Gaetano Villa

Magnetic resonance mammography in the evaluation of recurrence at the prior lumpectomy site after conservative surgery and radiotherapy

IntroductionThe aim was to assess the value of magnetic resonance mammography (MRM) in the detection of recurrent breast cancer on the prior lumpectomy site in patients with previous conservative surgery and radiotherapy.MethodsBetween April 1999 and July 2003, 93 consecutive patients with breast cancer treated with conservative surgery and radiotherapy underwent MRM, when a malignant lesion on the site of lumpectomy was suspected by ultrasound and/or mammography. MRM scans were evaluated by morphological and dynamic characteristics. MRM diagnosis was compared with histology or with a 36-month imaging follow-up. Enhancing areas independent of the prior lumpectomy site, incidentally detected during the MRM, were also evaluated.ResultsMRM findings were compared with histology in 29 patients and with a 36-month follow-up in 64 patients. MRM showed 90% sensitivity, 91.6% specificity, 56.3% positive predictive value and 98.7% negative predictive value for detection of recurrence on the surgical scar. MRM detected 13 lesions remote from the scar. The overall sensitivity, specificity, positive predictive value and negative predictive value of MRM for detection of breast malignancy were 93.8%, 90%, 62.5% and 98.8%, respectively.ConclusionMRM is a sensitive method to differentiate recurrence from post-treatment changes at the prior lumpectomy site after conservative surgery and radiation therapy. The high negative predictive value of this technique can avoid unnecessary biopsies or surgical treatments.

Local staging of penile cancer using magnetic resonance imaging with pharmacologically induced penile erection.

PurposeThis study was undertaken to compare the local staging of penile cancer by magnetic resonance imaging (MRI) combined with pharmacologically induced penile erection (PIPE), with clinical examination and pathology, and to verify whether MRI-PIPE led to changes in treatment planning in our cohort.Materials and methodsThirteen patients with untreated penile cancer underwent local staging by clinical examination and MRI-PIPE obtained by intracavernosal injection of 10 μg prostaglandin E1. Transverse, sagittal and coronal T2-weighted and T1-weighted (before and after intravenous gadolinium injection) images were obtained with a four-channel phased-array coil. Tumours were treated according to stage, as defined by MRI-PIPE and clinical examination. Stage T1 tumours underwent laser ablation and stage T2 or T3 tumours partial or total penectomy.ResultsTwelve penile cancers were squamous cell carcinomas and one was a sarcoma. MRI-PIPE correctly staged 12 out of 13 patients, failing to detect one in situ carcinoma. Clinical examination correctly staged eight out of 13 patients, overstaging two patients (one Tis was overstaged as T1 and one T1 as T2) and understaging three patients (two T2 as T1 and one T3 as T2).ConclusionMRI-PIPE performed better than the clinical examination and changed treatment planning in three patients.RiassuntoObiettiviConfrontare la stadiazione locale del tumore del pene definita con la risonanza magnetica abbinata all’erezione farmacologicamente indotta con iniezione intracavernosa di prostaglandine (RM con test di farmacoinfusione intracavernosa, RM-TFI) con l’esame clinico e con l’anatomia patologica. Verificare se la RM-TFI abbia determinato cambiamenti nella strategia terapeutica.Materiali e metodiTredici pazienti con tumore del pene mai trattato sono stati esaminati con RM-TFI (ottenuta con iniezione intracavernosa di 10 μg di prostaglandine E1). Sono state acquisite immagini assiali, coronali e sagittali pesate in T2 e T1 (prima e dopo iniezione endovenosa di gadolinio), utilizzando una bobina phased-array a quattro canali. In accordo con la stadiazione della RM-TFI e dell’esame clinico, i tumori in stadio T1 sono stati sottoposti ad ablazione laser, mentre i tumori T2 e T3 a penectomia parziale o totale.RisultatiDodici tumori del pene sono risultati squamocellulari e uno sarcoma. La RM-TFI ha stadiato correttamente dodici pazienti su tredici, non riconoscendo la presenza di un carcinoma in situ, e l’esame clinico otto pazienti su tredici, sovrastadiando due pazienti (un carcinoma in situ come T1 ed uno stadio T1 come T2) e sottostadiando tre pazienti (due stadi T2 come T1 ed uno stadio T3 come T2).ConclusioniLa RM-TFI si è dimostrata superiore all’esame clinico e ha modificato la strategia terapeutica in tre pazienti.

Clinical experience with axillary presentation breast cancer

We present our experience of 50 cases of occult primary tumours presenting as axillary metastases, all with histological report of adenocarcinoma compatible with mammary carcinoma. After bilateral US and mammography, with MRI and mammoscintigraphy where necessary, ipsilateral breast cancer was suspected in 23 cases and quadrantectomy performed. Breast cancer was found only in 12 (24%). In the other 27 women there was no clinical or instrumental suspicion of breast cancer or other primary disease site, so the main treatment was complete axillary dissection plus radiotherapy to the ipsilateral breast (given to all patients). Chemotherapy alone was given to 27 patients, hormone treatment to 5 patients, and both to 18. Mean follow-up is 41.3 months (range 108–1). Thirty-nine (84%) patients are alive with no evidence of disease, two are alive with breast disease, five patients have died of metastatic disease (with no evidence breast disease). Our experience, like that of the literature, confirms that the breast should be extensively investigated but that blanket investigations are not usually revealing. We present guidelines for the work-up of patients presenting with axillary disease.

Survey of computed tomography techniques and absorbed dose in Italian hospitals: a comparison between two methods to estimate the dose-length product and the effective dose and to verify fulfilment of the diagnostic reference levels.

The aim of this study was the production of the first Italian survey of radiation dose in computed tomography (CT) prior to the widespread adoption of multislice CT, in order to have a reference point to facilitate later investigation of dose exposure changes brought by this new CT modality. The collected dose data were compared with diagnostic reference levels (DRLs). The agreement between experimental dose evaluation and Monte Carlo (MC) simulations was investigated. The survey was carried out in 29 Italian hospitals, covered 48 CT scanners and 232 examinations. The dose–length product (DLP) and effective dose (E) values were estimated based on MC simulations for seven clinical protocols using the CT-Dose program. Statistical analysis showed a significant difference (p<0.01) in the DLP between the two methods, with MC values being greater than the experimental ones. For E, the MC values were greater in routine head (8.2%), cervical spine (2.7%) and lumbar spine (2.9%) studies. The weighted CT dose index, the DLP and E were always below the DRLs set by the European Community. This dose survey gives a good but incomplete picture of the Italian CT dose situation and may be useful as a reference baseline for defining clinical multislice protocols in the near future.

Magnetic resonance imaging of primary breast lymphoma

PurposePrimary lymphomas of the breast (PBNHL) are uncommon. Magnetic resonance imaging (MRI) features of these malignancies can be relevant in establishing the extent of disease and planning the appropriate therapeutic strategy, usually represented by chemo- and radiotherapy, rather than surgery. The purpose of this study was to assess MRI features of PBNHL.Materials and methodsMRI examinations performed on seven patients with known PBNHL were retrospectively evaluated. Lesions were analysed for both morphology and kinetics and classified according to the Breast Imaging Reporting and Data System (BI-RADS) categories.ResultsThe mean MRI maximum diameter was 44 mm (range 12–69). Six lesions showed a mass-like enhancement; one lesion showed a non-mass-like enhancement. For mass-like lesions, kinetic curve assessment of initial rise showed slow enhancement in one lesion, rapid enhancement in four lesions and medium enhancement in one lesion. Assessment of delayed enhancement showed plateau in five lesions and washout in one lesion. MRI BI-RADS categories were distributed as follows: one BI-RADS II, one BI-RADS III, three BI-RADS IV and two BI-RADS V.ConclusionsMRI features of primary breast lymphomas in this study cohort suggest that the occurrence of a PBNHL should be considered in the presence of large enhancing lesions of the breast, especially if associated with skin thickening. MRI may also have an important role in the assessment of response to therapy and diagnosis of recurrence.RiassuntoObiettivoI linfomi primitivi della mammella sono una patologia rara. Le caratteristiche alla risonanza magnetica (RM) di queste neoplasie possono essere importanti nello stabilire l’estensione della malattia e nel pianificare la più efficace strategia terapeutica, che di solito è rappresentata da chemio-radioterapia, piuttosto che dall’escissione chirurgica. L’obiettivo di questo studio è una valutazione delle caratteristiche RM dei linfomi primitivi della mammella.Materiali e metodiSono stati valutati retrospettivamente esami RM della mammella di 7 pazienti con linfoma primitivo mammario. Le lesioni sono state analizzate sia per la morfologia che per la cinetica e sono state classificate secondo le categorie Breast Imaging Reporting and Data System (BI-RADS) RM.RisultatiIl diametro principale medio delle lesioni alla RM è risultato di 44 mm (range 12–69); 6 lesioni hanno mostrato un enhancement di tipo nodulare; 1 lesione ha mostrato un enhancement di tipo non-nodulare. Per le lesioni nodulari, la fase iniziale della curva contrastografica dell’intensità del segnale nel tempo ha mostrato un enhancement lento in 1 lesione, intermedio in 1 lesione, rapido in 4 lesioni. La valutazione dell’enhancement tardivo ha mostrato plateau in 5 lesioni, wash out in 1 lesione. Le categorie RM BI-RADS sono state distribuite come segue: 1 BI-RADS II, 1 BI-RADS III, 3 BI-RADS IV, 2 BI-RADS V.ConclusioniLe caratteristiche RM dei linfomi primitivi mammari riscontrate nella nostra casistica non si sono dimostrate patognomoniche della patologia, tuttavia la presenza di un linfoma primitivo mammario dovrebbe essere presa in considerazione in caso di lesioni mammarie di grandi dimensioni, dotate di contrast-enhancement, specie se associate ad ispessimento cutaneo. La RM ha inoltre un ruolo importante nella valutazione della risposta alla terapia e nella diagnosi di recidiva.

Clinical stage I carcinoma of the uterine cervix value of preoperative magnetic resonance imaging in assessing parametrial invasion

Aims and Background The purpose of this prospective study was to assess the efficacy of different MR imaging techniques in the evaluation of parametrial tumor invasion in patients with early stage cervical cancer. Methods A total of 73 consecutive patients, clinically considered to have invasive tumor (<3 cm in diameter) confined to the cervix, underwent MR imaging studies at 1 T, according to the following protocol: fast spin-echo (FSE) T2-weighted, gadolinium-enhanced SE T1-weighted, and fat-suppressed gadolinium-enhanced SE T1-weighted sequences. Images obtained with each sequence were evaluated for parametrial invasion with the use of histopathologic findings as the standard of reference. Results In the assessment of tumor infiltration of the parametrium, with FSE T2-weighted images accuracy was 83%, with SE T1-weighted gadolinium-enhanced images was 65%, and with SE T1-weighted gadolinium-enhanced fat-suppressed images was 72%. The difference between the accuracy rate achieved with FSE T2-weighted images and those obtained with the other two MR sequences was statistically significant (P <0.05). The high negative predictive value (95%) for the exclusion of parametrial tumor invasion was the principal contributor to the staging accuracy obtained with FSE T2-weighted imaging. Conclusions Unenhanced FSE T2-weighted imaging is a reliable method for determining the degree of tumor invasion in patients with early stage cervical cancer. Our data suggest that contrast-enhanced sequences, even with the use of the fat suppression technique, have limited value in assessing tumor extension.

MRI quantification of pancreas motion as a function of patient setup for particle therapy —a preliminary study

Particle therapy (PT) has shown positive therapeutic results in local control of locally advanced pancreatic lesions. PT effectiveness is highly influenced by target localization accuracy both in space, since the pancreas is located in proximity to radiosensitive vital organs, and in time as it is subject to substantial breathing-related motion. The purpose of this preliminary study was to quantify pancreas range of motion under typical PT treatment conditions. Three common immobilization devices (vacuum cushion, thermoplastic mask, and compressor belt) were evaluated on five male patients in prone and supine positions. Retrospective four-dimensional magnetic resonance imaging data were reconstructed for each condition and the pancreas was manually segmented on each of six breathing phases. A k-means algorithm was then applied on the manually segmented map in order to obtain clusters representative of the three pancreas segments: head, body, and tail. Centers of mass (COM) for the pancreas and its segments were computed, as well as their displacements with respect to a reference breathing phase (beginning exhalation). The median three-dimensional COM displacements were in the range of 3 mm. Latero-lateral and superior-inferior directions had a higher range of motion than the anterior-posterior direction. Motion analysis of the pancreas segments showed slightly lower COM displacements for the head cluster compared to the tail cluster, especially in prone position. Statistically significant differences were found within patients among the investigated setups. Hence a patient-specific approach, rather than a general strategy, is suggested to define the optimal treatment setup in the frame of a millimeter positioning accuracy. PACS number(s): 87.55.-x, 87.57.nm, 87.61.Particle therapy (PT) has shown positive therapeutic results in local control of locally advanced pancreatic lesions. PT effectiveness is highly influenced by target localization accuracy both in space, since the pancreas is located in proximity to radiosensitive vital organs, and in time as it is subject to substantial breathing‐related motion. The purpose of this preliminary study was to quantify pancreas range of motion under typical PT treatment conditions. Three common immobilization devices (vacuum cushion, thermoplastic mask, and compressor belt) were evaluated on five male patients in prone and supine positions. Retrospective four‐dimensional magnetic resonance imaging data were reconstructed for each condition and the pancreas was manually segmented on each of six breathing phases. A k‐means algorithm was then applied on the manually segmented map in order to obtain clusters representative of the three pancreas segments: head, body, and tail. Centers of mass (COM) for the pancreas and its segments were computed, as well as their displacements with respect to a reference breathing phase (beginning exhalation). The median three‐dimensional COM displacements were in the range of 3 mm. Latero–lateral and superior–inferior directions had a higher range of motion than the anterior–posterior direction. Motion analysis of the pancreas segments showed slightly lower COM displacements for the head cluster compared to the tail cluster, especially in prone position. Statistically significant differences were found within patients among the investigated setups. Hence a patient‐specific approach, rather than a general strategy, is suggested to define the optimal treatment setup in the frame of a millimeter positioning accuracy. PACS number(s): 87.55.‐x, 87.57.nm, 87.61

Risonanza magnetica dei linfomi primitivi della mammella

PurposePrimary lymphomas of the breast (PBNHL) are uncommon. Magnetic resonance imaging (MRI) features of these malignancies can be relevant in establishing the extent of disease and planning the appropriate therapeutic strategy, usually represented by chemo- and radiotherapy, rather than surgery. The purpose of this study was to assess MRI features of PBNHL.Materials and methodsMRI examinations performed on seven patients with known PBNHL were retrospectively evaluated. Lesions were analysed for both morphology and kinetics and classified according to the Breast Imaging Reporting and Data System (BI-RADS) categories.ResultsThe mean MRI maximum diameter was 44 mm (range 12–69). Six lesions showed a mass-like enhancement; one lesion showed a non-mass-like enhancement. For mass-like lesions, kinetic curve assessment of initial rise showed slow enhancement in one lesion, rapid enhancement in four lesions and medium enhancement in one lesion. Assessment of delayed enhancement showed plateau in five lesions and washout in one lesion. MRI BI-RADS categories were distributed as follows: one BI-RADS II, one BI-RADS III, three BI-RADS IV and two BI-RADS V.ConclusionsMRI features of primary breast lymphomas in this study cohort suggest that the occurrence of a PBNHL should be considered in the presence of large enhancing lesions of the breast, especially if associated with skin thickening. MRI may also have an important role in the assessment of response to therapy and diagnosis of recurrence.RiassuntoObiettivoI linfomi primitivi della mammella sono una patologia rara. Le caratteristiche alla risonanza magnetica (RM) di queste neoplasie possono essere importanti nello stabilire l’estensione della malattia e nel pianificare la più efficace strategia terapeutica, che di solito è rappresentata da chemio-radioterapia, piuttosto che dall’escissione chirurgica. L’obiettivo di questo studio è una valutazione delle caratteristiche RM dei linfomi primitivi della mammella.Materiali e metodiSono stati valutati retrospettivamente esami RM della mammella di 7 pazienti con linfoma primitivo mammario. Le lesioni sono state analizzate sia per la morfologia che per la cinetica e sono state classificate secondo le categorie Breast Imaging Reporting and Data System (BI-RADS) RM.RisultatiIl diametro principale medio delle lesioni alla RM è risultato di 44 mm (range 12–69); 6 lesioni hanno mostrato un enhancement di tipo nodulare; 1 lesione ha mostrato un enhancement di tipo non-nodulare. Per le lesioni nodulari, la fase iniziale della curva contrastografica dell’intensità del segnale nel tempo ha mostrato un enhancement lento in 1 lesione, intermedio in 1 lesione, rapido in 4 lesioni. La valutazione dell’enhancement tardivo ha mostrato plateau in 5 lesioni, wash out in 1 lesione. Le categorie RM BI-RADS sono state distribuite come segue: 1 BI-RADS II, 1 BI-RADS III, 3 BI-RADS IV, 2 BI-RADS V.ConclusioniLe caratteristiche RM dei linfomi primitivi mammari riscontrate nella nostra casistica non si sono dimostrate patognomoniche della patologia, tuttavia la presenza di un linfoma primitivo mammario dovrebbe essere presa in considerazione in caso di lesioni mammarie di grandi dimensioni, dotate di contrast-enhancement, specie se associate ad ispessimento cutaneo. La RM ha inoltre un ruolo importante nella valutazione della risposta alla terapia e nella diagnosi di recidiva.

Magnetic resonance imaging of primary breast lymphoma@@@Risonanza magnetica dei linfomi primitivi della mammella

PurposePrimary lymphomas of the breast (PBNHL) are uncommon. Magnetic resonance imaging (MRI) features of these malignancies can be relevant in establishing the extent of disease and planning the appropriate therapeutic strategy, usually represented by chemo- and radiotherapy, rather than surgery. The purpose of this study was to assess MRI features of PBNHL.Materials and methodsMRI examinations performed on seven patients with known PBNHL were retrospectively evaluated. Lesions were analysed for both morphology and kinetics and classified according to the Breast Imaging Reporting and Data System (BI-RADS) categories.ResultsThe mean MRI maximum diameter was 44 mm (range 12–69). Six lesions showed a mass-like enhancement; one lesion showed a non-mass-like enhancement. For mass-like lesions, kinetic curve assessment of initial rise showed slow enhancement in one lesion, rapid enhancement in four lesions and medium enhancement in one lesion. Assessment of delayed enhancement showed plateau in five lesions and washout in one lesion. MRI BI-RADS categories were distributed as follows: one BI-RADS II, one BI-RADS III, three BI-RADS IV and two BI-RADS V.ConclusionsMRI features of primary breast lymphomas in this study cohort suggest that the occurrence of a PBNHL should be considered in the presence of large enhancing lesions of the breast, especially if associated with skin thickening. MRI may also have an important role in the assessment of response to therapy and diagnosis of recurrence.RiassuntoObiettivoI linfomi primitivi della mammella sono una patologia rara. Le caratteristiche alla risonanza magnetica (RM) di queste neoplasie possono essere importanti nello stabilire l’estensione della malattia e nel pianificare la più efficace strategia terapeutica, che di solito è rappresentata da chemio-radioterapia, piuttosto che dall’escissione chirurgica. L’obiettivo di questo studio è una valutazione delle caratteristiche RM dei linfomi primitivi della mammella.Materiali e metodiSono stati valutati retrospettivamente esami RM della mammella di 7 pazienti con linfoma primitivo mammario. Le lesioni sono state analizzate sia per la morfologia che per la cinetica e sono state classificate secondo le categorie Breast Imaging Reporting and Data System (BI-RADS) RM.RisultatiIl diametro principale medio delle lesioni alla RM è risultato di 44 mm (range 12–69); 6 lesioni hanno mostrato un enhancement di tipo nodulare; 1 lesione ha mostrato un enhancement di tipo non-nodulare. Per le lesioni nodulari, la fase iniziale della curva contrastografica dell’intensità del segnale nel tempo ha mostrato un enhancement lento in 1 lesione, intermedio in 1 lesione, rapido in 4 lesioni. La valutazione dell’enhancement tardivo ha mostrato plateau in 5 lesioni, wash out in 1 lesione. Le categorie RM BI-RADS sono state distribuite come segue: 1 BI-RADS II, 1 BI-RADS III, 3 BI-RADS IV, 2 BI-RADS V.ConclusioniLe caratteristiche RM dei linfomi primitivi mammari riscontrate nella nostra casistica non si sono dimostrate patognomoniche della patologia, tuttavia la presenza di un linfoma primitivo mammario dovrebbe essere presa in considerazione in caso di lesioni mammarie di grandi dimensioni, dotate di contrast-enhancement, specie se associate ad ispessimento cutaneo. La RM ha inoltre un ruolo importante nella valutazione della risposta alla terapia e nella diagnosi di recidiva.

Stadiazione locale del tumore del pene con risonanza magnetica abbinata a test di farmacoinfusione intracavernosa (RM-TFI)

PurposeThis study was undertaken to compare the local staging of penile cancer by magnetic resonance imaging (MRI) combined with pharmacologically induced penile erection (PIPE), with clinical examination and pathology, and to verify whether MRI-PIPE led to changes in treatment planning in our cohort.Materials and methodsThirteen patients with untreated penile cancer underwent local staging by clinical examination and MRI-PIPE obtained by intracavernosal injection of 10 μg prostaglandin E1. Transverse, sagittal and coronal T2-weighted and T1-weighted (before and after intravenous gadolinium injection) images were obtained with a four-channel phased-array coil. Tumours were treated according to stage, as defined by MRI-PIPE and clinical examination. Stage T1 tumours underwent laser ablation and stage T2 or T3 tumours partial or total penectomy.ResultsTwelve penile cancers were squamous cell carcinomas and one was a sarcoma. MRI-PIPE correctly staged 12 out of 13 patients, failing to detect one in situ carcinoma. Clinical examination correctly staged eight out of 13 patients, overstaging two patients (one Tis was overstaged as T1 and one T1 as T2) and understaging three patients (two T2 as T1 and one T3 as T2).ConclusionMRI-PIPE performed better than the clinical examination and changed treatment planning in three patients.RiassuntoObiettiviConfrontare la stadiazione locale del tumore del pene definita con la risonanza magnetica abbinata all’erezione farmacologicamente indotta con iniezione intracavernosa di prostaglandine (RM con test di farmacoinfusione intracavernosa, RM-TFI) con l’esame clinico e con l’anatomia patologica. Verificare se la RM-TFI abbia determinato cambiamenti nella strategia terapeutica.Materiali e metodiTredici pazienti con tumore del pene mai trattato sono stati esaminati con RM-TFI (ottenuta con iniezione intracavernosa di 10 μg di prostaglandine E1). Sono state acquisite immagini assiali, coronali e sagittali pesate in T2 e T1 (prima e dopo iniezione endovenosa di gadolinio), utilizzando una bobina phased-array a quattro canali. In accordo con la stadiazione della RM-TFI e dell’esame clinico, i tumori in stadio T1 sono stati sottoposti ad ablazione laser, mentre i tumori T2 e T3 a penectomia parziale o totale.RisultatiDodici tumori del pene sono risultati squamocellulari e uno sarcoma. La RM-TFI ha stadiato correttamente dodici pazienti su tredici, non riconoscendo la presenza di un carcinoma in situ, e l’esame clinico otto pazienti su tredici, sovrastadiando due pazienti (un carcinoma in situ come T1 ed uno stadio T1 come T2) e sottostadiando tre pazienti (due stadi T2 come T1 ed uno stadio T3 come T2).ConclusioniLa RM-TFI si è dimostrata superiore all’esame clinico e ha modificato la strategia terapeutica in tre pazienti.