Search

Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.

Neoadjuvant chemotherapy (NACT) today represents a cornerstone in the treatment of locally advanced breast cancer and highly chemo-sensitive tumors at early stages, increasing the possibilities of performing more conservative treatments and improving long term outcomes. Imaging has a fundamental role in the staging and prediction of the response to NACT, thus aiding surgical planning and avoiding overtreatment. In this review, we first examine and compare the role of conventional and advanced imaging techniques in preoperative T Staging after NACT and in the evaluation of lymph node involvement. In the second part, we analyze the different surgical approaches, discussing the role of axillary surgery, as well as the possibility of non-operative management after-NACT, which has been the subject of recent trials. Finally, we focus on emerging techniques that will change the diagnostic assessment of breast cancer in the near future.

A working hypothesis issues from patterns of methylation in the 5'-UTR of the DAT1 gene. We considered relationships between pairs of CpGs, of which one on the main-gene strand and another on the complementary opposite strand (COS). We elaborated on data from ADHD children: we calculated all possible combinations of probabilities (estimated by multiplying two raw values of methylation) in pairs of CpGs from either strand. We analyzed all correlations between any given pair and all other pairs. For pairs correlating with M6-M6COS, some pairs had cytosines positioning to the reciprocal right (e.g., M3-M2COS and M6-M5COS), other pairs had cytosines positioning to the reciprocal left (e.g., M2-M3COS; M5-M6COS). Significant pair-to-pair correlations emerged between main-strand and COS CpG pairs. Through graphic representations, we hypothesized that DNA folded to looping conformations: the C 1 GG C 2 GG C 3 GG and C 5 G C 6 G motifs would become close enough to allow cytosines 1-2-3 to interact with cytosines 5-6 (on both strands). Data further suggest a sliding, with left- and right-ward oscillations of DNA strands. While thorough empirical verification is needed, we hypothesize simultaneous methylation of main-strand and COS DNA ("methylation dynamics") to serve as a promising biomarker.

The management of myelomeningocele study trial showed significant prognostic improvement in fetal repair before 26 weeks of gestation. Hence, surgery in utero represents the best treatment option for open-neural tube defects (NTDs). Fetal surgery of open-NTDs has specific inclusion and exclusion criteria, which can be adequately studied with fetal MRI. The main concern: the spine (spinal defects other than Myelomeningocele and Myeloschisis, the level of the lesion higher than T1 or lower than S1 and the degree of kyphosis ≥ 30°), the skull/brain (no cerebellum herniation and Chiari II malformation and the presence of any intracranial abnormality unrelated to open NTDs), the uterus (cervix length less than 2 cm, multiple gestations and placental and uterine abnormalities) and any other fetal abnormality not attributed to spinal defect. In this review, we describe the fundamental role of fetal MRI in supporting therapeutic decisions in pre-surgery intrauterine planning through the accurate and comprehensive description of findings, providing a proposal of a structured report. In addition, we describe how post-surgical MRI is important in investigating the effectiveness of surgery and detecting repairing complications., (© 2022. Italian Society of Medical Radiology.)

Breast cancer (BC) is the most common cancer among women worldwide. Neoadjuvant chemotherapy (NACT) indications have expanded from inoperable locally advanced to early-stage breast cancer. Achieving a pathological complete response (pCR) has been proven to be an excellent prognostic marker leading to better disease-free survival (DFS) and overall survival (OS). Although diagnostic accuracy of MRI has been shown repeatedly to be superior to conventional methods in assessing the extent of breast disease there are still controversies regarding the indication of MRI in this setting. We intended to review the complex literature concerning the tumor size in staging, response and surgical planning in patients with early breast cancer receiving NACT, in order to clarify the role of MRI. Morphological and functional MRI techniques are making headway in the assessment of the tumor size in the staging, residual tumor assessment and prediction of response. Radiomics and radiogenomics MRI applications in the setting of the prediction of response to NACT in breast cancer are continuously increasing. Tailored therapy strategies allow considerations of treatment de-escalation in excellent responders and avoiding or at least postponing breast surgery in selected patients.

Purpose: Our aim was to explore the relation between FA and ADC, number and length of the periprostatic neurovascular fibers (PNF) by means of 1.5 T Diffusion Tensor Imaging (DTI) imaging through a multivariate linear regression analysis model., Methods: For this retrospective study, 56 patients (mean age 63.5 years), who underwent 1.5-T prostate MRI, including DTI, were enrolled between October 2014 and December 2018. Multivariate regression analysis was performed to evaluate the statistically significant correlation between FA values (dependent variable) and ADC, the number and the length of PNF (independent variables), if p -value <0.05. A value of 0.5 indicated poor agreement; 0.5-0.75, moderate agreement; 0.75-0.9, good agreement; 0.61-0.80, good agreement; and 0.9-1.00, excellent agreement., Results: The overall fit of the multivariate regression model was excellent, with R 2 value of 0.9445 ( R 2 adjusted 0.9412; p < 0.0001). Multivariate linear regression analysis showed a statistically significant correlation ( p < 0.05) for all the three independent variables. The r partial value was -0.9612 for ADC values ( p < 0.0001), suggesting a strong negative correlation, 0.4317 for the number of fiber tracts ( p < 0.001), suggesting a moderate positive correlation, and -0.306 for the length of the fiber tracts ( p < 0.05), suggesting a weak negative correlation., Conclusions: Our multivariate linear regression model has demonstrated a statistically significant correlation between FA values of PNF with other DTI parameters, in particular with ADC.

Purpose: The purpose of this study was to prospectively evaluate the capability of diffusion tensor imaging (DTI) of the lumbosacral plexus to identify parametrial invasion by uterine cervical cancer., Materials and Methods: Twenty-seven women with biopsy-proven cervical cancer were prospectively enrolled and underwent DTI at 1.5 TMRI. Fractional anisotropy (FA) values were calculated at the level of right and left L5 and S1 roots. The two sides of each patient were considered independently in two groups, according to the presence or absence of parametrial invasion. Differences between FA values of invaded parametria and those of non-invaded parametria were searched using Student t-test. Receiver operating characteristic (ROC) analysis was performed to identify the cut-off value of FA that yielded best sensitivity, specificity and accuracy for the diagnosis of parametrial invasion., Results: A total of 54 parametria in 27 participants (mean age, 52.9 ± 12 years; age range, 30-81 years) were analyzed. Invasion was present in 37/54 (68%) parametria and absent in 17/54 (31%) parametria. FA was greater in parametrial invasion (mean, 0.321 ± 0.036; range: 0.285-0.357) than in the absence of parametrial invasion (0.292 ± 0.02; range: 0.272-0.312) (P = 0.01). At ROC analysis, best cut-off value of FA for the diagnosis of parametrial invasion was >0.3099 (AUC, 0.681; 95% CI: 0.583- 0.768), yielding 62% sensitivity (95% CI: 50.3-73.64), 73% specificity (95% CI: 50.6-85.27) and 66% accuracy (95% CI: 54.62-73.91)., Conclusion: Using >0.3099 as cut off-value for FA of L5-S1 roots, DTI has an accuracy of 73% in the diagnosis of parametrial invasion by uterine cervical cancer., (Copyright © 2022 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: Cystadenofibroma (CAF) is a rare tumour of the ovary that can be confused with a borderline or malignant lesion due to its morphological characteristics. The study aims to analyse the MRI (magnetic resonance imaging) features of histologically proven ovarian cystadenofibromas according to lexicon-based and O-RADS (Ovarian-Adnexal Reporting and Data System) descriptors, with particular attention to time-intensity curves (TIC) and Diffusion-Weighted sequences (DWI); we also wanted to test the performance of O-RADS MRI risk stratification system in this particular subgroup of patients., Methods: We have included all patients who performed MR between October 2019 and December 2021 after an inconclusive trans-vaginal ultrasound. All patients underwent surgery with histological results of CAF. According to the O-RADS lexicon, we reported the morphological characteristics of each lesion and their appearance in the perfusion-weighted imaging (PWI) and DWI sequences. We assessed the risk of malignancy for each lesion through O-RADS MRI score., Results: Twenty-one histologically proven CAF were analysed, of which 20 benign and one borderline with degeneration into adenocarcinoma. We described the typical morphological characteristics of CAF according to lexicon-based and O-RADS descriptors. Analysis of time-intensity curves (TIC) in PWI sequences showed a slow and progressive enhancement of solid tissue (type I curve), configuring an O-RADS score of 2 or 3, except for the only malignant lesion that showed a type II curve and restriction in DWI (O-RADS 4)., Conclusions: Our study is the largest comprising PWI and DWI sequences, highlighting their pivotal role. O-RADS score correctly classified the masses as benign or malignant., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0-2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

Therapeutic options and clinical management of cervical and endometrial cancers differs significantly. When clinical and histological analysis of a uterine mass are unable to differentiate between an endocervical or endometrial origin, magnetic resonance imaging (MRI) plays a pivotal role in discriminating the anatomical origin, supporting the clinician in the treatment planning. Cervical adenocarcinomas are more likely to be centered in the cervical region and involving both cervical canal and stromal ring, with possible parametrial invasion. Endometrial adenocarcinomas usually present an elongated morphology and are centered in the endometrial cavity predominantly involving endometrium and myometrium. On contrast-enhanced sequences, cervical cancers are more frequently hypervascular compared to endometrial cancers. In cases of uncertain findings, diffusion-weighted imaging (DWI) can provide additional helpful information with significantly higher apparent coefficient diffusion (ADC) values in cervical adenocarcinomas compared to endometrial adenocarcinomas. However, even when MRI cannot precisely reveal the origin of the tumor, it provides valuable information on several prognostic factors that can help treatment planning., (Copyright © 2022 Elsevier B.V. All rights reserved.)

MR imaging provides excellent spatial and contrast resolution to stage locally advanced vulvar cancer (LAVC) for tumor and nodal evaluation in order to facilitate the planning of treatment. Although there are no standard indications for how to estimate the clinical stage of International Federation of Gynecology and Obstetrics at diagnosis, MR imaging can depict the tumor and its extension to the vulvar region and adjacent organs, such as the vagina, urethra, and anus. Optimizing the MR imaging protocol and technique is fundamental for correct staging. The aim of this overview was to focus on the role of MR imaging in LAVC staging. We define vulvar anatomy and corresponding MR imaging findings, MR imaging protocol, and technique. Moreover, we describe the MR imaging findings of LAVC with example cases stage by stage. Key imaging findings based on signal intensity, diffusion restriction, and enhancement are portrayed to correctly identify and stage vulvar cancer. A structured report for LAVC staging is reported in order to give all necessary information to the clinicians and to facilitate MR imaging comprehension.

Prostate cancer is the second most commonly diagnosed cancer in man. Since the first MRI was performed, enormous progress has been made in diagnosis, treatment, and follow up of PCa, mainly due to multiparametric prostatic MRI (mpMRI). Although mpMRI has become the best imaging tool for identifying PCa, some limitations still exist. Prostate imaging with mpMRI is, to date, the best way to locate suspicious lesions to trigger prostate biopsy, plan active surveillance, or definitive treatment. In case of relapse, mpMRI can help detect local disease and provide specific management. It is well known that there is a subset of patients in whom mpMRI fails to depict csPCa. These missed significant cancers demand great attention. Prostate mpMRI quality depends on several factors related to equipment (including equipment vendor, magnet field and gradient strength, coil set used, software and hardware levels, sequence parameter choices), patient (medications, body habitus, motion, metal implants, rectal gas), and most importantly the radiologic interpretation of images (learning curve effects, subjectivity of observations, interobserver variations, and reporting styles). Inter-reader variability represents a huge current limitation of this method. Therefore, mpMRI remains the best imaging tool available to detect PCa, guiding diagnosis, treatment, and follow up while inter-reader variability represents the best limitation. Radiomics can help identifying imaging biomarkers to help radiologist in detecting significant PCa, reducing examination times, and costs.

Immunotherapy is an effective treatment option for gynecological malignancies. Radiologists dealing with gynecological patients undergoing treatment with immune checkpoint inhibitors should be aware of unconventional immune-related imaging features for the evaluation of tumor response and immune-related adverse events. In this paper, immune checkpoint inhibitors used for gynecological malignancies and their mechanisms of action are briefly presented. In the second part, patterns of pseudoprogression are illustrated, and different forms of immune-related adverse events are discussed., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 The Korean Society of Radiology.)

Zinner syndrome (ZS) is a rare congenital malformation due to abnormal development of the urogenital tract. It is caused by a growth failure of the distal part of the Müllerian duct in early embryogenesis. It is characterised by the triad of unilateral renal agenesis, ipsilateral seminal vesicle cyst and ipsilateral ejaculatory duct obstruction. Over the years, several cases have been reported in the literature since the initial report by Zinner in 1914. This syndrome is frequently misdiagnosed because it may present different patterns and the symptoms may be not specific. In this paper, we present two patients with two different patterns of presentation of Zinner syndrome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The knowledge of periprostatic nerve fiber (pNF) is still incomplete by means of conventional MRI. The purpose of our study was to demonstrate if DTI imaging is able to depict anatomical features of pNF., Methods: For this retrospective study, fifty-six patients (mean age 63.5 years), who underwent 1.5-T prostate MRI, including 32 directions DTI, were enrolled between October 2014 and December 2018. ANOVA test and Student's t-test were performed between the mean values of the number, FA values, and fiber length of pNF between base and mid-gland, mid-gland and apex, base and apex, right and left side, and anterior and posterior face of the prostate. A qualitative analysis was performed to detect the main orientation of pNF through a colorimetric 3D tractographic reconstruction., Results: The number of pNF showed a decrease from the base (322) to mid-gland (248) and apex (75) (p < 0.05). The FA values were higher at base and mid-gland (0.435 and 0.456) compared to the apex (0.313) (p < 0.05). The length of pNF was higher at apex (13.4 mm) compared to base (11.5 mm) and mid-gland (11.7 mm) (p < 0.05). The number of pNF was higher on the posterior face compared to the anterior face at base (186 vs 137), (p < 0.001). The FA values were higher on the posterior face compared to the anterior face at base (0.452 vs 0.417), mid-gland (0.483 vs 0.429), and apex (0.42 vs 0.382), (p < 0.05). The length of the pNF was higher in the posterior (14.7 mm) than in the anterior face (12 mm) at apex (p < 0.001). The main orientation of pNF was longitudinal in all patients (56/56, 100%)., Conclusions: DTI imaging has been demonstrated able to depict anatomical features of pNF.

Biopsy proven Gleason score is essential to decide treatment modalities for prostate cancer, either surgical (radical prostatectomy) or non-surgical (active surveillance, watchful waiting, radiation therapy and hormone therapy). Several studies indicated that biopsy proven Gleason score may underestimate Gleason score at radical prostatectomy, hence we aimed to calculate the minimum length of biopsy cores needed to have Gleason score agreement. We evaluated 115 prostate cancer patients who underwent multiparametric magnetic resonance/transperineal ultrasonography fusion biopsy and subsequently, radical prostatectomy. Biopsy proven Gleason score was consistent with Gleason score at subsequent radical prostatectomy in 82.6% of patients, while in 17.4% of patients, Gleason score was higher at radical prostatectomy. Gleason score agreement showed a strong direct association with a ratio > 0.05 between the total volume of biopsies performed in tumor area and the volume of the corresponding tumor at radical prostatectomy. A significant association was also found with a ratio ≥ 0.0034 between the tumor volume in the biopsy and the volume of the corresponding tumor at radical prostatectomy and with a ratio ≥ 0.086 between the tumor volume in the biopsy and the total volume of biopsies performed in the tumor area. These results could be exploited to calculate the minimum length of biopsy cores needed to have a correct Gleason score estimation and therefore be used in fusion targeted biopsies with volume adjustments.

Purpose: To evaluate the role of DTI (with fibretracking) and T2-weighted imaging (T2-WI) used together for predicting extra-capsular extension in patients with localized prostate cancer., Method and Materials: Thirty-six patients with biopsy-proven diagnosis of prostatic neoplasia performed MRI and underwent radical prostatectomy. Histopathological analysis showed ECE in 15/36 and capsule sparing in 21/36. By means of T2-WI, ECE was evaluated in a qualitative manner, according to PI-RADS v.2 (two groups with low and high risk of ECE); sensitivity and specificity were calculated for both groups. We performed a quantitative analysis on two tractographic parameters, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) and computed the ratio between the lesion quadrant and its contralateral (L/H ratio). We compared L/H ratios of patients with and without ECE; ROC analyses were performed to determinate ECE cut-off values of tractographic parameters. These cut-off values were used in association with T2-WI to reassess patients and to evaluate whether specificity and sensitivity of ECE detection change., Results: T2-WI showed a sensitivity of 80% and a specificity of 71% in detection of ECE. Tractography displayed a significant difference in L/H ratio for FA and ADC between patients with and without ECE. The simultaneous use of T2-WI and tractography revealed high sensitivity (100%) on patients with low suspect of ECE (on T2-WI) and high specificity (83%) on patients with high suspect of ECE (on T2-WI)., Conclusion: The morphologic component of T2-weighted imaging and functional aspect of DTI should be interpreted together to more successfully assess the presence of ECE.

The aim of this review is to illustrate normal computed tomography (CT) findings and the most common complications in patients who underwent pelvic exenteration (PE) for advanced, persistent or recurrent gynecological cancers. We review the various surgical techniques used in PE, discuss optimal CT protocols for postsurgical evaluation and describe cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications. The interpretation of abdominopelvic CT imaging after PE is very challenging due to remarkable modifications of normal anatomy. After this radical pelvic surgery, the familiarity with expected CT appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent PE.

Objective: To evaluate if diffusion tensor imaging (DTI) is able to detect changes of periprostatic neurovascular fibers (PNFs) before and after radical prostatectomy (RP), and if these changes are related to post-surgical urinary incontinence and erectile dysfunction., Methods: 22 patients (mean age 62.6 years) with biopsy-proven prostate cancer underwent 1.5 T DTI before and after RP. The number, fractional anisotropy (FA) values and length of PNFs before and after RP were compared using Student's t-test. Each patient filled out two questionnaires before and after RP, one for the evaluation of urinary continence (ICIQ-SF) and one for the evaluation of erectile function (IIEF-5). The ratios of the number, FA values and length of PNFs before and after RP (DTI B-A RATIOs) and the ratios between the scores obtained before and after RP for both ICIQ-SF and IIEF-2 (ICIQ-SF B-A RATIOs and IIEF-2 B-A RATIOs) were calculated to perform the Kendall's τ-test between them., Results: There was a statistically significant decrease of the number of PNFs after RP at base, midgland, and apex (p < 0.01) and of FA values at midgland (p < 0.05), with positive statistically significant correlation between the DTI B-A RATIOs of the number of PNFs and IIEF-2 B-A RATIOs (p < 0.05, ρ = 0.47)., Conclusion: DTI was able to detect that the decrease of the number of the PNFs after RP was statistically related to the post-surgical erectile dysfunction (p < 0.05). Advances in knowledge: This work demonstrates that: (1) 1.5 T MRI DTI is able to detect the decrease of the number and of the FA of PNFs after prostatectomy; (2) the decrease of the number of PNFs after prostatectomy is related with the post-surgical erectile dysfunction; (3) 1.5 T MRI DTI has demonstrated to be a reproducible technique in detecting the changes of the PNFs induced by RP, with high interobserver agreement.

Background: Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months., Patients and Methods: The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again., Results: After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001)., Conclusions: Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.

Objective: To determine the accuracy of MRI in differentiating mucinous cystoadenomas (MCAs) from mucinous cystoadenocarcinomas (MCACs) of the pancreas, with histopathological analysis as the reference standard, for better surgical planning., Methods: A total of 65 patients with histopathologically proven mucinous cystic neoplasms (MCNs) underwent MRI and surgery. Quantitative image analysis included size, septa and wall thickness and number of loculations. Qualitative image analysis included nodules; hyperintensity of the cystic content on T1 weighted images; compression and/or infiltration of adjacent vessels or organs; and metastases. A comparison between MCAs and MCACs was performed with Student's t-test for quantitative variables and with Fisher test for qualitative variables. Receiver operating characteristic analysis was performed to determine the accuracy in the differential diagnosis between MCAs and MCACs on the basis of a score system obtained by giving 1 point for each quantitative and qualitative variable observed in each patient., Results: At histopathology, 43 lesions were MCAs and 22 lesions were MCACs. A statistically significant difference was observed for size >7cm (<0.001), septa and wall thickness >3 mm (<0.0001), number of loculations >4 (<0.0001), nodules (<0.0001), hyperintensity of the cystic content on T1 weighted images (<0.0001), compression (<0.01) and/or infiltration (<0.01) of adjacent vessels or organs and metastases (<0.05). The best cut-off value to discriminate MCAs from MCACs was the presence of three features (p < 0.001), with an accuracy of 91%., Conclusion: MRI has an accuracy of 91% in the differential diagnosis between MCA and MCAC, helping in identifying forms that could undergo parenchyma-sparing surgery (MCAs), reducing post-surgical morbidity and mortality., Advances in Knowledge: In this study, the differentiation between MCAs and MCACs of the pancreas by means of MRI is addressed. The differential diagnosis allows selecting benign forms, susceptible of parenchyma-sparing surgery, with the advantage of reducing post-surgical morbidity and stratifying prognosis of MCNs.

Background/aims: Nutcracker esophagus and non-specific motility disorders are the main causes of non-cardiac chest pain (NCCP), with gastroesophageal reflux in 60% of cases. Achalasia and diffuse esophageal spasm are the most frequent anomalies described in patients with dysphagia. The goal of this study was to evaluate the occurrence of esophageal body and lower esophageal sphincter motor abnormalities in patients with dysphagia, NCCP, or both., Materials and Methods: This study is a retrospective analysis of 716 patients with NCCP and/or dysphagia tested between January 1994 and December 2010. 1023 functional studies were performed, 707 of which were esophageal manometries, 225 esophageal pH-meters, and 44 bilimetries. We divided the patients into three groups: group 1 was composed of patients affected with dysphagia, group 2 with NCCP and group 3 with NCCP and dysphagia., Results: Manometric anomalies were detected in 84.4% of cases (p<0.001). The most frequent esophageal motility alteration was achalasia (36%). The lower esophageal sphincter was normal in 45.9% of patients (p<0.001). In all 3 groups, 80.9%, 98.8%, and 93.8, respectively, of patients showed normal upper esophageal sphincter (p=0.005)., Conclusion: Our data differs from those of other studies because they were collected from and analyzed by a single tertiary level referral center by a single examiner. This could have eliminated the variability found in different hands and different experiences. The high percentage of symptomatic patients with non-pathologic esophageal motility pattern suggests an unclear origin of the disease, with possible neuromuscular involvement. As a result, these patients may need more-detailed diagnostic studies.

Aim: The aim of this retrospective study was to evaluate the impact of some risk factors on mortality in patients with Acute mesenteric ischemia (AMI)., Materials and Methods: From September 2003 to August 2011, 200 patients were operated on for bowel infarction at our unit: 149 were included in the study. For each patient, socio-demographic (gender and age) and clinical data (extent of necrosis, predisposing factors, WBC, LDH, comorbidities) were collected from patients' clinical records., Results: Of the 149 patients who underwent surgery, 57 (38.3%) died. A significantly higher mortality was associated with older age (79.9 versus 74.2 years, p < 0.01), higher LDH serum levels (695 versus 636 UI/L, p < 0.01), higher WBC (25.1 versus 22.5 X 103/mm3; p < 0.01), and extent of necrosis (p< 0.01). Otherwise, there was no correlation between comorbidities and mortality. Finally, multivariate analysis confirmed the significantly higher risk of death in patients with right colon and massive small bowel infarction (adjOR= 3.58; 95% CI=1.36-9.42) and intestinal perforation (adjOR=31.1; 95% CI=2.45-395.7)., Discussion: The results of our study suggest that the contribution of laboratory tests is limited, even if increased indexes of necrosis (such as LDH) associated with neutrophilic leukocytosis and metabolic acidosis, may help in defining diagnosis/ prognosis, though with low accuracy., Conclusions: The extent of necrosis and diagnostic delay seem to be the most important prognostic factors even after adjusting for confounding due to age, presence of comorbidities, and laboratory tests (LDH and WBC)., Key Words: Acute mesenteric ischemia, Mortality, Predictive factors.

Aim: Postoperative ileus has been considered an inevitable consequence of abdominal surgery. The aim of the study was to investigate the efficacy of same treatments in resolving postoperative ileus in various surgical approaches., Methods: A total of 360 patients underwent abdominal surgery, and was divided into four groups: videolaparoscopic cholecystectomy, laparotomic colo-rectal surgery, laparotomic Hartmann procedure, laparotomic gastric surgery. In each group, patients received different postoperative treatments: chewing gum, olive oil, both, and water. Each group was compared with a control group., Results: In patients who underwent videolaparoscopic cholecystectomy, median postoperative first passage of flatus and stool in the water group was 10 and 34 hours, respectively (P=0.006, P=0.021) and significantly earlier than in the control group (median postoperative 24 and 72 hours). Postoperative stay for the water group was lower (median day 1, 3rd interquartile 2.5) compared with control (median day 3; 3rd interquartile 7.0, P=0.01). In patients who underwent gastric surgery, median postoperative first passage of stool in the olive oil and chewing gum group was 48 hours, significantly earlier than in the control (median postoperative hour 120, P=0.04). Median time to first passage of flatus and stool was also earlier in the other groups compared with the control group, though this difference was not significant., Conclusion: Chewing gum, olive oil or both do not induce a relevant reduction of ileus after surgery. Water may be a safe and inexpensive option in reducing ileus. (United States National Institutes of Health, www.clinicaltrial.gov, number NCT01869231).

Unlabelled: Cystic lymphangioma is a rare benign tumor commonly located in the head or neck. Approximately 100 adult cases have been reported in the literature. The etiopathogenesis is unclear, though trauma has been suggested as one of the possible causes., Case Report: We report a case of recurrent cystic lymphangioma arising in an adult who had been successfully treated in our department, leading us to review the literature for a critical examination of our therapeutic choices and the pathological, clinical and therapeutic aspects. We performed a dissection of the cyst respecting anatomical structures.Three days after the surgery, the patient showed a recurrence under the previous site of the excision, We then decided to place a suction drainage under local anesthesia, The suction drainage was removed 25 days later.The post-operative course of the patient showed no signs of recurrence for twenty-four months., Discussion: Complete surgical excision is the treatment of choice in symptomatic patients. In our experience, postoperative suction drainage improved the outcome. Some authors have come out in favor of experimental, non-surgical methods, such as percutaneous sclerotherapy, which they claim offer the most promising results., Conclusions: In our experience, totally excision of the mass was the treatment of choice but, placing just one suction drainage for weeks for new recurrence resulted in a surprising outcome. In fact, recurrence usually appears within the first nine months in about 10-15% of patients.

Purpose: Graves' disease can induce alterations of the psychosocial well-being that negatively influence the overall well-being of patients. Among the current treatments, surgery has limited indications, and its impact on the health-related quality of life has not been well clarified. The aim of this study was to assess the impact of surgery on the quality of life., Methods: Fifty-seven patients who underwent total thyroidectomy for Graves' disease in our surgical unit between April 2002 and December 2009 were administered a questionnaire concerning four issues: organic alterations and clinical manifestations, neurovegetative system disturbances, impairment of daily activities, psychosocial problems. Patients were retrospectively questioned after thyroidectomy about the presence of these symptoms in both the pre and postoperative periods., Results: There was a significant improvement after surgery in all four areas. Organic manifestations and psychosocial problems had higher average improvements, as did some aspects of the neurovegetative system and difficulties in undertaking daily activities. There were no reports of a worsening of symptoms., Conclusions: Surgery resolved the hyperthyroidism in 100 % of cases, and was associated with a quality of life improvement of about 70 % in the patients. Surgery can therefore provide an immediate and effective resolution of Graves' disease, with benefits in health-related quality of life.

Purpose: The aim of our study was to follow the evolution over time of multifocal intraductal papillary mucinous neoplasms (IPMN) of the pancreatic duct side branches by means of magnetic resonance imaging (MRI)., Materials and Methods: A total of 155 patients with multifocal IPMN of the side branches were examined with MRI and MR cholangiopancreatography (MRI/MRCP). Inclusion criteria were patients with ≥2 dilated side branches involving any site of the parenchyma; presence of communication with the main pancreatic duct and previous investigations by MRI/MRCP within at least six months. Median follow-up was 25.8 months (range, 12-217). Patients with a follow-up period shorter than 12 months (n=33) and those with a diagnosis of multifocal IPMN of the side branches without any follow-up (n=14) were excluded from the study. The final study population thus comprised 108 patients. A double, quantitative and qualitative, analysis was carried out. The quantitative image analysis included: number of dilated side branches in the head-uncinate process and body-tail; maximum diameter of lesions in the head-uncinate process; maximum diameter in the body-tail; maximum diameter of the main pancreatic duct in the head and body-tail. The qualitative image analysis included: presence of malformations or anatomical variants of the pancreatic ductal system; site of the lesions (head-uncinate process, body-tail, ubiquitous, bridge morphology); presence of gravity-dependent intraluminal filling defects; presence of enhancing mural nodules., Results: At diagnosis, the mean number of cystic lesions of the side branches was 7.09. The mean diameter of the cystic lesions was 13.7 mm. The mean diameter of the main pancreatic duct was 3.6 mm. At follow-up, the mean number of cystic lesions was 7.76. The mean diameter of the cystic lesions was 13.9 mm. The mean diameter of the main pancreatic duct was 3.7 mm. Intraluminal filling defects in the side branches were seen in 18/108 patients (16.6%); enhancing mural nodules were seen in 3/108 patients (2.7%)., Conclusions: Multifocal IPMN of the branch ducts shows a very slow growth and evolution over time. In our study, only 3/108 patients showed mural nodules which, however, did not require any surgical procedure, indicating that careful nonoperative management may be safe and effective in asymptomatic patients.

Aim: To assess the efficacy of two widely used topical haemostatic agents: oxidised regenerated cellulose gauze and Collagen- Fibrinogen-Thrombin Patch in patients undergoing total thyroidectomy., Material of Study: This was a prospective, comparative, non-randomised study in which consecutive patients undergoing total thyroidectomy for benign disease received standard treatment with no haemostatic agent, cellulose gauze, or CFTP. Main outcome measures were drainage volume 24 hours after surgical procedure and the occurrence of post-operative complications (haematoma, seroma, surgical-site infection)., Results: Two hundred seventy-one (271) patients undergoing total thyroidectomy for benign disease: 65 received standard treatment, 60 received cellulose gauze and 146 received CFTP. Seroma was significantly reduced in the CFTP group compared with both the cellulose gauze group (p=0.006) and the standard treatment group (p=0.017). A significant reduction in drainage volume was also observed with CFTP compared with the other two groups (both p<0.001). Drainage volume was also significantly reduced with cellulose gauze versus standard treatment (p<0.001). No septic events were observed after application of CFTP. One hematoma was observed in the non haemostatic group., Conclusions: Both haemostatic agents reduced the amount of sero-hematic fluid during the first 24 hours post-surgery, with CFTP more effective than oxidized cellulose gauze. The use of haemostatic agents may increase the quality of thyroid surgery, improve patient comfort after surgery, and reduce hospital stay.

Objective: Swallowing and voice impairment are common after thyroidectomy. We evaluated short-term functional changes in esophageal motility in a series of patients who had undergone total thyroidectomy. Several studies have investigated these symptoms by means of interviews or questionnaires., Study Design: Prospective study., Setting: Academic research., Materials and Methods: Thirty-six consenting patients were prospectively recruited. Eligibility criteria were thyroid volume ≤ 60 mL, benign disease, and age between 18 and 65 years. Exclusion criteria were previous neck surgery, severe thyroiditis, hyperthyroidism, and pre- or postoperative vocal cord palsy. Voice impairment score, swallowing impairment score, lower esophageal sphincter pressure, esophageal motility, upper esophageal pressure, and coordination were evaluated preoperatively and 30 to 45 days after surgery., Results: Postoperative swallowing impairment (appearance or worsening of dysphagia) was found in 20% of patients and voice impairment in more than 30%. Both preoperative and postoperative esophageal motility were similar. All patients showed an average decrease of 25% in upper esophageal pressure, although the pressure was within normal range. Swallowing alterations were associated with upper esophageal incoordination (P < .03), and proximal acid reflux was significantly associated with voice impairment (P < .02)., Conclusion: After uncomplicated thyroidectomy, decreased upper esophageal pressure may explain both pharyngeal (dysphagia) and laryngeal (vocal impairment) exposure to acid. In the future, proton pump inhibitor therapy protocols should be evaluated.

Objectives: Patients with chronic constipation due to food hypersensitivity (FH) had an elevated anal sphincter resting pressure. No studies have investigated a possible role of FH in anal fissures (AFs). We aimed to evaluate (1) the effectiveness of diet in curing AFs and to evaluate (2) the clinical effects of a double-blind placebo-controlled (DBPC) challenge, using cow's milk protein or wheat., Methods: One hundred and sixty-one patients with AFs were randomized to receive a "true-elimination diet" or a "sham-elimination diet" for 8 weeks; both groups also received topical nifedipine and lidocaine. Sixty patients who were cured with the "true-elimination diet" underwent DBPC challenge in which cow's milk and wheat were used., Results: At the end of the study, 69% of the "true-diet group" and 45% of the "sham-diet group" showed complete healing of AFs (P<0.0002). Thirteen of the 60 patients had AF recurrence during the 2-week cow's milk DBPC challenge and 7 patients had AF recurrence on wheat challenge. At the end of the challenge, anal sphincter resting pressure significantly increased in the patients who showed AF reappearance (P<0.0001), compared with the baseline values. The patients who reacted to the challenges had a significantly higher number of eosinophils in the lamina propria and intraepithelial lymphocytes than those who did not react to the challenges., Conclusions: An oligo-antigenic diet combined with medical treatment improved the rate of chronic AF healing. In more than 20% of the patients receiving medical and dietary treatment, AFs recurred on DBPC food challenge.

Background: Herlyn-Werner-Wunderlich (HWW) syndrome is a very rare congenital anomaly of the urogenital tract involving Müllerian ducts and Wolffian structures, and it is characterized by the triad of didelphys uterus, obstructed hemivagina and ipsilateral renal agenesis. It generally occurs at puberty and exhibits non-specific and variable symptoms with acute or pelvic pain shortly following menarche, causing a delay in the diagnosis. Moreover, the diagnosis is complicated by the infrequency of this syndrome, because Müllerian duct anomalies (MDA) are infrequently encountered in a routine clinical setting., Cases Presentation: two cases of HWW syndrome in adolescents and a differential diagnosis for one case of a different MDA, and the impact of magnetic resonance (MR) imaging technology to achieve the correct diagnosis., Conclusions: MR imaging is a very suitable diagnostic tool in order to perform the correct diagnosis of HWW syndrome.

Meticulous dissection and accurate hemostasis are required in thyroid surgery. The authors recently performed a number of thyroidectomies using a new device that combines heat and pressure for sealing and cutting tissue. A prospective randomized trial was conducted on 98 patients subjected to total thyroidectomy for benign disease: 49 patients (group A) with the Starion tissue welding system and 49 (group B) with the clamp-and-tie technique. The 2 groups were comparable in mean age, gender, thyroidal volume (20-60 mL), incision length (<35 mm), and pathology. The authors evaluated operative time, postoperative serum calcemia, dosage and length of postoperative calcium and vitamin D treatment, drainage volume, hospital stay, and complications. Student's t test was used for quantitative variables; for categorical variables, the chi(2) test or Fisher's exact test, as appropriate, was used. The mean operative time was 53.8 +/- 6.1 minutes in group A and 63.2 +/- 8 minutes in group B (P < .0001). The difference in terms of postoperative calcemia was significant (group A: 8.35 +/- 0.39 mg/dL; group B: 8.08 +/- 0.39 mg/dL; P < .001). The duration of postoperative treatment with calcium and vitamin D was significantly different (group A: 4 days; group B: 5 days; P < .039). No significant difference in terms of postoperative complications was found. The new system reduced operative time and the duration of postoperative hypocalcemia, and there was minimal tissue necrosis and thermal spread. The reduction in duration of postoperative calcium and vitamin D treatment is also an indication of improvement in quality of the treatment.

Adaptive behavior in unicellular organisms (i.e., bacteria) depends on highly organized networks of proteins governing purposefully the myriad of molecular processes occurring within the cellular system. For instance, bacteria are able to explore the environment within which they develop by utilizing the motility of their flagellar system as well as a sophisticated biochemical navigation system that samples the environmental conditions surrounding the cell, searching for nutrients or moving away from toxic substances or dangerous physical conditions. In this paper we discuss how proteins of the intervening signal transduction network could be modeled as artificial neurons, simulating the dynamical aspects of the bacterial taxis. The model is based on the assumption that, in some important aspects, proteins can be considered as processing elements or McCulloch-Pitts artificial neurons that transfer and process information from the bacterium's membrane surface to the flagellar motor. This simulation of bacterial taxis has been carried out on a hardware realization of a McCulloch-Pitts artificial neuron using an operational amplifier. Based on the behavior of the operational amplifier we produce a model of the interaction between CheY and FliM, elements of the prokaryotic two component system controlling chemotaxis, as well as a simulation of learning and evolution processes in bacterial taxis. On the one side, our simulation results indicate that, computationally, these protein 'switches' are similar to McCulloch-Pitts artificial neurons, suggesting a bridge between evolution and learning in dynamical systems at cellular and molecular levels and the evolutive hardware approach. On the other side, important protein 'tactilizing' properties are not tapped by the model, and this suggests further complexity steps to explore in the approach to biological molecular computing.