCT. Image quality of CBCT was judged to be equivalent to that of MSCT for visualising teeth and bone but inferior for visualising soft tissues. Beam-hardening artefacts due to dental-care material and implants were weaker at CBCT than at MSCT.ConclusionsWhen panoramic radiography is not sufficient in the study of the teeth and jaw bones, CBCT can provide identical information to MSCT, with a considerable dose reduction. MSCT is, however, indicated when evaluation of soft tissue is required.RiassuntoObiettivoScopo di questo lavoro è confrontare le performances dosimetriche e diagnostiche di tomografia computerizzata multidetettore (TCMD) e tomografia computerizzata a fascio conico (TCFC) nello studio delle arcate dentarie.Materiali e metodiSi è provveduto alla misurazione della dose alle strutture di capo e collo e della dose efficace con dosimetri a termoluminescenza (TLD) posti in un fantoccio antropomorfo Alderson Rando utilizzando un protocollo TCFC ed uno TCMD ottimizzato. Sono stati esaminati 5 pazienti, con circonferenza al piano occlusale entro un range prestabilito (54–59 cm) e che avevano necessità di effettuare controlli ravvicinati nel tempo (range 1-3 mesi), con entrambi i sistemi TC ed è stata valutata la qualità delle immagini ottenute.RisultatiLa dose efficace agli organi è superiore per la TCMD rispetto alla TCFC. La qualità delle immagini della TCFC è stata giudicata sovrapponibile alla TCMD nello studio dei denti e dell’osso, inferiore nella valutazione dei tessuti molli. Artefatti da indurimento del fascio dovuti alla presenza di materiale medicamentoso e protesico incidono negativamente sulla qualità dell’immagine maggiormente nel caso della TCMD rispetto alla TCFC.ConclusioniLo studio delle strutture ossee può essere effettuato, se la radiografia ortopanoramica non è sufficiente, mediante TCFC, che fornisce informazioni sovrapponibili a quelle della TCMD con notevole risparmio di dose; la TCMD è indicata qualora sia necessario valutare anche i tessuti molli.

Radiofrequency ablation of intrahepatic cholangiocarcinoma: preliminary experience

The purpose of this study was to evaluate the safety and efficacy of percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) in patients with intrahepatic cholangiocarcinoma (ICCA) in a small, nonrandomized series. From February 2004 to July 2008, six patients (four men and two women; mean age 69.8 years [range 48 to 83]) with ICCA underwent percutaneous US-guided RFA. Preintervetional transarterial embolization was performed in two cases to decrease heat dispersion during RFA in order to increase the area of ablation. The efficacy of RFA was evaluated using contrast-enhanced dynamic computed tomography (CT) 1 month after treatment and then every 3 months thereafter. Nine RFA sessions were performed for six solid hepatic tumors in six patients. The duration of follow-up ranged from 13 to 21 months (mean 17.5). Posttreatment CT showed total necrosis in four of six tumors after one or two RFA sessions. Residual tumor was observed in two patients with larger tumors (5 and 5.8 cm in diameter). All patients tolerated the procedure, and there with no major complications. Only 1 patient developed post-RFA syndrome (pain, fever, malaise, and leukocytosis), which resolved with oral administration of acetaminophen. Percutaneous RFA is a safe and effective treatment for patients with hepatic tumors: It is ideally suited for those who are not eligible for surgery. Long-term follow-up data regarding local and systemic recurrence and survival are still needed.

Conservative treatment by chemotherapy and uterine arteries embolization of a cesarean scar pregnancy.

We report a case of a viable cesarean scar pregnancy diagnosed at 7 weeks of gestation. The patient was conservatively managed by chemotherapy, intra-amniotic instillation of potassium chloride, and bilateral uterine artery embolization. The gestational sac was not sonographically visible 44 days after the treatment. No surgical treatment was necessary.

Cystic islet cell tumors of the pancreas. A clinico-pathological report of two nonfunctioning cases and review of the literature

SummaryCystic islet cell tumors of the pancreas are extremely rare. The authors report their personal experience with two cases of nonfunctioning cystic endocrine neoplasms. The tumor was diagnosed preoperatively in one case by ultrasonography (US)-guided fine-needle aspiration cytology, while in the other it was identified only in the surgical specimen after a clinical-radiologic diagnosis of pancreatic mucinous cystic tumor. Immunohistochemical assay showed positivity for the generic neuroendocrine markers (neuron specific enolase, or NSE, synaptophysin, and chromogranin A) in both cases and also for glucagon in one case. The neoplasms were resected by distal pancreatectomy with splenectomy and intermediate pancreatectomy respectively. Both patients are alive and recurrence-free 6 mo and 2.5 yr, respectively, after surgery. The authors also review the existing literature, discussing the pathogenesis of such tumors and the imaging techniques and surgical strategies adopted in their management.

Complications of microwave and radiofrequency lung ablation: personal experience and review of the literature

PurposeComplications correlated with percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) of lung tumours were retrospectively reviewed to compare them with data from the literature and to assess risk factors related with the procedures.Materials and methodsFrom January 2003 to January 2009, 29 patients (36 lung lesions) were treated with RFA; from January 2007 to January 2009, 16 patients (17 lung lesions) were treated with MWA. Complications recorded at our institution are reported following the Society of Interventional Radiology guidelines. A systematic review of the literature was performed.ResultsAny major complication of RFA or MWA was recorded. In agreement with the literature, pneumothorax was the most frequent complication, even though the incidence in our series was lower than reported in the literature (3.5% vs. 4.3–18%). Other complications of RFA were pleural effusion and subcutaneous emphysema. No massive haemorrhages, haemoptysis, abscesses, pneumonia, infections or tumour seeding were recorded in our series. The most common complication of MWA was pneumothorax (25% vs. 39% reported in the literature). Pleural effusion was a common reaction, but therapeutic drainage was never required.ConclusionsPneumothorax is the most common complication of both techniques. RFA and MWA are both excellent choices in terms of safety and tolerance.RiassuntoObiettivoScopo del presente studio è stato analizzare retrospettivamente le complicanze registrate nel trattamento termo-ablativo con radiofrequenze (RFA) e con microonde (MWA) di tumori polmonari, confrontarli con i dati riportati in letteratura e valutare i fattori di rischio correlati alle due procedure.Materiali e metodiDa gennaio 2003 a gennaio 2009, 29 pazienti (36 lesioni polmonari) sono stati trattati con RFA; da gennaio 2007 a gennaio 2009, 16 pazienti (17 lesioni polmonari) sono stati trattati con MWA. Le complicanze da noi registrate sono state riportate seguendo le linee guida della Society of Interventional Radiology (SIR). È stata eseguita anche una revisione della letteratura.RisultatiNessuna complicanza maggiore è stata osservata. In accordo con i dati presenti in letteratura, lo pneumotorace è la complicanza più frequente anche se la sua incidenza nella nostra casistica è più bassa (5,8% versus 4,3%–18% in letteratura). Nella nostra casistica, le complicanze post-RFA includono la soffusione pleurica e l’enfisema sottocutaneo. Non è stato osservato nessun caso di emorragia massiva, emottisi, nessuna infezione polmonare, né ascesso né disseminazione tumorale. Anche, nei pazienti trattati con MWA, la complicanza più frequente è stata lo pneumotorace (25% versus 39% riportato in letteratura). La soffusione pleurica è un riscontro frequente, ma in nessun caso è stato necessario il posizionamento di un drenaggio.ConclusioniLo pneumotorace è la complicanza più frequente in entrambe le procedure. La termo-ablazione percutanea, sia RFA che MWA, rappresenta un’ottima opzione terapeutica in termini di sicurezza e tolleranza.

The contribution of ultrasonography and computed tomography in the diagnosis of nonfunctioning islet cell tumors of the pancreas

The personal series of 12 nonfunctioning islet cell tumors (NFIT) of the pancreas is reported. The ultrasound and computed tomography features of NFIT are analyzed, and a few signs are identified that may be useful in the differential diagnosis vs ductal carcinoma. The necessity to complete the diagnostic work up by means of fine needle aspiration biopsy and cytologic smears is also emphasized.