Pasquale Marano

MR imaging and MRCP of hilar cholangiocarcinoma

Hilar cholangiocarcinoma, or Klatskin tumor, is a primary malignancy arising from the bile duct epithelium, at the confluence of the right and left hepatic ducts, within the porta hepatis [1]. The relative incidence of cholangiocarcinoma among primary liver cancers reported in autopsy series is relatively rare, ranging from 5% to 30% [2]; however, it is the most common primary malignancy of the biliary tree [3]. Hilar cholangiocarcinoma appears most frequently in the sixth and seventh decades of life [4], but most patients with risk factors may develop the neoplasm at younger ages; men are affected more frequently than women. Risk factors for cholangiocarcinoma are primary sclerosing cholangitis, choledochal cysts, familial polyposis, congenital hepatic fibrosis, infection with Clonorchis siniensis (Chinese liver fluke), and a history of chemical and thorium dioxide exposure (Thorotrast). The prognosis is poor, with an overall 5-year survival rate of 1% [5]. Because of this poor prognosis, many patients were treated with palliative drainage rather than with surgery. However, because of technical advances in diagnostic imaging that allow for better patient selection, and because of improved surgical techniques resulting in lower operative morbidity and mortality, more patients are being treated with surgical resection. This has improved overall 5-year survival rates after surgery to 20% [6, 7]. Surgical exploration should be undertaken only when preoperative examination has shown a potential for curative resection because the risks of palliative surgery for malignant obstructive jaundice are high, with surgical mortality rates of 20–30% [8]. Further, accurate preoperative assessment of hilar cholangiocarcinoma resectability has increased its importance because percutaneous and endoscopic palliative techniques for biliary drainage are now available. For these reasons, an accurate preoperative assessment of hilar cholangiocarcinoma is critical in choosing treatment planning.

Delayed MR imaging of hepatocellular carcinoma enhanced by Gadobenate Dimeglumine (Gd-BOPTA).

The purpose of this study was to determine the efficacy of gadobenate dimeglumine (Gd‐BOPTA)‐enhanced magnetic resonance (MR) imaging for evaluation of hepatocellular carcinoma HCC. MR images were obtained in 14 patients with 31 HCC nodules as a part of a phase III clinical trial. T1‐ and T2‐weighted images were obtained before and after iv administration of 0.1 mmol/kg of Gd‐BOPTA. Two blinded readers evaluated pre‐ and delayed postcontrast images separately for detection of tumor nodules. Quantitative measurements of signal‐to‐noise (SNR) and tumor/liver contrast‐to‐noise (CNR) ratios were also performed. A signal/intensity ratio was calculated. Tumor enhancement was correlated with histologic findings. Consensus agreement of precontrast T1‐ and T2‐weighted images revealed 23/31 HCC nodules in 14 patients; postcontrast T1‐weighted images demonstrated 24/31 HCC nodules in the same number of patients. Combining both pre‐ and postcontrast images, 27/31 lesions were detected. Four patients had four well‐differentiated HCC nodules detected only on postcontrast images, while three well‐differentiated lesions in two patients were only seen on precontrast images. Quantitative evaluation showed an SNR ratio increase in both liver parenchyma and HCC nodules, as well as a significant increase in the absolute CNR ratio on postcontrast T1‐weighted gradient‐recalled images (P < 0.05). Well‐differentiated HCC lesions showed a greater enhancement than poorly differentiated HCC lesions. J. Magn. Reson. Imaging 1999;9:704–710.

Contrast-enhanced gray-scale and color Doppler voiding urosonography versus voiding cystourethrography in the diagnosis and grading of vesicoureteral reflux.

The purpose of this study was to compare contrast‐enhanced gray‐scale voiding urosonography (CE‐VUS) and contrast‐enhanced color Doppler voiding urosonography (CE‐CDVUS) with voiding cystourethrography (VCUG) to verify whether the use of color Doppler imaging improves the diagnosis and grading of vesicoureteral reflux (VUR).

The accuracy of transrectal ultrasound in predicting the pathological stage of low-lying rectal cancer after preoperative chemoradiation therapy

PURPOSE There has been a growing interest in the use of preoperative radiation therapy in rectal cancer treatment in the last years. The need for accurate preoperative staging is important so as to avoid overtreatment in stage I patients, and to select patients who require downstaging prior to surgery as they are technically inoperable. While transrectal ultrasound (TRUS) has been reported to accurately stage preoperative patients, its efficacy postradiation has been questioned. The authors report a series studied by TRUS to contribute to the discussion on the role of this method. METHODS AND MATERIALS Twenty-eight patients with rectal cancer were accrued. Twenty-six patients, clinically staged T2-T4 or/and N1-N3 between March 1990 to October 1993, underwent preoperative chemoradiation. Two patients (T2N0) were treated by local excision and postoperative radiotherapy. Following therapy and just before surgery, each patient was restaged by TRUS. These results were subsequently compared with a pathological stage of resected specimen for both the primary tumor (T) and regional lymph nodes (LN). RESULTS The accuracy of TRUS for T stage after chemoradiation was 92.8% (positive predictive value [PPV] 94.4%, negative predictive value [NPV] 90.0%). The accuracy for LN staging after chemoradiation was 60.7% (PPV 100.0%, NPV 54.0%), because LN located outside the scanning range were missed. CONCLUSION Based on our results, we conclude that TRUS of the primary tumor is an accurate staging technique for patients with rectal cancer treated with preoperative chemoradiation.

Magnetic resonance imaging in breast cancer recurrence.

AbstractPurpose. To determine the sensitivity, specificity and accuracy of magnetic resonance imaging (MRI) in detecting breast cancer recurrence. Materials and methods. Forty women conservatively treated for breast cancer underwent MRI and confirmation on histology and cytology of suspected local recurrence. In these patients both clinical and mammographic/ultrasound features of local recurrence were nonspecific or suspicious. All patients were examined at least 1 year after completion of radiation treatment. Dynamic magnetic resonance imaging was performed with a 1.5 T unit using a dedicated bilateral breast coil. Qualitative and quantitative data were obtained. Statistical analysis was also performed with the Student T-test. Results. Breast cancer recurrence was confirmed on histology in 22 patients. MRI identified all the 22 breast recurrent cancers. False-positive contrast enhancement was seen in only two patients. In four patients recurrence was classified as multifocal. In one patient the tumor was detected in the contralateral breast. MRI showed 95% accuracy, 100% sensitivity, 88.8% specificity with 5% false-positives and 100% negative predictive value. Conclusion. Dynamic MRI appears a valuable technique for differentiation of post-treatment changes from recurrent carcinoma and for guiding the histological confirmation. Its high negative predictive value may have an impact on follow-up of treated breast.

Destructive spondyloarthropathy of the cervical spine in long-term hemodialyzed patients: a five-year clinical radiological prospective study.

Abstract. Objective:To describe the radiographic features and progression of cervical spine destructive spondyloarthropathy (DSA) in hemodialyzed patients, and to evaluate the relationship between this disease and patient characteristics, biochemical values, and hemodialysis duration. Design and patients:Standard radiographs, and lateral flexion and extension views of the cervical spine, were performed annually for 5 years in 31 hemodialyzed patients who were divided into three groups at the commencement of the study: those showing (I) DSA, (II) vertebral rim erosions (VRE) without DSA, and (III) absence of DSA and VRE. Magnetic resonance (MR) imaging and computed tomography (CT) were performed in seven and two patients respectively. The imaging features were evaluated for the presence and progression of spondyloarthropathy and correlated with clinical and biochemical variables. Statistical analysis was performed using one-way analysis of variance. Results: The duration of hemodialysis appeared to be the main predictive factor (P=0.0003) for DSA, which was found in six patients (19%). DSA was found to correlate with higher levels of beta2-microglobulin (P<0.00001), parathyroid hormone (P<0.05), and alkaline phosphatase (P<0.05). Clinical symptoms were minimal. In two patients, MR imaging revealed changes mimicking spondylodiscitis. In another patient, CT of the craniocervical junction showed bone resorption due to a pseudotumor, and basilar invagination. Conclusions: DSA of the cervical spine is often clinically silent. Pathogenesis of DSA may be multifactorial but its progression is most influenced by the duration of hemodialysis. On MR imaging, DSA may mimic spondylodiscitis.

Sonographic diagnosis of distal biceps tendon rupture: a prospective study of 25 cases.

To describe the sonographic findings of distal biceps tendon ruptures and to assess the accuracy of the technique.

Role of color Doppler sonography in the assessment of musculoskeletal soft tissue masses.

Fifty‐six patients with soft tissue masses of the limbs (36 benign, 20 malignant) prospectively underwent sonography (color Doppler and pulsed Doppler examinations) to assess the role of Doppler interrogation in differentiating benign from malignant lesions. Sonography showed 60% sensitivity, 55% specificity, 71% negative predictive value, 42% positive predictive value, and 57% accuracy. Color Doppler evaluation showed 85% sensitivity, 88% specificity, 91% negative predictive value, 80% positive predictive value, and 87% accuracy. Diastolic and venous velocities and pulsatility index values were not statistically significant. Mean systolic velocity was 0.27 m/s in benign lesions and 0.55 m/s in malignant lesions. By combining sonographic and Doppler data, a correct diagnosis was obtained in 51 of 56 patients (90% sensitivity, 91% specificity, 85% positive predictive value, 94% negative predictive value, 91% accuracy). Color Doppler and pulsed Doppler evaluations represent a useful adjunct to sonography and should be routinely included in the evaluation of musculoskeletal soft tissue masses by ultrasonography.

Intraluminal brachytherapy in the treatment of pancreas and bile duct carcinoma

PURPOSE A new method of palliation of malignant obstructive jaundice is presented. METHODS AND MATERIALS Twelve patients with carcinoma of the extrahepatic bile ducts (EHBD-five patients) or pancreatic head (PH-seven patients) received radiation therapy between 1988 and 1991. Percutaneous transhepatic biliary drainage was performed in four EHBD patients and an endoprosthesis was placed during endoscopic retrograde cholangiopancreatography (ERCP) in the other eight patients. All 12 received intraluminal brachytherapy (ILBT): 20-50 Gy calculated at 1 cm from the Iridium-192 (192Ir) wire. In four PH patients the source was placed in the duct of Wirsung; in the other eight patients ILBT was performed via the common bile duct. Five of the seven PH patients and one of the five EHBD patients received External Beam Radiation Therapy (EBRT): 26-50 Gy, alone or with concomitant 5-Fluorouracil (5-FU). RESULTS Cholangitis occurred in six patients. Three PH patients treated with EBRT+ILBT developed gastrointestinal toxicities. With a minimum follow-up of 18 months, median survival times were 14 months (EHBD) and 11.5 months (PH); one of the seven PH patients is alive (29 months) and two of the EHBD patients are alive (18 and 43 months). All patients had satisfactory control of jaundice. CONCLUSIONS The results in the EHBD patients suggest that the addition of ILBT after biliary drainage prolongs survival. Further experience is necessary to determine whether ILBT in the common bile duct and/or in the duct of Wirsung may be, in PH patients, an alternative boost technique to Interstitial Brachy-therapy (IBT) or Intraoperative Electron Beam Radiation Therapy (IOEBRT).

The accuracy of voiding urosonography in detecting vesico-ureteral reflux: a summary of existing data

Abstract. The primary objective of this review was to assess the diagnostic accuracy of voiding urosonography (VUS) in detecting reflux (VUR). As a secondary objective, the reported technical suggestions and diagnostic mistakes were shown to improve the examination protocol and provide the most accurate results. Using a Medline Database search, the published articles comparing the grey-scale (GS) or colour-Doppler (CD) VUS with voiding cystourethrography (VCUG) as the gold standard were selected. Articles were excluded when data were not sufficient to construct 2×2 tables or when the gold standard was different from VCUG. For the analyses of diagnostic accuracy values, 95% confidence intervals were given. Agreements in the results of GSVUS and VCUG and in those of CDVUS and VCUG were determined by Kappa statistics. GSVUS and CDVUS were compared for diagnostic accuracy by the McNemar test. Results showed that the range of GSVUS sensitivity and specificity in detecting VUR was 69%–100% and 86%–97%, respectively. The agreement between GSVUS and VCUG diagnoses ranged from 90% to 97% (K score range 0.61–0.92; P<0.001). The range of CDVUS sensitivity and specificity in detecting VUR was 93%–100% and 86%–93%, respectively. The agreement between CDVUS and VCUG diagnoses ranged from 89% to 96% (K score range 0.77–0.91; P<0.001). One study comparing both VUS modalities with VCUG in the same group of patients, showed that the diagnostic accuracy of CDVUS was significantly higher than that of GSVUS (96% versus 90% of cases correctly classified; McNemar chi squared =4; P<0.05). Conclusion: the existing data indicate that false-negative voiding urosonographic diagnoses (8%–31%) and underestimated reflux grading cases using the same technique are related to anatomical conditions, patient cooperation and contrast medium administration. False-positive (3%–14%) and overestimated reflux grading cases using voiding urosonography could be correctly assessed cases. The intermittent nature of vesico-ureteral reflux is better detected by a technique employing a prolonged observation time, such as voiding urosonography. This might question the current role of voiding cystourethrography in the investigation of reflux.