Fabio Pinto

Long-term results of percutaneous ethanol injection therapy for hepatocellular carcinoma in cirrhosis: a European experience

Abstract. The objective of our work was to evaluate the long-term results of percutaneous ethanol injection (PEI) for the treatment of hepatocellular carcinoma (HCC) in patients with liver cirrhosis. A total of 184 cirrhotic patients with HCC underwent PEI as the only anticancer treatment over an 8-year period. Patients were followed after therapy by means of clinical examinations, laboratory tests, and US and CT studies performed at regular time intervals. Survival rates were determined according to the Kaplan-Meier method. The overall survival was 67 % at 3 years, 41 % at 5 years, and 19 % at 7 years. The 3-, 5-, and 7-year survival rates of patients with single HCC ≤ 3 cm (78, 54, and 28 %, respectively) were significantly higher (p < 0.01) than those of patients with single HCC of 3.1–5 cm (61, 32, and 16, respectively) or multiple HCCs (51, 21, and 0 %, respectively). Survival of Child-Pugh A patients (79 % at 3 years, 53 % at 5 years, and 32 % at 7 years) was significantly longer (p < 0.01) than that of Child-Pugh B patients (50 % at 3 years, 28 % at 5 years, and 8 % at 7 years). A selected group of 70 patients with Child-Pugh A cirrhosis and single HCC ≤ 3 cm had a 7-year survival of 42 %. Long-term survival of cirrhotic patients with HCC treated with PEI is comparable to that reported in published series of matched patients submitted to surgical resection.

Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography

Purpose.The purpose of this study was to determine the role of plain chest radiography in the evaluation of patients with suspected foreign–body aspiration.Materials and methods.During a 5–year period, 31 patients (18 men and 13 women; age range 6 months to 85 years) were referred to our observation for clinical suspicion of foreign–body aspiration. Clinically, the patients presented with cough in 27/31 cases (87.1%), decreased breath sounds in 22/31 (71%), choking in 18/31 (58.1%), fever in 7/31 (22.6%) and cyanosis in 5/31 (16.1%). Suspected foreign–body aspiration had occurred 2–72 h before hospitalisation. Within 2 h of hospitalisation, all patients underwent plain chest radiography performed in the upright position (two projections) in 10/31 (32.3%) patients and in the supine decubitus position in the remaining 21 (67.7%) patients. Plain chest radiography was subsequently integrated with multislice computed tomography (MSCT) of the chest in 3/31 (9.7%) patients and with bronchoscopy in 27/31 (87.1%) patients.Results.Plain chest radiography showed the presence of a foreign body in the tracheobronchial tree in 7/31 (22.6%) patients, who subsequently underwent successful bronchoscopy in all cases. Foreign bodies included tooth fragment (three cases), nail (two cases), metallic spiral of a ball–point pen (one case) and an earring (one case). In the remaining 24/31 patients, plain chest radiography was positive in 14 cases, showing atelectasis (seven cases), pneumonia (six cases), pulmonary hyperinflation (one case) and pneumomediastinum (one case). Such findings had been caused by an aspirated foreign body, which was subsequently removed by means of bronchoscopy in all 14 patients. Moreover, three of the remaining ten patients with negative plain chest radiograph were submitted to MSCT of the chest, which required in 1 case tracheobronchial aspiration of a foreign body that was subsequently removed by means of bronchoscopy. Overall, plain chest radiography showed the presence of foreign–body aspiration and/or pleuroparenchymal lesions in 21/31 patients (67.7%); bronchoscopy was positive in 23/27 patients (85.2%), localising the foreign body in the right main bronchus in 16/27 patients (59.3%), left main bronchus in 7/27 patients (25.9%), intermediate bronchus in 2/27 patients (7.4%) and right lower lobe bronchus in 2/27 patients (7.4%). No late complications were observed within 6 months of hospital discharge.Conclusions.Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Nevertheless, in the case of negative chest radiography and a clinical suspicion of foreign–body aspiration, MSCT—possibly integrated with virtual bronchoscopy—should be considered in order to avoid unnecessary bronchoscopy.

Differentiation of hepatocellular adenoma and focal nodular hyperplasia of the liver: comparison of power Doppler imaging and conventional color Doppler sonography

The aim of our study was to compare the diagnostic efficacy of power Doppler imaging and conventional color Doppler sonography for differentiating between hepatocellular adenoma (HCA) and focal nodular hyperplasia (FNH) of the liver. Thirty-one focal liver lesions (in 29 patients) with histologic proof of HCA (n = 9) or FNH (n = 22) were studied with power and color Doppler sonography according to a standardized examination protocol. The size of the lesions ranged between 1.5 and 14.5 cm (HCA, 3.5–14.5 cm, mean ± SD 7.3 ± 3.3 cm; FNH, 1.5–9.1 cm, mean ± SD 5.1 ± 2.1 cm). Intratumoral vessels with a venous Doppler spectrum, associated with either pulsatile or continuous peripheral flow, were detected in HCA (eight of nine lesions by power Doppler imaging and six of nine by color Doppler imaging) but not in FNH. In contrast, color signals with an arterial Doppler spectrum, radiating from the center to the periphery of the lesion, were depicted in FNH (20 of 22 cases by power Doppler imaging and 15 of 22 by color Doppler sonography) but not in HCA. Differentiation of HCA and FNH was achieved in 28 of 31 cases (90 %) by power Doppler imaging and in 21 of 31 (68 %) by color Doppler sonography (p < 0.01). Power Doppler imaging is superior to conventional color Doppler sonography in the depiction of the intratumoral flow characteristics of HCA and FNH, and enables a more accurate differential diagnosis than color Doppler sonography.

Combined transcatheter arterial chemoembolization and percutaneous ethanol injection for the treatment of large hepatocellular carcinoma: local therapeutic effect and long-term survival rate.

Abstract. The aim of our study was to investigate local therapeutic effects and long-term results of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of large hepatocellular carcinoma (HCC). Eight-six patients (67 males and 19 females, age range 48–75 years, mean age 65.1 years) with Child-Pugh class A (n = 48) or B (n = 38) liver cirrhosis and a large HCC (main tumor 3.1–8 cm in diameter with no more than two daughter nodules) were enrolled in a prospective study. All patients underwent a single TACE session followed by PEI. Follow-up ranged from 4 to 65 months (mean 27.8 months, median 26 months). No major complication occurred. The local therapeutic effect, as assessed on the basis of findings at CT and MR imaging, was complete response in 71 of 86 patients (82 %) and partial response in 15 of 86. Overall survival rates by the Kaplan-Meier method were 92 % at 1 year, 83 % at 2 years, 69 % at 3 years, 58 % at 4 years, and 47 % at 5 years. Survival of Child-Pugh A patients (75 % at 3 years and 59 % at 5 years) was significantly longer (p < 0.01) than that of Child-Pugh B patients (61 % at 3 years and 35 % at 5 years). Combined TACE and PEI is an effective treatment for large HCC.

Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma.

The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.

Intrahepatic metastatic nodules of hepatocellular carcinoma detected at Lipiodol-CT: imaging-pathologic correlation

Abstract.Background: The purpose of this study was to determine whether tiny (<2 cm) areas of iodized-oil retention diagnosed as intrahepatic metastatic nodules of hepatocellular carcinoma (HCC) at computed tomography (CT) following intraarterial injection of Lipiodol (Lipiodol-CT) correlate with truly cancerous foci on the corresponding sectioned pathologic specimens. Methods: Thirty-two consecutive patients with biopsy-proven HCC (26 men and six women, aged 41–72 years) underwent prospective evaluation with Lipiodol-CT before undergoing surgery (hepatic resection, 30 patients; liver transplantation, two patients). Imaging findings were correlated with intraoperative and pathologic findings. Results: Twenty-one areas of retained Lipiodol (0.5–1.6 cm in diameter, mean ± SD: 0.9 ± 0.3 cm) had features consistent with intrahepatic metastatic nodules of HCC on Lipiodol-CT scans. Nineteen of the 21 areas correlated with tumor deposits at pathologic examination of the surgical specimens, whereas two of 21 were due to abnormal retention of iodized oil within noncancerous liver parenchyma. The positive predictive value of findings at Lipiodol-CT for the diagnosis of intrahepatic metastatic nodule of HCC was 90.5%. Conclusions: Findings at Lipiodol-CT enable a reliable diagnosis of intrahepatic metastatic nodules of HCC.

Role of Imaging in the Assessment of Impacted Foreign Bodies in the Hypopharynx and Cervical Esophagus

Impaction of foreign bodies in the upper digestive tract is a serious pathologic condition in ear, nose, and throat practice and is particularly common in children, prisoners, and psychiatric patients. Commonly found objects include fish bones, chicken bones, pieces of glass, dental prostheses, coins, and needles. The goals of the initial patient assessment are to identify the type of object, its location in the gastrointestinal tract, the presence of any associated complications, and the presence of any underlying esophageal conditions. Radiographic evaluation is helpful to confirm the location of foreign bodies and associated complications. Plain films of the neck and chest commonly will show the location of radiopaque objects, such as coins. Both anteroposterior and lateral views are necessary, as some radiopaque objects overlying the vertebral column may only be visible on the lateral view. Multidetector row computed tomography is superior to plain radiographs for the detection of pharyngoesophageal foreign bodies and provide additional crucial information for the management of complicated cases especially related to sharp or pointed ingested foreign bodies.

Accuracy of ultrasonography in the diagnosis of acute appendicitis in adult patients: review of the literature

BackgroundUltrasound is a widely used technique in the diagnosis of acute appendicitis; nevertheless, its utilization still remains controversial.MethodsThe accuracy of the Ultrasound technique in the diagnosis of acute appendicitis in the adult patient, as shown in the literature, was searched for.ResultsThe gold standard for the diagnosis of appendicitis still remains pathologic confirmation after appendectomy. In the published literature, graded-compression Ultrasound has shown an extremely variable diagnostic accuracy in the diagnosis of acute appendicitis (sensitivity range from 44% to 100%; specificity range from 47% to 99% ). This is due to many reasons, including lack of operator skill, increased bowel gas content, obesity, anatomic variants, and limitations to explore patients with previuos laparotomies.ConclusionsGraded-compression Ultrasound still remains our first-line method in patients referred with clinically suspected acute appendicitis: nevertheless, due to variable diagnostic accuracy, individual skill is requested not only to perform a successful exam, but also in order to triage those equivocal cases that, subsequently, will have to undergo assessment by means of Computed Tomography.

E-learning and education in radiology

PURPOSE To evaluate current applications of e-learning in radiology. MATERIAL AND METHODS A Medline search was performed using PubMed (National Library of Medicine, Bethesda, MD) for publications discussing the applications of e-learning in radiology. The search strategy employed a single combination of the following terms: (1) e-learning, and (2) education and (3) radiology. This review was limited to human studies and to English-language literature. We reviewed all the titles and subsequent the abstract of 29 articles that appeared pertinent. Additional articles were identified by reviewing the reference lists of relevant papers. Finally, the full text of 38 selected articles was reviewed. RESULTS Literature data shows that with the constant development of technology and global spread of computer networks, in particular of the Internet, the integration of multimedia and interactivity introduced into electronic publishing has allowed the creation of multimedia applications that provide valuable support for medical teaching and continuing medical education, specifically for radiology. Such technologies are valuable tools for collaboration, interactivity, simulation, and self-testing. However, not everything on the World Wide Web is useful, accurate, or beneficial: the quality and veracity of medical information on the World Wide Web is variable and much time can be wasted as many websites do not meet basic publication standards. CONCLUSION E-learning will become an important source of education in radiology.

The Concept of Error and Malpractice in Radiology

Since the early 1970s, physicians have been subjected to an increasing number of medical malpractice claims. Radiology is one of the specialties most liable to claims of medical negligence. The etiology of radiological error is multifactorial. Errors fall into recurrent patterns. Errors arise from poor technique, failures of perception, lack of knowledge, and misjudgments. Every radiologist should understand the sources of error in diagnostic radiology as well as the elements of negligence that form the basis of malpractice litigation. Errors are an inevitable part of human life, and every health professional has made mistakes. To improve patient safety and reduce the risk from harm, we must accept that some errors are inevitable during the delivery of health care. We must play a cultural change in medicine, wherein errors are actively sought, openly discussed, and aggressively addressed.