Velocità di iniezione di Gd-EOB-DTPA a confronto nello studio RM di pazienti cirrotici. Effetti su enhancement del parenchima epatico e su qualità dell'immagine nelle due fasi arteriose.

Obiettivo: L'obiettivo dello studio e stato vericare se dierenti velocita di iniezione (3 mL/s e 1,5mL/s) di Gd-EOB-DTPA in uenzano l'Enhancement Ratio (ER) del parenchima epatico, Signal to Noise Ratio (SNR) e la qualita dell'immagine di RM. Lo studio e stato condotto su una popolazione di pazienti cirrotici sottoposti a studio RM con apparecchi 1,5T o a 3T. Materiali e metodi: Sono stati retrospettivamente analizzati gli studi RM mirati alla valutazione del paren- chima epatico condotti nel periodo Settembre 2010 - Settembre 2013. La somministra- zione del mezzo di contrasto e stata eettuata mediante iniettore automatico; in tutti gli studi sono state acquisite due fasi arteriose (fase arteriosa precoce e fase arteriosa parenchimale) attraverso una metodica predenita di xed scan delay. Per ciascuna delle due fasi arteriose sono stati calcolati: Enhancement Ratio (ER) del parenchima epatico e del lume dell'aorta addominale e SNR. Inoltre in entrambe le fasi arteriose e stata eettuata un'analisi qualitativa dell'immagine, mirata a valutare presenza e grado di artefatti. Risultati: Dei 435 pazienti cirrotici che hanno eettuato lo studio di RM, 249 sono stati considerati idonei per il nostro studio. I pazienti sono stati suddivisi in quattro gruppi in base all'intensita del campo magnetico (1,5T vs 3T) ed alla velocita di iniezione del mezzo di contrasto (1,5mL/sec vs 3mL/sec). Gruppo I: 77 pazienti (1,5 T e 1,5mL/s) Gruppo II: 89 pazienti (1,5T e 3mL/s) Gruppo III: 34 pazienti (3T e 1,5mL/s) Gruppo IV: 49 pazienti (3T e 3 mL/s). La velocita d'iniezione del mezzo di contrasto non ha in uenzato signicativamente ne gli ERs del parenchima epatico in alcuna delle due fasi arteriose (rispettivamente p: 0.9573 e p: 0.0308), ne il SNR del parenchima epatico in alcuna delle due fasi arteriose, ne l'incidenza degli artefatti. Conclusioni: I nostri risultati suggeriscono che la velocita d'iniezione del mezzo di contrasto Gd-EOB- DTPA non determina alterazioni signicative dell'ERs del parenchima epatico nelle fasi arteriose indipendentemente dall'intensita del campo magnetico utilizzato. L'utilizzo di sequenze dinamiche dedicate ed ottimizzate puo limitare la presenza degli artefatti indipendentemente dalla velocita di iniezione del mezzo di contrasto

Liquid Biopsy in Rare Cancers: Lessons from Hemangiopericytoma

Hemangiopericytoma (HPT) is a rare mesenchymal tumor of fibroblastic type and for its rarity is poorly studied. The most common sites of metastatic disease in patients with intracranial HPT are the bone, liver, and lung, suggestive for an hematogenous dissemination; for this reason, we investigated, for the first time, the presence of circulating tumor cells (CTCs) in hemangiopericytoma patient by CellSearch® and SceenCell® devices. Peripheral blood samples were drawn and processed by CellSearch, an EpCAM-dependent device, and ScreenCell®, a device size based. We found nontypical CTCs by CellSearch system and the immunofluorescence analysis performed on CTCs isolate by ScreenCell demonstrated the presence of single CTCs and CTC clusters. The molecular characterization of single CTCs and CTC clusters, using antibodies directed against EpCAM, CD34, cytokeratins (8, 18, and 19), and CD45, showed a great heterogeneity in CTC clusters. We believe that the present study may open a new scenario in the rare tumors: the introduction of the liquid biopsy and the molecular characterization of circulating tumor cells could lead to personalized targeted treatments and also for rare tumors

"Non-phosphaturic" variant of phosphaturic mesenchymal tumor of the middle ear expressing multiple phosphatonins

Phosphaturic mesenchymal tumors (PMTs) are rare tumors commonly arising in soft tissues and bones. They are the main cause of tumor-induced osteomalacia (TIO), a paraneoplastic syndrome caused by production of FGF23 and other phosphatonins. “Non-phosphaturic” variant of PMTs (i.e., not associated with TIO) have been also reported. We describe a patient with a PMT of the middle ear, a very rare site for PMTs, in which TIO failed to develop although three phosphatonins were expressed

Short-term efficacy of a fixed association of Palmitoylethanolamide and other phytochemicals as add-on therapy in the management of chronic pain in elderly patients: a real-world retrospective study

Phytochemicals are promising adjuvant agents for the treatment of pain. This study aimed to explore the short-term efficacy and safety of a fixed-dose combined therapy with Palmitoylethanolamide and other phytochemicals as add-on therapy in elderly patients. Data on 47 elderly patients with non-oncologic chronic pain of mild-moderate degree were analyzed in a retrospective, descriptive, no-profit, double-center realworld study. Patients were administered the combined phytochemical therapy for 6 weeks, in addition to analgesics administered when needed. Patients showed a reduction in pain intensity both in mixed /nociceptive and in neuropathic pain and improvements in functional abilities, quality of life, and in the subjective belief about the efficacy of treatment. These results were also observed in the small subgroup of patients in monotherapy with phytochemicals (n=13). No adverse event led to treatment withdrawal. This exploratory study suggests that phytochemicals may represent an effective source of analgesics to be added to chemically synthesized drugs, therefore reducing the need of their up-titration and the risk of toxicity. These data must be considered as preliminary and need to be tested in randomized trials

Appropriate dosing of burosumab in tumor-induced osteomalacia

We appreciated the recently published paper of Crotti and coworkers in which the authors reported a patient with tumor-induced osteomalacia (TIO) treated with burosumab for over 2 years for a tumor located in the pre-sacral region that recurred 18 months after excision. Recurrence was associated with decline of serum phosphate (SP) and increase of serum FGF23. After 4 years of treatment with calcitriol and phosphorus supplements without SP normalization, burosumab was started “at the dose of 0.3 mg/kg/month.” The starting dose of burosumab used in this patient was the same used in two previous trials on TIO adult patients. However, in these studies, the overall effects were not completely satisfactory

Brain lesions. is there a role for internist

A 67-year-old woman was admitted to the Emergency Department due to aphasia, deficit VII cranial nerve (central deficit), and right hemiparesis with positive Mingazzini’s manoeuver. At admission, the National Institutes of Health Stroke Scale (NIHSS) was 5. The remaining physical examination was regular

Circulating tumor cells: from fiction to reality

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Cardiovascular manifestations of primary hyperparathyroidism: A narrative review

Data on cardiovascular disease in primary hyperparathyroidism (PHPT) are controversial; indeed, at present, cardiovascular involvement is not included among the criteria needed for parathyroidectomy. Aim of this narrative review is to analyze the available literature in an effort to better characterize cardiovascular involvement in PHPT. Due to physiological effects of both parathyroid hormone (PTH) and calcium on cardiomyocyte, cardiac conduction system, smooth vascular, endothelial and pancreatic beta cells, a number of data have been published regarding associations between symptomatic and mild PHPT with hypertension, arrhythmias, endothelial dysfunction (an early marker of atherosclerosis), glucose metabolism impairment and metabolic syndrome. However, the results, mainly derived from observational studies, are inconsistent. Furthermore, parathyroidectomy resulted in conflicting outcomes, which may be linked to several potential biases. In particular, differences in the methods utilized for excluding confounding co-existing cardiovascular risk factors together with differences in patient characteristics, with varying degrees of hypercalcemia, may have contributed to these discrepancies. The only meta-analysis carried out in PHPT patients, revealed a positive effect of parathyroidectomy on left ventricular mass index (a predictor of cardiovascular mortality) and more importantly, that the highest pre-operative PTH levels were associated with the greatest improvements. In normocalcemic PHPT, it has been demonstrated that cardiovascular risk factors are almost similar compared to hypercalcemic PHPT, thus strengthening the role of PTH in the cardiovascular involvement. Long-term longitudinal randomized trials are needed to determine the impact of parathyroidectomy on cardiovascular diseases and mortality in PHPT

Occipital bone and tumor-induced osteomalacia. a rare tumor site for an uncommon paraneoplastic syndrome

Introduction: Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome due to the overproduction of fibroblast growth factor 23 (FGF23). It is predominantly caused by mesenchymal tumors and cured upon their complete removal. Non-surgical treatment is an alternative option but limited to specific clinical conditions. Methods: We report a challenging case of TIO caused by a tumor involving the occipital bone. We also performed a literature review of TIO caused by tumors localized at this site, focusing on clinical findings, treatment, and outcomes. Results: The patient, a 62-year-old male, presented with a long-lasting history of progressive weakness. Biochemical evaluation revealed severe hypophosphatemia due to low renal tubular reabsorption of phosphate with raised intact FGF23 values. A 68 Ga-DOTATATE PET/TC imaging showed a suspicious lesion located in the left occipital bone that MRI and selective venous catheterization confirmed to be the cause of TIO. Stereotactic gamma knife radiosurgery was carried out, but unfortunately, the patient died of acute respiratory failure. To date, only seven additional cases of TIO have been associated to tumors located in the occipital bone. Furthermore, the tumor involved the left side of the occipital bone in all these patients. Conclusion: The occipital region is a difficult area to access so a multidisciplinary approach for their treatment is required. If anatomical differences could be the basis for the predilection of the left side of the occipital bone, it remains to be clarified