Role of ultrasonography and contrast-enanced ultrasosography in a case of Krukenberg tumor

We report a case of Krukenberg tumor of gastric origin with adnexal metastasis, in which ultrasonography (US) and contrast-enhanced US (CEUS) played a key diagnostic role. An 64-year-old female patient was referred to our department for abdominal pain, nausea and ascites. US examination was performed as first line diagnostic imaging approach, confirming the presence of ascites and detecting marked thickness of the gastric wall and a right adnexal mass. CEUS was immediately performed and showed arterial enhancement followed by wash-out in the venous phase of both the gastric wall and the adnexal mass, suggesting the diagnosis of gastric cancer with right adnexal metastasis (Krukenberg syndrome). The patient underwent USguided paracentesis and esophagogastroduodenoscopy that showed linitis plastica. Cytologic examination of the peritoneal fluid revealed the presence of signetring cells, and histologic examination of the specimen obtained by endoscopic biopsy showed primary gastric mucus-producing adenocarcinoma with signet ring cells. Although transvaginal US is undoubtedly the method of choice to evaluate ovarian tumors, abdominal US and CEUS can provide key diagnostic elements

Safety and effectiveness of percutaneous laser ablation of liver metastases from neuroendocrine neoplasm - a retrospective study

Purpose: To retrospectively assess safety and efficacy of percutaneous laser ablation (LA) of multiple liver metastases (LM) from neuroendocrine neoplasm (NEN) Material and methods: Twenty-one patients with at least 3 small LM (< 4 cm in diameter) from NEN underwent ultrasonography-guided LA. Up to seven LM were ablated in a single session; if the number of LM exceeded seven, the remaining LM were ablated in further LA sessions with a time interval of three-four weeks each other. LA was performed according to the multifiber technique. The patients underwent contrast-enhanced CT one month after LA, and were subsequently monitored every three months for the first two years, then every six months. Results: On the whole, 189 LM were treated (mean per patient 9 ± 8.2, median 6) in 41 LA sessions (range 1-5). One grade 4 complication was observed (0.53%): a bowel perforation successfully managed by surgery. Technical efficacy was 100%, primary efficacy rate 94.7%, and secondary efficacy rate 100%. Complete relief of hormone-related symptoms was obtained in all the 13 symptomatic patients. The median follow-up was 39 months (range 10 – 93). 1-, 2-, 3-, and 5-year survival rates were 95%, 86%, 66%, and 40%, respectively. Overall survival resulted significantly higher for patients with Ki-67 expression ≤7% than for those with Ki-67 >7% (p= 0,0347). Conclusion: LA is a promising and safe technique to treat LM from NEN. Further prospective studies involving larger series of patients followed for a longer time are strongly needed to provide definitive information on the long-term efficacy of this liver-directed therapy

Prophylactic balloon occlusion of internal iliac arteries in women with placenta previa: analysis of the radiation dose to the foetus

Purpose: To evaluate the foetal radiation exposure during the prophylactic balloon occlusion of the internal iliac arteries (PBOIIA) for the prevention of intrapartum hemorrhage. Moreover, we analyzed the safety and efficacy of this procedure. Material and methods: We evaluated six consecutive pregnant women with placenta previa which underwent PBOIIA in conjunction with cesarean section. Three procedures were performed in the obstetric operating room fitted with a moveable angiographic C-arm system and three in the angiographic room with a fixed C-arm system. Fluoroscopic times, dose area products and foetal radiation doses were recorded. We also compared PBOIIA group with no endovascular intervention group (two cases) in terms of pre- and post-delivery hemoglobin, blood transfusion and the postoperative hospitalization time. Results: The total mean dose area product (mGycm2), mean foetal radiation dose (mGy) and mean fluoroscopic time (min) were 20978, 9.03 and 3.63, respectively. The mean foetal radiation dose and mean fluoroscopic time were 6.63 and 4.97 for the procedures performed in the obstetric operating room, but 11.43 and 2.29 when considering procedures in the angiographic room. Technical success was achieved in all six cases. One case needed blood transfusion (post-delivery hemoglobin from 8.5 to 7.4 g/dL). The mean postoperative hospitalization time was 3.33 days. In the no endovascular intervention group all patients needed transfusion and one had hysterectomy. The length of hospital stay was 4 days. Conclusion: PBOIIA was associated with an acceptable foetal radiation dose, which is below the specific threshold level for deterministic effect. It was safe and effective with the blood loss volume effectively controlled

Massive rectal bleeding treated with transcatheter artery embolization: an unusual presentation of the solitary rectal ulcer syndrome

Clinical History/Pre-treatment Imaging: A 35-year-old paraplegic man because of a thoracic spinal cord injury and, history of constipation and self-digitation maneuver to evacuate, complained rectal bleeding and maroon-colored stools from some days. Laboratory findings revealed hemoglobin of 8.3 g/dL and a hematocrit of 25% requiring the transfusion of 3 units of packed blood cells. Esophagogastroscopy was negative and colonoscopy was inconclusive showing blood and clots. Abdominal contrast enhanced CT showed endorectal active contrast extravasation from left superior hemorrhoidal artery (SHA). Endovascular angiography and embolization was performed for controlling acute bleeding. Treatment Options/Results: Selective catheter angiography at the inferior mesenteric artery demonstrated active extravasation from a peripheral posterior branch of the left SHA (Fig.1). It was subsequently super-selective embolized with coils. Post-embolization images demonstrated resolved bleeding (Fig.2). Two days later endoscopy revealed a single shallow longitudinal ulcerating lesion covered by white slough on a hyperemic surrounding mucosa. Combination of symptomatology, patient history and endoscopy prompted the diagnosis of Solitary Rectal Ulcer Syndrome (SRUS). Discussion: SRUS is a rare benign disorder supposed to be secondary to straining, self-inducted trauma, paradoxical contraction of puborectal muscle, rectal prolapse and intussusception. Although rectal bleeding is one of the most common clinical features, massive hemorrhage is extremely rare. Patients with a massively bleeding rectal ulcer that does not stabilize with endoscopic or supportive therapy must be considered for operative treatment, including endovascular embolization. Take-home points: -SRUS is an extremely rare cause of massive lower gastrointestinal bleeding. -Embolization is a safe and effective alternative to endoscopic treatment and surgery for the rapid clinical stabilization

White matter lesions and sudden sensorineural hearing loss

Aim of this paper is to investigate the presence of White Matter Lesions (WMLs) in subjects affected by Sudden Sensorineural Hearing Loss (SSNHL) and possibly to evaluate the significance of WMLs in SSNHL patients. A total of 64 patients (cases) affected by SSNHL were included in this case-control study. Hearing tests were performed at SSNHL onset, after 7 days and after 30 days. Cerebral MRI sequences were performed to rule out retrocochlear pathology, and WMLs were evaluated if present. MRI control group included 32 subjects, without hearing loss, affected by pituitary adenoma, who underwent cerebral MRI of follow-up. WML presence in those affected by SSNHL resulted having a similar distribution to that of the control group; however, we observed complete hearing recovery in 42,9% of patients without WML and in 11,6% of patients with WML >1 (p = 0,017*). The incidence of WML in patients with SSNHL was not different compared to that of the control group; however, MRI could have a prognostic role for SSNHL patients, as the presence of WMLs can been linked to a poorer hearing recovery rate

Gastrointestinal bleeding from Dieulafoy’s lesion: endovascular management with gelfoam and coil

Clinical History/Pre-treatment Imaging: A 56-year-old man was admitted to our hospital for some day of asthenia. He reported aspirin intake for a mouth. His past medical history included splenectomy for trauma. Laboratory tests showed hemoglobin of 9.1 g/dL and digital rectal examination revealed melena. Esophagogastroduodenoscopy showed, in proximal gastric body, active arterial spurting from two close minute mucosal defect. These lesions were successfully treated with combined mechanical hemostasis and injection therapy. However, a following laboratory test revealed hemoglobin drop. Treatment Options/Results: Patient performed endovascular angiography but no active source of gastrointestinal (GI) bleeding were found. After celiac trunk catheterization, images revealed distal left gastric artery branches maintaining constant arterial caliber and tortuous appearance (Fig.1), finding suspected of Dieulafoy’s lesion. To minimize risk of premature rebleeding, embolization with gelfoam and coil was performed demonstrating reduce flow towards the proximal stomach (Fig.2). Discussion: Although often misdiagnosed, Dieulafoy’s lesion represents an important etiology of acute, life-threatening and recurrent GI bleeding. Hemostasis with angiographic embolization has been reported in sporadic case reports. To minimize the risk of bowel infarction, the super-selective catheterization technique and a temporary agent such as gelfoam slurry is mandatory. In our patient, despite active bleeding was no seen, we have decided to release also a proximal single coil. To our knowledge, it allows to reduce recurrent bleeding risk decreasing perfusion pressure but to maintain sufficient tissue blood flow avoiding ischemia. Take-home points: The embolization strategy is essential in the endovascular management of Dieulafoy’s lesion to balance the risk of rebleeding and the risk of bowel ischemia

Percutaneous embolization of recurrent varicocele in pediatric population: patient dose exposure analysis

Purpose: Spermatic vein embolization represent an effective and minimally invasive option for varicocele. In pediatric population it is currently reserved for surgical relapse. Aim of this work is to prove that the varicocele endovascular treatment in pediatric patients entails low rate of complications and recurrences with a low ionizing radiation exposure. Material and methods: A consecutive retrospective series of 47 adolescent patients treated with endovascular retrograde embolization after post-surgical recurrence was collected. Images were acquired according to a strict protocol of low dose radioscopy. Dose area product (DAP) was recorded for each procedure. We estimated with Monte-Carlo Simulator by our Health Physics Unit the Effective dose ( E) and malignancy risk. Results: Results were as follows: therapeutic success in 46/47 patients (98%) with complete resolution in 41/46 (89%) and degree reduction in 5/46 (11%). No significant complications occurred. Average DAP was equal to 18881 mGyxcm2; average DAP was equal to 13208 mGyxcm2 after the introduction of flat panel (2013). Average E equal to 1,6 mSv and a risk of malignancy equal to 8,7 x 10^-5. Conclusion: Percutaneous embolization of varicocele appears to be effective as surgical correction. Pediatric patients undergoing this treatment have very low values of ionizing radiation exposure with an equally low risk of malignancy. New technological devices combined with a greater experience of the operators can further reduce the dose administered to these young patient

Transanal total mesorectal excision (TaTME): single-centre early experience in a selected population

Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2 min (range 240–494). Eleven out 12 patients (91.6%) had less than 200 mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6 days (range 5–19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (< 30 days) were observed in 5 patients (41.6%). Histopathology showed in all cases an intact mesorectum. Mean number of lymphnodes harvested was 13.6 ± 6.6 (range 4–29). Distal and circumferential margin was, respectively, of 20.8 ± 14.2 mm (range 2–45 mm) and 16.1 ± 7.6 mm (range 3–30 mm). The comparative analysis showed significant differences concerning mean operative time (p = 0.0473) and estimated blood loss (p = 0.0367). This study confirms this technique is safe and feasible, but more evidence to support its use over conventional laparoscopic surgery is needed