Flow cytometry significantly improves the diagnostic value of fine needle aspiration cytology of lymphoproliferative lesions of salivary glands.

OBJECTIVE: Lymphoid proliferations of the salivary glands can be either reactive or malignant. Diagnosis based solely on fine needle aspiration (FNA) cytology may be troublesome in view of the difficulty in distinguishing low-grade B-cell and mucosa-associated lymphoid tissue (MALT) lymphomas from reactive lymphoid proliferations. We report our experience with FNA cytology combined with flow cytometry (FC) immunophenotyping for the diagnosis of lymphoproliferative processes affecting the salivary glands. METHODS: Sixty-one FNA specimens, obtained from salivary glands over a 10-year period, were analysed by cytology and FC. The results were correlated with histological follow-up if available. RESULTS: A diagnosis of lymphoma was given in 37 of 61 (61%) specimens; 22 of 61 (36%) specimens were considered as benign/reactive or non-lymphomatous processes; two of 61 (3%) specimens were considered as suspicious for lymphoma on cytological analysis and negative on FC. Histological control was available in 23 malignant, four non-lymphomatous and one cytologically suspicious case. Data obtained by the combination of cytology and FC were confirmed in all but one case: the case suspicious on cytology received a histological diagnosis of carcinoma. Four of seven cases with small populations of clonal cells (less than 15%) were histologically confirmed as lymphoma, whereas two remain under surveillance and one was reactive. Correlation with histological data showed a sensitivity of 100% and a specificity of 83% for the combination of cytology and FC. CONCLUSIONS: FC is fundamental for the diagnosis of lymphoproliferative lesions of the salivary glands. It may solve cytologically suspicious cases and detect the presence of neoplastic B or T cells. This combined approach reduces the time to therapy and may prevent unnecessary surgical biopsies.

Diagnostic role of colour Doppler US at 1-year follow-up after orthotopic liver transplantation.

PURPOSE: This paper discusses the role of colour Doppler ultrasound (CDUS) in the midterm follow-up of patients after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: We retrospectively studied 134 patients--102 men and 32 women, age range 21-68 years--who underwent liver transplantation between May 2006 and April 2007. In the first week after OLT, CDUS examination was performed daily in patients with anastomoses at a high risk of thrombosis, and on the basis of clinical and laboratory findings in other patients. After discharge, follow-up was performed 1, 3, 6 and 12 months after transplantation. Any new parenchymal focal lesion was studied by computed tomography (CT) and, where needed, biopsy. RESULTS: CDUS identified the following complications: 22 biliary (B), nine vascular (V) and seven focal lesions (FL). Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were, respectively: 79.2%, 97.3%, 86.3%, 95.5%, 94% (B), 100%, 99.2%, 88.9%, 100%, 99.3% (V) and 100%, 96.9%, 42.8%, 100%, 97% (FL). CDUS also showed 16 blood collections and eight suspected biliary collections (four of which were confirmed by percutaneous puncture). CONCLUSIONS: CDUS is an essential diagnostic tool in the follow-up of OLT. An early diagnosis of complications can improve graft integrity and patient survival.

Ectopic secretion of LH by an endocrine pancreatic tumor.

Ectopic production of biologically active glycoprotein hormones other than hCG has been reported in exceptional cases. A 61-yr-old man came to our Unit complaining of weakness, fatigue and reduced libido with erectile dysfunction. There was also a history of polycythemia, known for about 10 yr and never further investigated. The physical examination showed acne and redness of facial skin and upper chest; no other significant abnormalities were detected. Serum levels of LH were very high, whereas alpha-subunit and hCG were only slightly increased. Testosterone and 17beta-estradiol levels were increased too. Abdominal computed tomography (CT) scan revealed a large hypervascularized mass within the pancreatic tail, which was surgically removed by distal splenopancreatectomy. Diffuse immunoreactivity for LH was detected in more than 70% of the tumor cells. The alpha-subunit was also positive, while chorionic gonadotropin had only a focal reactivity. Reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern Blot analysis confirmed the synthesis of LH by the tumor. Four weeks after surgery, serum levels of LH, alpha-subunit, testosterone, hCG and 17beta-estradiol were all undetectable. The redness of facial skin and upper chest had disappeared, but libido was still reduced. At a further control, 3 months after surgery, serum levels of LH, FSH, hCG, alpha-subunit and 17beta-estradiol were all within the normal range, as well as hemoglobin concentration and the red blood cells count. Testosterone was slightly below normal, but the patient reported an increase of libido. This is an unusual case of ectopic secretion of LH from an endocrine tumor of the pancreas.

CT-MRI image fusion for delineation of volumes in three-dimensional conformal radiation therapy in the treatment of localized prostate cancer.

The objective of this study was to assess the utility of CT-MRI image fusion software and compare both prostate volume and localization with CT and MRI studies. We evaluated the differences in clinical volumes in patients undergoing three-dimensional conformal radiation therapy for localized prostate cancer. After several tests performed to ensure the quality of image fusion software, eight patients suffering from prostate adenocarcinoma were submitted to CT and MRI studies in the treatment position within an immobilization device before the start of radiotherapy. The clinical target volume (CTV) (prostate plus seminal vesicles) was delineated on CT and MRI studies and image fusion was obtained from the superimposition of anatomical fiducial markers. A comparison of dose-volume histograms relative to CTV, rectum, bladder and femoral heads was performed for both studies. Image fusion showed a mean overestimation of CTV of 34% with CT compared with MRI. Along the anterior-posterior and superior-inferior direction, CTV was a mean 5 mm larger with CT study compared with MRI. The dose-volume histograms resulting from CT and MRI comparison showed that it is possible to spare a mean 10% of rectal volume and approximately 5% of bladder and femoral heads, respectively. This study confirmed an overestimation of CTV with CT images compared with MRI. Because this finding only allows a minimal sparing of organs at risk, considering the organ motion during each radiotherapy session and the excellent outcomes of prostate cancer treatment with CT based target identification, we are still reluctant to reduce the CTV to that identified by MRI.

Gonadotroph cell pituitary adenomas in males.

BACKGROUND: Considered exceptional in the past, gonadotroph cell pituitary adenomas account for 3.5-6.4% of total surgically excised pituitary adenomas when examined with immunospecific staining. The aim of this study was to describe the clinical, hormonal, radiological and immunohistochemical features, the management and the follow-up of our patients with gonadotroph adenoma. METHODS: In this retrospective study we describe 14 male subjects aged 19-70 yrs affected by gonadotroph cell pituitary adenomas; the patients were studied by hormonal, radiological and immunohistochemical investigations and followed up for 3-13 yrs by ambulatory and/or hospitalized care. RESULTS: Visual impairment and/or decreased libido and erectile dysfunction were the symptoms at presentation. Increased serum gonadotropin concentrations were shown in 3 patients. Reduced levels of testosterone were present in 9 patients, and normal in the remainder. At diagnosis all patients had pituitary macroadenomas, with wide extrasellar extension in 12. All patients underwent trans-sphenoidal surgery and immunohistochemical staining of surgically excised specimens showed the presence of gonadotroph and alpha-subunit cells in all pituitary adenomas. After surgery 3 patients had clear radiological evidence of normal pituitary; in the others a doubtful MRI picture or a residual adenomatous tissue were present. In the patients who did not undergo radiotherapy immediately after surgery, a regrowth of tumoral tissue was shown in 1-10 yrs. CONCLUSIONS: We stress the importance of a close follow-up of patients with gonadotroph adenomas after surgery, and we raise the question of whether radiotherapy may be useful for avoiding any further adenomatous regrowth.

[Tridimensional ultrasonography. First clinical experience with dedicated devices and review of the literature]. / Ecotomografia tridimensionale. Prime esperienze cliniche con apparecchiatura dedicata e revisione della letteratura.

PURPOSE: We report our preliminary clinical experience with three-dimensional ultrasound (3D US) in abdominal and small parts imaging, comparing the yield of 3D versus 2D US and through a literature review. MATERIAL AND METHODS: We used a Tomtec Echo-Scan 3.1 connected to a Philips P 700 unit with a 3.5 MHz convex probe and to a Toshiba SSA-340 A (equipped with power Doppler) with a 3.5 MHz convex and a 7.5 MHz linear probes. The system consists of: a) a workstation (166 MHz Intel Pentium, 128 Mbytes RAM, 520 Mbytes hard disk, 1.3 Gbyte Magneto-Optical drive); b) a spatial location system (3D Freehand Scanning) whose sensor, attached to the probe, provides spatial coordinates for each US scan in an electromagnetic field created by a transmitter; the software can thus correctly stack 2D US images to make 3D reconstructions of anatomical structures. The technical steps are: 1) setting; 2) image acquisition; 3) image processing and 3D rendering using surface or volume modes; 4) image archiving. 2D US was performed on 50 subjects, namely 20 volunteers and 30 patients with different pathologic conditions and 3D reconstructions were obtained from the best US images. We evaluated which anatomical structures and pathologic conditions are best suited for 3D rendering. RESULTS: The best 3D images were obtained from anatomical structures and pathologic conditions with a liquid content (i.e., bladder and gallbladder; cysts), or those adjacent to them (i.e., uterus and prostate). Major limitations were encountered in the assessment of the parenchyma of liver, kidneys, pancreas, thyroid, testis and breast, due to intrinsic texture low contrast, while intraparenchymal liquid structures (i.e., vessels, urinary cavities) and structures surrounded by liquid (i.e., hydrocele, ascites) were better demonstrated. DISCUSSION: The system permits accurate spatial location, and therefore stacking, of each US scan; this provides good-quality 3D images with fewer artifacts. The system can be connected to any existing US unit and to many kinds of probes. Incorrect processing or rendering may worsen 3D image quality and thus anatomical reconstructions; other drawbacks may come from difficult stacking of reconstructed images or limited field of view. Our personal experience and the review of 3D US literature indicate that the system may be used for the following clinical applications: anatomical assessment of lesions for minimally invasive treatment; targeting areas of interest and adjacent structures during radiotherapy; lesion volume studies during therapy; 3D vascular mapping with power Doppler; 3D reconstructions by intraluminal approach; real-time 3D scanning for US guidance during minimally invasive procedures. CONCLUSIONS: Our preliminary experience suggests that technological progress will soon lead to a widespread use of 3D US and its applications.

Embolization of a complete prosthetic aortic valve to the abdominal aorta. Long-term survival after surgery.

We describe a case of complete embolization of an aortic valve prosthesis to the abdominal aorta. To our knowledge, this patient is the 1st asymptomatic long-term survivor of this catastrophic event. In such cases, we recommend emergency surgery on the basis of echocardiographic results alone. Delay for more complete diagnostic evaluation is not warranted.

Naltrexone must not be considered a real therapy in functional hypothalamic amenorrhea. The results of a double blind controlled study.

Endogenous opioids exert a tonic inhibitory control on GnRH pulsatility at the hypothalamic level and it must be responsible for some hypogonadotropic hypogonadic syndromes such as functional hypothalamic amenorrhea (FHA). We treated 22 patients suffering from FHA with an oral anti-opioid drug, Naltrexone Hydrochloridrate (NH), 50 mg once a day or placebo, in a double blind controlled study. Six patients exhibited a regular resumption of their menstrual cycles (4 on placebo and only 2 on NH). There was an increase of 17BE2 in 3 of these 6 patients; progesterone levels did not change at all. Gynaecological echography demonstrated folliculogenesis in 4 of these 6 patients (only 1 on NH). The results show that NH is not a real therapy in patients suffering from FHA. Furthermore placebo, useful to the resumption of menstrual bleeding in 4 patients, underlines the importance of psychosomatic effects in the therapeutic management of FHA.

[Ultrasonic evaluation of primary hyperparathyroidism]. / Valutazione ecotomografica dell'iperparatiroidismo primitivo.

The authors evaluated the diagnostic reliability of echotomography in detecting parathyroid masses: 37 patients were studied with primary hyperparathyroidism, in four cases recurrent. They all underwent surgical ablation of the mass, identification of all glands, and biopsy of an apparently normal parathyroid. Echotomography was accurate in 91.4% of cases: it identified 27 out of 39 pathological glands (sensibility 69.2%) and gave no false-positive results (specificity 100%). Since parathyroid is often ectopic, oblique scans are suggested, i.e. of jugulum while the patient is swallowing. Such scans were always used in our study, in order to identify lesions even in case of "difficult" locations, such as the superior mediastinum.

[Disorders of heart rhythm during urography studied with Holter monitoring. Comparison of ionic and non-ionic contrast media]. / Le turbe del ritmo cardiaco in corso di urografia studiate con monitoraggio Holter. Raffronto tra mdc ionico e non ionico.

Given the disagreements in the literature over the extent of cardiac complications during urography it was decided to assess any arrhythmias following the injection of ionic and non-ionic contrast media and a placebo by means of 24 hours dynamic Holter monitoring. The results were subjected to meticulous statistical analysis and showed no connection between electrocardiographic alterations and the substance injected. The absence of statistical significance and the variability of the results suggest that alterations in the physiological parameters and/or arrhythmias arising during the administration of contrast media should be assessed with extreme caution.

[Magnetic resonance in the study of the adrenal glands]. / La risonanza magnetica nello studio dei surreni.

Current usage of MR in the clinical study of adrenal pathology is assessed with a review of the advantages and limitations of this new imaging technique and a critical analysis of data deriving both from the literature and from personal experience. The possibility of a multiplanar study offered by MR permits a more accurate anatomical-topographical definition of the adrenal masses though it is not yet capable of the tissue characterisation that would diagnose the nature of the lesion, though it can differentiate between inert adenomas and metastases.

[Diagnostic accuracy of sequential angio-urography with the spot-camera in clinical practice]. / Accuratezza diagnostica dell'angiourografia sequenziale (AUS) con spot-camera nella practica clinica.

In this perspective study the authors examined 57 patients to evaluate diagnostic accuracy of sequential angiourography (AUS) using spot-camera and image subtraction for the visualization of the vascular phase of the renal arteries. All the subjects underwent surgery or follow-up with other clinical and radiological methods. The results obtained with this technique, of low cost and simple execution, were satisfactory: accuracy 98%, sensitivity 100%, specificity 98%.