Elvio De Fiori

Early lung-cancer detection with spiral CT and positron emission tomography in heavy smokers: 2-year results

BACKGROUND Low-dose spiral CT of the chest effectively detects early-stage lung cancer in high-risk individuals. The high rate of benign nodules and issues of making a differential diagnosis are critical factors that currently hamper introduction of large-scale screening programmes. We investigated the efficacy of repeated yearly spiral CT and selective use of positron emission tomography (PET) in a large cohort of high-risk volunteers. METHODS We enrolled 1035 individuals aged 50 years or older who had smoked for 20 pack-years or more. All patients underwent annual low-dose CT, with or without PET, for 5 years. Lesions up to 5 mm were deemed non-suspicious and low-dose CT was repeated after 12 months (year 2). FINDINGS By year 2, 22 cases of lung cancer had been diagnosed (11 at baseline, 11 at year 2). 440 lung lesions were identified in 298 (29%) participants, and 95 were recalled for high-resolution contrast CT. PET scans were positive in 18 of 20 of the identified cancer cases. Six patients underwent surgical biopsy for benign disease because of false-positive results (6% of recalls, 22% of invasive procedures). Complete resection was achieved in 21 (95%) lung cancers, 17 (77%) were pathological stage I (100% at year 2), and the mean tumour size was 18 mm. There were no interval lung cancers in the 2.5 years of follow-up (average time on study from randomisation to last contact), although 19 individuals were diagnosed with another form of cancer (two deaths and 17 non-fatal admissions). INTERPRETATION Combined use of low-dose spiral CT and selective PET effectively detects early lung cancer. Lesions up to 5 mm can be checked again at 12 months without major risks of progression.

In vivo repeatability of automated volume calculations of small pulmonary nodules with CT.

OBJECTIVE The objectives of our study were to evaluate the in vivo reproducibility of automated volume calculations of small lung nodules with both low-dose and standard-dose CT and to assess whether repeatability within each technique varies according to the diameter, site, or morphology of the nodule or to percentage of emphysema. SUBJECTS AND METHODS Sixty-six subjects with 83 solid pulmonary nodules between 5 and 10 mm in diameter were enrolled in this prospective study. Four consecutive MDCT data sets, two low dose and two standard dose, were obtained for each nodule on separate breath-holds during the same session. The volume of each nodule was calculated by automated software. Repeatability was evaluated by Bland-Altmans approach and the coefficient of repeatability. Associations of the percentage of volume variation between two measurements with nodule diameter, emphysema percentage, nodule site, and nodule morphology were assessed by Spearmans correlation coefficient and the Kruskal-Wallis test. A p value of < 0.05 was considered statistically significant. RESULTS The range of variation of the volumes of pulmonary nodules between two subsequent measurements was -38% +/- 60% for low-dose CT and -27% +/- 40% for standard-dose CT. No significant statistical association was found between variation in volume measurements and nodule site, nodule diameter, nodule morphology, or emphysema percentage by semiautomated calculation of lung density. CONCLUSION Automated volume calculations of small pulmonary nodules can significantly differ between two subsequent breath-holds with both low-dose and standard-dose CT techniques; in clinical practice we recommend that a volume variation of greater than 30% for nodules between 5 and 10 mm should be confirmed by follow-up CT to be sure that a nodule is actually growing.

Pulmonary Nodules: Contrast-Enhanced Volumetric Variation at Different CT Scan Delays

OBJECTIVE The purpose of this study was to assess the effects of IV contrast medium and different CT scan delays on volumetric measurements of pulmonary nodule. MATERIALS AND METHODS Automated volumes of 35 pulmonary nodules were calculated with two dedicated software packages (designated as software A and software B) for each unenhanced and contrast-enhanced CT scan at 30-, 60-, 120-, 180-, and 300-second delays (injection protocol, 2 mL/s and 2 mL/kg). Nodule attenuation was also determined. Differences between unenhanced and contrast-enhanced volumes were analyzed by Wilcoxons signed rank test. Contrast-enhanced volume ratio was calculated as the ratio between contrast-enhanced and unenhanced nodule volume. RESULTS Contrast-enhanced volumes were significantly larger than unenhanced volumes (p < 0.05) for all the timing delays except at 30 seconds for software A, and no significant differences were found among volumes measured with both software programs at different contrast-enhanced delays. Median volume ratios between contrast-enhanced and unenhanced volumes were 1.04-1.07 for software A and 1.04-1.06 for software B, and median volume ratios within different contrast-enhanced delays were 0.99-1.03 for software A and 0.99-1.04 for software B. We did not find any significant association between contrast-enhanced volume ratio and nodule diameter, site, shape, unenhanced density, or contrast-enhanced density ratio (p > 0.05). CONCLUSION We recommend comparing volume of pulmonary nodules obtained from CT examinations only if they are all performed with or without contrast material, whereas nodule volumes obtained by use of enhanced CT performed with different scan delays are comparable.

Ultrasound-guided transcutaneous Tru-Cut biopsy to diagnose laryngopharyngeal masses: a pilot study.

Patients with bulky laryngopharyngeal masses and a relative or absolute contraindication to general anesthesia present diagnostic difficulties. In the current study, the authors assessed the utility of transcutaneous ultrasound‐guided Tru‐Cut biopsy (USGTCB) under local anesthesia in such individuals.

Radio-guided ultrasound lymph node localization: Feasibility of a new technique for localizing and excising nonpalpable lymph nodes ultrasound suspicious for melanoma metastases

Identification of lymph nodes suspicious for metastases is crucial in melanoma patients during the follow-up. We propose a procedure called radio-guided ultrasound lymph node localization (RULL) for melanoma patients with ultrasound (US) suspicious, not palpable, lymph nodes. The aim of this study was to evaluate the feasibility of this technique, and to assess the efficacy of this new method. RULL was applied in 12 consecutive melanoma patients with non-palpable lymph nodes found suspicious for metastases during US follow-up. Macro-aggregates of human serum albumin labelled with diluted technetium-99m were injected into the suspected lymph node under US guidance and followed by a scintigraphy. The surgical treatment was carried out with the support of hand-held γ-probe used for sentinel node biopsy. The tracer was correctly positioned in all 12 patients. Pathological examination revealed seven patients with metastatic lymph nodes, four with no metastatic lymph node, one patient with Hodgkin disease. No surgical complications were described. In conclusion, RULL may integrate the standard ultrasound-guided fine-needle aspiration to improve the diagnostic accuracy on US suspicious nodes and might replace the more logistically complicated wire identification or less accurate cutaneous marker identification of these nodes. Sensibility and specificity of this approach should be defined through a large multicentric study.

The role of ultrasound-guided transcutaneous tru-cut biopsy in diagnosing untreated and recurrent laryngo-hypopharyngeal masses

OBJECTIVE To evaluate the diagnostic performance of Ultrasound-guided Transcutaneous Tru-Cut biopsy (USGTCB) of laryngo-hypopharyngeal masses suspicious for malignancy. Furthermore we investigated whether USGTCB is accurate for both untreated masses and suspected recurrences. MATERIALS AND METHODS From August 2004 to July 2014 we prospectively enrolled 66 patients for a total of 68 USGTCBs: 38 USGTCB were performed for a suspicious untreated mass and in 30 for a suspected recurrence. We calculated the sensitivity, specificity, positive predictive value and negative predictive value for all procedures and separately for untreated masses and suspected recurrences. RESULTS USGTCB diagnosed 57 malignancies (51 squamous cell carcinomas, 6 other tumors) and 11 benign lesions. There were no false positives reported, whereas five false negatives were observed: two in patients with an untreated mass, three in patients with a suspected recurrence. Overall, the sensitivity of the technique was 91.9% (95% confidence interval [CI]: 82.2-97.3%); the specificity was 100% (95% CI: 54.1-100%); positive and negative predictive values were 100% (95% CI: 93.7-100%) and 54.5% (95% CI: 23.5-83.1%) respectively, with similar performances in untreated masses and suspected recurrences of SCC. CONCLUSION USGTCB is an effective procedure for the histological diagnosis of laryngo-hypopharyngeal masses suspicious for malignancy in patients showing contraindications to biopsy via microlaryngoscopy under general, with similar performances for untreated masses and suspected recurrences.

Core needle biopsy as a front line diagnostic approach for lymphoma patients

The modern concept of personalized medicine acknowledges the ancient teaching ‘first do no harm’ by delivering the minimum efficacious rather than the maximum tolerable treatment. Along this line, a diagnostic procedure should be well-tolerated and associated with very low morbidity, besides sensitive, accurate, reproducible and cost-effective. As a consequence, core needle biopsy (CNB) is increasingly used for the diagnosis as well as the evaluation of predictive and prognostic characteristics of primary and metastatic solid tumours. Diagnosing lymphomas is a challenging task accomplished only by carefully integrating clinical, morphological, phenotypical and molecular data [1]. None of these tools may be considered the ‘magic bullet’, but the traditional histopathological evaluation still maintains its pivotal role in the diagnostic algorithm, contributing to the narrow spectrum of the most likely diseases, and therefore appropriately driving the subsequent phenotypical and molecular analyses. On the other hand, the introduction of commercial fluorescent in situ hybridization kits for detecting the hallmark translocations of the commonest types of lymphomas has further improved the efficacy of the ‘molecular’ diagnostic armoury, already including a continuously broadening panel of antibodies for immunophenotyping and polymerase chain reaction for clonality detection. In this rapidly evolving scenario, the diagnostic guidelines for lymphomas still establish that a surgically excised lymph node should always be available for ensuring the histopathological evaluation of lymph node architecture, tumour growth pattern and cell composition, and providing enough tissue for molecular analyses and research purposes [1]. Although theoretically faultless and certainly reassuring for pathologists and researchers, a surgical procedure devoted merely to diagnostic purposes has a number of practical and psychological downsides for patients and their physicians, because it requires hospitalization and potentially harmful interventions under local or general anaesthesia. CNB is associated with fewer complications and lower costs than excision biopsy, especially when deeply seated lymph nodes are involved, and is already used in lymphomas arising in extranodal sites, either because there are no alternative options, as in the case of bone or central nervous system lymphomas, or because surgery itself has been demonstrated to jeopardize patients’ prognosis, as in the case of gastric marginal zone lymphomas.

Contrast-enhanced ultrasound sonography optimises the assessment of lymph nodes in oncology

Ultrasound sonography (US) plays an important role in the assessment of lymph nodes in oncology. However, ultrasound findings are often equivocal in not allowing the differentiation of reactive from metastatic lymph nodes. Here, we present the successful use of contrast-enhanced US in the assessment of a metastatic lymph node, improving the performance of conventional US and optimising the US-guided percutaneous biopsy.

Percutaneous laser ablation for thyroid benign and malignant diseases

Minimally invasive image-guided thermal ablation is becoming increasingly common as an alternative to surgery for the treatment of benign thyroid nodules. Among the various techniques for thermal ablation, laser ablation (LA) is the least invasive, using the smallest applicators available on the market and enabling extremely precise energy deposition. However, in some cases, multiple laser fibers must be used simultaneously for the treatment of large nodules. In this review, the LA technique is described, and its main clinical applications and results are discussed and illustrated.

Imaging and screening strategies in oncology: Monday 11 October 2004, 09:00–9:30.

This paper aims to discuss the role of diagnostic imaging in screening protocols for early detection of cancer of the breast, colon and rectum, prostate and lung. The latest attitude of scientists and public health managers towards screening programmes is mainly driven by evidence results, but randomised trials are often difficult to start due to ethical reasons, and difficult to conclude because of the merging new technologies and the long time required. While mammography, even if sometimes controversial, is nowadays a consolidated tool for early diagnosis of breast cancer, other diagnostic techniques, such as low-dose computed tomography for detection of lung cancer, need to prove their efficacy and avoid extended times required to obtain evidence-based results.