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Year of Publication
1.  Multidetector CT imaging of post-robot-assisted laparoscopic radical prostatectomy complications 
Insights into Imaging  2013;4(5):711-721.
Background
Robot-assisted laparoscopic radical prostatectomy (RALRP) is currently accepted as the preferred minimally invasive surgical treatment for localised prostate cancer, with optimal oncologic and functional results. Despite growing surgical experience, reduced postoperative morbidity and hospital stays, RALRP-related complications may occur, which are severe in 5–7 % of patients and sometimes require reoperation. Therefore, in hospitals with an active urologic surgery, urgent diagnostic imaging is increasingly requested to assess suspected early complications following RALRP surgery.
Methods
Based upon our experience, this pictorial review discusses basic principles of the surgical technique, the optimal multidetector CT (MDCT) techniques to be used in the postoperative urologic setting, the normal postoperative anatomy and imaging appearances.
Results
Afterwards, we review and illustrate the varied spectrum of RALRP-related complications including haemorrhage, urinary leaks, anorectal injuries, peritoneal changes, surgical site infections, abscess collections and lymphoceles, venous thrombosis and port site hernias.
Conclusion
Knowledge of surgical procedure details, appropriate MDCT acquisition techniques, and familiarity with normal postoperative imaging appearances and possible complications are needed to correctly perform and interpret early post-surgical imaging studies, particularly to identify those occurrences that require prolonged in-hospital treatment or surgical reintervention.
Teaching points
• Robot-assisted laparoscopic radical prostatectomy allows minimally invasive surgery of localised cancer
• Urologic surgeons may request urgent imaging to assess suspected postoperative complications
• Main complications include haemorrhage, urine leaks, anorectal injuries, infections and lymphoceles
• Correct multidetector CT techniques allow identifying haematomas, active bleeding and extravasated urine
• Imaging postoperative complications is crucial to assess the need for surgical reoperation
doi:10.1007/s13244-013-0280-6
PMCID: PMC3781251  PMID: 24018752
Prostatectomy; Robotic surgery; Laparoscopic surgery; Complications; Haemorrhage; Anastomotic leak; Urine leak; Computed tomography (CT); Cystography
2.  Combination of a Toll-like receptor 9 agonist with everolimus interferes with the growth and angiogenic activity of renal cell carcinoma 
Oncoimmunology  2013;2(8):e25123.
The mTOR inhibitor everolimus is currently approved for the treatment of renal cell carcinoma (RCC) and several Toll-like receptor 9 (TLR9) agonists, including immunomodulatory oligonucleotides (IMOs), have been tested for their therapeutic potential against advanced RCC. However, no clinical trials investigating the combination of mTOR inhibitors with TLR9 agonists in RCC patients have been performed to date. Our results may pave the way to translate this combinatorial approach to the clinical setting.
doi:10.4161/onci.25123
PMCID: PMC3782521  PMID: 24083076
mTOR; TLR9; everolimus; renal cell carcinoma; microenvironment
3.  Early non-aneurysmal infectious aortitis: Cross-sectional imaging diagnosis 
In patients without history of vascular surgery, infectious aortitis is a very uncommon, life-threatening condition with nonspecific clinical manifestations, which exposes the patient to uncontrolled sepsis and to the risk of retroperitoneal rupture. State-of-the-art cross-sectional imaging with contrast-enhanced multidetector computed tomography and magnetic resonance imaging allows confident diagnosis and characterization of unsuspected aortitis in septic patients at an early stage before the development of aneurysmal dilatation. The asymmetric distribution of periaortic inflammatory tissue is helpful for the differentiation of this exceptional disorder from other periaortic abnormalities such as retroperitoneal fibrosis or lymphoma.
doi:10.4103/0974-2700.110811
PMCID: PMC3665067  PMID: 23723629
Aortitis; computed tomography; magnetic resonance imaging; sepsis; Staphylococcus aureus
4.  Water enema multidetector CT technique and imaging of diverticulitis and chronic inflammatory bowel diseases 
Insights into Imaging  2013;4(3):309-320.
Background
Water enema multidetector computed tomography (WE-MDCT) is currently considered the most accurate imaging modality to provide high-resolution multiplanar visualisation of the colonic wall and surrounding structures.
Methods
This pictorial review presents our experience with WE-MDCT applications outside colorectal tumour staging, particularly for investigating diverticular disease and chronic inflammatory bowel diseases. A detailed explanation of the technique is provided, including patient preparation, the acquisition protocol, and study interpretation.
Results
WE-MDCT allows accurate preoperative visualisation of diverticular disease, acute and complicated diverticulitis. Ulcerative, indeterminate, or Crohn’s colitis can be assessed including longitudinal distribution, mural thickening and enhancement patterns, pseudopolyps, associated perivisceral changes, adjacent organ involvement, and features suggesting carcinoma. Elective WE-MDCT represents a useful complementary technique in patients with impossible, incomplete, or inconclusive endoscopy, can allow study of a stricture’s features and the upstream bowel, and helps planning medical, endoscopic, or surgical treatments.
Conclusion
Urgent WE-MDCT with limited or no bowel preparation may prove useful in acutely symptomatic patients, as it may obviate a risky or contraindicated endoscopy, can determine disease severity, and allows making correct therapeutic choices.
Teaching Points
• Water enema multidetector CT provides high-resolution multiplanar visualisation of the colonic wall.
• WE-MDCT allows accurate visualisation of diverticular disease, acute and complicated diverticulitis.
• In chronic inflammatory bowel diseases WE-MDCT depicts the distribution, mural and perivisceral changes.
• Elective WE-MDCT usefully complements incomplete endoscopy to assess strictures and upstream colon.
• Urgent WE-MDCT with limited or no bowel preparation in acute diseases may obviate endoscopy.
doi:10.1007/s13244-013-0239-7
PMCID: PMC3675246  PMID: 23508934
Contrast enema; Computed tomography (CT); Colonoscopy; Diverticular disease; Acute diverticulitis; Chronic inflammatory bowel diseases; Ulcerative colitis; Crohn’s disease; Indeterminate colitis
5.  Erratum to: MRI and CT of anal carcinoma: a pictorial review 
Insights into Imaging  2013;4(1):63.
doi:10.1007/s13244-013-0221-4
PMCID: PMC3579988  PMID: 23361151
6.  Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography 
Spontaneous esophageal perforation (Boerhaave syndrome) is a very uncommon, life-threatening surgical emergency that should be suspected in all patients presenting with lower thoracic-epigastric pain and a combination of gastrointestinal and respiratory symptoms. Variable clinical manifestations and subtle or unspecific radiographic findings often result in critical diagnostic delays. Multidetector computed tomography complemented with CT-esophagography represents the ideal “one-stop shop” investigation technique to allow a rapid, comprehensive diagnosis of BS, including identification of suggestive periesophageal abnormalities, direct visualization of esophageal perforation and quantification of mediastinitis.
doi:10.4103/0974-2700.106329
PMCID: PMC3589863  PMID: 23493470
Computed tomography; contrast medium; esophagography; esophageal perforation; esophagus
7.  MRI and CT of anal carcinoma: a pictorial review 
Insights into Imaging  2012;4(1):53-62.
Background
Squamocellular anal carcinoma is increasingly diagnosed in patients with risk factors.
Methods
State-of-the-art imaging with magnetic resonance imaging (MRI) using phased-array coils and volumetric multidetector computed tomography (CT) provides detailed visualisation of anal disorders, identification and extent assessment of neoplastic tissue, detection and characterisation of nodal and visceral metastases. MRI has been recommended by the European Society for Medical Oncology (ESMO) as the preferred modality of choice to stage anal cancer, taking into account the maximum tumour diameter, invasion of adjacent structures and regional lymph node involvement.
Results
Cross-sectional imaging techniques allow the identification of coexisting complications, and differentiation from other perineal abnormalities.
Conclusion
Cross-sectional imaging is useful for planning radiotherapy, surgical drainage or salvage abdomino-perineal resection. After chemo-radiotherapy, MRI follow-up provides confident reassessment of therapeutic response, persistent or recurrent disease.
Teaching Points
• Anal carcinoma is increasingly diagnosed in patients with human immunodeficiency virus (HIV), anoreceptive intercourse, chronic inflammatory bowel disease.
• An established association exists with human papillomavirus (HPV) infection and premalignant intra-epithelial dysplasia.
• Phased-array MRI is recommended as the preferred imaging modality for regional staging.
• Imaging allows detection of infectious complications, planning of radiotherapy or salvage surgery.
• Follow-up MRI allows reliable assessment of therapeutic response after chemo-radiotherapy.
doi:10.1007/s13244-012-0199-3
PMCID: PMC3579995  PMID: 23208584
Anal carcinoma; Anus; Human immunodeficiency virus; Chronic inflammatory bowel diseases; Computed Tomography (CT); Magnetic Resonance Imaging (MRI)
8.  Pulmonary cement embolism after pedicle screw vertebral stabilization 
Pulmonary arterial embolization of polymethylmethacrylate cement, most usually occurring after vertebroplasty or kyphoplasty, is very uncommon following vertebral stabilization procedures. Unenhanced CT scans viewed at lung window settings allow confident identification of cement emboli in the pulmonary circulation along with possible associate parenchymal changes, whereas hyperdense emboli may be less conspicuous on CT-angiographic studies with high-flow contrast medium injection. Although clinical manifestations are largely variable from asymptomatic cases to severe respiratory distress, most cases are treated with anticoagulation.
doi:10.4103/0974-2700.99710
PMCID: PMC3440899  PMID: 22988411
Vertebral stabilization; vertebroplasty; pulmonary embolism; polymethylmethacrylate bone cement
9.  Septic thrombophlebitis in a HIV-positive intravenous drug user 
Septic thrombophlebitis of the pelvic veins may occur secondary to non-sterile intravenous drug injection and represents an uncommon yet life-threatening condition, most usually manifesting with persistent spiking fever and limb edema. Risk is further increased in HIV-infected people. High clinical suspicion and prompt imaging assessment with contrast-enhanced multidetector CT are necessary for correct diagnosis and staging, since early treatment prevents further complications such as systemic embolization.
doi:10.4103/0974-2700.99711
PMCID: PMC3440900  PMID: 22988412
Computed tomography; human immunodeficiency virus infection; intravenous drug abuse; sepsis; thrombophlebitis
10.  Mycotic visceral aneurysm complicating infectious endocarditis: Imaging diagnosis and follow-up 
One of the rarest complications of endocarditis, infected (mycotic) aneurysms result from haematogenous dissemination of septic emboli and occur more frequently in patients with cardiac valvular abnormalities or prosthetic valves, intravenous drug abuse, diabetes and immunosuppression conditions such as HIV infection. Although often clinically unsuspected, mycotic aneurysms are potentially life-threatening because of disseminated sepsis and propensity to rupture. Contrast-enhanced multidetector CT provides prompt detection, characterization and vascular mapping of these lesions, allowing correct planning of surgical or interventional therapies and reproducible follow-up. Because of their characteristically unpredictable behaviour, mycotic aneurysms may undergo spontaneous thrombosis, size reduction, rapid enlargement or rupture, therefore strict imaging surveillance with CT and/or color Doppler ultrasound is necessary.
doi:10.4103/0974-2700.96501
PMCID: PMC3391851  PMID: 22787357
Endocarditis; mesenteric artery; mycotic aneurysm; sepsis; visceral aneurysm
11.  Multidetector CT cystography for imaging colovesical fistulas and iatrogenic bladder leaks 
Insights into Imaging  2012;3(2):181-187.
Multidetector computed tomography (MDCT) cystography currently represents the modality of choice to image the urinary bladder in traumatized patients. In this review we present our experience with MDCT cystography applications outside the trauma setting, particularly for diagnosing bladder fistulas and leaks. A detailed explanation is provided concerning exam preparation, acquisition technique, image reconstruction and interpretation. Colovesical fistulas most commonly occur as a complication of sigmoid diverticular disease, and often remain occult after extensive diagnostic work-up including cystoscopy and contrast-enhanced CT. We consistently achieved accurate preoperative visualization of colovesical fistulas using MDCT cystography. Urinary leaks and injuries represent a non-negligible occurrence after pelvic surgery, particularly obstetric and gynaecological procedures: in our experience MDCT cystography is useful to investigate iatrogenic bladder leaks or fistulas. In our opinion, MDCT cystography should be recommended as the first line modality for direct visualization or otherwise confident exclusion of both spontaneous enterovesical fistulas and bladder injuries following instrumentation procedures, obstetric or surgical interventions.
Main Messages
• Explanation of exam preparation, acquisition technique, image reconstruction and interpretation.
• Preoperative visualization of colovesical fistulas, usually secondary to sigmoid diverticulitis.
• Visualization or exclusion of iatrogenic bladder injuries following instrumentation or surgery.
doi:10.1007/s13244-011-0145-9
PMCID: PMC3314733  PMID: 22696044
Computed tomography (CT); Urinary bladder; Urinary bladder fistula; Colonic diverticulitis; Postoperative complications
12.  Multidetector CT cystography for imaging colovesical fistulas and iatrogenic bladder leaks 
Insights into Imaging  2012;3(2):181-187.
Multidetector computed tomography (MDCT) cystography currently represents the modality of choice to image the urinary bladder in traumatized patients. In this review we present our experience with MDCT cystography applications outside the trauma setting, particularly for diagnosing bladder fistulas and leaks. A detailed explanation is provided concerning exam preparation, acquisition technique, image reconstruction and interpretation. Colovesical fistulas most commonly occur as a complication of sigmoid diverticular disease, and often remain occult after extensive diagnostic work-up including cystoscopy and contrast-enhanced CT. We consistently achieved accurate preoperative visualization of colovesical fistulas using MDCT cystography. Urinary leaks and injuries represent a non-negligible occurrence after pelvic surgery, particularly obstetric and gynaecological procedures: in our experience MDCT cystography is useful to investigate iatrogenic bladder leaks or fistulas. In our opinion, MDCT cystography should be recommended as the first line modality for direct visualization or otherwise confident exclusion of both spontaneous enterovesical fistulas and bladder injuries following instrumentation procedures, obstetric or surgical interventions.
Main Messages
• Explanation of exam preparation, acquisition technique, image reconstruction and interpretation.
• Preoperative visualization of colovesical fistulas, usually secondary to sigmoid diverticulitis.
• Visualization or exclusion of iatrogenic bladder injuries following instrumentation or surgery.
doi:10.1007/s13244-011-0145-9
PMCID: PMC3314733  PMID: 22696044
Computed tomography (CT); Urinary bladder; Urinary bladder fistula; Colonic diverticulitis; Postoperative complications
13.  Hemoperitoneum from splenic rupture in an expatriate 
Splenic rupture with hemoperitoneum represents a life-threatening surgical emergency. Malaria should be highly suspected as the probable underlying disease in returning travellers, expatriates, or recent immigrants from endemic countries. Malarial complications involving the spleen occur even with appropriate prophylaxis or during antimalarial therapy. Among them, splenic infarction has a favourable course and is treated conservatively, whereas life-threatening rupture requires immediate or delayed splenectomy. Computed tomography (CT) allows confident differentiation between these two complications by identifying ruptured spleen with clotted hematoma and associated high-density peritoneal effusion; furthermore, CT allows differential diagnosis from other causes of spontaneous hemoperitoneum.
doi:10.4103/0974-2700.93100
PMCID: PMC3299142  PMID: 22416169
Malaria; plasmodium falciparum; splenic rupture; hemoperitoneum
14.  Addition of erlotinib to fluoropyrimidine-oxaliplatin-based chemotherapy with or without bevacizumab: Two sequential phase I trials 
The combination of EGFR inhibitors and anti-angiogenic drugs has a strong pre-clinical rationale, yet its use has produced controversial clinical results. We conducted two sequential phase I trials to evaluate the feasibility and the recommended dose of erlotinib when combined with fluoropyrimidine-oxaliplatin-based chemotherapy with or without bevacizumab. A total of 21 metastatic colorectal cancer (mCRC) patients were treated in two sequential phase I trials. In the first trial, 12 patients were treated with escalating doses of erlotinib plus FOLFOX. In the second, 9 patients were treated with escalating doses of erlotinib combined with oxaliplatin, capecitabine and bevacizumab. No MTD was reached in either of the trials. The only dose-limiting toxicities observed were neutropenia and diarrhea. No unexpected toxicities were noted. Hematological toxicity was the most frequently noted adverse event with infusional 5FU therapy, while gastrointestinal toxicity was the most common adverse event. In the second trial most patients withdrew from treatment due to toxicity, and less than half completed the therapeutic program as per protocol, mostly due to toxicity. In conclusion, the present study confirms the disappointing results of the double combination of EGFR inhibitors and anti-angiogenic drugs in mCRC patients.
doi:10.3892/etm.2011.218
PMCID: PMC3440709  PMID: 22977524
phase I trial; colorectal cancer; bevacizumab; erlotinib; capecitabine; FOLFOX
15.  Adjuvant FOLFOX-4 in patients with radically resected gastric cancer: Tolerability and prognostic factors 
The aim of the present study was to evaluate the toxicity and efficacy of the FOLFOX-4 regimen as adjuvant chemotherapy in patients with gastric cancer after radical surgery. Fifty-four patients (1 stage Ib, 6 stage II, 22 stage IIIa, 14 stage IIIb and 11 stage IV) received 8-12 cycles of FOLFOX-4 (oxaliplatin 85 mg/m2, Day 1; leucovorin 100 mg/m2 i.v., Days 1 and 2; 5-fluorouracil 400 mg/m2 i.v. bolus, Days 1 and 2 and 600 mg/m2 in 22 h i.v. continuous infusion, Days 1 and 2; every 14 days). Toxicity was recorded at each cycle according to the National Cancer Institute Common Toxicity Criteria. Disease-free (DFS) and overall survival (OS) were calculated according to the Kaplan-Meier method. Thirty-eight patients (70.4%) completed the prescribed number of cycles of chemotherapy. The toxicity was mild. Grade 3–4 neutropenia occurred in 57% of patients, thrombocytopenia and anemia in 2% of cases. Peripheral neuropathy was experienced by 46% of the patients (grade 4 in 2% of cases). Five patients experienced grade 3 gastrointestinal toxicity. After a median follow-up of 33.1 months, 17 patients relapsed and 17 succumbed to the disease. The mean observed DFS and OS were 49.7 months (range 40.7–58.8) and 57.9 months (range 49.6–66.2), respectively. At univariate analysis, females and patients who had received <8 cycles of chemotherapy had a significantly worse probability of DFS and OS. The Cox model showed gender to be independent of the factors affecting DFS. Adjuvant FOLFOX-4 is feasible and well-tolerated in patients radically resected for gastric cancer. Receiving <4 months of adjuvant FOLFOX-4 could be detrimental to prognosis.
doi:10.3892/etm_00000096
PMCID: PMC3445918  PMID: 22993584
gastric cancer; oxaliplatin; adjuvant
16.  Overcoming resistance to molecularly targeted anticancer therapies: rational drug combinations based on EGFR and MAPK inhibition for solid tumours and haematologic malignancies 
Accumulating evidence suggests that cancer can be envisioned as a “signaling disease”, in which alterations in the cellular genome affect the expression and/or function of oncogenes and tumour suppressor genes. This ultimately disrupts the physiologic transmission of biochemical signals that normally regulate cell growth, differentiation and programmed cell death (apoptosis). From a clinical standpoint, signal transduction inhibition as a therapeutic strategy for human malignancies has recently achieved remarkable success. However, as additional drugs move forward into the clinical arena, intrinsic and acquired resistance to “targeted” agents becomes an issue for their clinical utility. One way to overcome resistance to targeted agents is to identify genetic and epigenetic aberrations underlying sensitivity/resistance, thus enabling the selection of patients that will most likely benefit from a specific therapy. Since resistance often ensues as a result of the concomitant activation of multiple, often overlapping, signaling pathways, another possibility is to interfere with multiple, cross-talking pathways involved in growth and survival control in a rational, mechanism-based, fashion. These concepts may be usefully applied, among others, to agents that target two major signal transduction pathways: the one initiated by epidermal growth factor receptor (EGFR) signaling and the one converging on mitogen-activated protein kinase (MAPK) activation. Here we review the molecular mechanisms of sensitivity/resistance to EGFR inhibitors, as well as the rationale for combining them with other targeted agents, in an attempt to overcome resistance. In the second part of the paper, we review MAPK-targeted agents, focusing on their therapeutic potential in hematologic malignancies, and examine the prospects for combinations of MAPK inhibitors with cytotoxic agents or other signal transduction-targeted agents to obtain synergistic anti-tumour effects.
doi:10.1016/j.drup.2007.03.003
PMCID: PMC2548422  PMID: 17482503
Targeted therapy; drug resistance; combination therapy; molecular markers; EGFR; IGFR1; MAPK; MEK inhibitors; AML

Results 1-16 (16)