Gianluca Gatta

Gastrointestinal perforation: ultrasonographic diagnosis

Gastrointestinal tract perforations can occur for various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body or a neoplasm that require an early recognition and, often, a surgical treatment.Ultrasonography could be useful as an initial diagnostic test to determine, in various cases the presence and, sometimes, the cause of the pneumoperitoneum.The main sonographic sign of perforation is free intraperitoneal air, resulting in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance.It is best detected using linear probes in the right upper quadrant between the anterior abdominal wall, in the prehepatic space.Direct sign of perforation may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs, like thickened bowel loop and air bubbles in ascitic fluid or in a localized fluid collection, bowel or gallbladder thickened wall associated with decreased bowel motility or ileus.Neverthless, this exam has its own pitfalls. It is strongly operator-dependant; some machines have low-quality images that may not able to detect intraperitoneal free air; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema. Although CT has more accuracy in the detection of the site of perforation, ultrasound may be particularly useful also in patient groups where radiation burden should be limited notably children and pregnant women.

Differential diagnosis between fibroadenoma, giant fibroadenoma and phyllodes tumour: sonographic features and core needle biopsy

PurposeThe aim of this study was to analyse mammographic and ultrasound (US) features of fibroadenoma and phyllodes tumour and assess the diagnostic accuracy of mammography, US and US-guided core needle biopsy (CNB) in the differential diagnosis of these two lesions.Materials and methodsThe results of the pathological analysis of excision biopsy of 83 lesions (67 fibroadenomas and 16 phyllodes tumours) were correlated with the findings of mammography, US and US-guided CNB performed on 83 women with a mean age of 45.4 years (range 18–75 years).ResultsSensitivity, specificity and positive predictive values compared with histology were 45%, 50% and 79% for mammography, 34%, 69% and 82% for US and 81%, 97% and 87% for US-guided CNB (p=0.001).ConclusionsThe almost complete overlap between mammographic and US parameters of fibroadenomas and phyllodes tumours and the absence of pathognomonic features preclude the differential diagnosis between the two histological types. US-guided CNB is a valuable tool in the differential diagnosis between fibroadenoma and phyllodes tumour.RiassuntoObiettivoScopo del nostro lavoro è stato analizzare le caratteristiche mammografiche e ultrasonografiche di fibroadenoma e tumore filloide e calcolare láccuratezza diagnostica della mammografia, dellécografia e della core needle biosy (CNB) ecoguidata nella diagnosi differenziale tra fibroadenoma e tumore filloide.Materiali e metodiI risultati anatomopatologici della biopsia escissionale (BE) di 83 lesioni (67 fibroadenomi e 16 tumori filloidi) sono stati confrontati con i risultati dellésame mammografico, ecografico e della CNB ecoguidata, eseguita in 83 donne di età media di 45,4 anni (range 18–75 anni).RisultatiI valori di sensibilità, specificità, valore predittivo positivo erano del 45%, 50%, 79% per la mammografia, del 34%, 69%, 82% per lécografia e dell’81%, 97% e 87% per la CNB ecoguidata, confrontate con lístologia definitiva (p=0,001).ConclusioniLa sostanziale sovrapposizione tra i parametri mammografici e ultrasonografici dei fibroadenomi e dei tumori filloidi e lássenza di caratteristiche patognomoniche non consentono di fare diagnosi differenziale tra i due istotipi. La CNB ecoguidata rappresenta un valido strumento nella diagnosi differenziale tra fibroadenoma e tumore filloide.

Crohn's disease imaging: a review.

Crohns disease is a chronic granulomatous inflammatory disease of the gastrointestinal tract, which can involve almost any segment from the mouth to the anus. Typically, Crohns lesions attain segmental and asynchronous distribution with varying levels of seriousness, although the sites most frequently involved are the terminal ileum and the proximal colon. A single gold standard for the diagnosis of CD is not available and the diagnosis of CD is confirmed by clinical evaluation and a combination of endoscopic, histological, radiological, and/or biochemical investigations. In recent years, many studies have been performed to investigate the diagnostic potential of less invasive and more patient-friendly imaging modalities in the evaluation of Crohns disease including conventional enteroclysis, ultrasonography, color-power Doppler, contrast-enhanced ultrasonography, multidetector CT enteroclysis, MRI enteroclysis, and 99mTc-HMPAO-labeled leukocyte scintigraphy. The potential diagnostic role of each imaging modality has to be considered in different clinical degrees of the disease, because there is no single imaging technique that allows a correct diagnosis and may be performed with similar results in every institution. The aim of this paper is to point out the advantages and limitations of the various imaging techniques in patients with suspected or proven Crohns disease.Crohns disease is a chronic granulomatous inflammatory disease of the gastrointestinal tract, which can involve almost any segment from the mouth to the anus. Typically, Crohns lesions attain segmental and asynchronous distribution with varying levels of seriousness, although the sites most frequently involved are the terminal ileum and the proximal colon. A single gold standard for the diagnosis of CD is not available and the diagnosis of CD is confirmed by clinical evaluation and a combination of endoscopic, histological, radiological, and/or biochemical investigations. In recent years, many studies have been performed to investigate the diagnostic potential of less invasive and more patient-friendly imaging modalities in the evaluation of Crohns disease including conventional enteroclysis, ultrasonography, color-power Doppler, contrast-enhanced ultrasonography, multidetector CT enteroclysis, MRI enteroclysis, and 99mTc-HMPAO-labeled leukocyte scintigraphy. The potential diagnostic role of each imaging modality has to be considered in different clinical degrees of the disease, because there is no single imaging technique that allows a correct diagnosis and may be performed with similar results in every institution. The aim of this paper is to point out the advantages and limitations of the various imaging techniques in patients with suspected or proven Crohns disease.

Ultrasound-guided aspiration and ethanol sclerotherapy for treating endometrial cysts

PurposeThe authors sought to evaluate the effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy in treating endometrial cysts and adopt this procedure as an alternative to surgery.Materials and methodsFifty consecutive patients with an average age of 25.2 years [standard deviation (SD) 6.5; range 16–40 years) and US diagnosis of endometrial cyst who were pregnant or presenting with high anaesthesia risk, adhesions or who refused surgery underwent US-guided aspiration of a total of 54 endometrial cysts (40 with transabdominal approach and the remaining 14 with transvaginal approach) and ethanol sclerotherapy.ResultsThe procedure was successful in all patients. Follow-up imaging was carried out at 12 h, 24 h, 15 days, 3 months, 6 months and 12 months. After 12 months, four patients (8%) showed recurrence, three of whom opted for a second session of US-guided aspiration and ethanol sclerotherapy.ConclusionsUS-guided aspiration and sclerotherapy with 95% ethanol provides a valid alternative to surgery in treating endometrial cysts.RiassuntoObiettivoScopo del nostro lavoro è stato valutare l’efficacia dell’aspirazione e dell’alcolizzazione ecoguidata delle cisti endometriosiche dell’ovaio e proporre questa procedura quale alternativa all’intervento chirurgico.Materiali e metodiCinquanta pazienti consecutivi di età media di 25,2 anni (deviazione standard [DS] 6,5; range 16–40 anni) con diagnosi ecografica di cisti endometriosica, in caso di gravidanza, aderenze, elevato rischio anestesiologico e rifiuto dell’intervento chirurgico, sono state sottoposte ad aspirazione ed alcolizzazione ecoguidata di 54 cisti endometriosiche (40 con approccio transaddominale; 14 con approccio transvaginale).RisultatiLa procedura è stata effettuata con successo in tutte le pazienti. Sono stati eseguti controlli ecografici a 12, 24 ore, 15 giorni, 3, 6, 12 mesi. Dopo 12 mesi, 4 pazienti (8%) hanno presentato recidiva di patologia; 3 si sono sottoposte nuovamente ad aspirazione ed alcolizzazione, 1 ad intervento chirurgico.ConclusioniL’aspirazione e l’alcolizzazione con etanolo 95° delle cisti endometriosiche rappresenta una valida alternativa all’intervento chirurgico.

Vascular and interventional radiology radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: literature review

Thermal radiofrequency ablation is a relatively new, minimally invasive modality employed as an alternative to surgery in patients with benign thyroid nodules and recurrent thyroid cancers. Different recommendations are necessary for the optimal use of radiofrequency ablation for thyroid nodules. These recommendations are based on a comprehensive analysis of the current literature, the results of multicenter studies, and expert consensus.

Vacuum-assisted biopsy diagnosis of atypical ductal hyperplasia and patient management

PurposeThis study sought to evaluate the accuracy of vacuum-assisted biopsy (VAB) in the diagnosis of atypical ductal hyperplasia (ADH) by determining the rate of VAB underestimation compared with definitive histology. In addition, an attempt was made to identify parameters that could help determine the most appropriate patient management.Materials and methodsWe retrospectively reviewed 1,776 VAB procedures performed between November 1999 and January 2008 for suspicious subclinical breast lesions visible only at mammography. A total of 177 patients with a VAB diagnosis of pure ADH were studied. Patients with a diagnosis of ADH associated with other lesions (lobular intraepithelial neoplasia, papilloma), atypical lobular hyperplasia, lobular carcinoma in situ and any lesions with a microhistological diagnosis other than ADH were excluded. Mammographic appearance of lesions was as follows: 152 mostly clustered microcalcifications (86%); five opacities with microcalcifications (3%); 12 single opacities (3%); and eight parenchymal distortions (4%), of which five were without and three were with microcalcifications. In cases underestimated by VAB, we evaluated the extent of ADH within ducts and lobules. Based on results, patients were subdivided into two groups: ≤2 ADH foci; >2 ADH foci. Patients were subdivided into two groups: one was referred for surgery and the other for follow-up care. The decision to either perform or not perform surgery was based on combined analysis of the following parameters: patient age; risk factors in the patient’s history; mammographic extent of microcalcifications; complete excision of microcalcifications at VAB; and final Breast Imaging Reporting and Data System (BI-RADS) assessment.ResultsIn the first group (n=98), comparison of microhistology with final histology revealed that 19 cases of ADH had been underestimated by VAB. In the second group (n=79), six cases of ADH showed progression of the mammographic abnormality, which was subsequently confirmed by surgical biopsy.ConclusionsThe most relevant parameters affecting the decision to proceed to surgical excision were lesion diameter >7 mm on mammography, >2 ADH foci, incomplete removal of the calcifications and a family and/or personal history of breast cancer. Although there are no definite mammographic predictors of malignancy, a radiological assessment of suspicious lesion in the presence of an additional equivocal parameter always warrants surgical management.RiassuntoObiettivoScopo del nostro lavoro è stato valutare l’accuratezza della vaccum assisted biopsy (VAB) nella diagnosi di iperplasia duttale atipica (ADH), individuando le sottostime della metodica rispetto all’esame istologico definitivo ed identificare parametri utili al corretto management delle pazienti.Materiali e metodiÈ stata effettuata un’analisi retrospettiva di 1776 VAB per lesioni mammarie sospette infracliniche, visibili solo alla mammografia, eseguite da novembre 1999 a gennaio 2008. Sono state incluse nel nostro studio 177 pazienti con diagnosi VAB di ADH pura; sono state escluse le pazienti con diagnosi di ADH associata ad altre lesioni (neoplasia intraepiteliale lobulare [LIN], papilloma), iperplasia lobulare atipica (ALH), carcinoma lobulare in situ (LCIS) e tutti le lesioni con diagnosi microistologiche differenti. La tipologia mammografica di tali lesioni è stata la seguente: 152 microcalcificazioni per la maggior parte in cluster (86%); 5 opacità con microcalcificazioni (3%); 12 opacità singole (3%); infine, 8 distorsioni parenchimali (4%) di cui 5 senza microcalcificazioni e 3 con microcalcificazioni. Nei casi sottostimati è stata valutata l’estensione dell’ADH all’interno dei dotti e dei lobuli dividendo le pazienti in due gruppi: ADH≤2 foci, ADH>2 foci. Le pazienti sono state suddivise in due gruppi: uno inviato ad intervento chirurgico e l’altro monitorato nel tempo. La decisione d’inviare o meno la paziente ad intervento chirurgico si è basata sull’analisi combinata dei seguenti parametri: età della paziente, eventuali fattori di rischio anamnestici, estensione mammografica delle microcalcificazioni, completa exeresi delle microcalcificazioni alla VAB e giudizio breast imaging reporting and data system (BIRADS) radiologico espresso.RisultatiNel primo gruppo (n=98), il confronto tra microistologia bioptica e istologia definitiva ha individuato 19 casi di ADH sottostimati dalla VAB. Nel secondo gruppo (n=79), 6 casi di ADH hanno mostrato un’evoluzione del quadro mammografico, poi confermato dalla biopsia chirurgica.ConclusioniDai dati emersi nel nostro studio i parametri più rilevanti per la decisione all’exeresi della lesione sono stati: diametro mammografico>7 mm, estensione dell’ADH>2 foci, incompleta rimozione delle calcificazioni ed anamnesi familiare e/o personale di neoplasia. Sebbene non vi siano caratteristiche mammografiche predittive di malignità certa, un giudizio radiologico sospetto, in presenza di un ulteriore parametro dubbio, dovrebbe comunque indirizzare all’exeresi.

Abdominal Hernias, Giant Colon Diverticulum, GIST, Intestinal Pneumatosis, Colon Ischemia, Cold Intussusception, Gallstone Ileus, and Foreign Bodies: Our Experience and Literature Review of Incidental Gastrointestinal MDCT Findings

Incidental gastrointestinal findings are commonly detected on MDCT exams performed for various medical indications. This review describes the radiological MDCT spectrum of appearances already present in the past literature and in todays experience of several gastrointestinal acute conditions such as abdominal hernia, giant colon diverticulum, GIST, intestinal pneumatosis, colon ischemia, cold intussusception, gallstone ileus, and foreign bodies which can require medical and surgical intervention or clinical follow-up. The clinical presentation of this illness is frequently nonspecific: abdominal pain, distension, nausea, fever, rectal bleeding, vomiting, constipation, or a palpable mass, depending on the disease. A proper differential diagnosis is essential in the assessment of treatment and in this case MDCT exam plays a central rule. We wish that this article will familiarize the radiologist in the diagnosis of this kind of incidental MDCT findings for better orientation of the therapy.

Management of breast cancer in elderly patients

Even if there is not a general consensus, we consider elderly patients of 65 years old or more. The degree of aging is extremely variable so that we can individuate different groups of patients that are different one from the other in relation with Performance Status, the presence of other pathology, and of eventual social discomfort. Breast Cancer is the most common Tumor in elderly woman and it represent the first death cause The 45% of Breast Cancer arise in women more than 65 years old and the 33% arise in women of more than 70 years old. Despite these data elderly women are often excluded from screening schedules, moreover despite there is no evidence that breast cancer is less aggressive in elderly patient they are generally non considered in trial studies so that they are under treated if compared to young patients thats why we cannot observe a decrease of mortality such as in younger patients Relative survival between 5 and 10 years in patients more than 75 years old its lesser than the one observed in younger patients (between 45 and 70 years old) maybe thats because of the incongruity in the access to sanitary structures and because of the social and economic discomfort. When we speak about Breast Cancer we cannot be able to leave a multidisciplinary approach out of consideration. Patients evaluation must be done by a group of dedicated specialists that are: Radiologist, Pathologist, Surgeon, Radiotherapist and Oncologist. The team need to analyze all data to improve treatment and obtain a better cosmetic result [4]. Complex cases must be discussed collectively before surgery to obtain the best therapeutic strategy. Moreover its strictly important patients involvement in treatment selection. Consensus is mandatory and it can be obtained only if the patient is well informed about treatment phases, adverse effects, and results.

Use of Ethanol in the Trans-Arterial Lipiodol Embolization (TAELE) of Intermediated-Stage HCC: Is This Safer than Conventional Trans-Arterial Chemo-Embolization (c-TACE)?

Purpose To evaluate safety and efficacy of Trans-Arterial Ethanol-Lipiodol Embolization (TAELE) compared with conventional Trans-Arterial Chemo-Embolization (cTACE) in the treatment of small intermediate-HCC (BCLC-Stage B). Materials and Methods A random sample of 87 patients (37.93% male; 62.07% female; age range, 36–86 years) with documented small intermediate-HCC and treated with TAELE (mixture 1:1 of Ethanol and Lipiodol) or cTACE (mixture of 50mg-Epirubicin and 5cc-Lipiodol) were retrospectively studied in an institutional review board approved protocol. The two procedures were compared with χ2-test, χ2-test with Yates correction, McNemar’s exact test, ANOVA test and log-rank test. Results TAELE and cTACE therapies were performed in 45 and 42 patients, respectively. Thirty days after the procedure, a Multi-Detector Computed Tomography (MDCT) showed no significant difference in the number of patients with partial and complete response between the two groups (p-value = 0.958), according to mRECIST. Contrary, significant differences were found in tumor-devascularization, lesion-reduction and post-embolization syndrome occurrence (p-value = 0.0004, p-value = 0.0003 and p-value = 0.009, respectively). Similar survival was observed during 36-month follow-up (p-value = 0.884). Conclusion Compared to cTACE, TAELE showed a better toxicity profile with similar 36-month survival and similar one-month anti-tumor effects, which makes it better tolerated by patients, especially in case of more than one treatment.

Breast ultrasound in the management of gynecomastia in Peutz–Jeghers syndrome in monozygotic twins: two case reports

IntroductionPeutz–Jeghers syndrome is an autosomal dominant disease with incomplete penetrance and variable expression caused by germline mutation of serine threonine kinase 11/liver kinase B1; it is characterized by hamartomatous polyps in the gastrointestinal tract, mucocutaneous melanin pigmentation, and increased predisposition to neoplasms. In Peutz–Jeghers syndrome, bilateral Sertoli cell testicular tumors cause endocrine manifestations including gynecomastia and feminization.This study aimed to assess the role of breast ultrasound in the evaluation of the effectiveness of an innovative surgical approach.Case presentationThis report presents a pair of European 9-year-old identical male twins with Peutz–Jeghers syndrome, bilateral prepubertal gynecomastia, and testicular multifocal calcifications. Both twins were treated with anastrozole for 2 years. After finishing treatment, both underwent subcutaneous mastectomy performed by the “modified” Webster technique. Breast examination and ultrasound were performed before and after the pharmacological and surgical treatment. A breast ultrasound scan before surgery showed bilateral gynecomastia in both patients. No solid nodular or cystic formations were present on either side. After pharmacological therapy and surgical glandular removal, a breast examination showed a significant reduction in breast volume; 1 year after surgery, a breast ultrasound scan of both patients showed a total absence of glandular parenchyma, with muscle planes well represented.ConclusionsBreast examination and ultrasound have proved to be a valid approach in the assessment of the treatment of prepubertal gynecomastia because they allow the efficacy of the pharmacological and surgical treatment to be evaluated in a multidisciplinary approach to one of the most frequent endocrine manifestations of Peutz–Jeghers syndrome.