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We describe a case of 51-year-old male with fever, abdominal pain and inguino-scrotal hernia. Laboratory examination revealed hypercreatininemia and hyperglycemia, firstly interpreted as diabetic nephropathy. US and CT scan showed a hernia of the bladder into the scrotum. Surgery revealed multiple bladder perforations with peritoneal diffusion of urine. So, hypercreatininemia was caused by peritoneal reabsorption of urea and creatinine, a condition that may be described as "inverted peritoneal auto-dialysis". Surgical reposition and repairment of the bladder led to rapid normalization of serum urea and creatinine. Discharged diagnosis was intraperitoneal rupture of inguino-scrotal hernia of the bladder in patient with recent onset of diabetes mellitus.

A 49-year-old operated for aortic coartaction patient presented with thoracic and ascending aortic aneurysm. He was asymptomatic. Angio-magnetic resonance nuclear scan and angiography revealed an ascending aortic aneurysm (5.2 cm), bicuspid aortic valve, 6-cm proximal descending aortic pseudoaneurysm at the site of the previous operation with involvement of the left subclavian artery. Restenosis at the original site of coarctation and aortic arch hypoplasia distally to the brachiocefalic trunk was also found. The operation performed was a "modified Bentall - De Bono". The pseudoaneurysm was not accessible through median sternotomy due to the massive lung adhesions following the previous surgery. The left common carotid artery was explanted from the aortic arch and connected with a graft to the ascending aortic conduit. A proximal neck suitable for landing zone of the endovascular stent-graft was then established. The postoperative course was uneventful. After two weeks, the patient was readmitted. The exclusion of the thoracic descending aortic pseudoaneurysm by endovascular implantation of the stent-graft prosthesis was performed. The left subclavian artery was excluded because left vertebral artery was closed. The patient did not develop hand claudicatio. The procedure was successful.

In the last years, the understanding of HHT has greatly progressed. The two genes for most on cromosomes 9 and 12 have been discovered and the existence of a third involved gene has been predicted. Recent progress in the field of genetics has allowed the identification of many gene mutation thus facilitating the characterisation of the at risk members of the same family. Complications from bleeding or shunting (pulmonary AVMs) may be sudden and life-threatening (hemothorax, haemoptysis, stroke and brain abscess). Catastrophic events are preventable by early diagnosis and treatment. Appropriate screening programmes are mandatory and multi-specialistic cooperation is needed. Special centers have been developed in the world, where physicians, who are specialised and trained in all aspects of HHT, are working to develop better therapeutic approaches for the disease and to locate new genes in view of the future potential of gene therapy for this condition.

Computed tomography (CT) is a very useful tool in the assessment of pancreatic disease. Searching for subtle signs, as in chronic pancreatitis or staging of adenocarcinoma, high spatial and contrast resolution is needed. The high resolution computed tomography (HRCT) technique for pancreatic scans, and its evolution from dynamic CT to multislice spiral CT, is described. 2D and 3D dimensional reconstructions are depicted and their role in diagnosis is focused. Together with spatial resolution, contrast enhancement protocols are discussed, aimed to achieve optimal contrast between the lesion and normal parenchyma.

The lymphatic system, consisting of the lymph nodes and the lymphatic vessels as well as the spleen and various sites of lymphoid tissue, is deputed to important tasks: the immune response, the transport of lipids absorbed at the intestinal level and the reabsorption of water and other substances from the interstitial spaces; the lymph nodes in particular are involved in immunity and lymph filtration-depuration. Therefore, the knowledge of lymph node cellular architecture as well as of the structure and course of lymphatic vessels is of great importance. The pathologic processes that affect the lymphatic system can involve the canalicular and/or nodal part, resulting in patterns directly correlated with their respective function: lymphedema and lymphagitis on one hand, and disorders induced by accumulation, inflammation and tumors, on the other.

The identification and characterization of lymphadenopathies is one of the fascinating challenges of modern diagnostic imaging. At present, the real problem is the distinction between normal and pathologic signs. For twenty years, the differentiation was based on the dimensional criterion, namely a short axis1 cm, however it was shown to be inadequate. After an overview of the anatomy, ATS classification, the role of N factor in lung cancer (60% of N0 patients survive at 5 years) while only 20% of N2 patients survive), the new signs evidenced on CT are analyzed and interpreted. With thin section, late phase CT, a retrospective study and a perspective study were carried out on densitometric changes in lymph nodes correlated with histology findings. The role of intranodal hypodensity, peripheral rim and adipose tissue was stressed. The results of these studies were concordant with histology findings and confirmed the better accuracy in staging and the impact on survival of extranodal spread detected, based on radiologic criteria.

To evaluate the role of CT in identifying other morphological signs of metastatic lymph node involvement from non small cell bronchogenic carcinoma. This is done to improve N staging, a critical step in this disease. In fact, since diameter is the only criterion used to distinguish normal form abnormal lymph nodes, medistinal CT only has 80% diagnostic accuracy.137 patients with known or suspected lung cancer were examined with Helical CT during early and late arterial phases (2 min delay, 3 mm thickness, 5 mm interslice gap) to depict node characteristics. Mediastinal lymph nodes, located according to the American Thoracic Society mapping, were considered normal when they were not visible or, if visible, less than 1 cm in diameter and of homogeneous density; lymph nodes over 1 cm in diameter and homogeneous density were considered reactive. A lymph node was considered metastatic when, independent of size, the following signs were found: central hypodensity; hyperdense thin/thick rim, with nodules within; hyperdense strands or diffuse hyperdensity in perinodal adipose tissue. The tumor site was also considered.Seventy patients were excluded because they were inoperable. Sixty-five of the remaining 67 patients were operated on, 1 underwent mediastinoscopy and another one mediastinoscopy followed by surgery. Based on the above CT signs, 46 patients were staged as N0, 61 as N1 and 15 as N2. In 44/46 N0 patients there was agreement between anatomical and pathologic findings; 3 of the 44 patients had lymph nodes over 1 cm in diameter and with homogeneous density. Micrometastases to mediastinal lymph nodes (N2) were found at histology in 2/46 patients (CT false negatives). In the 6 N1 and the 15 N2 patients there was complete agreement between anatomical and pathologic findings; in particular, 9 N2 patients had lymph nodes less than 1 cm in diameter with signs of metastasis and 4 had lymph nodes over 1 cm in diameter with signs of metastasis and 2 had lymph nodes either over or less than 1 cm. In all N2 patients the tumor histotype and the mediastinal location were also considered relative to the lesion site.A closer correlation was found with node morphology and density than with size. Indeed, CT sensitivity, specificity and diagnostic accuracy were 97, 100 and 97%, respectively, for the former versus 52, 93 and 77% for the latter. Adenocarcinoma was the predominant histotype (70.5%) in N2 patients. Metastases to node region 4 were predominant in right upper lobe carcinomas while node region 5 was predominant in left upper lobe lesions.Other criteria can be associated with size to improve CT diagnostic accuracy in N staging. Technique optimization plays a major role particularly in the late, thin slice, examination phase.

Objectives. To describe the radiological features of primitive neuroectodermal tumour (PNET) of the chest wall (Askin tumour) at diagnosis and to analyse the radiological changes occurring as a consequence of treatment and during follow-up. Materials and methods. Nine children with histologically proven PNET were studied. At diagnosis, all patients underwent chest X-ray (CXR), chest CT and bone scintigraphy; three patients also had MR and three had US. During treatment and follow-up, CT was performed in all patients. Results. CT demonstrated a solid heterogeneous chest wall mass in all children at diagnosis and six had a rib lesion. Small nodular densities in the extra-pleural fat were identified in three patients at diagnosis. US, performed in three patients, excluded tumour infiltration of the lung or diaphragm, which had been suspected on CT. On MR, the lesions showed high signal intensity in T1-weighted/proton-density images and intermediate/high signal intensity in T2-weighted images compared with muscle. Minimal chest wall involvement was demonstrated in one case by MRI. Extensive necrosis of tumour mass with pseudo-cystic appearance was documented in the five patients who underwent chemotherapy. Macroscopically complete resection was performed in five patients but there was early local recurrence after surgery in two, identified by CT in one and by MR in the other. Conclusions. PNET of the chest wall should be considered in a child with a chest wall mass. CT is valuable for evaluating tumour extension at diagnosis, the effects of chemotherapy and assessing tumour recurrence after surgery. However, CT can overestimate pleural, lung or diaphragmatic infiltration, which are better evaluated by US. MR was superior to CT in the evaluation of tumour extension in one of three patients and may be considered complementary to CT, particularly in very large chest wall tumours.

Pulmonary tuberculosis in its primary and postprimary form is a widespread disease. Radiologic and CT findings in the acute phase of the disease, its many different aspects, as well as the alterations observed following the outcomes of tuberculosis at the parenchymal and pleural level, are examined.

Computed Tomography (CT) with the advent of new techniques as high resolution computed tomography (HRTC) and spiral CT with 3D reconstructions (3D CT) allows a new morphologic-qualitative as well as functional-quantitative evaluation of pulmonary perfusion and ventilation. HRCT allows the identification of secondary lobule and a detailed morphologic and comparative analysis of minute distal anatomical structures with combined densitometric evaluation of lung parenchyma on perfusion. In particular, a new, more specific significance could be attributed to changes in density of lung parenchyma (mosaic pattern) with associated assessment of the vessel number, caliber and distribution, and a comparative evaluation of vessels and density between healthy and impaired areas. The "optical" HRCT evaluation on serial axial scans in inspiration and expiration allows the functional assessment of compartments which require spirometry and tests of respiratory function. Spiral CT allows volumetric acquisitions in a single breath which can be reconstructed and processed according to single requirements. 3D tailored reconstruction of spiral CT exam in maximum inspiration and expiration with a dedicated densitometric window (-1024/+ 100 HU) allows the calculation of total lung volume (TLV), of both lungs, of a single lung or selected sections. With the "air" densitometric window (-1024/-400 HU) the total lung capacity (TLC) and residual volume (RV) are calculated. The ratio between these values and the corresponding TLV represents the lung aeration index (LAI). 3D reconstruction with fixed densitometric value corresponding to median air density (peak of histogram) allows the scintigraphic-like "alveolographic" reconstruction of lung ventilation. Combined 3D CT and HRCT evaluation possibly from a single spiral CT exam, is used in the morphologic-functional diagnosis of respiratory pathophysiology.

In the course of the years the concept of functional radiology has gradually been developed. It represents the integration of chest radiography with some basic concepts of respiratory pathophysiology. The correlation between the higher vascularization at the bases of lung as compared to the apex with the gravitation factor was the initial reference. From this data, combined with physiologic parameters, over the years, relatively simple but diagnostically significant semeiotic findings were achieved. The different combinations of acquired "morphofunctional" signs allow the differential diagnosis in a number of organic and hemodynamic alterations, adding to conventional "morphologic" radiology. New contributions to the functional radiology of the lung might come from procedures as high resolution computed tomography (HRCT) which with the dynamic study supplies morphologic and densitometric information to be correlated with changes in pulmonary flow and ventilation/perfusion ratio.

Chest radiograph plays a major role in patients with suspected pulmonary embolism because it frequently allows the visualization of the radiologic signs of pulmonary embolism without or with infarct while at the same time the presence of other diseases which mimic it, can be detected. Combined with other investigations this finding allows the precise diagnosis of a higher number of diseases while other diagnostic exams can be selected. Numerous radiologic signs are visualized. They involve the vascularization, the parenchyma, the pleura and diaphragms. They allow to distinguish between embolism with infarct from embolism without infarct. They require a global interpretation to attribute a diagnostic role to chest radiograph. This should be carefully performed to represent a valid support to the diagnostic approach.

CT is at present considered the most accurate procedure in the staging of tumors of the pancreatic head area. Accuracy is based on a rigorous exam performed either with a conventional equipment or with spiral CT. Basic signs and symptoms and staging criteria according to TNM classification are analyzed. Comparison with other imaging methods is made based on a review of the literature. The role of a high resolution procedure is stressed especially in case of vascular infiltration, the determining factor to indicate resectability. In this respect CT is still to be considered the most reliable method.

The work-up conducted in order to reach a correct diagnosis based on a combined modality staging in patients with low risk rectal cancer, is presented. The diagnostic accuracy of each imaging technique is analyzed by the comparison of the radiologic TN with the histologic TN in 13 patients directly referred to surgery based on combined modality staging. Control with histologic findings has staged as T1-T2 13 patients directly referred to surgery, while only a patient was shown to have microinfiltration of perirectal fat. As for T, diagnostic accuracy was 90% for transrectal US, 66% for MRI, 61% for CT. Accuracy of transrectal sonography in the differentiation of T1 from T2 was 70% with a trend towards overstaging. None of the procedures has suggested the presence of metastatic lymph nodes while on histology small neoplastic foci were evidenced in a normal-sized perirectal lymph node. The high diagnostic accuracy of US in the definition of T in rectal cancer is confirmed. It is underlined that no procedure enables the detection of neoplastic microinfiltration of normal lymph nodes.

An accurate analysis of the rectal anatomy and of its "setting" is carried out. The various anatomical structures are defined by the available imaging procedures to supply information on a reasoned combined modality imaging of rectal anatomy.

Sarcoidosis is a systemic granulomatous disease of unknown etiology, characterized by an immunological disorder with accumulation of activated lymphocytes and macrophages in all the organs and apparatus. The intrathoracic lymphnodes and the lung remain the most common sites of such disease. The gastrointestinal sarcoidosis, particularly of the stomach, is very rare. The stomach may be the primitive or the secondary (systemic sarcoidosis) site of sarcoid granuloma. The endoscopic aspects of the gastric mucosa are variable: localized or diffused hyperemia, single or multiple ulcers, aspects of atrophic gastritis with easy bleeding during contact, rigid mucosa and so on. Generally asymptomatic, the disease may show symptoms as pain in the epigastrium, nausea, vomiting, haematemesis and so on. The wide range of gastric pathologies resembling sarcoidosis both on a histological level and on a clinic-endoscopical one (syphilis, histoplasmosis, Crohn's disease, stomach cancer) require an extremely accurate diagnosis above all for the setting out of the therapy with steroids which are the most appropriate drugs (prednisone). Three out of thirty-two patients observed for respiratory problems, already affected by cutaneous and pulmonary sarcoidosis, started suffering from gastric symptoms of different kind: pain in the epigastrium, haematemesis, weight loss, nausea and post-prandial vomiting. Gastroscopy and biopsy, with histopathologic examination of gastric mucosal specimens taken from the most suspicious sites, confirmed the diagnosis of sarcoidosis.(ABSTRACT TRUNCATED AT 250 WORDS)

An interdisciplinary study relative to non-small cell lung cancers was activated in 1990 at the Policlinico A. Gemelli, Rome, Italy. A working group including radiologists, radiotherapists, oncologists, surgeons, respiratory physiopathologists and pathologists defined the goals to reach and the protocols to follow for staging, treatment, and follow-up. A hundred and ninety patients with non-small cell lung cancer were examined: 134 of them, who were in the initial or locally advanced phases, were considered, together with 6 patients with postoperative recurrences. Ninety-three cases were considered to be resectable and therefore operated: the extant 41, considered unresectable/slightly resectable, and the 6 with postoperative recurrences were started on combined chemo- and radiotherapy. Primary tumor (T) and lymph nodes (N) were staged by means of CT. In the evaluation of T in resectable patients, CT exhibited 78.5% agreement with pathology, with a tendency to understaging. In the evaluation of N, CT exhibited 62.4% agreement with pathology, once again with a tendency to understaging. Surgery was exploratory in 4.3% of cases only. Combined chemo- and radiotherapy in unresectable patients and in postoperative recurrences yielded50% response in 18/47 patients, that is 40.4% especially relative to the cases treated with carboplatinum in continual infusion. Eight of 18 responsive patients were considered to be resectable and therefore submitted to surgery: in 2 of them histology showed no neoplastic cells. This study, which is still in progress, is aimed at verifying its hypotheses and attaining its prefixed goals.

Since a few years ago, in our department the bedside chest X-rays of intensive care patients have been reported by means of a computer program which has also storing function. This computer program is a guideline for the radiologist and is organized in pages having a logical sequence. The program has proved very useful in learning the correct reporting of bedside chest X-rays. The nosographic data of the patients, the ventilatory and the technical data are stored for a better clinico-radiological correlation. The last four reports are displayed on the monitor to better understand the patient's history. The other reports become part of a "historical" archive. Most important is the cooperation with the referring physician: to make the most of it, a system has been implemented which sends the images from the Radiology Department to Intensive Care. The images are filmed with a camera and then digitalized on 1024 x 768 matrix with 16 million colors and 256 gray levels. Each workstation is composed of: AT286 computer with 60-MB hard disk, hardware or the digitalization and compression of images, a high-resolution monitor, an intercommunication system, and a modem. It is possible to zoom on the images, but a close-up on the image with the camera is better for improved spatial resolution. The images are stored on the hard disk: each image requires 3M bytes, but it can be compressed down to 25:1 with no detail loss. The images are transmitted via modem in at least 20 seconds/image. More images can be sent out-line. During transmission, it is possible to talk by the intercommunication system, pointing out structures on the monitor or drawing objects on both sides of the system. In our experience, image quality is good. We are therefore considering extending the network to other Departments and making the transmission of images of pathologic specimens possible. The natural evolution of this system is the teleconsult.