Giovanni Battista Meloni

Percutaneous treatment of hepatic cysts by aspiration and sclerotherapy

We treated 35 patients who had hepatic cysts (30 congenital cysts, 5 hydatid cysts) with percutaneous puncture and sclerotherapy. After puncture and drainage of the cyst, a 95% alcohol solution was instilled as sclerosing agent into the cystic cavity. In all the patients, cyst puncture and drainage was successful. Follow-up in all cases was at least 12 months. In three uncooperative patients, cysts recurred due to incomplete sclerosis of the lining epithelium of the cyst wall. No major complications were encountered in all cases. All congenital cysts were treated on an outpatient basis. Patients with hydatid cyst were hospitalized for 48 h after puncture and aspiration. In our opinion, percutaneous drainage and sclerosis of congenital hepatic cysts can be considered an effective alternative to surgical treatment.

Cauda Equina Syndrome Secondary to Idiopathic Spinal Epidural Lipomatosis

Study Design. Three cases of idiopathic epidural lipomatosis are reported. Objectives. Description of the relationship between spinal pathologic overgrowth of fat tissue and neurologic symptoms. Summary of Background Data. Idiopathic epidural lipomatosis is a very rare condition; it is usually secondary to chronic steroid therapy or endocrinopathic diseases. Methods. Three men with a mean age of 58.5 years, who experienced intermittent claudication, bilateral radicular pain in both legs, and urinary dysfunction with hypoesthesia in the perineal region, were evaluated by plain radiography and magnetic resonance imaging, the results of which demonstrated a pathologic overgrowth of fat tissue in the spinal canal with a marked impingement of the dural sac. Obesity, endocrinopathic diseases, and chronic steroid therapy were excluded for all patients. Surgical treatment was performed by wide multilevel laminectomies, fat debulking, and instrumented posterolateral fusion. Results. After surgery there was a gradual improvement in symptoms and signs so that 2 years later the patients returned to daily activities and were neurologically normal. Conclusions. Spinal epidural lipomatosis can be a cause of back pain but rarely radicular impingement. Magnetic resonance imaging is the procedure of choice. The treatment must be performed early by wide surgical decompression.

Determining the best catheter for sonohysterography

OBJECTIVE To compare the characteristics of six different catheters for performing sonohysterography (SHG) to identify those that offer the best compromise between reliability, tolerability, and cost. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Six hundred ten women undergoing SHG. INTERVENTION(S) We performed SHG with six different types of catheters: Foleycath (Wembley Rubber Products, Sepang, Malaysia), Hysca Hysterosalpingography Catheter (GTA International Medical Devices S.A., La Caleta D.N., Dominican Republic), H/S Catheter Set (Ackrad Laboratories, Cranford, NJ), PBN Balloon Hystero-Salpingography Catheter (PBN Medicals, Stenloese, Denmark), ZUI-2.0 Catheter (Zinnanti Uterine Injection; BEI Medical System International, Gembloux, Belgium), and Goldstein Catheter (Cook, Spencer, IN). MAIN OUTCOME MEASURE(S) We assessed the reliability, the physicians ease of use, the time requested for the insertion of the catheter, the volume of contrast medium used, the tolerability for the patients, and the cost of the catheters. RESULT(S) In 568 (93%) correctly performed procedures, no statistically significant differences were found among the catheters. The Foleycath was the most difficult for the physician to use and required significantly more time to position correctly. The Goldstein catheter was the best tolerated by the patients. The Foleycath was the cheapest whereas the PBN Balloon was the most expensive. CONCLUSION(S) The choice of the catheter must be targeted to achieving a good balance between tolerability for the patients, efficacy, cost, and the personal preference of the operator.

Usefulness of magnetic resonance in patients with invasive cancer eligible for breast conservation: a comparative study.

BACKGROUND The role of magnetic resonance imaging (MRI) in newly detected breast cancer remains controversial. We investigated the impact of preoperative MRI on surgical management of infiltrating breast carcinoma (IBC). METHODS We reviewed data of 237 patients with IBC who were suitable for breast-conserving surgery (BCS) between 2009 and 2011. Of these patients, 109 underwent preoperative MRI (46%; MRI group) and 128 did not (54%; no-MRI group). We analyzed MRI-triggered changes in surgical plan and compared differences in rates of positive margins and mastectomy. RESULTS Tumor size was larger in the MRI group (16.8 mm vs. 13.9 mm; P < .001). MRI changed the initial surgical planning in 18 of 109 patients (16.5%) because of detection of larger tumor diameter requiring wider resection (8 patients [7.3%]) or additional malignant lesions in the ipsilateral (9 patients [8.2%]) or contralateral breast (1 patient [0.9%]). MRI-triggered treatment changes included mastectomy (n = 12), wider excision (n = 5), and contralateral BCS (n = 1). Reoperation rates for positive margins after BCS appeared higher in the no-MRI group (4.1% vs. 8.6%), but the difference missed statistical significance (P = .9). Overall mastectomy rates were higher in the MRI group (13.7% vs. 7.0%; P < .05). The likelihood of having a change of treatment resulting from MRI was significantly higher for patients with tumors > 15 mm and for those with positive lymph nodes. CONCLUSION Lymph node positivity and tumor size > 15 mm may predict an MRI-triggered change in surgical plan. Preoperative MRI resulted in higher mastectomy rates justified by biopsy-proven additional foci of carcinoma and did not significantly reduce reoperation rates for positive margins.

A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal obstruction

OBJECTIVE To assess whether a second hysterosalpingography (HSG) can permit tubal patency, reducing the use of selective salpingography in patients with proximal tubal obstruction. DESIGN Prospective study. SETTING University hospital. PATIENT(S) The study population consisted of 360 infertile women. INTERVENTION(S) In patients with unilateral or bilateral proximal tubal obstruction, a second HSG was performed after about 1 month. In those cases with persistent obstruction, an immediate selective salpingography and tubal catheterization were performed. MAIN OUTCOME MEASURE(S) Tubal opacification. RESULT(S) Forty patients underwent a second HSG procedure for proximal tubal occlusion. Among these, 24 achieved bilateral tubal patency. Thus, repetition of a conventional HSG after 1 month avoided unnecessary salpingography in 60% of patients. CONCLUSION(S) In infertile women with proximal tubal obstruction, we believe it is best to perform a second HSG. HSG is easy to carry out and subjects patients to a lower dosage of radiation and fewer risks than selective salpingography. The latter technique should be reserved for unsuccessful cases.

Combined Biliary and Duodenal Stenting for Palliation of Pancreatic Cancer

The aim of this case report was to evaluate the usefulness of combined biliary and duodenal stenting in the palliation of pancreatic cancer. We report a series of 4 consecutive patients (2 men and 2 women, mean age 58.5 years, range 38–77 years) who underwent combined biliary and duodenal stenting in our department between March 2000 and April 2001. All patients had cancer of the head of the pancreas causing stricture of the common bile duct and second portion of the duodenum. Biliary and duodenal stents were successfully positioned, with relief of symptoms in all cases. No early complications were observed, except for a transient increase in serum lipase and amylase in one case. Mean follow‐up was 7.5 months (range 5–14 months). One patient presenting recurrence of vomiting after 4 months because of tumour overgrowth at the distal edge of the prosthesis was successfully treated by insertion of a partially overlapping second coaxial stent. Combined biliary and duodenal stenting for the palliation of pancreatic cancer was performed safely and successfully. Stents allowed effective re‐canalization of the biliary tract and duodenum, relieving both jaundice and vomiting. This procedure should be considered as an alternative to palliative surgery, especially in critically ill patients.

Multidetector-row helical CT enteroclysis

The authors illustrate the technique for small-bowel imaging using enteroclysis with multidetector-row computed tomography (MDCT), underscoring the important role played by CT in the assessment of the small bowel thanks to the advent of first the spiral and later the multidetector technique. The paper makes a detailed comparison of the various methods that have been used in CT study of the small bowel and proposes a standardised technique to achieve correct distension of bowel loops and adequate evaluation of bowel wall vascularity, making reference to the well-consolidated experiences of the various Italian research groups. The paper accurately describes the different procedures required for CT assessment of the small bowel, from nasojejunal intubation to the selection of the most appropriate acquisition phases for assessment of bowel wall vascularity.

The role of planar scintimammography with high-resolution dedicated breast camera in the diagnosis of primary breast cancer.

Planar scintimammography (SM) acquired with a conventional γ camera has proved a useful complementary tool to mammography (Mx) in breast cancer (BC) diagnosis, but with unsatisfactory sensitivity in small size carcinomas. In this study we assessed the role of planar SM with a high-resolution dedicated breast camera (DBC) in BC diagnosis, comparing the results with those of Mx. A consecutive series of 145 patients scheduled for biopsy for suspected BC underwent Tc-99m tetrofosmin planar SM using a newly developed DBC. Scintigraphic data were compared with Mx findings and correlated to histology. Histopathologic analysis revealed 165 lesions: 143 malignant and 22 benign. SM detected 139/143 carcinomas (overall sensitivity: 97.2%) and was true negative in 19/22 benign lesions (overall specificity: 86.4%). SM sensitivity was 91% in ≤10-mm carcinomas. SM was more accurate than Mx in 42/145 cases (29%), detecting cancer in 9 patients with Mx indeterminate for dense breasts (8/9 tumors were <10 mm), assessing additional tumor foci (all <10 mm) in 5 points with multifocal disease and correctly classifying 28 patients with inconclusive mammographic findings as affected by cancer or by benign disease. Mx was more accurate than SM in 3 patients, in each detecting 1 subcentimeter BC false negative on SM. DBC planar SM seems a highly sensitive diagnostic tool in the detection of BC, even when small in size, and in the assessment of multifocal disease. A wider employment of this procedure is thus suggested, especially in indeterminate or inconclusive mammographic findings to improve sensitivity and specificity of Mx.

Palliative Airway Stenting Performed Under Radiological Guidance and Local Anesthesia

PurposeTo assess the effectiveness of airway stenting performed exclusively under radiological guidance for the palliation of malignant tracheobronchial strictures.MethodsWe report our experience in 16 patients with malignant tracheobronchial stricture treated by insertion of 20 Ultraflex self-expandable metal stents performed under fluoroscopic guidance only. Three patients presented dysphagia grade IV due to esophageal malignant infiltration; they therefore underwent combined airway and esophageal stenting. All the procedures were performed under conscious sedation in the radiological room; average procedure time was around 10 min, but the airway impediment never lasted more than 40 sec.ResultsWe obtained an overall technical success in 16 cases (100%) and clinical success in 14 patients (88%). All prostheses were successfully placed without procedural complications. Rapid clinical improvement with symptom relief and normalization of respiratory function was obtained in 14 cases. Two patients died within 48 hr from causes unrelated to stent placement. Two cases (13%) of migration were observed; they were successfully treated with another stent. Tumor overgrowth developed in other 2 patients (13%); however, no further treatment was possible because of extensive laryngeal infiltration.ConclusionsTracheobronchial recanalization with self-expandable metal stents is a safe and effective palliative treatment for malignant strictures. Airway stenting performed exclusively under fluoroscopic view was rapid and well tolerated.

A Rare Case of Primary Actinomycosis of the Breast Caused by Actinomyces viscosus: Diagnosis by Fine-needle Aspiration Cytology under Ultrasound Guidance

Abstract:  We report the case of a 27‐year‐old woman with primary actinomycosis of the breast. Diagnosis was established by culture examination of specimen recovered by fine‐needle aspiration cytology (FNAC) under ultrasound guidance. To our knowledge, this is the first description in the literature of a case of primary actinomycosis of the breast caused by Actinomyces viscosus. Twenty‐nine previous cases of primary actinomycosis of the breast have been published, but these were caused by the more common species Actinomyces israelii. Targeted antibiotic therapy did not ameliorate the condition, thus drainage and excision of the mass were carried out. No other medical therapy was administered. Six years after surgery, no recurrence has been observed on both ultrasonographic and mammographic examinations.