Salvatore Minniti

Congenital anomalies of the venae cavae: embryological origin, imaging features and report of three new variants

Abstract. Due to the complexity of their developmental stages, the venae cavae may undergo a very large number of congenital anomalies. All the possible abnormalities which, to our knowledge, have been observed in the literature are reported, differentiating those of the superior vena cava and the azygos system, those of the inferior vena cava and the complex anomalies that concern the venous system as a whole. Moreover, we present three new variants: a right double inferior vena cava with azygos continuation of the posterior-medial vein; an agenesis of the superior vena cava with drainage through the azygos and hemiazygos veins to the inferior vena cava; and a double inferior vena cava with hemiazygos and azygos continuation of the left one.

Nonfunctioning endocrine tumors of the pancreas: Possibilities of spiral CT characterization

Abstract. The aim of this study was to assess the ability of spiral CT to adequately characterize the nonfunctioning endocrine tumors (NFETs) of the pancreas, distinguishing this lesion from the other pancreatic tumors. The spiral CT examinations of 21 cases of histologically proven NFETs, along with those of 29 cases of other pancreatic tumors and tumor-like lesions, were retrospectively reviewed in a blinded fashion by two radiologists, in order to correctly classify the lesions, highlighting the typical signs reported in the literature. Discordant cases were further analyzed in the presence of a third radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The histopathologic examination was considered the gold standard. The sensitivity, specificity, and positive and negative predictive values of CT were calculated. After the consensus evaluation, the correct diagnosis was reached in 72% of cases, with 10% of nonspecific diagnoses of solid pancreatic tumor and 18% of wrong diagnoses. The sensitivity and specificity of spiral CT in identifying NFETs were 66.6 and 82.7%, respectively. The positive and negative predictive values were 73.7 and 77.4%, respectively. In up to 70% of cases the NFET demonstrates a typical aspect of a mass hyperdense in the arterial contrastographic phase eventually associated with hyperdense hepatic metastases in more than half of the patients. This finding does allow the diagnosis of NFET but without certainty indeed, since other tumors can show a similar densitometric behavior and among them particularly the ductal adenocarcinoma. On the other hand, both the solid, hypovascularized NFETs, and the cystic form, cannot be differentiated from the other solid and cystic tumors of the pancreas.

Comparison of CT Features of Aspergillus and Bacterial Pneumonia in Severely Neutropenic Patients

Purpose To establish whether a relationship exists between computed tomography features of lung opacities in severely neutropenic patients and their Aspergillus or bacterial etiology. Methods Computed tomography scans of 124 patients with lung opacities larger than 5 mm occurring during severe (neutrophils <500/mm3) and prolonged (>7 d) neutropenia—induced by bone marrow transplantation and/or high-dose chemotherapy for hematologic malignancies—were reviewed. Invasive pulmonary aspergillosis or bacterial pneumonia were assessed by means of bronchoalveolar lavage, bronchial washing, trans-bronchial biopsy or (for bacteria only) blood cultures. Pulmonary opacities were classified as nodules or as consolidations. The presence of a perinodular ground-glass halo, the similarity of consolidations to a pulmonary infarction and the presence of cavitation (crescent-shaped or not) were recorded. Results Invasive pulmonary aspergillosis was diagnosed in 68 patients; bacterial pneumonia in 56. Nodules (85) were more common than consolidations (39); their distribution among the patients with aspergillosis (52 nodules and 16 consolidations) and those with bacterial pneumonia (33 nodules and 23 consolidations) was even. Out of the 19 nodules surrounded by a halo 17 were due to aspergillosis. Nine consolidations (3 due to aspergillosis) were infarctionlike shaped. Cavitation appeared during 22/68 aspergillosis and 31/56 bacterial pneumonias; an air-crescent in 6 patients with aspergillosis and in 24 with bacterial pneumonia. Conclusions Although rare enough, the perinodular halo is highly specific for invasive aspergillosis. The nodular pattern of lung opacities, their similarity to a pulmonary infarction, the occurrence of cavitation and the air-crescent are not related to aspergillosis.

Therapeutic Embolization of Idiopathic Renal Arteriovenous Fistula Using the “Stop-Flow” Technique

Purpose: To present a case of massive idiopathic arteriovenous fistula (AVF) successfully treated with an endovascular procedure. Case Report: A 42-year-old woman with microscopic hematuria was found to have a massive idiopathic renal AVF. Percutaneous embolization was undertaken using a dual approach to deliver an occluding balloon through the draining vein and an arterial access to selectively catheterize the aneurysmal afferent artery. With the balloon inflated to interrupt flow (“stop-flow” technique), acrylic glue was delivered precisely to occlude the lesion. Duplex scans at 12 months have documented continued complete occlusion of the anomalous communication. Conclusions: The dual arterial and venous approach with the “stop-flow” technique makes it possible to successfully treat idiopathic AVFs that have constant high-flow connections.

Renovascular disease: effect of ACE gene deletion polymorphism and endovascular revascularization.

BACKGROUND Renal artery stenosis (RAS) is associated with high cardiovascular mortality and significant clinical complications, including resistant hypertension and ischemic nephropathy. Despite availability of endovascular revascularization techniques, determining which patients should undergo revascularization and the timing of the procedure still are controversial. Several studies have reported a higher frequency of the DD genotype of the insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE) gene in patients with RAS, and one study found higher mortality in patients with the DD genotype. Material and methods We retrospectively studied 100 patients with documented atherosclerotic RAS and evaluated long-term (median follow-up, 28 months) mortality, blood pressure control, and renal function in relation to the ACE genotype and two therapeutic strategies, that is, endovascular treatment with percutaneous renal transluminal angioplasty or stenting (ET group) versus conservative drug therapy (CT group). RESULTS Comparison between therapeutic groups showed a higher cumulative probability of survival (86.7% vs 67.1%), better blood pressure control (57.4% vs 29%), and slower decline in renal function (17.9% vs 48.4%) in the ET group. The DD genotype was strongly represented in our study patients (DD, 50%; II, 15.5%; I/D, 34.5%), but bore no relation to mortality, blood pressure control, decline in renal function, or rate of recurrent stenosis. CONCLUSIONS Conservative medical treatment of RAS, compared with endovascular treatment, is associated with higher mortality, poorer blood pressure control, and impaired renal function over the long term. Early endovascular treatment enables amelioration of this unfavorable evolution. The DD genotype does not predict clinical outcome of RAS.

ARFI: from basic principles to clinical applications in diffuse chronic disease—a review

The many factors influencing the shear wave velocity (SWV) measured with Acoustic Radiation Force Impulse (ARFI) are examined in order to define the most correct examination technique. In particular, attention is given to the information achieved by experimental models, such as phantoms and animal studies. This review targets the clinical applications of ARFI in the evaluation of chronic diffuse disease, especially of liver and kidneys. The contribution of ARFI to the clinical workout of these patients and some possible perspectives are described.Teaching Points• Stiffness significantly varies among normal and abnormal biological tissues.• In clinical applications physical, geometrical, anatomical and physiological factors influence the SWV.• Elastographic techniques can quantify fibrosis, which is directly related to stiffness.• ARFI can be useful in chronic diffuse disease of liver and kidney.

Focal breast lesions with benign appearances. Review of eight breast cancers with initial features of intramammary lymph node.

Purpose.The aim of this study was to evaluate whether certain histological types of early breast cancer may share radiographic features with intramammary lymph nodes.Materials and methods.The previous mammograms of patients with histologically proven breast cancer and lesions displaying the morphological features of intramammary lymph nodes were retrospectively reviewed.Results.Retrospective evaluation demonstrated eight breast cancers of varying histological nature – mostly ductal carcinomas not otherwise specified (NOS) – whose early radiographic features were similar to intramammary lymph nodes.Conclusions.Although uncommon, a lesion with the radiographic features of an intramammary lymph node may hide an early breast cancer. No significant relationship exists between histological type and the presence of such features.

The Role of Ultrasound in Acute Pancreatitis

Ultrasound (US) is frequently used as an initial diagnostic study for patients suffering from acute abdominal pain (Merkle and Goerich 2002; Panzironi et al. 1997). It can both diagnose acute pancreatitis (AP) and exclude many other causes of abdominal pain (Bennett and Hann 2001; Lecesne and Drouillard 1999). Both increasing operator experience and technological advances in equipment (such as tissue harmonics), the pancreas can now be evaluated by US in over 90% of cases (Atri and Finnegan 1998; Bennett and Hann 2001; Jeffrey 1989; Karlson et al. 1999; Minniti et al. 2003). In AP, ultrasonographic evaluation is hampered in 25%–30% of patients due to over lapping gastrointestinal gas (Manfredi et al. 2001).