G Di Candio

Small hepatocellular carcinoma - Detection with US, CT, MR imaging, DSA, and Lipiodol-CT

Twenty-two patients with 37 small (3 cm or less) nodular lesions of hepatocellular carcinoma (HCC) were examined with ultrasonography (US), CT, MR imaging, digital subtraction angiography (DSA), and CT following intraarterial injection of Lipiodol (Lipiodol-CT). All patients subsequently underwent surgery, and the gold standard was provided by intraoperative US. The detection rate was 70% for US, 65% for CT, 62% for MR imaging, 73% for DSA, and 86% for Lipiodol-CT. A significant difference (p<0.05) was observed between the detection rate of Lipiodol-CT and the detection rates of all the other imaging modalities. The difference was even more manifest (p<0.02) when only lesions smaller than or equal to 1 cm were considered. It is concluded that Lipiodol-CT is the single most sensitive examination to detect small nodules of HCC. It should therefore be considered a mandatory step in the preoperative evaluation of patients with HCC considered to be surgical candidates after noninvasive imaging studies.

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.

Laparoscopy and Laparoscopic Ultrasonography for Staging Pancreatic Cancer: Critical Appraisal

Abstract. A pilot study was designed to elucidate the role of staging laparoscopy for determining resectability in patients with pancreatic cancer. The additional value of laparoscopic contact ultrasonography (LCU) was also evaluated with specific regard to its ability to detect hepatic metastases and assess vascular infiltration of the portomesenteric trunk. A consecutive sample of 50 patients referred for operation of a suspected pancreatic cancer were submitted to preoperative contrast-enhanced high-resolution computed tomography (CT) and staging laparoscopy combined with LCU at a university hospital. For those progressing to exploratory laparotomy, the intraoperative findings relating to tumor diffusion and vascular infiltration were compared to CT, laparoscopic, and LCU data. Analytical description of the laparoscopic findings is given. Row data of predicted versus observed vascular infiltration were tabulated for CT and LCU. The sensitivity, specificity, and overall accuracy of each diagnostic test were calculated for comparative analysis. Laparoscopy alone prevented unnecessary laparotomy in 20% of cases. A complete procedure could not be achieved in 28% of patients. Three false-negative staging results occurred. LCU identified small (benign) hepatic nodules not seen by CT in 8% of patients. Sensitivity, specificity, and overall accuracy for assessing vascular infiltration were 82%, 53%, and 69% for CT and 94%, 80%, and 87% for LCU. Laparoscopy was confirmed to be safe and effective for staging pancreatic cancer. Because of its unique capabilities to detect even small peritoneal tumor deposits a quick exploration immediately before laparotomy is advised in all patients. The additional benefit of a more extensive procedure is not supported by our results. Although LCU appears to define the vascular involvement more accurately than conventional CT, the limitation of getting clinically useful ultrasound data in all the patients suggests its adoption in only a selected population.

Renal hydatid disease: Report of 9 cases and discussion of urologic diagnostic procedures

Nine cases of renal hydatid disease are reported. All diagnostic procedures are discussed and the important role of ultrasound renal scan and cyst puncture is emphasized. Although it is rare, renal secondary location has to be suspected in cases of hepatic echinococcosis and conservative surgical treatment is required to preserve renal function.

Operative technique for the laparoscopic staging of pancreatic malignancy

SummarySpecial technique and equipment is required for staging and pre-operative assessment of patients with pancreatic cancer. The operative steps to explore the pancreas through an infragastric route used in 21 consecutive patients with pancreatic neoplasms are described in this paper. This entails the use of distally curved coaxial instruments and of endosurgical staplers to open the gastro-colic ligament. A wide exposure of the pancreatic body and tail allows laparoscopic contact ultrasonography of the whole gland. Both longitudinal and transversal sections of the pancreas are obtained for the purpose of defining tumour limits, lymph nodal involvement and possible spread to regional vessels. Analysis of preliminary results supports the view that laparoscopic assessment of pancreatic cancer is safe and effective in achieving the goal of an accurate staging. Laparoscopic related information in this series led to a change in diagnosis or surgical strategy in 9.5% and 38% of patients, respectively. This a...

Renal hypertension due to giant perirenal haematoma: permanent resolution by percutaneous ultrasound-guided drainage.

We describe a case of renovascular hypertension accompanied by renal failure, arising in a young man with a solitary kidney 4 months after a blunt abdominal trauma. A giant haematoma was found around the right kidney and ultrasound-guided percutaneous drainage completely relieved the symptom complex. Nine years later, the patient is normotensive with normal renal function.

Contrast-Enhanced Ultrasonography in the Diagnosis of Upper Urinary Tract Urothelial Cell Carcinoma: A Preliminary Study

PURPOSE The main objective was to assess the effectiveness of contrast-enhanced ultrasonography (CEUS) in the diagnosis of upper urinary tract malignancies by comparing with multidetector computed tomographic urography (MDCTU) and magnetic resonance urography (MRU). Secondary objectives were to compare the tumor size measured with CEUS, MDCTU and MRU and to assess the usefulness of CEUS in distinguishing high-grade tumors from low-grade ones. MATERIALS AND METHODS In connection with this prospective study carried out from January 2009 to September 2011, 18 patients underwent MDCTU or MRU, grayscale ultrasonography (US), color Doppler ultrasonography and CEUS followed by surgery and histological examination of the specimen. Quantitative analysis was performed using perfusion software. Time intensity curves were extracted and the following parameters were considered: wash-in time, time-to-peak, maximum signal intensity and wash-out time. RESULTS Grayscale US identified 15/18 lesions; color Doppler showed no flow signal in 8 lesions, low color signal in 9 lesions and an intense color signal in 1 lesion; CEUS identified 17/18 lesions with the undetected lesion being the smallest one (1.2 cm) located in the upper pelvicalyceal system. Semi-quantitative analysis produced different data for high-grade and low-grade urothelial cell carcinoma (UCC). All detected upper urinary tract masses were UCCs. MRU, MDCTU and grayscale US overestimated the tumor size, while CEUS was the most accurate. CONCLUSION CEUS is useful for evaluating upper urinary tract masses as this method permits differentiation between high-grade and low-grade tumors as well as distinction of the tumor from the adjacent structures and accurate mass measurements.

Unsuspected choledochal cyst during laparoscopic cholecystectomy

Cystic dilation of the extrahepatic bile ducts is rarely encountered during elective biliary surgery planned for different indications. We report here on a patient with unremarkable preoperative workup and normal intraoperative anatomy of the cystic pedicle in whom a type I choledochal cyst containing a large stone was detected by the combined use of laparoscopic contact ultrasonography and intraoperative cholangiography. This case report highlights the importance of intraoperative imaging modalities of the ductal system not only in preventing iatrogenic injuries and their related complications, but also in detecting unsuspected associated biliary pathology which might significantly change the course of surgical intervention.

Role of color Doppler sonography in post-transplant surveillance of vascular complications involving pancreatic allografts

PURPOSE To evaluate the role of color Doppler ultrasonography in the postoperative surveillance of the vascular complications involving pancreas allografts. METHODS A retrospective analysis of a consecutive series of 223 pancreas transplantations was performed. All recipients received antithrombotic prophylaxis, which was tailored to the individuals estimated risk of thrombosis. All patients were monitored with daily color Doppler ultrasonography during the first post-transplant week and thereafter whenever clinically indicated. Vascular complications were defined as all thrombotic events requiring: increased anticoagulant therapy, angiography with fibrinolytic therapy, or repeat surgery. RESULTS The overall patient survival rates at one, three, and five years after transplantation were 94.7%, 93.3%, and 91%, respectively. The overall graft survival rates at the same time points were 87.4%, 79.6%, and 75.6%, respectively. In 28 of the 223 cases (12.5%) graft thromboses were diagnosed with Doppler ultrasound within the first 10 days after transplantation. In 3 cases, graft pancreatectomies were performed because of a complete loss of blood flow in the parenchyma. An attempt to rescue the graft was made in 18 patients. Fourteen of these grafts were saved and are still functioning (77.7%); and 4 rescue attempts failed and the grafts were subsequently explanted (32.3%). CONCLUSION Color Doppler ultrasound is a suitable tool for postoperative surveillance of pancreas transplant recipients. Its use can lead to early diagnosis and timely treatment of vascular complications.

Intraoperative Ultrasound for Hepatic Metastases

The confirmed presence of liver metastases alters the surgical strategy of many abdominal neoplasms. At the time of initial treatment of primary tumor, for which surgery is advisable only in localized cases, such as in pancreatic cancer, even detection of the smallest metastatic nodule involves a poor prognosis and any surgical approach becomes palliative. In the case of colorectal or neuroendocrine tumor metastases, the identification of number and site of nodules is crucial, since the therapeutic role of hepatic resection in the 10% of patients where it is technically allowed is clearly proven (August et al. 1985).