Biomedical subjects
Publications and source records attributed to R Galeotti.
Tumor necrosis factor alpha (TNF-alpha) seems to play a key role in the pathogenesis of Langerhans' cell histiocytosis (LCH). Thalidomide is an immunomodulator agent of inflammatory cytokines including TNF-alpha. To our knowledge this is the first case of disseminated LCH successfully treated with thalidomide.
Skeletal metastases represent the most common malignant bone tumor. They occur mainly in adults and even more frequently in the elderly. The most common metastases in men are from prostate cancer (60%) and in women from breast cancer (70%). Other primitive tumors responsible for bone metastases are: lung, kidney, thyroid, alimentary tract, bladder, and skin. The spine and pelvis are the most common metastatic sites, due to the presence of red (haematopoietic active) bone marrow in a high amount. As a general rule, the radiographic pattern was lytic type; other aspects were osteosclerotic, mixed, lytic vs mixed and osteosclerotic vs lytic patterns. The main symptom is pain, although many bone metastases are asymptomatic. The most severe consequences are pathologic fractures and cord compression. Clinical evaluation of patients with skeletal metastases needs multimodal diagnostic imaging, able to detect lesions, to assess their extension and localization, and eventually drive the biopsy (for histo-morphological diagnosis). These techniques give different performances in terms of sensitivity and specificity; but none of the modalities alone seems to be adequate to yield a reliable diagnostic outcome. Therefore multidisciplinary cooperation is required to optimize the screening, clinical management and follow-up of the patients. In other terms, what is the efficacy of these new diagnostic tests compared to the "older" diagnostic tests? Frequently the new procedures do not replace the older one, but it is added to the diagnostic workup, thereby increasing costs without impacting the "patient's condition". The aim of the present work is to propose an "algorithm" for the detection and diagnosis of skeletal metastases, which may be applied differently in symptomatic and asymptomatic oncologic patients. Bone scintigraphy remains the first choice technique in the evaluation of asymptomatic patients, in whom skeletal metastases are supposed. Although it has a high sensitivity, scintigraphy is unspecific. So that a negative scan response has to be re-evaluated with other methods: if clinical status remains "negative", the diagnostic route can stop. On the contrary, in patients with "positive" scan or with local symptoms and pain, the screening of metastatic lesions must be accomplished by a combination of radiography and CT: the result may be negative (for low sensitivity of conventional radiology), not conclusive (in this case bone biopsy is necessary) or symptoms are not due to metastatic lesions (i.e., osteoarthritis). CT represents an excellent mean of defining the extent of any metastatic lesions, especially those located at sites difficult to evaluate (vertebral column and pelvis). Before bone biopsy is carried out, MRI must be performed, because it is the only technique that makes it possible to distinguish between bone marrow components. It has been used most extensively in the evaluation of spine metastases. The limitation of MRI is the unspecificity of its findings, which may lead to an equivocal diagnosis, and because only part of the skeleton can be studied.
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PURPOSE: To assess the role of CT in the diagnosis and management of multiple myeloma (MM) and to investigate if CT findings can influence the clinical approach, prognosis and treatment. STUDY DESIGN AND PATIENTS: We reviewed the findings relative to 273 MM patients submitted to CT June, 1994, to December, 1996. The patients were 143 men and 130 women (mean age: 65 years): 143 were stage I, 38 stage II and 92 stage III according to Durie and Salmon's clinical classification. All patients were submitted to blood tests, spinal radiography and CT, the latter with serial 5-mm scans on several vertebral bodies. The CT unit was a Philips Tomoscan SR 7000. RESULTS: CT showed lysis foci in some vertebral bodies (4 cases) where conventional radiography had shown only aspecific osteopenia. CT also depicted vertebral arch and process involvement in 3 cases with the vertebral pedicle sign. Moreover, CT proved superior to radiography in showing the spread of myelomatous masses into the soft tissues in a case with solitary permeative lesion in the left pubic bone, which facilitated subsequent biopsy. As for extraosseous localizations, CT demonstrated thoracic soft tissue (1 woman) and pelvic (1 man) involvement by myelomatous masses penetrating into surrounding tissues. In our series, only a case of osteosclerotic bone myeloma was observed in the pelvis, associated with lytic abnormalities. DISCUSSION AND CONCLUSIONS: The role of CT in the diagnosis and management of MM has not been assessed, because this technique demonstrates tumor extent more accurately than radiography but CT findings do not seem to improve the clinical approach and therapeutic management of the disease. Nevertheless, we recommend CT for some myelomatous conditions, namely: a) in the patients with focal bone pain but normal skeletal radiographs; b) in the patients with M protein, bone marrow plasmocytosis and back pain, but with an inconclusive MM diagnosis; c) to assess bone spread in the regions which are anatomically complex or difficult to study with radiography and to depict soft tissue involvement; d) for bone biopsy.
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Membranous obstruction of the inferior vena cava (MOIVC) is a rare, congenital or acquired, cause of Budd-Chiari syndrome leading to hepatocellular carcinoma in 20 to 40% of the patients. It has a very poor prognosis when treated medically and balloon angioplasty (PTA) represents, nowadays, the treatment of choice, having no mortality or significant morbidity with follow-up as long as 5 years; transatrial membranotomy, direct reconstruction of IVC and bypass surgery are alternative techniques when PTA is not feasible. One case of Budd-Chiari syndrome due to an incomplete membranous obstruction of the suprahepatic portion of the inferior vena cava is reported. A PTA was not feasible as it was not possible to pierce the membranous obstruction. A successful inferior vena cava-right atrium PTFE bypass, with a 3.5-year follow-up, was performed. This surgical approach is a valuable alternative to transatrial membranotomy and direct reconstruction of the IVC.
This study was aimed at assessing the role of stress 201Tl leg scintigraphy, compared with digital angiography, in the diagnosis and prognosis of peripheral arterial obstructive disease (PAOD) before and after surgical treatment. Fifty-four patients with known PAOD in Fontaine stages IIb, III or IV submitted to revascularization (36) or lumbar ganglionectomy (18), were examined with both angiography and scintigraphy. A statistical analysis of 360 segments (thighs and calves) was performed; in particular, correlation values were derived from 216 preoperative and 144 postoperative segments (18 patients who underwent lumbar ganglionectomy were not submitted to postoperative angiography). Scintigraphy vs. angiography sensitivity (84%), specificity (80%) and diagnostic accuracy (90%) values obtained in this study are in agreement with those reported in international literature. Scintigraphy yields information on the locoregional perfusion of an angiography-demonstrated anatomic lesion, under physiologic stress, which is particularly useful in symptomatic patients with angiographically unimportant stenoses. At present, 201Tl leg scintigraphy is the only technique yielding semiquantitative data in the assessment of single muscle groups perfusion increase in Fontaine IV patients submitted to lumbar ganglionectomy. The original contribution of this study consists in the evidence of a high predictive value (p < 0.01) of scintigraphy in the calculation of pain-free intervals in the patients with successful revascularization at clinics and angiography. This finding, if confirmed, shows a possible role for 201Tl leg scintigraphy in the diagnosis of peripheral arterial obstructive disease.
US was used to study 60 patients with different types of plastic (Home-made, Lunderquist, Miller, Carey-Coons, Lammer) and metallic (Z-stent, Wallstent) biliary stents, from October 1990 to March 1993. The optimal US approach was assessed, together with several US features which are typical of each type of endoprosthesis. As far as plastic endoprostheses are concerned, independent of manufacturing differences, the typical US pattern on longitudinal scans is a hyperechoic double line while, on transverse scans, the prosthesis cylinder is represented by short hyperechoic lines, resembling the mathematic equal sign. According to the different types, metallic stents appear as thin hyperechoic lines or narrow gratings on longitudinal scans and as hyperechoic spots following a circular pattern or as a hyperechoic ring on transverse scans.
Even though extracorporeal shock wave lithotripsy (ESWL) is nowadays considered the treatment of choice for the majority of upper urinary tract calculi, percutaneous stone removal will continue to be an alternative treatment method in selected cases. Therefore, percutaneous techniques must not be forgotten by the interventional radiologist. In order to assess the effects and the potential damage caused by this interventional procedure to kidney and perirenal tissues, CT was performed on 20 patients before and after percutaneous nephrolithotripsy. In the cases where no complications occurred during the maneuver, post-nephrolithotripsy scans demonstrated low incidence of significant renal abnormalities. Thickening of pararenal fascia (8 patients) and irregular renal outline (10 patients) were our most frequent findings. In 5 patients we found edema of the pyelo-ureteral junction, in 3 thickening of the bridging perinephric septa and retained stone fragments, in 2 perirenal hematomas, in one a subcapsular fluid collection. Urinoma with pelvic laceration was demonstrated in the only patient in whom the maneuver presented marked technical problems. On the basis of this series of pre- and post-nephrolithotripsy CT scans of treated kidneys, the authors conclude that this percutaneous technique is quite atraumatic.
Tuberous sclerosis, first described by Bourneville in 1880, is a syndrome characterized essentially by mental deterioration, seizures and cutaneous sebaceous adenoma; an association with malformative lesions of the kidney and cardiovascular apparatus has been documented. Recently a case of a young woman with tuberous sclerosis has come to our observation; she was also affected by abdominal aortal aneurysm and stenosis due to compression of the truncus coeliacus; previously she operative elsewhere for right nephrectomy for breakage of nephric right arterial aneurysm: the histological examination of the removed kidney manifested the presence of a mesoblastic nephroma and afterward tuberous sclerosis was diagnosed. The angiomyolipomatosis evidence confirmed the suspicion of a notable inclination to polydistrict malformations in tuberous sclerosis.
We compared two non-invasive methods to evaluate primary varicoceles: ultrasonography and Doppler examination. We submitted to ultrasonography and Doppler 216 patients, 147 of them were treated by sclerotherapy and 69 by surgery. All ultrasonographic studies were performed by means of a real-time equipment (7.5 Mhz transducer), while Doppler examination was performed with continuous wave equipment. Ultrasonographic findings are reliable for testicular morphology. Doppler examination is useful to evaluate reversed flow. In 4.1% of cases ultrasonography did not agree with the Doppler examination.
An anomalous (because of the advanced age of its onset) case of isthmic coarctation of the aorta in preductal site observed at the persistence of hypertensive symptomatology associated with cephalgic and lipothymic attacks is reported. Instrumental examinations confirmed the clinical suspicion and resective-reconstructive surgical treatment led to complete resolution of both cause and effect.
The Authors report their experience in the treatment of 92 cases of post-surgical biliary tract stones: 17 early cases (18.5%) were treated by percutaneous nonsurgical extraction (10 cases) or by operative procedures (7 cases); 75 late cases (81.5%) were surgically treated. The Authors summarize the results of the treatment, discussing advantages and disadvantages of the various techniques.
A case of retroesophageal right subclavian artery, occasionally observed in a patient submitted to diagnostic investigation and surgical treatment for bilateral steno-obstructive involvement of the carotid district, is described.
Percutaneous transvenous treatment has become the elective therapy for varicocele because it is a simple, safe, economic and reliable procedure. The presence of proximal anastomoses connecting a competent valved spermatic trunk with the renal vein can be responsible for a varicocele and make its treatment difficult. In such cases; the valve of the spermatic venous trunk can be bypassed using an open-ended guidewire with a removable mandril core, and then injecting the sclerosing agent through the guide. Moreover, the guidewire can facilitate the insertion of the catheter through the competent valve, thus allowing the placement of Gianturco coils. During the past 12 months we have successfully treated 4 patients affected by varicocele with competent valved venous trunk using the open-ended guidewire.
Ten young patients affected with thalassemia major with hypersplenism were treated with subtotal percutaneous embolization. Percutaneous procedure was used to correct hypersplenism, while preserving a small portion of splenic parenchyma. Embolization was successful in 9 patients, and no significant complications were observed; in 1 patient arterial catheterization and splenic embolization were not possible due to splenic artery tortuosity. Post-procedural clinical course was characterized by intense pain, not always reduced by therapy. Hospitalization time was similar to that of surgical splenectomy. Effectiveness of percutaneous embolization was evaluated with splenic scintigraphy, clearance of erythrocytes marked with 99mTc and denatured with BMHP and with the analysis, both before and after percutaneous procedure, of the following 3 parameters: annual blood consumption, behavior of pre-transfusional hemoglobin, and transfusional pause. Six patients underwent a 4-year follow-up. In all cases scintigraphy showed the effectiveness of subtotal embolization, and clearance of erythrocytes appeared slower than before. As for clinics, an improvement was observed in transfusional parameters. The results from our series, though numerically limited, support the role of percutaneous splenic embolization as an alternative to surgical splenectomy in high risk patients or in patients who refuse surgery.
Idiopathic varicocele is nowadays accepted as a "social disease" for both its high incidence among young men and its affecting male fertility. Screening is thus required for young people and, above all, early and definitive treatment. We have evaluated the effectiveness of percutaneous sclerotherapy, which has become a standard procedure, in spite of its recent introduction in interventional radiology. One hundred and thirty-nine percutaneous occlusions were performed on 147 patients with varicocele using a sclerosing agent--polidocanol--and stainless steel coils. The failure rate of percutaneous treatment was about 12%. Complications never required hospitalization or surgery; recurrence rate is 3.66%. The patients were followed 3, 6, 12 and 24 months by US and Doppler to survey recurrences, and sperm analysis to estimate the clinical results of percutaneous therapy in infertile patients. Statistical analysis with linear regression of data from spermiograms showed constant improvement in sperm count, sperm motility percentage, and sperm morphology percentage. Fertility index improvement was similar to that of surgical ligation. The radiation dose received by the patient is negligible. Percutaneous therapy represent thus the treatment of choice in case of varicocele: compared with surgery, it offers similar clinical results and a lower recurrence rate, and it can be performed on an outpatient basis. Surgery should be performed only when anatomic variants make percutaneous treatment not feasible.