Francesco Coppolino

Cementoplasty in the management of painful extraspinal bone metastases: our experience

PurposeThe aim of this study was to demonstrate the effectiveness of interventional techniques in the palliative management of painful extraspinal bone metastases.Materials and methodsCementoplasty alone or in combination with radiofrequency (RF) ablation was performed in 14 skeletal extravertebral segments in 13 patients with ages ranging from 50 to 74 (average 67) years. The primary tumours were myeloma (n=5), renal carcinoma (n=5), hepatocellular carcinoma (n=2) and bladder carcinoma (n=2). Metastases were located at the acetabulum (n=4), femur (n=5), humerus (n=1), scapula (n=2) and iliac bone (n=2). The clinical indication was a pain intensity score >4 on the visual analogue scale (VAS) partially or totally refractory to analgesic medication. Clinical evaluation was based on clinical and neurological conditions before and immediately after the procedure and during the follow-up.ResultsTechnical success was achieved in all cases. Ten patients were treated by cementoplasty alone and four cases by cementoplasty combined with RF ablation. After treatment, all patients experienced improved symptoms, as demonstrated by the VAS score, which remained constant during follow-up. All patients were followed for between 2 and 14 (average 6.1) months. We had one major complication in a patient who developed an abscess, which was treated by percutaneous drainage.ConclusionsIn our experience, cementoplasty alone for small lesions or combined with RF ablation in larger lesions is an effective and safe therapy in the palliative management of painful extraspinal bone metastases.RiassuntoObiettivoScopo del nostro lavoro è quello di riportare la nostra esperienza nel trattamento palliativo delle metastasi ossee extra-spinali mediante cementoplastica da sola o in combinazione con l’ablazione a radiofrequenze (RF).Materiali e metodiSono state trattate con cementoplastica 14 lesioni in 13 pazienti con età compresa tra 50 e 74 anni, media 67 anni, quattro di queste precedute dalla ablazione con RF; le neoplasie primitive erano mieloma (n=5), carcinoma renale (n=5), carcinoma epatocellulare (n=2), carcinoma vescicale (n=2). Le lesioni erano localizzate all’acetabolo (n=4), al femore (n=5), all’omero (n=1), alla scapola (n=2) ed all’osso iliaco (n=2). L’indicazione clinica al trattamento è stata data dalla presenza di un valore della visual analogue scale (VAS) superiore a 5, refrattario o parzialmente refrattario al trattamento con analgesici. La valutazione clinica è stata basata sulle condizioni generali e neurologiche dei pazienti prima, immediatamente dopo e durante i follow-up.RisultatiIl successo tecnico della procedura è stato ottenuto in tutti i casi. In 10 pazienti è stata eseguita la sola cementoplastica mentre in 3 pazienti rispettivamente con grossa metastasi scapolare successivamente recidivata e con masse osteolitiche all’osso iliaco, la cementoplastica è stata preceduta dalla ablazione con RF. Tutti i pazienti hanno avvertito un miglioramento della sintomatologia immediatamente dopo la procedura riscontrato in una riduzione del valore VAS rimasto pressoché costante durante i follow-up successivi. Il follow-up è stato ottenuto in tutti i pazienti ed è variato da 2 a 14 mesi (media: 6,1). Abbiamo avuto una sola complicanza in un paziente che ha sviluppato un ascesso nella sede di intervento drenato percutaneamente.ConclusioniNella nostra esperienza la cementoplastica, da sola in lesioni di piccole dimensioni o preceduta dalla ablazione con RF per lesioni di maggiori dimensioni rappresenta una efficace terapia nel trattamento del dolore derivante da metastasi ossee extra-spinali.

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.

The role of US examination in the management of acute abdomen

Acute abdomen is a medical emergency, in which there is sudden and severe pain in abdomen of recent onset with accompanying signs and symptoms that focus on an abdominal involvement. It can represent a wide spectrum of conditions, ranging from a benign and self-limiting disease to a surgical emergency. Nevertheless, only one quarter of patients who have previously been classified with an acute abdomen actually receive surgical treatment, so the clinical dilemma is if the patients need surgical treatment or not and, furthermore, in which cases the surgical option needs to be urgently adopted. Due to this reason a thorough and logical approach to the diagnosis of abdominal pain is necessary. Some Authors assert that the location of pain is a useful starting point and will guide a further evaluation. However some causes are more frequent in the paediatric population (like appendicitis or adenomesenteritis) or are strictly related to the gender (i.e. gynaechologic causes). It is also important to consider special populations such as the elderly or oncologic patients, who may present with atypical symptoms of a disease. These considerations also reflect a different diagnostic approach. Today, surely the integrated imaging, and in particular the use of multidetector Computed Tomography (MDCT) has revolutionised the clinical approach to this condition, simplyfing the diagnosis but burdening the radiologists with the problems related to the clinical management. However although CT emerging as a modality of choice for evaluation of the acute abdomen, ultrasonography (US) remains the primary imaging technique in the majority of cases, especially in young and female patients, when the limitation of the radiation exposure should be mandatory, limiting the use of CT in cases of nondiagnostic US and in all cases where there is a discrepancy between the clinical symptoms and negative imaging at US.

Intestinal Ischemia: US-CT findings correlations

BackgroundIntestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.MethodsBasing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).ResultsTo make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.ConclusionAt present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.

Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature

BackgroundTo evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities.MethodsThe authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) computed tomography, (4) magnetic resonance cholangiopancreatography and (5) cholescintigraphy. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.ResultsSonography is still used as the initial imaging technique for evaluating patients with suspected acute calculous cholecystitis because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability. Cholescintigraphy still has the highest sensitivity and specificity in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern the use of cholescintigraphy is limited in clinical practice. CT is particularly useful for evaluating the many complications of acute calculous cholecystitis. The lack of widespread availability of MRI and the relatively high cost prohibits its primary use in patients with acute calculous cholecystitis.ConclusionsUS is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis.

Long head of the biceps tendon and rotator interval

The term “biceps brachii” is a Latin phrase meaning “two-headed (muscle) of the arm.” As its name suggests, this muscle has two separate origins. The short head of biceps is extraarticular in location, originates from the coracoid process of the scapula, having a common tendon with the coracobrachialis muscle. The long head of biceps tendon (LBT) has a much more complex course, having an intracapsular and an extracapsular portion. The LBT originates from the supraglenoid tubercle, and in part, from the glenoid labrum; the main labral attachments vary arising from the posterior, the anterior of both aspects of the superior labrum (Bletran et al. in Top Magn Reson Imaging 14:35–49, 2003; Vangsness et al. in J Bone Joint Surg Br 76:951–954, 1994). Before entering the bicipital groove (extracapsular portion), the LBT passes across the “rotator cuff interval” (intracapsular portion). Lesions of the pulley system, the LBT, and the supraspinatus tendon, as well as the subscapularis, are commonly associated (Valadie et al. in J Should Elbow Surg 9:36–46, 2000). The pulley lesion can be caused by trauma or degenerative changes (LeHuec et al. in J Should Elbow Surg 5:41–46, 1996). MR arthrography appears to be a promising imaging modality for evaluation of the biceps pulley, through the distention of the capsule of the rotator interval space and depiction of the associated ligaments.

Comparison of iodinated contrast media for the assessment of atherosclerotic plaque attenuation values by CT coronary angiography: observations in an ex vivo model

OBJECTIVE To compare the influence of different iodinated contrast media with several dilutions on plaque attenuation in an ex vivo coronary model studied by multislice CT coronary angiography. METHODS In six ex vivo left anterior descending coronary arteries immersed in oil, CT (slices/collimation 64×0.625 mm, temporal resolution 210 ms, pitch 0.2) was performed after intracoronary injection of a saline solution, and solutions of a dimeric isosmolar contrast medium (Iodixanol 320 mgI ml(-1)) and a monomeric high-iodinated contrast medium (Iomeprol 400 mgI ml(-1)) with dilutions of 1/80 (low concentration), 1/50 (medium concentration), 1/40 (high concentration) and 1/20 (very high concentration). Two radiologists drew regions of interest in the lumen and in calcified and non-calcified plaques for each solution. 29 cross-sections with non-calcified plaques and 32 cross-sections with calcified plaques were evaluated. RESULTS Both contrast media showed different attenuation values within lumen and plaque (p<0.0001). The correlation between lumen and non-calcified plaque values was good (Iodixanol r=0.793, Iomeprol r=0.647). Clustered medium- and high-concentration solutions showed similar plaque attenuation values, signal-to-noise ratios (SNRs) (non-calcified plaque: medium solution SNR 31.3±15 vs 31.4±20, high solution SNR 39.4±17 vs 37.4±22; calcified plaque: medium solution SNR 305.2±133 vs 298.8±132, high solution SNR 323.9±138 vs 293±123) and derived contrast-to-noise ratios (p>0.05). CONCLUSION Differently iodinated contrast media have a similar influence on plaque attenuation profiles. ADVANCES IN KNOWLEDGE Since iodine load affects coronary plaque attenuation linearly, different contrast media may be equally employed for coronary atherosclerotic plaque imaging.

MDCT anatomic assessment of right inferior phrenic artery origin related to potential supply to hepatocellular carcinoma and its embolization.

PurposeTo prospectively assess the anatomic variation of the right inferior phrenic artery (RIPA) origin with multidetector computed tomography (MDCT) scans in relation to the technical and angiographic findings during transcatheter arterial embolization of hepatocellular carcinoma (HCC).MethodsTwo hundred patients with hepatocellular carcinomas were examined with 16-section CT during the arterial phase. The anatomy of the inferior phrenic arteries was recorded, with particular reference to their origin. All patients with subcapsular HCC located at segments VII and VIII underwent arteriography of the RIPA with subsequent embolization if neoplastic supply was detected.ResultsThe RIPA origin was detected in all cases (sensitivity 100%), while the left inferior phrenic artery origin was detected in 187 cases (sensitivity 93.5%). RIPAs originated from the aorta (49%), celiac trunk (41%), right renal artery (5.5%), left gastric artery (4%), and proper hepatic artery (0.5%), with 13 types of combinations with the left IPA. Twenty-nine patients showed subcapsular HCCs in segments VII and VIII and all but one underwent RIPA selective angiography, followed by embolization in 7 cases.ConclusionMDCT assesses well the anatomy of RIPAs, which is fundamental for planning subsequent cannulation and embolization of extrahepatic RIPA supply to HCC.

Femoroacetabular impingement: role of imaging

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427–1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412–1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264–272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head–neck junction and reduced depth of the femoral waist lead to abutment of the femoral head–neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage’s extension.

US in the assessment of acute scrotum

BackgroundThe acute scrotum is a medical emergency . The acute scrotum is defined as scrotal pain, swelling, and redness of acute onset. Scrotal abnormalities can be divided into three groups , which are extra-testicular lesion, intra-testicular lesion and trauma. This is a retrospective analysis of 164 ultrasound examination performed in patient arriving in the emergency room for scrotal pain.The objective of this article is to familiarize the reader with the US features of the most common and some of the least common scrotal lesions.MethodsBetween January 2008 and January 2010, 164 patients aged few month and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analyzed. The presentation symptoms including scrotal pain, painless scrotal mass or swelling, and trauma.ResultsOf 164 patients, 125 (76%) presented with scrotal pain, 31 (19%) had painless scrotal mass or swelling and 8 (5%) had trauma. Of the 125 patients with scrotal pain, 72 had infection,10 had testicular torsion, 8 had testicular trauma, 18 had varicocele, 20 had hydrocele, 5 had cryptorchidism, 5 had scrotal sac and groin metastases, and 2 had unremarkable results. In the 8 patients who had history of scrotal trauma, US detected testicular rupture in 1 patients, scrotal haematomas in 2 patients .Of the 19 patients who presented with painless scrotal mass or swelling, 1 6 had extra-testicular lesions and 3 had intra-testicular lesions. All the extra-testicular lesions were benign. Of the 3 intra-testicular lesions, one was due to tuberculosis epididymo-orchitis, one was non-Hodgkin’s lymphoma, and one was metastasis from liposarcomaConclusionsUS provides excellent anatomic detail; when color Doppler and Power Doppler imaging are added, testicular perfusion can be assessed