Risultati a lungo termine del trattamento endoluminale dell’aneurisma dell’aorta addominale

Risultati a lungo termine del trattamento endoluminale dell’aneurisma dell’aorta addominale Riassunto della tesi Scopo: Valutare i risultati clinici a lungo termine dei pazienti con aneurisma dell’aorta addominale (AAA) sottorenale sottoposti a trattamento endovascolare di posizionamento di endoprotesi aortica (EVAR) da Novembre 1998 a Gennaio 2007. Materiali e Metodi: Lo studio ha incluso 196 pazienti (M/F: 191/5, età media 72,4 anni) con AAA sottorenale (diametro trasverso massimo, Dmax, medio 52,4±9,7mm). Sono stati utilizzati 11 differenti tipi commerciali di endoprotesi, prevalentemente biforcate (n=183, 93,4%). Tutti i pazienti sono stati sottoposti a stretto follow-up clinico e strumentale, mediante eco-color Doppler (ECD) e angio-Tomografia Computerizzata (TC). È stata valutata l’incidenza di complicanze a breve e lungo termine (con particolare riferimento agli endoleak, EL), la sopravvivenza e la correlazione dei dati ECD e TC in termini di variazione del Dmax della sacca aneurismatica e della presenza di EL. Risultati: Il successo tecnico immediato è stato del 97,4% (191/196 pazienti), con 5 casi di conversione chirurgica immediata. Il follow-up medio è stato di 3,5±2,4 anni (range 0-8,4). La mortalità perioperatoria è stata del 1% (2/196 pazienti), mentre la sopravvivenza cumulativa a 1, 3 e 5 anni è stata del 97,8%, 83,7% e 75,7%, con un unico caso (1/190, 0,5%) di decesso correlato alla rottura di AAA ed un caso di conversione chirurgica tardiva per progressivo incremento della sacca aneurismatica. La mortalità è risultata significativamente associata all’età del paziente (P=.02) ed al Dmax preprocedurale (P=.01). L’incidenza cumulativa di EL a 1, 3 e 5 anni è stata del 29,8%, 38,4% e 44,3% (70/190 pazienti, 36,8%), di cui 29 (41,4%) EL primari e 41 (58,6%) EL secondari, prevalentemente rappresentati da EL tipo II (54/70, 77,1%); il 54,3% degli EL sono stati sottoposti ad uno o più trattamenti, con un successo secondario complessivo del 75,5% (148/196 pazienti). È stata osservata un’ottima correlazione tra ECD e TC nella misurazione del Dmax (k=.96) e nel definirne le variazioni significative (k=0.67). Utilizzando l’indagine TC come gold standard, sensibilità, specificità, valori predittivi positivo (VPP) e negativo (VPN) dell’ECD nella identificazione dell’EL sono stati del 44,5%, 97,6%, 77,6% e 90,3%, rispettivamente. Conclusioni: EVAR è una procedura sicura, con bassa mortalità e morbidità periprocedurale ma con incidenza di complicanze in corso di follow-up relativamente elevata, di cui solo circa il 30% ha significato clinico. È possibile ridurre i costi del follow-up attraverso il prevalente utilizzo dell’indagine ECD, limitando l’uso della TC solo a casi selezionati, nonché attraverso un minor ricorso a re-interventi. Nuovi studi clinici randomizzati saranno quindi necessari alla luce di questi nuovi protocolli diagnostici e terapeutici per valutare gli effettivi costi del trattamento endovascolare

Role of perfusion CT in the evaluation of functional primary tumour response after radiochemotherapy in head and neck cancer: Preliminary findings

Objective: To report the initial results of a prospective study aimed at evaluating the CT perfusion parameter changes (ΔPCTp) of the primary tumour after radiochemotherapy (RCT) in head and neck cancer (HNC) and to correlate with positron emission tomography (PET)/CT response. Methods: Eligibility criteria included HNC (Stage III-IV) candidates for RCT. Patients underwent perfusion CT (PCT) at baseline and at 3 weeks and 3 months after treatment. Blood volume, blood flow, mean transit time (MTT) and permeability surface (PS) product were computed. Moreover, PET/CT was performed at baseline and 3 months after treatment. The ΔPCTp were evaluated between baseline and 3-week/3-month evaluations, whereas PET/CT response was based on the maximum standardized uptake value changes according to the European Organization for Research and Treatment of Cancer criteria. Results: Between July 2012 and July 2015, 25 patients were enrolled. A significant reduction of all CT tumour perfusion parameters (PCTp) was observed from the baseline to after RCT (p<0.001). Specifically, a significant reduction was shown at 3 weeks for all PCTp except MTT (from 6.18 to 5.14s; p=0.722). Differently, a significant reduction of all PCTp (p<0.001) including MTT (from 6.18 to 2.24s; p=0.001) was shown at 3 months. Moreover, the reduction of PS resulted in a significant prediction of PET/CT response at 3 months (p=0.037) with the trend also at 3 weeks (p=0.099) at the multivariate analysis. Conclusion: Our preliminary findings seem to show that almost all PCTp are significantly reduced after RCT, whereas PS seems to come out as the strongest factor in predicting the PET/CT response. Advances in knowledge: This article provides information on the potential useful role of PCT in evaluating tumour response after both early and late RCT

Performance of Whole-Body Integrated 18F-FDG PET/MR in Comparison to PET/CT in Patients with Head and Neck Squamous Cell Carcinoma.

Aim of this study was to evaluate the performance of PET/MR in patients with Head and Neck Cancer including in the evaluation an acquisition protocol which we composed for this new modalities and a comparison of the quantification ability of the new device in terms of standardized uptake value (SUV) and its diagnostic outcome with that of PET/CT. The study population comprised 28 patients with head and neck cancer who underwent a single-injection dual imaging protocol with PET/CT and subsequent PET/MR. PET/CT scans were performed applying standard clinical protocols. Subsequently PET/MR was performed using whole-body Dixon MR-sequence for attenuation correction and a dedicated protocol for the neck. Artifacts and image quality, Intensity of [18F] FDG uptake, delineation, lesion characterization of all primary or recurrent tumours and cervical lymph nodes detected in PET/CT and PET/MR were analyzed and compared. Further SUVs for suspicious lesions in the head and neck and normal cervical muscles calculated in the two different modalities were compared. Histopathology, imaging and clinical follow-up data were used as reference standards for the final lesions' classification. Artifacts and image quality was better for PET/MR than for PET/CT with statistically significant difference (p=0.004). Mean delineation of primary/recurrent and lymph nodes concerning intensity of FDG uptake was similar for PET/MR and PET/CT, while PET/MR allowed statistically higher delineation of primary/recurrent and metastatic lymph nodes than PET/CT. PET/MR characterization of primary/recurrent tumour resulted in 100% sensitivity and 75% specificity while sensitivity and specificity of PET/CT was 90.9% and 75% respectively. No substantial differences in sensitivity and specificity between PET/MR and PET/CT were observed concerning characterization of cervical lymph nodes. Quantitative analysis revealed highly significant correlations between maximum and mean SUVs of all lesions evaluated at PET/CT and PET/MR. SUVmean and SUVmax were significantly higher in PET/MR than PET/CT for tumour lesions, while were significantly lower in PET/MR than PET/CT for cervical normal muscles. Conclusion: Simultaneous PET/MR acquisition was feasible and delivered in a reasonable acquisition time high quality, diagnostically sufficient PET and MR data. In particular, our data indicate that the combination of MR and PET was beneficial especially for assessment of the primary or recurrent tumour. Moreover, results of the quantitative analysis show that SUVs derived from [18F] FDG-positive lesions on PET/MR and in normal cervical muscles correlated well with those derived from PET/CT

Mesolimbic dopaminergic dysfunction in Parkinson's disease depression: evidence from a 123I-FP-CIT SPECT investigation.

Abstract We investigated the striatal and extrastriatal DAT availability (SPM8) by [123I]FP-CIT-SPECT in 15 PD patients with depression and 35 PD patients without depression. A cluster with significant (p\0.05) lower tracer binding in PD with depression was found in left cingulate cortex, persistent after correction for age, disease severity and duration, and inversely correlated with depression scores (r -0.336, p\0.05). Our data indicate a significant association between PD depression and cingulate dopaminergic denervation supporting the dopaminergic hypothesis of PD depression

Metastasis of renal cell carcinoma to the parathyroid gland 16 years after radical nephrectomy: A case report

Renal cell carcinoma (RCC) has a high metastatic potential, and most commonly metastasizes via the bloodstream, although lymphatic metastases also occur. RCC is well-known for its propensity to metastasize to unusual sites, and late metastasis, even after a number of years, is common. The occurrence of RCC metastasis to the head and neck region is uncommon, and occurs primarily in the thyroid gland and in patients with widespread dissemination. Involvement of the parathyroid gland in metastatic carcinoma is extremely rare. In the present report, a case of metastasis confined to the parathyroid gland is described, likely with intrathyroidal localization, arising from a RCC that occurred 16 years after nephrectomy. A 66-year-old man was referred to the Department of Surgery of the University Hospital of Pisa (Pisa, Italy) with a preoperative fineneedle aspiration diagnosis of a follicular lesion in the context of nodular goiter of the thyroid gland. The previous medical history of the patient included a right nephrectomy for the treatment of clear cell RCC in February 1997. No other distant metastases were identified as of the latest followup in March 2014. At the time of thyroid surgery, the thyroid and parathyroid function tests were normal. The gross appearance of the surgical specimen was a multinodular goiter with a solid nodule measuring 33 mm on the left lobe of the thyroid gland. Microscopic examination revealed a completely encapsulated lesion consisting of clear cells arranged in a solid pattern and intermixed with fragments of parathyroid tissue. Following immunohistochemical examination, the clear cell lesion was negative for thyroid transcription factor-1 and thyroglobulin and strongly positive for epithelial membrane antigen, cluster of differentiation 10 and vimentin. To the best of our knowledge,this is the second case of metastasis to the parathyroid gland from a RCC reported in the literature

The value of oro-pharyngo-esophageal scintigraphy in the management of patients with aspiration into the tracheo-bronchial tree and consequent dysphagia

Tracheo-bronchial aspiration is the most invalidating condition which can happen to patients affected by dysphagia, especially when caused by central neurologic disorders; the associated pneumonia episodes represent the most frequent cause of death in these patients. Oro-pharyngo-esophageal scintigraphy (OPES) allows both functional imaging and semiquantitative evaluation of the subsequent phases of swallowing. CASE REPORT: We evaluated by means of OPES a woman who had previously undergone high-dose external beam radiation therapy for a nasopharyngeal carcinoma, which determined tissue fibrosis and progressive dysphagia. CONCLUSION: In this patient with dysphagia, OPES was a simple, inexpensive, noninvasive, and reliable technique that allowed to show the presence of bolus aspiration and quantified tracheobronchial aspirate

Brain metabolic correlates of Locus Coeruleus degeneration in Alzheimer's disease: a multimodal neuroimaging study

Locus Coeruleus (LC) degeneration occurs early in Alzheimer’s disease (AD) and this could affect several brain regions innervated by LC noradrenergic axon terminals, as these bear neuroprotective effects and modulate neurovascular coupling/neuronal activity. We used LC-sensitive Magnetic Resonance imaging (MRI) sequences enabling LC integrity quantification, and [18F]Fluorodeoxyglucose (FDG) PET, to investi- gate the association of LC-MRI changes with brain glucose metabolism in cognitively impaired patients (30 amnesticMCI and 13 demented ones). Fifteen cognitively intact age-matched controls (HCs) were sub- mitted only to LC-MRI for comparison with patients. Voxel-wise regression analyses of [18F]FDG images were conducted using the LC-MRI parameters signal intensity (LC CR ) and LC-belonging voxels (LC VOX ). Both LC CR and LC VOX were significantly lower in patients compared to HCs, and were directly associ- ated with [18F]FDG uptake in fronto-parietal cortical areas, mainly involving the left hemisphere (p < 0.0 01, kE > 10 0). These results suggest a possible association between LC degeneration and cortical hy- pometabolism in degenerative cognitive impairment with a prevalent left-hemispheric vulnerability, and that LC degeneration might be linked to large-scale functional network alteration in AD pathology

Impact of baseline gadoxetic acid-enhanced liver magnetic resonance and diffusion-weighted imaging in resectable colorectal liver metastases: A prospective, monocentric study

Background: Liver magnetic resonance imaging (MRI) utilizing hepatocyte-specific contrast agent and diffusion -weighted imaging (DWI) is currently used to properly stage colorectal liver metastases (CRLM) in patients candidate to liver surgery. However, the added value of liver MRI in choosing the treatment strategy in resectable CRLM over computed tomography (CT)-scan is not clear.Patients and methods: This is a prospective monocentric collection of consecutive cases of patients with CRLM conceived with the aim to assess the added value of liver MRI in changing the initial treatment strategy planned according to CT-scan. Potential changes in the initially planned strategy were defined as: -from upfront surgery to perioperative chemotherapy (fluoropyrimidine and oxaliplatin) -from upfront surgery to first-line systemic therapy (doublet or triplet plus a biological agent) -from perioperative chemotherapy to first-line systemic therapy.Hypothesising that MRI may induce a change in the choice of the treatment strategy in the 20% of cases (alternative hypothesis), against a null hypothesis of 5%, with one-tailed alpha and beta errors of 0.05 and 0.20 respectively, 27 patients were needed. The added value of liver MRI would have been considered clinically meaningful if at least 4 changes in the treatment strategy were observed.Results: Among 27 enrolled patients, upfront surgery and perioperative chemotherapy strategies were chosen in 17 (63%) and 10 (37%) cases, respectively, based on CT-scan. After liver MRI, additional liver lesions were found in 8 patients (30%) and the initial strategy was changed in 7 patients (26%) (4 initially deemed candidate to upfront surgery and 3 initially sent to perioperative chemotherapy) that were treated with first-line systemic therapy.Conclusions: Our results support the indication of the current guidelines on the routine use of liver MRI in the initial workup of patients with resectable CRLM with an MRI-driven changes of initial treatment plan in a relevant percentage of cases