P. Mannella

Imaging of the scrotum: role of MRI

PurposeThe aim of this study was to evaluate the usefulness of imaging for correct clinical and therapeutic management of patients with scrotal disease.Materials and methodsBetween 2000 and 2007, 801 patients with suspected scrotal disease underwent colour Doppler ultrasonography (CDUS) at our centre. In 46 patients, the CDUS study was followed by magnetic resonance imaging (MRI).ResultsCDUS revealed an inflammatory process in 277 patients (34.58%), testicular trauma in 112 (13.9%), funicular torsion or torsion of the vestigial remnant in 44 (5.4%), findings suggestive of testicular neoplasm in 35 (4.3%) and no abnormality in 41.5%. MRI, used to further investigate the CDUS findings in 46 cases, showed three cases of intraparenchymal haematoma, one of intrascrotal cavernous body rupture, one of testicular abscess with intrascrotal fistula, two of testicular infarction and 15 of neoplasm. MRI allowed the exclusion of focal abnormalities in ten patients with testicular microlithiasis, in three with chronic orchitis and in four with atrophic involution. MRI confirmed the finding of inguinal hernia in three cases.ConclusionsOn the basis of our experience, CDUS is irreplaceable as an initial approach to patients affected by scrotal disease, whereas MRI is an ideal second-line investigation. MRI offers useful, and in some cases decisive, information, as it is capable of revealing unexpected findings and elucidating complex aspects. MRI helps improve patient management, with an overall reduction in costs.RiassuntoObiettivoScopo del lavoro è stato quello di valutare l’utilitá delle metodiche di immagine nei pazienti con patologia dello scroto per un corretto approccio clinico-terapeutico.Materiali e metodiOttocentouno pazienti sono stati sottoposti ad indagine eco-color Doppler (ECD) e successivamente 46 pazienti sono stati indagati con risonanza magnetica (RM).RisultatiL’ECD ha rilevato: in 277 pazienti (34,58%) processo flogistico, in 112 (13,9%) trauma del testicolo, in 44 (5,4%) torsione del funicolo o di un residuo embrionario, in 35 (4,3%) alterazioni riconducibili ad eteroplasia testicolare mentre nel 41,5% non erano presenti alterazioni patologiche. In 46 casi si è ricorsi alla RM per chiarimento o miglior definizione diagnostica del reperto ECD rilevando: 3 casi di ematoma intraparenchimale, 1 caso di rottura intrascrotale del corpo cavernoso, 1 caso di ascesso testicolare con fistola intrascrotale, 2 casi di infarto, 15 casi di eteroplasia. Inoltre ha permesso di escludere alterazioni focali in 10 pazienti affetti da microlitiasi testicolare (MT), in 3 con orchite cronica e in 4 con involuzione atrofica. In 3 casi ha confermato il reperto di ernia inguinale.ConclusioniDalla nostra esperienza l’indagine ECD appare di insostituibile utilitá nel primo approccio ai pazienti con patologia scrotale e l’indagine RM rappresenta un ideale metodica di secondo livello. La RM è utile in casi selezionati, potendo rilevare situazioni complesse e precedentemente insospettabili, risultando in un miglioramento della gestione del paziente e in un contenimento globale dei costi.

Association between testicular microlithiasis and primary malignancy of the testis: our experience and review of the literature

PurposeThe aims of this study were to evaluate the association of testicular microlithiasis with testicular neoplasm, to assess the accuracy of ultrasonography (US) in comparison with histology in detecting microlithiasis, and to identify the prevalent cytohistological features that accompany testicular cancer.Materials and methodsBetween 2004 and 2005, 14 patients were referred to us for US examination, 13 of whom underwent surgery for testicular cancer. Their age ranged from 19 to 43 years, except for one patient aged 60. US findings and histological examination were compared to assess the accuracy of US in detecting microlithiasis associated with testicular cancer.ResultsIn two patients (15.3%), microlithiasis had been detected in a previous US examination, and two patients (15.3%) had altered sperm function. At US examination, testicular cancer was associated with microlithiasis in seven out of 13 patients (53.8%) (the distribution pattern of microlithiasis was intranodular in two, perinodular in two and both intra-and perinodular in three), and colour-Doppler US showed perinodular and intranodular vascularity. Histological evaluation identified nine seminomas, two mixed germ-cell tumours, one embryonal carcinoma, one yolk-sac tumour and one benign Sertoli-cell tumour. In nine (69.2%) patients, microlithiasis was confirmed at histologic evaluation, and its distribution was intranodular in two, perinodular in five and both intra-and perinodular in two. Tubular hyalinisation was demonstrated in 12 out of 13 patients (92.3%).ConclusionsTesticular microlithiasis and poor sperm function represent risk factors for testicular cancer: in our study, 30.6% of the patients who developed cancer presented these features. At US examination, testicular microlithiasis is often associated with testicular cancer (53.8%). A high accuracy has been demonstrated for US in detecting microlithiasis (53.8%) compared with histological evaluation (69.2%). At histology, tubular hyalinisation (92.3% of cases) is, with testicular microlithiasis, the most frequent finding in the parenchyma adjacent to testicular cancer.RiassuntoObiettivoAnalizzare se esistono correlazioni fra la microlitiasi testicolare e le neoplasie testicolari maligne e valutare l’affidabilità dell’ecografia nel rilevare la microlitiasi confrontandola con l’esame istologico; ricercare quali siano gli aspetti citoistologici prevalenti di accompagnamento alla eteroplasia testicolare.Materali e metodiDal 2004 al 2005, sono giunti alla nostra osservazione e sottoposti ad indagine ecografica 14 pazienti, di cui 13 operati per neoplasia maligna, di età compresa tra 19 e 43 anni e solo un caso di 60 anni. Abbiamo comparato l’affidabilità dell’esame ecografico ed istologico nel rilevare le microlitiasi testicolari associate alla neoplasia testicolare maligna.RisultatiDue pazienti (15,3%) presentavano microlitiasi testicolare in precedente indagine ecografica e due pazienti (15,3%) presentavano alterazioni dello spermiogramma. All’indagine ecografica la neoplasia testicolare maligna nel 53,8% (7/13) era associata alla presenza di microlitiasi testicolare (in 2/7 in sede intranodulare, in 2/7 in sede perinodulare e in 3/7 casi in sede peri-intranodulare) e presentava vascolarizzazione peri ed intranodulare all’eco color doppler. All’esame istologico, 9 risultarono seminomi, 2 forme miste, 1 carcinoma embrionario, 1 tumore del sacco vitellino e 1 tumore a cellule di Sertoli sottotipo sclerosante. In 9 casi su 13 (69,2%) di neoplasie testicolari maligne, sono state rilevate microcalcificazioni (in 2/9 intranodulare, in 5/9 perinodulari e in 2/9 peri ed intranodulari). In 12/13 casi (92,3%) era presente scleroialinosi dei tubuli.ConclusioniLe microlitiasi testicolari e le alterazioni del liquido seminale rappresentano fattore di rischio nelle neoplasie maligne del testicolo: infatti, complessivamente, il 30,6% ha sviluppato una eteroplasia maligna. All’indagine ecografica, le microlitiasi testicolari sono spesso presenti (53,8%) in accompagnamento alle neoplasie testicolari maligne. È stata rilevata buona attendibilità dell’ecografia nel rilevare la microlitiasi testicolare (53,8%) rispetto l’esame istologico (69,2%). La scleroialinosi dei tubuli (presente nel 92,3% dei casi) appare, insieme alla microlitiasi testicolare, il reperto più frequente nel parenchima adiacente alla eteroplasia testicolare maligna.

Anomalous origin of the coronary arteries in children: diagnostic role of three-dimensional coronary MR angiography

When the anomalous origin of coronary arteries (AOCA) is suspected in children (especially athletes), due to signs and symptoms of myocardial ischemia or on the basis of echocardiographic assessment, three-dimensional coronary magnetic resonance angiography (3D-CMRA) can be proposed for the fine morphological evaluation of coronary branches anatomy and course. We tested the diagnostic potential of CMRA angiography in a prospective study on AOCA in young patients. Between July 2005 and June 2008, 15 patients aged 6-29 years (mean age, 13.5 years+/-5.6 S.D.; median, 14) with clinical and echocardiographic suspicion of AOCA underwent CMRA (1.5 T), 3D whole-heart, free-breathing technique, without the use of contrast medium and beta-blockers, with a mean examination time of 30 min. We acquired a second scan of all patients to ameliorate the quality of the acquisition and to improve our experience. AOCA was confirmed by 3D-CMRA in 8 out of 15 cases (53%) and three different anatomical variants were demonstrated, that is, ectopic origin of the left circumflex artery arising from the right coronary artery with retro-aortic course in four cases, single coronary artery arising from the right sinus of Valsalva with interarterial course in one case, ectopic right coronary artery arising from the left sinus of Valsalva with interarterial course in one case; in two patients without anomalies of origin of the coronary arteries, elongated LMCA with angulation of the proximal segment of the left circumflex artery was present. When AOCA is suspected particularly in children (especially athletes), CMRA without the use of contrast medium is an effective diagnostic technique, which is useful to clarify the spatial position of the anomalous course of the main coronary branches in order to suggest the most convenient management of the disease. CMRA does not need contrast medium, needles, and beta-blockers; is repeatable in the same examination without the exposure to X-rays; allows a parent to stay near the child; and needs low collaboration in low-stress conditions.

Role of color-Doppler sonography in the follow-up of renal artery stenting

PurposeThe aim of this study was to evaluate the utility of color-Doppler ultrasound (CDUS) in detecting haemodynamically significant in-stent restenosis in patients who underwent endoluminal renal artery revascularisation by stent deployment.Materials and methodBetween January 2000 and December 2006, 42 patients (nine women and 33 men, age range 45–87 years) treated by endovascular renal artery stenting were studied with CDUS. Renal artery haemodynamics were evaluated to identify haemodynamically significant restenosis. Patients with CDUS signs of restenosis underwent angiography for a possible further revascularisation procedure.ResultOf 42 patients examined by CDUS, 13 (31%) showed signs of haemodynamically significant in-stent renal artery restenosis. Of these 13, three did not undergo endoluminal renal artery revascularisation because renal ischaemia deterioration and irreversible renal circulation impairment. In the remaining ten patients (23.8%), who had no signs of severe nephropathy, angiography confirmed the CDUS findings of in-stent restenosis in all cases. Restenoses were successfully treated by a repeat endovascular revascularisation procedure.ConclusionOur results confirm the fundamental role of CDUS in the follow-up of patients after renal artery stenting. It enables early restenosis detection and evaluation of renovascular disease associated with renal artery stenosis. CDUS provides essential information for the subsequent clinical management of these patients.RiassuntoObiettivoValutare l’utilità dell’eco-color Doppler (ECD) nel rilevare precoci alterazioni flussimetriche indicative di ristenosi dell’arteria renale nel follow-up dei pazienti sottoposti a trattamento endovascolare di rivascolarizzazione mediante posizionamento di stent.Materali e metodiNel periodo 2000–2006 sono stati studiati mediante ECD 42 pazienti (9 donne e 33 uomini, range 45–87 anni) portatori di stent dell’arteria renale. In tutti è stata valutata l’emodinamica dell’arteria renale tramite ECD allo scopo di evidenziare alterazioni emodinamicamente significative a livello dello stent. I pazienti con segni ECD di ristenosi sono stati sottoposti ad esame angiografico per eventuale ulteriore intervento di rivascolarizzazione.RisultatiDei 42 pazienti esaminati mediante ECD, 13 (31%) presentavano segni di ristenosi emodinamicamente significativa a livello dello stent. Di questi, 3 non sono stati sottoposti ad angiografia per peggioramento della nefropatia ischemica ed irreversibile compromissione emodinamica del circolo renale. Nei restanti 10 pazienti (23,8%), che non presentavano segni di severa nefropatia, il reperto ECD di ristenosi a livello dello stent è stato confermato in tutti i casi. Le restenosi sono state trattate con successo per via endovascolare.ConclusioniL’ECD svolge un ruolo fondamentale nel monitoraggio dei pazienti sottoposti a rivascolarizzazione dell’arteria renale mediante posizionamento di stent, consentendo una diagnosi precoce di ristenosi ed una valutazione della nefropatia spesso associata alla stenosi dell’arteria renale (SAR). L’ECD fornisce elementi essenziali alla successiva gestione terapeutica di questi pazienti.

Imaging of segmental testicular infarction: our experience and literature review

PurposeThe purpose of this study was to evaluate the usefulness of the main methods of diagnostic imaging in patients with segmental testicular infarction (STI) for obtaining accurate clinical and therapeutic approaches.Materials and methodsBetween January 2004 and January 2011, 798 patients were examined with colour Doppler ultrasound (CDUS) for disease of the scrotum. Fourteen patients with CDUS findings suspicious for STI were subjected to magnetic resonance imaging (MRI). In five patients, contrast-enhanced ultrasonography (CEUS) was performed.ResultsCDUS showed hypoechoic avascular areas suspicious for STI in 14 patients (1.75%). MRI confirmed the presence of predominantly hypointense lesions in T1- and T2-weighted sequences, with perilesional vasculature and no intrinsic contrast enhancement in 13 patients. In follow-up examinations, these abnormalities gradually decreased. This finding was confirmed in the five patients examined with CEUS. Only in one case did MRI reveal discrete intralesional contrast enhancement after injection of contrast medium, and the lesions appeared stable during the CDUS and MRI follow-up; this patient underwent orchiectomy, with a diagnosis of B-cell lymphoma.ConclusionsIn our experience CDUS, CEUS and MRI proved indispensable for accurate clinical and therapeutic approaches in suspected STI.RiassuntoObiettivoScopo del lavoro è stato valutare l’utilità delle principali metodiche di diagnostica per immagini nel paziente con infarto segmentale del testicolo (IST) per un corretto approccio clinico-terapeutico.Materiali e metodiNel periodo compreso tra gennaio 2004 e gennaio 2011 sono stati esaminati con eco-color Doppler (ECD) 798 pazienti per patologia dello scroto. Quattordici pazienti con reperti ECD sospetti per IST sono stati sottoposti a risonanza magnetica (RM). In 5 pazienti è stata eseguita ecografia con mezzo di contrasto (CEUS).RisultatiQuattordici pazienti (1,75%) presentavano aree ipoecogene avascolari sospette per IST all’indagine ECD. L’RM ha confermato la presenza di lesioni prevalentemente ipointense nelle sequenze dipendenti dal T1 e dal T2, prive di contrast enhancement e con vascolarizzazione principalmente perilesionale in 13 pazienti. Nel follow-up queste alterazioni si sono progressivamente ridotte. Il dato è stato confermato anche mediante CEUS in 5 pazienti. Solo in 1 caso la RM ha documentato un discreto contrast enhancement delle lesioni e, vista la stazionarietà del reperto ECD e RM al follow-up, il paziente è stato sottoposto a orchiectomia, con diagnosi di linfoma a cellule B.ConclusioniDalla nostra esperienza ECD, CEUS e RM si sono dimostrate metodiche indispensabili per un corretto approccio clinico-terapeutico nel sospetto di IST.

Interventional radiology in percutaneous management of bile duct obstruction:: Biliary drainage through a spontaneous common hepatic duct-duodenal fistula

Bile duct injuries are a serious complication of biliary surgery. We report a case of benign obstruction of the common hepatic duct associated with common hepatic duct-duodenal spontaneous fistula following complex surgical intervention. We managed percutaneously the fistula with balloon dilatation and long-term stenting, as the fistula allowed biliary flow in the duodenum. We avoided reintervention preserving biliary flow, with good clinical results after a follow-up of a 3 years. We emphasize the role of a clinically focused approach to percutaneous management of complications following biliary surgery.