Cesare Fava

Effect of Preoperative Radiological Treatment of Hepatocellular Carcinoma Before Liver Transplantation: A Retrospective Study

AbstractPurpose: To assess the results of radiological treatment of patients with hepatocellular carcinoma (HCC) performed before orthotopic liver transplantation (OLT). Methods: Sixty-two transplanted patients with a total of 89 HCC nodules were studied; 50 lesions in 38 patients had been treated prior to OLT with transcatheter arterial chemoembolization (TACE: n=29), percutaneous ethanol injection (PEI; n=10), or combined therapy (TACE+PEI; n=11). The induced necrosis was pathologically evaluated. The recurrence rate after OLT in the treated group of patients (n=38) was compared with that in the non-treated group (n=24). Results: After TACE, necrosis was complete in 7 of 29 lesions (24.1%), partial in 11 of 29 (37.9%), and absent in 11 of 29 (37.9%). After PEI, necrosis was complete in 8 of 10 lesions (80%), and partial in 2 of 10 (20%). Using combined therapy, necrosis was complete in 11 of 11 lesions (100%). Four of 24 untreated and 4 of 38 treated patients did not survive OLT from causes not related to the HCC; 3 of 20 non-treated patients (15%) and 4 of 34 treated patients (11.8%) had post-OLT recurrence (these last four patients had undergone only TACE and did not have tumor necrosis at pathological examination). Conclusion: TACE of HCC prior to OLT had no influence on the recurrence rate. PEI and combined therapy (TACE + PEI) may be recommended in patients awaiting OLT.

Accuracy of CT-guided transthoracic needle biopsy of lung lesions: Factors affecting diagnostic yield

PurposeThis study was performed to analyse the variables affecting the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle biopsy of pulmonary lesions.Materials and methodsA retrospective study of 612 consecutive procedures with confirmed final diagnoses was undertaken. Benign and malignant needle biopsy results were compared with final outcomes to determine diagnostic accuracy. A statistical analysis of factors related to patient characteristics, lung lesions and biopsy technique was performed to determine possible influences on diagnostic yield. A p value less than 0.05 was interpreted as statistically significant.ResultsThere were 508 (83%) malignant and 104 (17%) benign lesions. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy for a diagnosis of malignancy were 90.2%, 99.0%, 99.8%, 67.3% and 91.7%, respectively. Overall diagnostic accuracy was 83.3%. Variables affecting diagnostic accuracy were the final diagnosis (benign 67%, malignant 92%; p<0.001) and lesion size (lesions<1.5 cm 68%, lesions 1.5–5.0 cm 87%, lesions>5 cm 78%; p<0.05).ConclusionsIn CT-guided transthoracic needle biopsy, the final diagnosis and lesion size affect diagnostic accuracy: benign lung lesions and lesions smaller than 1.5 cm or larger than 5.0 cm in diameter provide lower diagnostic yield.RiassuntoObiettivoValutare i fattori che influenzano l’accuratezza diagnostica dell’agobiopsia transtoracica percutanea TC-guidata di lesioni polmonari.Materiali e metodiSono state considerate retrospettivamente 612 procedure bioptiche consecutive per le quali è risultata disponibile la diagnosi definitiva. I reperti bioptici benigni e maligni sono stati confrontati con la diagnosi finale, ricavando l’accuratezza diagnostica della metodica. È stata quindi condotta un’analisi statistica relativamente a variabili proprie del paziente, della lesione e della tecnica bioptica per determinare possibili influenze sui valori di accuratezza. I dati ottenuti sono stati considerati statisticamente significativi per valori di p<0,05.RisultatiCinquecentootto lesioni (83%) sono risultate, alla diagnosi finale, maligne, mentre 104 (17%) benigne. I valori di sensibilità, specificità, valore predittivo positivo, valore predittivo negativo ed accuratezza, riferiti ad una diagnosi di malignità, sono risultati rispettivamente del 90,2%, 99,0%, 99,8%, 67,3% e 91,7%. L’accuratezza diagnostica globale della procedura è stata dell’83,3%. Le variabili che hanno influenzato significativamente i livelli di accuratezza sono risultate la diagnosi finale (espansi benigni 67%, maligni 92%; p<0,001) ed il diametro medio della lesione (lesioni<1,5 cm 68%, tra 1,5 e 5,0 cm 87%, >5 cm 78%; p<0,005).ConclusioniLa diagnosi finale (benignità versus malignità) e le dimensioni della lesione influenzano l’accuratezza diagnostica della metodica: addensamenti polmonari di natura benigna e lesioni con diametro <1,5 cm o >5 cm sono caratterizzati da livelli minori di accuratezza diagnostica.

Combined evaluation of total and functional liver plasma flows and intrahepatic shunting

A diagnostic protocol was studied, designed to evaluate the main parameters of liver circulation in man. A water solution ofd-sorbitol (S) and indocyanine green (ICG) was infused intravenously in six controls and nine cirrhotics. Steady-state renal and hepatic S clearances as well as hepatic ICG clearance were calculated. In controls the values (mean ±sd) of the independent measurements of S and ICG hepatic clearance were 978±107 and 519±142 ml/min, respectively, while in cirrhotic patients they were 554±238 and 231±90 ml/min. Owing to the kinetic properties of S, its hepatic clearance may be regarded as a measure of functional liver plasma flow (FLPF). The total liver plasma flow (TLPF) values (mean±sd), calculated according to Ficks principle, were 1091±157 ml/min (S method) and 1033±153 ml/min (ICG method) in controls, and 1251±554 and 1284±677 ml/min in cirrhotics. In controls, FLPF was found to be very close to TLPF. In cirrhotic patients the difference between TLPF and FLPF (ranging from 169 to 2093 ml/min when measured by S method) was considered as an approximate estimate of intrahepatic shunting. The procedure is safe and simple and may add a new dimension to the investigation of hepatic circulation.

Ultrasound diagnosis of pneumothorax

Purpose.The purpose of this study was to show the effectiveness of ultrasound (US) in the evaluation of pneumothorax by comparison with X–rays and computed tomography (CT).Materials and methods.A series of 184 patients (130 men and 54 women), aged 26 to 82 years, underwent chest US after percutaneous needle biopsy. US findings were compared with CT postbiopsy selective slices and to X–rays.Results.Pneumothorax was identified in 46 patients (25%) by CT, in 44 by US, with no false positives, and in 19 by X–rays. US sensitivity was 95.65%, specificity 100% and diagnostic effectiveness 98.91%.Conclusions.Chest US was found to be a valuable diagnostic tool in pneumothorax diagnosis, with diagnostic effectiveness well beyond X–rays and similar to CT.

Second Italian consensus conference on malignant pleural mesothelioma : state of the art and recommendations

Malignant pleural mesothelioma (MPM) is a relevant public health issue. A large amount of data indicate a relationship between mesothelioma and asbestos exposure. MPM incidence has considerably and constantly increased over the past two decades in industrialized countries and is expected to peak in 2010-2020. In Italy, the standardized incidence rate in 2008 was 3.6 and 1.3 per 100,000 in men and women respectively, with wide differences from one region to another. The approach to this disease remains difficult and complex in terms of pathogenic mechanism, diagnosis, staging and treatment thus an optimal strategy has not yet been clearly defined. The Second Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Turin (Italy) on November 24-25, 2011: recommendations on MPM management for public health institutions, clinicians and patients are presented in this report.

Contrast–enhanced ultrasonography in Crohn’s disease

Purpose.The purpose of this study was to demonstrate the diagnostic efficacy of contrast–enhanced power Doppler (CEPD) after ultrasound (US) with colour power Doppler (CPD) in defining disease activity in patients with ileal Crohn’s disease in the acute phase and during treatment follow–up.Materials and methods.The study included 15 patients with ileal Crohn’s disease, 12 of whom were examined in the acute phase of their illness and then 30–60 days after treatment. Three patients were studied during clinical quiescence. All patients were examined prior to treatment with US–CPD study and then with contrast–enhanced power Doppler (CEPD) examination (CEPD) with the use of US contrast agent (SonoVue, Bracco), together with clinical assessment and laboratory tests. Disease activity was defined by the Crohn’s Disease Activity Index (CDAI) and some of the most sensitive biohumoural markers. After initial US, CPD and CEPD were performed to assess enhancement of the thickened bowel wall with the use of a reference box and a semiquantitative scoring system.Results.The CEPD study is more reliable then US–CPD in the diagnosis of Crohn’s disease and statistically agrees significantly with clinical and laboratory indices for disease activity.Conclusions.This study demonstrates the importance of US–CPD in the follow–up of patients with Crohn’s disease and suggests systematic use of the US contrast agent, which can improve diagnostic performance of abdominal US study. It also provides more information about patients both in the acute phase and during follow–up, thus improving treatment planning and better monitoring of treatment efficacy.

Tumor staging but not grading is associated with adverse clinical outcome in neuroendocrine tumors of the appendix: a retrospective clinical pathologic analysis of 138 cases.

Appendiceal neuroendocrine neoplasms (NENs) are rare and usually incidentally discovered. Most cases are clinically indolent, although the rare aggressive ones are poorly predictable. The aim of this study was to test the applicability and prognostic significance of the new World Health Organization (WHO) classification and to test the several pathologic features and TNM staging systems (American Joint Committee on Cancer and European Neuroendocrine Tumor Society) in these tumors. A multi-institutional retrospective series of 138 appendiceal NENs was selected on the basis of the availability of both pathologic material and clinical information, including follow-up data. All cases were reviewed to record pathologic features and to apply year 2000 and 2010 WHO classifications, as well as European Neuroendocrine Tumor Society and American Joint Committee on Cancer TNM stages. Clinical and pathologic characteristics were compared with disease outcome by contingency, univariate, and multivariate survival analyses. Although up to one third of cases presented several malignancy-associated pathologic features, only 4 patients died of the disease. Adverse outcome was significantly associated with extramural extension (including mesoappendix), well-differentiated carcinoma diagnosis (2000 WHO classification), pT3-4 stage, older age, and presence of positive resection margins, but not with tumor size, mitotic or proliferative indexes, and, consequently, 2010 WHO grading. In the appendix, at variance with midgut/hindgut NENs, the 2000 WHO classification performs better than the grading-based 2010 WHO scheme and, together with tumor stage, is the most relevant parameter associated with clinical aggressiveness.

CT features of solitary fibrous tumour of the pleura: experience in 26 patients

Purpose.The purpose of this study was to identify the typical computed tomography (CT) features of solitary fibrous tumours of the pleura (SFTP) and determine which findings would allow confirmation of the pleural origin or benign behaviour of the tumour.Materials and methods.Twenty–six preoperative CT studies of the chest (23 enhanced and 14 unenhanced) were retrospectively reviewed.Results.Up to 50% of SFTP were larger than 10 cm. At unenhanced CT, they showed homogeneous attenuation in 5 cases (35.7%) and inhomogeneous attenuation in 9 (64.3%). At contrastenhanced CT, they were inhomogeneous in 21 cases (91.3%), with geographic pattern (61.9% of cases), serpiginous linear areas of enhancement (intralesional vessels) (23.8%), rounded (52.4%) or linear (33.3%) areas of low attenuation (necrosis).Conclusions.Depending on location, size and histological features, SFTP may produce a large spectrum of findings. Typical CT features of small SFTP were well–defined margins and smooth contours, homogeneous attenuation and right or obtuse angles with the pleura. Larger lesions were characterised by well–defined margins and lobulated contours, geographic pattern in enhanced CT scans, acute angles or smooth tapering margins with the pleura.

Role of diffusion- and perfusion-weighted MR imaging for brain tumour characterisation

PurposeThis study was undertaken to correlate apparent diffusion coefficient (ADC) and relative regional cerebral blood volume (rrCBV) to histological findings in a large series of patients with primary or secondary brain tumours to evaluate diffusion-weighted (DWI) and perfusionweighted (PWI) imaging in the characterisation of cerebral tumors.Materials and methodsNinety-eight patients with cerebral tumours, 46 of which were primary (seven grade 0-I, nine low-grade gliomas, two gliomatosis cerebri, nine lymphomas and 19 high-grade gliomas) and 52 secondary, underwent conventional magnetic resonance (MR) imaging completed with DWI and dynamic contrast susceptibility PWI. Both ADC and rrCBV were calculated on a workstation by using Functool 2 software. Student’s t test was used to determine any statistically significant differences in the ADC and rrCBV values.ResultsSeventeen of 98 tumours were cystic or necrotic (12/17 hypointense and 5/17 hyperintense on DWI); the ADC value of hyperintense cystic areas was 0.97±0.23×10−3 mm2/s. The ADC value of solid tumours varied between 0.64 and 3.5×10−3 mm2/s. The rrCBV value was 1.4 (σ 0.66) in low-grade gliomas; 1.22 (σ 0.25) in lymphomas; 4.5 (σ 0.85) in grade III gliomas; 3.18 (σ 1.26) in grade IV gliomas and 2.53 (σ 1.6) in metastases.ConclusionsDWI has an important role in the differential diagnosis of cystic cerebral masses but not in tumour characterisation. PWI is helpful in differentiating high-from low-grade gliomas and lymphomas from high-grade gliomas.RiassuntoObiettivoCorrelare i valori del coefficiente di diffusione apparente (ADC) e del volume cerebrale medio (rrCBV), ottenuti su un’ampia serie di pazienti con tumori cerebrali (primitivi o secondari), con il dato istologico per valutare l’apporto delle tecniche di diffusione (DWI) e perfusione (PWI) nella caratterizzazione dei tumori cerebrali.Materiali e metodiNovantotto pazienti con tumore cerebrale, 46 con tumore primitivo (7 di grado 0–I, 9 gliomi a basso grado, 2 gliomatosi cerebri, 9 linfomi, 19 gliomi ad alto grado) e 52 con metastasi sono stati sottoposti ad esame RM convenzionale completato da acquisizione DWI e da studio perfusionale ottenuto durante la somministrazione di un bolo di gadolinio. Su tutte le lesioni sono state effettuate rielaborazioni su una work-station per il calcolo dell’ADC e della rrCBV utilizzando il software “functool 2”. Sono state effettuate rielaborazioni statistiche utilizzando il test t di Student per dati non appaiati.RisultatiDiciassette tumori erano costituiti da una componente centrale cistica che in 5 casi era iperintensa in DWI (valore medio ADC 0,97±0,23×10−3 mm2/s). L’ADC della parte solida dei tumori aveva valori compresi tra 0,64 e 3,5×10−3 mm2/s. L’rrCBV media è risultata di 1,4 (σ 0,66) nei gliomi a basso grado; 1,22 (σ 0,25) nei linfomi; 4,5 (σ 0,85) nei gliomi grado III; 3,18 (σ 1,26) nei gliomi grado IV e 2,53 (σ 1,6) nelle metastasi.ConclusioniLe acquisizioni DWI hanno un ruolo rilevante nella diagnosi delle masse cistiche, mentre non sembrano avere un ruolo nella caratterizzazione dei tumori. La PWI fornisce elementi utili nella diagnosi differenziale tra gliomi a basso ed alto grado e tra gliomi ad alto grado e linfomi.

Acute abdomen as an unusual presentation of hepatic PEComa. A case report

Perivascular epithelioid cell (PEC) tumors (or PEComas) are myomelanocytic lesions defined by coexpression of melanocytic and muscle markers, suggesting dual differentiation. They are rare mesenchymal tumors and include subtypes with distinct clinical features: angiomyolipoma, lymphangioleiomyomatosis, and clear cell “sugar” tumors of the lung, pancreas and uterus. Consequent upon the World Health Organizations recognition of PEC-derived tumors as a distinct entity, an increasing number of reports has documented PEComas arising at various anatomical locations. Clear cell myomelanocytic tumors of the falciform ligament/ligamentum teres (CCMTs) represent a rare variant of the PEComas. These hepatic PEComas, different from angiomyolipoma of the liver, pose a clinical, radiological and morphological diagnostic challenge. Because of their rarity, the clinical features and biological behavior of these tumors have yet to be established. We experienced our first case of CCMT in a 36-year-old woman who presented to our emergency department with a 3-day history of abdominal discomfort and progressive growth of an epigastric bulk. Intralesional hemorrhage was causing abdominal distension, which progressed to acute abdomen soon after. The hemoglobin concentration was 9.9 g/dL. Liver laboratory tests showed slight elevation of AST, ALT and gamma-GT. The alpha-fetoprotein level was not elevated. The radiological images showed a hemorrhagic mass with some bizarre features in left hepatic lobe, immediately adjacent to the ligamentum teres and falciform ligament. The patient underwent a left hepatic lobectomy. The diagnosis of CCMT was based on histological and immunohistochemical staining. The postoperative course was uneventful. The patient received no adjuvant treatment and is currently, 34 months after surgery, alive and disease free. In this report we describe a peculiar and hitherto undescribed clinical presentation of this tumor and its further course. Moreover, we discuss previously undescribed diagnostic imaging. We recommend that all unusual carcinomas and mesenchymal tumors of the liver should be tested for HMB-45: when positive, there is a high likelihood of PEComa.