Davide Fiore

Evaluation of the post-pneumonectomy space by computed tomography

Twenty-two patients who had undergone pneumonectomy for various reasons were evaluated by computed tomography (CT) in order to study the post-pneumonectomy space (PPS). In 13 of 22 cases, the residual PPS contained fluid, even years following surgery. In 9 of 22 cases, the PPS was obliterated. Obliteration of the PPS, one of the events that may follow pneumonectomy, is significantly correlated with the expansion of the nonoperated lung (coefficient, 0.84). Obliteration of the PPS does not present a significant coefficient of correlation with the following parameters, also considered in this study: time interval between surgery and CT, presurgical tests of respiratory function, hemidiaphragm elevation, and retraction of operated hemithorax. The fluid contained in the PPS does not organize but persists or is reabsorbed. Mediastinal shift depends on the expansion of the residual lung. The mediastinum rotates following right pneumonectomy and shifts following left pneumonectomy. The usefulness of CT in the follow-up of the pneumonectomized patient is stressed.

An ectopic mediastinal parathyroid adenoma accurately located by a single-day imaging protocol of Tc-99m pertechnetate-MIBI subtraction scintigraphy and MIBI-SPECT-computed tomographic image fusion.

Purpose Because ectopic parathyroid adenoma (PA) is a frequent cause of failed initial surgery, an imaging approach with accurate preoperative localization is recommended by some authors in patients with primary hyperparathyroidism (HPT). Methods The authors describe a 52-year-old woman in whom primary HPT was diagnosed incidentally during a screening program for osteoporosis. The peculiarity of this case is that the patient was examined before operation in a single-day multimodal imaging protocol based on the combination of high-resolution cervical ultrasound, planar Tc-99m pertechnetate–MIBI scans, and an MIBI-SPECT–computed tomographic (CT) image fusion study. An ectopic PA was accurately located in the upper middle mediastinum, close to the lower margin of the sternal notch. Results Guided by the MIBI-SPECT–CT fusion images, the surgeon performed a limited median sternotomy and easily removed the PA that was revealed before operation. To confirm the completeness of resection, a bilateral neck exploration was performed through the same incision, with identification of three normally sized parathyroid glands. Conclusions Our experience suggests the utility of multimodality imaging procedures for the accurate preoperative localization of PAs, particularly when they are present in ectopic mediastinal locations. Such procedures, including the MIBI-SPECT–CT image fusion study, can be performed in a single day.

The role of computed tomography in the evaluation of bullous lung disease

Three cases illustrate the value of computed tomography in bullous lung disease. Computed tomography offers additional information over standard radiography regarding the number, size, and origin of the bullae. Differential diagnosis between bullae and loculated pneumothorax is also possible. Computed tomography is indicated in postoperative follow-up to evaluate pulmonary re-expansion and to identify small residual peripheral bullae or pneumothorax.

Morbidity, mortality, and survival after bronchoplastic procedures for lung cancer.

OBJECTIVE Bronchoplastic procedures represent an effective surgical therapy for benign lesions, tumors of low-grade malignancy and also bronchogenic carcinoma in patients with a limited pulmonary function. We analyzed our experience in order to verify the mortality, morbidity, and long term survival in our patients. METHODS From 1980 to 1994, 217 patients underwent bronchoplastic procedures. We performed 92 bronchoplasties, 94 bronchial sleeves, and 31 tracheo-bronchial sleeves. Histologic examination revealed 133 epidermoid carcinomas, 28 adenocarcinomas, 11 small cells lung cancers, 5 large cells carcinomas, 2 adenosquamous carcinomas, 29 bronchial carcinoids, 6 adenoidocistic carcinomas, and 3 mucoepidermoid tumors. Regarding nodal status, 99 patients had N0 disease, 64 patients had N1 disease, and 54 patients had N2 disease. Thirty-six patients had preoperative irradiation and 181 patients had no preoperative irradiation. In 63 patients we used a perianastomotic pedicled flap; in 154 we did not use it. We considered all the 217 patients for the analysis of 30-day mortality and morbidity; of the 217 patients we analyzed long-term survival only in 179 because we excluded 38 patients with low grade malignant neoplasm. RESULTS Twenty-seven patients (12.5%) had postoperative complications. The 30-day mortality was 6.2% (14 patients). Survival at 5 and 10 years for all patients but those with low grade malignant neoplasm was 49 and 38%, respectively. For patients with N0 status 5- and 10-year survival was 72.4 and 59.4%; for patients with N1 status these rates were 35.7 and 26.8%; for patients with N2 status, 5- and 10-year survival was 22 and 14.4%. Postoperative complication rates for patients with or without pedicled flap are not significantly different; however, the rates for patients with or without preoperative irradiation are significantly different. CONCLUSIONS Bronchoplastic procedures are a safe and effective therapy for selected patients with pulmonary malignancy. Tracheo-bronchial sleeves are associated with high postoperative mortality and complication rates and these procedures should be limited to patients without N2 disease. Preoperative irradiation increases significantly the mortality and morbidity. A multivariate analysis shows that only the nodal status affects long-term survival (P = 0.0002).

Adrenocortical oncocytoma: case report and review of the literature.

Only 9 oncocytic neoplasms of true adrenal origin have been described to date. It therefore seemed of interest to study the histochemical and ultrastructural features of a non-functioning monolateral adrenocortical oncocytoma which was incidentally detected by ultrasonography and magnetic resonance imaging in a 28-year-old woman. The tumor was round, well encapsulated and weighed 73 g. It consisted of islets of eosinophilic cells, and did not display any sign of necrosis. The proliferation rate (as evaluated by mitotic index and percentage of MIB-1 Ki67 positive cells) was low, and atypic mitoses were absent; some rare cells with nuclear atypias were observed and the capsule was focally invaded by oncocytes. Immunocytochemistry did not show expression of vimentin or cytokeratin. The oncocytes had an abundant cytoplasm packed with mitochondria containing plate-like cristae. Smooth endoplasmic reticulum was virtually absent, while rough endoplasmic reticulum cisternae and free ribosomes were abundant. Although the classic histological approach clearly indicates the benign nature of the tumor, the immunocytochemical and ultrastructural features of oncocytes may suggest their potential for malignant behavior.

Imaging before and after multimodal treatment for malignant pleural mesothelioma

Purpose.Computed tomography (CT), magnetic resonance (MR) and positron emission tomography (PET) have a very important role in the diagnosis of malignant pleural mesothelioma (MPM) in the choice of chemoradiotherapy alone or in combination with surgery and in evaluating possible recurrence. It is also essential for assessing the possible benefits of radical surgery (pleuropneumonectomy) in terms of patient survival,Materials and methods.We considered 28 patients suffering from MPM whose mean survival after diagnosis was 15–18 months. Sixteen of these patients had radiotherapy or chemoradiotherapy alone, according to standard protocols, while 12 also underwent surgery. The CT features of MPM were thoroughly examined, as was the role of PET and CT–PET in achieving accurate disease staging and consequent selection of candidates for surgery.Results.Nine of the 12 patients who underwent pleuropneumonectomy had no significant survival advantage over the mean survival in the 16 who were not operated whereas the other three lived 1–3 years longer. Two patients underwent surgery after an optimal response to chemoradiotherapy, but both survived less than a year due to particularly aggressive recurrences.Conclusions.CT, PET and CT–PET are indicated for diagnosis and, above all, for staging of MPM, in the selection of patients who might benefit from surgery after neoadjuvant therapy and also in identifying small recurrences and/or remote metastases. Being highly specific, PET is essential in the follow–up of patients undergoing chemoradiotherapy alone and/or surgery. Each imaging modality has its advantages and limitations, but their combined use is crucial in determining the most appropriate treatment options for patients with MPM.

CT demonstration of bilateral Castleman tumors in the mediastinum.

A case of bilateral Castleman tumors in the posterior mediastinum is described. Computed tomography proved to be an accurate, noninvasive method of investigation since it identified not only a large mass but also a smaller mass, which was not visible on standard chest X-ray film. Complete surgical excision was possible. The high attenuation values of both masses demonstrated the hypervascularity of the lesion.

Computed tomography of the liver in von Gierke's disease

The computed tomography findings in the liver of a patient with von Gierkes disease are presented. Precontrast scans demonstrated diffuse decreased density throughout the liver. In the postcontrast scans, a focal right sided hyperdense area was visualized.

Multimodal imaging of esophagus and cardia cancer before and after treatment

Purpose.Prognosis and treatment of esophagus and cardia cancer (ECC) depend on the precision with which the disease is staged according to the American Joint Committee of Cancer (AJCC) criteria. Imaging modalities normally used in clinical staging are esophagography, esophagoscopy, endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography- CT fusion (CT-PET). The combination of these methods is crucial in determining not only the right diagnosis but also the stage and follow-up after multimodal treatment. The purpose of our investigation was to define the role of each imaging modality in determining the most appropriate treatment options in patients with ECC.Materials and methods.Fifty-six patients with ECC diagnosed by X-ray of the upper digestive tract, endoscopy and biopsy were staged using EUS, chest and abdomen CT scan, and CT-PET. Thirty-four patients in stage II and 18 patients in stage III underwent surgery after neoadjuvant chemotherapy; four patients in stage IV were treated with the positioning of an endoprosthesis after chemoradiotherapy. In the 52 patients who had surgery, follow-up included digestive tract X-ray, endoscopy and CT of the chest and abdomen every 6–8 months for the first 3 years. CT-PET was only performed in patients with a clinical suspicion of recurrence and/or CT findings suspicious of persistent disease (12 cases).Results.In all 56 patients, endoscopy, EUS, CT and CT-PET in combination were crucial in determining the site of disease, locoregional extent and depth of esophageal wall penetration (T), and any involvement of the mediastinal lymph nodes (N1), extrathoracic lymph nodes (M1) or hepatic metastases. In the locoregional staging of ECC before chemotherapy, we were able to differentiate T2–T3 from T4 in 40 patients; T4 disease was found in 12 potentially resectable cases. We were able to distinguish N0 from N1 in 12 patients. In four cases, the presence of small lymph node and/or liver metastases prompted positioning of an endoprosthesis. The specificity of CT in detecting small lymph nodes in the mediastinum was less than 50% while for CT-PET, it was more than 80%; EUS revealed sensitivity higher than 90% but a low specificity in seven cases. Only CT-PET revealed metastatic subdiaphragmatic lymph nodes (diameter <15 mm) in three cases. Presurgical restaging of the 18 patients (stage III) who had chemotherapy was based on endoscopy, EUS, CT of the chest and abdomen and CT-PET (only in suspected cases) and was compatible with surgery. Anastomotic recurrence was diagnosed in 16 patients by endoscopy with associated biopsy; any intramediastinal spread from anastomotic recurrences was evaluated by chest CT, and CT-PET in suspected cases.Conclusions.X-ray of the upper digestive tract and chest and abdomen CT scan are useful in preliminary evaluation of ECC. Endoscopy is particularly indicated for evaluating tumour morphology, taking biopsies for a histological diagnosis and the early diagnosis of anastomotic recurrences. EUS is indicated mainly for evaluating T stage before and after chemotherapy or chemoradiotherapy. CT-PET is extremely useful in identifying small mediastinal metastatic lymph nodes (N1) or extrathoracic lymph nodes (M1) and hepatic metastases (≤1 cm), which may escape multislice CT. PET alone is useful for identifying residual or recurrent tumour in the esophageal wall when an endoprosthesis is in place.

Clinically silent giant parathyroid adenoma: Differential diagnosis and therapeutic approach

A giant parathyroid adenoma described in this article was characterized by only a slight increase in serum calcium levels and a complete absence of symptoms. It is difficult to explain why such a large adenoma was clinically silent. There is no clear-cut correlation between the severity of hyperparathyroidism and adenoma size.