Simone Gusmini

Contrast enhanced 4D-CT imaging for target volume definition in pancreatic ductal adenocarcinoma.

A procedure to improve target volume definition in pancreatic ductal adenocarcinoma by contrast enhanced 4D-CT imaging has been implemented for radiotherapy planning. The procedure allows good quality images to be obtained over the whole patients breathing cycle in terms of anatomical details, pancreatic enhancement and vessel definition.

Hypofractionated Image-Guided IMRT in Advanced Pancreatic Cancer With Simultaneous Integrated Boost to Infiltrated Vessels Concomitant With Capecitabine: A Phase I Study

PURPOSE To determine the maximum tolerated radiation dose (MTD) of an integrated boost to the tumor subvolume infiltrating vessels, delivered simultaneously with radical dose to the whole tumor and concomitant capecitabine in patients with pretreated advanced pancreatic adenocarcinoma. METHODS AND MATERIALS Patients with stage III or IV pancreatic adenocarcinoma without progressive disease after induction chemotherapy were eligible. Patients underwent simulated contrast-enhanced four-dimensional computed tomography and fluorodeoxyglucose-labeled positron emission tomography. Gross tumor volume 1 (GTV1), the tumor, and GTV2, the tumor subvolume 1 cm around the infiltrated vessels, were contoured. GTVs were fused to generate Internal Target Volume (ITV)1 and ITV2. Biological tumor volume (BTV) was fused with ITV1 to create the BTV+Internal Target Volume (ITV) 1. A margin of 5/5/7 mm (7 mm in cranium-caudal) was added to BTV+ITV1 and to ITV2 to create Planning Target Volume (PTV) 1 and PTV2, respectively. Radiation therapy was delivered with tomotherapy. PTV1 received a fixed dose of 44.25 Gy in 15 fractions, and PTV2 received a dose escalation from 48 to 58 Gy as simultaneous integrated boost (SIB) in consecutive groups of at least 3 patients. Concomitant chemotherapy was capecitabine, 1250 mg/m(2) daily. Dose-limiting toxicity (DLT) was defined as any treatment-related G3 nonhematological or G4 hematological toxicity occurring during the treatment or within 90 days from its completion. RESULTS From June 2005 to February 2010, 25 patients were enrolled. The dose escalation on the SIB was stopped at 58 Gy without reaching the MTD. One patient in the 2(nd) dose level (50 Gy) had a DLT: G3 acute gastric ulcer. Three patients had G3 late adverse effects associated with gastric and/or duodenal mucosal damage. All patients received the planned dose of radiation. CONCLUSIONS A dose of 44.25 Gy in 15 fractions to the whole tumor with an SIB of 58 Gy to small tumor subvolumes concomitant with capecitabine is feasible in chemotherapy-pretreated patients with advanced pancreatic cancer.

Arterial vs pancreatic phase: which is the best choice in the evaluation of pancreatic endocrine tumours with multidetector computed tomography (MDCT)?

PurposeThe aim of this study was to assess whether the pancreatic phase may replace the arterial phase in the evaluation of endocrine pancreatic tumours.Materials and methodsTwenty-nine endocrine pancreatic lesions with definitive morphological and immunohistochemical characterisation after surgical treatment (n=24) or fine-needle-aspiration cytology under endoscopic ultrasonography guidance (n=5) were retrospectively evaluated. All lesions were studied with triple-phase 16-row multidetector computed tomography (MDCT). Images obtained during each phase were separately interpreted by two senior radiologists experienced in pancreatic pathology and who were blinded to surgical results. Endocrine tumour and normal pancreas attenuation and the mean absolute tumour-to-gland attenuation difference were measured in each phase, and data were analysed with Student’s t test. Visualisation of arterial vascular abnormalities and hypervascular liver metastases in the arterial and pancreatic phases and the diagnostic contribution of the two phases were compared.ResultsFor both radiologists, the mean absolute tumour-to-gland attenuation difference was significantly higher (p<0.05) in the pancreatic phase (40±53 HU and 34±56 HU) than in the arterial phase (31±38 HU and 26±43 HU). There were no differences in the detection of arterial vascular abnormalities or hypervascular liver metastases in the two phases. The diagnostic contribution was higher in the pancreatic phase.ConclusionsIn our experience, the pancreatic phase can replace the arterial phase in the evaluation of pancreatic endocrine tumours.RiassuntoObiettivoDeterminare se la fase pancreatica possa sostituire quella arteriosa nella valutazione di tumori endocrini pancreatici.Materiali e metodiSono state valutate retrospettivamente 29 lesioni endocrine pancreatiche, con diagnosi definitiva alla valutazione morfologica e immuno-istochimica, dopo trattamento chirurgico (n=24) o prelievo citologico sotto guida ecoendoscopica (n=5). Tutte le lesioni sono state studiate con MDCT (16 canali), con tecnica trifasica. Le immagini ottenute in ciascuna fase sono state interpretate da due radiologi, esperti in patologia pancreatica, all’oscuro delle diagnosi definitive, valutando le densità di ghiandola pancreatica e tumore e la differenza di attenuazione tumore-ghiandola in valore assoluto, in ogni fase; i dati ottenuti sono stati analizzati con il test t di Student. Sono state inoltre confrontate la capacità delle due fasi nel visualizzare anomalie vascolari arteriose e metastasi epatiche ipervascolari e il loro contributo alla confidenza diagnostica.RisultatiPer entrambi i radiologi il valore assoluto della differenza di attenuazione tumore-ghiandola in fase pancreatica (40±53 HU e 34±56 HU) è risultata significativamente maggiore (p<0,05) di quella ottenuta in fase arteriosa (31±38 HU e 26±43 HU). Non c’era differenza nella detezione di anomalie vascolari arteriose e metastasi epatiche ipervascolari nelle due fasi. Il contributo della fase pancreatica alla confidenza diagnostica era maggiore.ConclusioniNella nostra esperienza la fase pancreatica può sostituire quella arteriosa nella valutazione di tumori endocrini pancreatici.

Vascular involvement in periampullary tumors: MDCT, EUS, and CDU

In patients affected by periampullary tumors, surgical resection represents the only treatment with curative intent. Preoperative evaluation of vascular involvement is necessary to avoid surgical treatments unable of curative intent resection. The aim of our update article is to assess the performance of multidetector computed tomography (MDCT), endoscopic ultrasonography (EUS), and color Doppler ultrasonography (CDU) in the evaluation of vascular involvement of major peripancreatic vessels, in periampullary tumors, analyzing the current and past literature.

Endovascular Treatment of Visceral Artery Aneurysms and Pseudoaneurysms in 100 Patients: Covered Stenting vs Transcatheter Embolization:

Purpose: To retrospectively report a large single-center experience of visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) treated with covered stenting (CS) as the first therapeutic option vs transcatheter embolization (TE). Methods: One hundred patients (mean age 59±14 years; 58 men) underwent 59 elective and 41 emergent endovascular procedures to treat 51 VAAs and 49 VAPAs. Seventy patients had TE and 30 received CS (27 Viabahn and 3 coronary stent grafts). Both TE and CS were performed in 10 cases. Results: Technical success was 96% (97% CS, 96% TE), and 30-day clinical success was 83% (87% CS, 81.4% TE). Four major complications occurred; 30-day mortality was 7%, mainly due to septic shock following pancreatic surgery. The midterm follow-up was 20.8 months in the total population and 32.8 months in the CS group. More than 6 months after CS all aneurysms remained excluded; stent patency was achieved in 88%. Twelve CS patients with >3 years’ follow-up had maintained stent patency. Conclusion: In endovascular treatment of visceral aneurysms, covered stenting was feasible in 30%. CS showed a slightly better efficacy than TE and good midterm patency. The Viabahn covered stent seems to be suitable for endovascular repair of tortuous visceral arteries affected by true or false aneurysms.

MR-guided stereotactic breast biopsy using a mixed ferromagnetic-nonmagnetic coaxial system with 12- to 18-gauge needles: clinical experience and long-term outcome

PurposeThis study investigated the clinical application of a magnetic-resonance (MR)-guided breast biopsy (MRBB) system consisting of a nonmagnetic coaxial needle and a ferromagnetic core biopsy needle.Materials and methodsMRBB was performed on 70 breast lesions. The biopsy device consisted of a nonmagnetic 14- to 16-gauge coaxial needle and a ferromagnetic 16- to 18-gauge biopsy needle.ResultsOf the 70 lesions, 29 were malignant and 41 nonmalignant. All 29 malignant lesions underwent surgery and were confirmed as malignant at final histology. Of the 41 nonmalignant lesions, 35 underwent follow-up breast MR imaging (mean, 26±19 months), which demonstrated no lesions changes; six lesions underwent surgery because of poor radiological-pathological correlation; of these 6 lesions, 3 were nonmalignant, one was borderline (lobular carcinoma in situ) and two were malignant (well-differentiated tubular carcinoma and infiltrating ductal carcinoma). Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were, respectively, 93.5%, 100%, 100%, 95.1% and 97.1% if the lobular carcinoma in situ was considered a nonmalignant histological result, and 90.6%, 100%, 100%, 92.7% and 95.7% if the lobular carcinoma in situ was considered malignant.ConclusionsMRBB with a ferromagnetic-nonmagnetic coaxial system represented an easy way to perform a biopsy procedure and was easily applicable in the routine clinical setting.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’applicazione clinica di un sistema di biopsia mammaria guidata da risonanza magnetica (MRBB) composto da ago coassiale amagnetico e ago ferromagnetico per core biopsy.Materiali e metodiLa MRBB è stata eseguita su 70 lesioni mammarie. Il materiale per le biopsie consisteva in un ago amagnetico coassiale da 14–16 Gauge e un ago ferromagnetico da biopsia da 16–18 Gauge.Risultati. Delle 70 lesioni, 29 sono risultate maligne e 41 non maligne. Tutte le 29 lesioni maligne sono andate incontro a intervento chirurgico e sono state confermate come maligne all’istologia definitiva. Delle 41 lesioni non maligne, 35 sono state sottoposte a MRI mammaria di follow-up (media 26±19 mesi), che non ha dimostrato modificazioni delle lesioni stesse; 6 lesioni sono andate incontro a intervento chirurgico a causa della insufficiente correlazione radiologica-patologica e sono risultate essere non maligne in 3 casi, bordeline in 1 caso (carcinoma lobulare in situ) e maligne in 2 casi (carcinoma tubulare ben differenziato e carcinoma duttale infiltrante). Sensibilità, specificità, valori predittivi positive e negativo, accuratezza diagnostica sono risultati essere, rispettivamente, 93,5%, 100%, 100%, 95,1% e 97,1% considerando il carcinoma lobulare in situ un risultato istologico non maligno; 90,6%, 100%, 100%, 92,7% e 95,7% considerandolo benignoConclusioniLa MRBB con un sistema coassiale ferromagnetico-amagnetico ha rappresentato un modo semplice per eseguire una procedura bioptica ed è stata facilmente applicabile nella routine clinica.

Covered stenting and transcatheter embolization of splenic artery aneurysms in diabetic patients: A review of endovascular treatment of visceral artery aneurysms in the current era

ABSTRACT Diabetes mellitus is associated with both microvascular and macrovascular complications, which can result in visceral aneurysms as for example splenic artery aneurysms: in their management, an endovascular treatment, less invasive than surgery, is generally preferred. Endovascular treatment of splenic artery aneurysms can be based either on covered stenting (CS) or transcatheter embolization (TE). CS generally allows aneurysm exclusion with vessel preservation, while TE usually determines target artery occlusion with potential risk of distal ischemia. We performed a review of the existing literature on endovascular treatment of visceral artery aneurysms (VAAs) and psudoaneurysms (VAPAs) in the current era.

Biopsia mammaria stereotassica RM-guidata mediante sistema coassiale misto ferromagnetico-amagnetico con aghi da 12-18 Gauge: esperienza clinica e risultati a lungo termine

PurposeThis study investigated the clinical application of a magnetic-resonance (MR)-guided breast biopsy (MRBB) system consisting of a nonmagnetic coaxial needle and a ferromagnetic core biopsy needle.Materials and methodsMRBB was performed on 70 breast lesions. The biopsy device consisted of a nonmagnetic 14- to 16-gauge coaxial needle and a ferromagnetic 16- to 18-gauge biopsy needle.ResultsOf the 70 lesions, 29 were malignant and 41 nonmalignant. All 29 malignant lesions underwent surgery and were confirmed as malignant at final histology. Of the 41 nonmalignant lesions, 35 underwent follow-up breast MR imaging (mean, 26±19 months), which demonstrated no lesions changes; six lesions underwent surgery because of poor radiological-pathological correlation; of these 6 lesions, 3 were nonmalignant, one was borderline (lobular carcinoma in situ) and two were malignant (well-differentiated tubular carcinoma and infiltrating ductal carcinoma). Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were, respectively, 93.5%, 100%, 100%, 95.1% and 97.1% if the lobular carcinoma in situ was considered a nonmalignant histological result, and 90.6%, 100%, 100%, 92.7% and 95.7% if the lobular carcinoma in situ was considered malignant.ConclusionsMRBB with a ferromagnetic-nonmagnetic coaxial system represented an easy way to perform a biopsy procedure and was easily applicable in the routine clinical setting.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’applicazione clinica di un sistema di biopsia mammaria guidata da risonanza magnetica (MRBB) composto da ago coassiale amagnetico e ago ferromagnetico per core biopsy.Materiali e metodiLa MRBB è stata eseguita su 70 lesioni mammarie. Il materiale per le biopsie consisteva in un ago amagnetico coassiale da 14–16 Gauge e un ago ferromagnetico da biopsia da 16–18 Gauge.Risultati. Delle 70 lesioni, 29 sono risultate maligne e 41 non maligne. Tutte le 29 lesioni maligne sono andate incontro a intervento chirurgico e sono state confermate come maligne all’istologia definitiva. Delle 41 lesioni non maligne, 35 sono state sottoposte a MRI mammaria di follow-up (media 26±19 mesi), che non ha dimostrato modificazioni delle lesioni stesse; 6 lesioni sono andate incontro a intervento chirurgico a causa della insufficiente correlazione radiologica-patologica e sono risultate essere non maligne in 3 casi, bordeline in 1 caso (carcinoma lobulare in situ) e maligne in 2 casi (carcinoma tubulare ben differenziato e carcinoma duttale infiltrante). Sensibilità, specificità, valori predittivi positive e negativo, accuratezza diagnostica sono risultati essere, rispettivamente, 93,5%, 100%, 100%, 95,1% e 97,1% considerando il carcinoma lobulare in situ un risultato istologico non maligno; 90,6%, 100%, 100%, 92,7% e 95,7% considerandolo benignoConclusioniLa MRBB con un sistema coassiale ferromagnetico-amagnetico ha rappresentato un modo semplice per eseguire una procedura bioptica ed è stata facilmente applicabile nella routine clinica.

MR-guided stereotactic breast biopsy using a mixed ferromagnetic-nonmagnetic coaxial system with 12- to 18-gauge needles: clinical experience and long-term outcome@@@Biopsia mammaria stereotassica RM-guidata mediante sistema coassiale misto ferromagnetico-amagnetico con aghi da 12–18 Gauge: esperienza clinica e risultati a lungo termine

PurposeThis study investigated the clinical application of a magnetic-resonance (MR)-guided breast biopsy (MRBB) system consisting of a nonmagnetic coaxial needle and a ferromagnetic core biopsy needle.Materials and methodsMRBB was performed on 70 breast lesions. The biopsy device consisted of a nonmagnetic 14- to 16-gauge coaxial needle and a ferromagnetic 16- to 18-gauge biopsy needle.ResultsOf the 70 lesions, 29 were malignant and 41 nonmalignant. All 29 malignant lesions underwent surgery and were confirmed as malignant at final histology. Of the 41 nonmalignant lesions, 35 underwent follow-up breast MR imaging (mean, 26±19 months), which demonstrated no lesions changes; six lesions underwent surgery because of poor radiological-pathological correlation; of these 6 lesions, 3 were nonmalignant, one was borderline (lobular carcinoma in situ) and two were malignant (well-differentiated tubular carcinoma and infiltrating ductal carcinoma). Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were, respectively, 93.5%, 100%, 100%, 95.1% and 97.1% if the lobular carcinoma in situ was considered a nonmalignant histological result, and 90.6%, 100%, 100%, 92.7% and 95.7% if the lobular carcinoma in situ was considered malignant.ConclusionsMRBB with a ferromagnetic-nonmagnetic coaxial system represented an easy way to perform a biopsy procedure and was easily applicable in the routine clinical setting.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’applicazione clinica di un sistema di biopsia mammaria guidata da risonanza magnetica (MRBB) composto da ago coassiale amagnetico e ago ferromagnetico per core biopsy.Materiali e metodiLa MRBB è stata eseguita su 70 lesioni mammarie. Il materiale per le biopsie consisteva in un ago amagnetico coassiale da 14–16 Gauge e un ago ferromagnetico da biopsia da 16–18 Gauge.Risultati. Delle 70 lesioni, 29 sono risultate maligne e 41 non maligne. Tutte le 29 lesioni maligne sono andate incontro a intervento chirurgico e sono state confermate come maligne all’istologia definitiva. Delle 41 lesioni non maligne, 35 sono state sottoposte a MRI mammaria di follow-up (media 26±19 mesi), che non ha dimostrato modificazioni delle lesioni stesse; 6 lesioni sono andate incontro a intervento chirurgico a causa della insufficiente correlazione radiologica-patologica e sono risultate essere non maligne in 3 casi, bordeline in 1 caso (carcinoma lobulare in situ) e maligne in 2 casi (carcinoma tubulare ben differenziato e carcinoma duttale infiltrante). Sensibilità, specificità, valori predittivi positive e negativo, accuratezza diagnostica sono risultati essere, rispettivamente, 93,5%, 100%, 100%, 95,1% e 97,1% considerando il carcinoma lobulare in situ un risultato istologico non maligno; 90,6%, 100%, 100%, 92,7% e 95,7% considerandolo benignoConclusioniLa MRBB con un sistema coassiale ferromagnetico-amagnetico ha rappresentato un modo semplice per eseguire una procedura bioptica ed è stata facilmente applicabile nella routine clinica.

Fase arteriosa vs fase pancreatica: Qual'è la scelta migliore nella valutazione dei tumori endocrini pancreatici con TC multidetettore (MDCT)?

PurposeThe aim of this study was to assess whether the pancreatic phase may replace the arterial phase in the evaluation of endocrine pancreatic tumours.Materials and methodsTwenty-nine endocrine pancreatic lesions with definitive morphological and immunohistochemical characterisation after surgical treatment (n=24) or fine-needle-aspiration cytology under endoscopic ultrasonography guidance (n=5) were retrospectively evaluated. All lesions were studied with triple-phase 16-row multidetector computed tomography (MDCT). Images obtained during each phase were separately interpreted by two senior radiologists experienced in pancreatic pathology and who were blinded to surgical results. Endocrine tumour and normal pancreas attenuation and the mean absolute tumour-to-gland attenuation difference were measured in each phase, and data were analysed with Student’s t test. Visualisation of arterial vascular abnormalities and hypervascular liver metastases in the arterial and pancreatic phases and the diagnostic contribution of the two phases were compared.ResultsFor both radiologists, the mean absolute tumour-to-gland attenuation difference was significantly higher (p<0.05) in the pancreatic phase (40±53 HU and 34±56 HU) than in the arterial phase (31±38 HU and 26±43 HU). There were no differences in the detection of arterial vascular abnormalities or hypervascular liver metastases in the two phases. The diagnostic contribution was higher in the pancreatic phase.ConclusionsIn our experience, the pancreatic phase can replace the arterial phase in the evaluation of pancreatic endocrine tumours.RiassuntoObiettivoDeterminare se la fase pancreatica possa sostituire quella arteriosa nella valutazione di tumori endocrini pancreatici.Materiali e metodiSono state valutate retrospettivamente 29 lesioni endocrine pancreatiche, con diagnosi definitiva alla valutazione morfologica e immuno-istochimica, dopo trattamento chirurgico (n=24) o prelievo citologico sotto guida ecoendoscopica (n=5). Tutte le lesioni sono state studiate con MDCT (16 canali), con tecnica trifasica. Le immagini ottenute in ciascuna fase sono state interpretate da due radiologi, esperti in patologia pancreatica, all’oscuro delle diagnosi definitive, valutando le densità di ghiandola pancreatica e tumore e la differenza di attenuazione tumore-ghiandola in valore assoluto, in ogni fase; i dati ottenuti sono stati analizzati con il test t di Student. Sono state inoltre confrontate la capacità delle due fasi nel visualizzare anomalie vascolari arteriose e metastasi epatiche ipervascolari e il loro contributo alla confidenza diagnostica.RisultatiPer entrambi i radiologi il valore assoluto della differenza di attenuazione tumore-ghiandola in fase pancreatica (40±53 HU e 34±56 HU) è risultata significativamente maggiore (p<0,05) di quella ottenuta in fase arteriosa (31±38 HU e 26±43 HU). Non c’era differenza nella detezione di anomalie vascolari arteriose e metastasi epatiche ipervascolari nelle due fasi. Il contributo della fase pancreatica alla confidenza diagnostica era maggiore.ConclusioniNella nostra esperienza la fase pancreatica può sostituire quella arteriosa nella valutazione di tumori endocrini pancreatici.