[Primary antiphospholipid antibody syndrome with left atrial intracardiac thombosis]

The present report describes a case of right atrial thrombus in an active 49-year-old man with a primary antiphospholipid syndrome. In 1984, the patient was admitted for autoimmune hemolytic anemia; during the hospitalization it was diagnosed a chronic hepatitis B. In July 1991, the patient had fever, mild jaundice, splenomegaly and pancytopenia; a diagnosis of hairy cell leukemia was made but it was not subsequently confirmed. Interferon therapy was started and the patient's clinical course mildly improved. However, over the same year, he experienced again a clinical deterioration. Lumbar ischemic ulcers occurred. The patient underwent elective splenectomy. Bone marrow biopsy revealed mielodisplastic syndrome. Necrotizing vasculitis with granulomatosis was diagnosed. The patient's condition improved after splenectomy. Repeated laboratory tests showed positivity for antiphospholipid antibodies. Transthoracic and transesophageal echocardiography demonstrated the presence of a right atrial thrombus, confirmed by nuclear magnetic resonance. The patient was started on long-term anticoagulant therapy, that resulted effective in reducing thrombus size.

Middle mediastinum lesions: preliminary experience with CT-guided fine-needle aspiration biopsy with a suprasternal approach

The technical feasibility and safety of a suprasternal approach in the computed tomography (CT)-guided biopsy of lesions in the middle mediastinum was studied in 30 patients. Patients were positioned on their back with their head hyperextended. Biopsies were performed with local anesthesia and 22-gauge needles. Adequate biopsy material for diagnosis was obtained in 25 (83%) of 30 patients. A single biopsy specimen was sufficient in 14 patients, but as many as three biopsy specimens were necessary in 16 patients. Nineteen (63%) patients had various histotypes of lung cancer. In 24 (89%) of 27 adequate specimens, findings at fine-needle aspiration biopsy were consistent with findings at pathologic examination. No major complications were observed. CT-guided biopsy of middle mediastinum lesions was safe and successful with a suprasternal approach.

S-100 protein expression in a case of elastofibroma dorsi

Elastofibroma is a rare tumorlike process that manifests as slowly growing, solid mass in the subscapular region of elderly persons. Histologically, it is characterized by the presence of fibrous connective tissue in which eosinophilic fibers and globular masses, stained by the elastic tissue stains, are interspersed. We report the immunohistochemical study of the cellular component in a case of subscapular elastofibroma in a 41-year-old man. An unexpected immunoreactivity for S-100 protein was detected in most fibroblast-like cells. S-100 protein expression may be related to a chondroid metaplasia of fibroblast-like cells in response to the continuous traumatic process occuring during the friction between the scapula and the underlying chest wall.

[The use of computed tomography guided needle biopsy in thoracic lesions in childhood]

Percutaneous fine-needle aspiration biopsy (FNAB) is widely used in adult but not in pediatric patients, probably because young patients cooperate little. Twenty-six CT-guided FNABs were performed in children aged 40 days to 15 years (mean: 11.6 years) from January through December, 1993. The lesions were found in anterior mediastinum (17 cases), posterior mediastinum (5 cases) and lung (4 cases). Some specimens were fixed for cytology and some were cultured. Twenty-five of 26 biopsies (96.1%) provided adequate material for the cytologic assay, while in one case the result was poor because of much necrotic material. Cytologic findings were compared with postoperative biopsy results in 9 cases and confirmed by follow-up in 17 non-surgical lesions.

[Magnetic resonance in surgical planning in hepatocarcinomas]

The diagnostic accuracy of Magnetic Resonance Imaging (MRI) in the preoperative staging of unifocal hepatocellular carcinoma (HCC) was investigated and compared with that of ultrasonography (US) and Computed Tomography (CT). Eighteen patients with focal HCCs underwent MRI, CT and US scans before surgery. In all cases the histopathologic diagnosis was made with CT-guided fine-needle aspiration biopsy (FNAB). The diagnostic accuracy of each imaging modality was investigated with the assessment of three parameters thought to be of the utmost importance for surgical planning, i.e., lesion unifocality, the presence of a capsule and finally vascular involvement. MRI proved to be more sensitive than CT in demonstrating both lesion unifocality (100% vs. 94.4%) and the presence of a capsule (100% vs. 71.4%). In 2 of 18 patients some blood vessels were involved, which was clearly demonstrated only by MRI, CT missing it. Both MRI and CT had 100% specificity in the detection of a perilesional capsule and of vascular involvement. To conclude, MRI exhibited higher diagnostic accuracy than US and CT, thus confirming its major role in the preoperative staging of unifocal HCCs.

CT-guided biopsy of lung lesions

CT is the most accurate method for guiding fine needle biopsies in deep and/or small sized lung and mediastinic lesions. The authors have performed 2109 CT-guided lung biopsies (FNAB). The results are given in terms of sensitivity, specificity and rate of complications. In ever examination, Westcott or Chiba needles (22 or 21 gauge) were used. From 2109 lung examinations performed, 1413 (66.99%) were positive, 538 (25.5%) negative, 15 (0.7%) suspicious and 143 (6.78%) inadequate for diagnosis, 267 patients underwent surgical or clinical follow-up and, in all cases, the cytological diagnosis was confirmed. Other considerations were made on lesion topography, histological type, dimensions, complication rate, sensitivity, specificity and diagnostic accuracy. CT, of course, is the best method for guiding fine needle biopsy of the lung for its high spatial resolution and excellent anatomical definition, so that samples with smaller than 2 cm lesions, even in continuity with large vessels or other critical organs, are performed. Nevertheless, the result quality depends on the ability of the operator.

[Color Doppler ultrasonography in the identification and characterization of secondary focal lesions of the liver]

This study was aimed at assessing the potentials of color Doppler US in the detection of hepatic metastases by measuring changes in hepatic perfusion. Color-Doppler US was performed on 40 patients with multiple metastatic lesions (mean theta: 3 cm). In each patient both smaller and bigger lesions were studied--80 lesions on the whole. Differences in flow distribution (peritumoral or intratumoral) and the highest systolic peak flow velocity were investigated on color Doppler US scans. Hepatic arterial and portal venous blood flow measured in 40 patients with hepatic metastases were compared with those in 40 healthy controls. The two groups were homogeneous relative to age, sex, height and weight. The ratio of hepatic arterial to total liver blood flow (Doppler perfusion index, DPI) and the ratio of hepatic arterial to portal venous blood flow (Doppler flow ratio, DFR) were calculated. Color flow US scans were obtained in 56 of 80 metastatic lesions. We observed peritumoral flow in 76% of the lesions, intratumoral flow in 6% and mixed peritumoral and intratumoral flow in 18% of cases. The DPI and DFR values were significantly higher in the patients with liver metastases than in the control group. The changes in DPI and DFR resulted from an increase in hepatic arterial flow; no changes in portal venous blood flow were observed. These results suggest that Doppler measurements of hemodynamic hepatic changes may be of great value for the earlier detection of hepatic metastases.

[Magnetic resonance in the diagnosis and follow-up of soft-tissue sarcomas]

The authors analyze the advantages of MR imaging in the detection, staging and follow-up of malignant soft-tissue sarcomas. The role of MR imaging is retrospectively evaluated in 34 patients (16 men and 18 women) ranging in age from 3 to 82 years (mean: 38); 19 of them had a primary neoplasm, while the extant 15 patients were examined after surgery, and residual or recurrent tumors were present. Ten examinations were performed on an 0.5 T imager (CGR Magniscan 5000), and 27 were obtained with a 1.5 T system (Magnetom 42 SP Siemens). In all cases T1 and T2 sequences were acquired; in 3 patients T1-weighted sequences were performed after Gd-DTPA administration. In the 19 patients with primary tumors pathologic specimens were obtained. The value of MR imaging in the evaluation and characterization of soft-tissue sarcomas and its capabilities in detecting neurovascular encasement and bone involvement are discussed. Post-Gd-DTPA scans may help in the differentiation of necrotic areas from active tumors. MR diagnostic criteria of malignancy, including tissue heterogeneity and irregular margins, were not fulfilled in 3 of the studied cases.

[Instrumental diagnosis in shoulder instability]

The authors call attention to the pathology caused by glenohumeral instability and, in particular, to painful shoulders in athletes which so often cause problems in diagnosis. An instrumental protocol for diagnosis is suggested, based on several specific radiographic views, Ct scan and arthro-Ct scan, with double contrast medium, the latter having the task of determining lesion which would not otherwise be able to be studied.

[Use of magnetic resonance in the diagnosis of congenital and acquired cardiopathies. Preliminary note]

The authors describe their personal experience using Magnetic Resonance Imaging (MRI) in the evaluation of cardio-vascular diseases. MRI made it possible to obtain multiplanar anatomical images of the cardio-vascular system without X-rays and conventional contrast medium. MRI supplied with indirect flow evaluation, too. MRI was particularly useful in the assessment of congenital heart diseases, since it shows the heart chambers and the great vessels at the same time and in the different phases of cardiac revolution. MRI was also useful in the evaluation of many acquired heart diseases, such as myocardium diseases, valve diseases, myocardial ischemias, pericardium diseases. Moreover, MRI correctly showed aortic aneurysms. In all the 55 patients examined, it was possible to obtain a good definition of the cardiac structures, especially when "cardiac gating" was employed. In the 3 ventricular and in the 5 atrial defects, the dimensions of the defect and the dilatation of the involved cardiac chambers were precisely assessed. In the 6 aortic coarctations, MRI evaluated the level and the grade of the stenosis, with consequent definition of the anatomic type. Moreover, collateral circulation and dilatation before and/or after the stenosis were evident. In all the 7 complex cardiopathies examined (3 Fallot tetralogies, 1 Fallot pentalogy, 1 aortic cervical arch, and 2 Ebstein diseases) MRI demonstrated each single anomaly of the malformations, at both cardiac and vascular levels. In 2 patients with atrial fibrillation, MRI visualized endoatrial thrombi. In the 7 patients with previous myocardial infarction, the site of ischemia was depicted as a thinning of the wall, while the remaining myocardium appeared hypertrophic. MRI correctly demonstrated all thoracic aorta aneurysms, even in a case where both CT and angiography were negative, due to the aneurysm being thrombosed. Mural thrombi were evident with both MRI and CT, but not always visible with angiography. In the 5 dissected aneurysms, MRI--like CT--assessed the origin of the dissection, and the dimensions of the true and false lumen; moreover, it indirectly evaluated the slow and turbulent blood flow within the true lumen, and the presence of thrombi in the false lumen.

[Isolated traumatic rupture of the ascending aorta. Clinical case and review of the literature]

Rupture of the descending aorta after severe blunt chest trauma is a well recognised injury. Instead, isolated traumatic rupture of the ascending aorta is rarely diagnosed, with only five cases reported in the literature. A case of isolated traumatic rupture of the ascending aorta is here reported and the role of medical treatment is described.

[Angioplasty of renal arteries in the treatment of renovascular hypertension. Our experience in 63 cases]

Percutaneous transluminal angioplasty for treatment of renovascular hypertension was performed on 63 patients during a 5 years period. No compliance related to this procedure set in. At follow-up, the clinical results were shown to be positive in 85.7% of the cases.

[Palliative radiotherapy of bone metastases. Comparison between 2 fractionations]

One hundred and twenty two symptomatic osseous metastases in 74 patients were treated with palliative irradiation, using two dose/time treatment plans. Pain relief was obtained in 92% of valuable cases (complete response in 68% and improvement in 24%). The complete responses were obtained in 4 weeks in 64% of responsive patients. The median duration of response was 166 days. In advanced cancer patients the short course radiotherapy achieved the same quality and duration of pain relief as conventional treatment.

[Clinico-radiologic evaluation of glomus tumors for permanent embolization]

The utility of the preoperative embolization of glomus tumors observed in 7 cases is reported. Two patient have been embolized with non reabsorbable materials and haven't been operated. The possibility of a definitive embolizing therapy as alternative to a surgical treatment is therefore supposed.