A novel nomogram predicting lymph node invasion among patients with prostate cancer: The importance of extracapsular extension at multiparametric magnetic resonance imaging.

PURPOSE: To develop a novel risk tool that allows the prediction of lymph node invasion (LNI) among patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND). METHODS: We retrospectively identified 742 patients treated with RARP + ePLND at a single center between 2012 and 2018. All patients underwent multiparametric magnetic resonance imaging (mpMRI) and were diagnosed with targeted biopsies. First, the nomogram published by Briganti et al. was validated in our cohort. Second, three novel multivariable logistic regression models predicting LNI were developed: (1) a complete model fitted with PSA, ISUP grade groups, percentage of positive cores (PCP), extracapsular extension (ECE), and Prostate Imaging Reporting and Data System (PI-RADS) score; (2) a simplified model where ECE score was not included (model 1); and (3) a simplified model where PI-RADS score was not included (model 2). The predictive accuracy of the models was assessed with the receiver operating characteristic-derived area under the curve (AUC). Calibration plots and decision curve analyses were used. RESULTS: Overall, 149 patients (20%) had LNI. In multivariable logistic regression models, PSA (OR: 1.03; P= 0.001), ISUP grade groups (OR: 1.33; P= 0.001), PCP (OR: 1.01; P= 0.01), and ECE score (ECE 4 vs. 3 OR: 2.99; ECE 5 vs. 3 OR: 6.97; P< 0.001) were associated with higher rates of LNI. The AUC of the Briganti et al. model was 74%. Conversely, the AUC of model 1 vs. model 2 vs. complete model was, respectively, 78% vs. 81% vs. 81%. Simplified model 1 (ECE score only) was then chosen as the best performing model. A nomogram to calculate the individual probability of LNI, based on model 1 was created. Setting our cut-off at 5% we missed only 2.6% of LNI patients. CONCLUSIONS: We developed a novel nomogram that combines PSA, ISUP grade groups, PCP, and mpMRI-derived ECE score to predict the probability of LNI at final pathology in RARP candidates. The application of a nomogram derived cut-off of 5% allows to avoid a consistent number of ePLND procedures, missing only 2.6% of LNI patients. External validation of our model is needed.

Breast MR with special focus on DW-MRI and DCE-MRI.

The use of magnetic resonance imaging (MRI) for the assessment of breast lesions was first described in the 1970s; however, its wide application in clinical routine is relatively recent. The basic principles for diagnosis of a breast lesion rely on the evaluation of signal intensity in T2-weighted sequences, on morphologic assessment and on the evaluation of contrast enhancement behaviour. The quantification of dynamic contrast behaviour by dynamic contrast-enhanced (DCE) MRI and evaluation of the diffusivity of water molecules by means of diffusion-weighted MRI (DW-MRI) have shown promise in the work-up of breast lesions. Therefore, breast MRI has gained a role for all indications that could benefit from its high sensitivity, such as detection of multifocal lesions, detection of contralateral carcinoma and in patients with familial disposition. Breast MRI has been shown to have a role in monitoring of neoadjuvant chemotherapy, for the evaluation of therapeutic results during the course of therapy. Breast MRI can improve the determination of the remaining tumour size at the end of therapy in patients with a minor response. DCE-MRI and DW-MRI have shown potential for improving the early assessment of tumour response to therapy and the assessment of residual tumour after the end of therapy. Breast MRI is important in the postoperative work-up of breast cancers. High sensitivity and specificity have been reported for the diagnosis of recurrence; however, pitfalls such as liponecrosis and changes after radiation therapy have to be carefully considered.

Intraobserver and interobserver variability in the calculation of apparent diffusion coefficient (ADC) from diffusion-weighted magnetic resonance imaging (DW-MRI) of breast tumours.

PURPOSE: This study evaluated intraobserver and interobserver variability in the measurement of apparent diffusion coefficient (ADC) values in breast carcinomas. MATERIALS AND METHODS: Twenty-eight patients with solid breast lesions >10 mm underwent conventional contrast-enhanced magnetic resonance imaging (MRI) and diffusion-weighted MRI (DW-MRI). Two observers (expert and trainee) segmented the lesion from the surrounding breast tissue on DW images with high b-value (1,000 s/mm(2)). This analysis was repeated by the expert reader after 6 months. Volumes were analysed to obtain mean, median and standard deviation (SD) of the ADC values. Interobserver and intraobserver variation was analysed using the Bland-Altman graph. RESULTS: All lesions were breast carcinomas, with a mean ADC value of 1.07 × 10(-3) mm(2)/s. The mean of the differences was 0.012 × 10(-3) mm(2)/s, corresponding to an intraobserver variability of 1.1% (limits of agreement: -5%/+8%). The mean interobserver difference was 0.022 × 10(-3) mm(2)/s, corresponding to an interobserver variability of 2% (limits of agreement: -9%/+14%). CONCLUSIONS: We found a low intraobserver and interobserver variability in calculating ADC in breast carcinomas, which supports its potential use in routine clinical practice.

DW-MRI of the urogenital tract: applications in oncology.

Diffusion-weighted magnetic resonance imaging (DW-MRI) appears to hold promise as a non-invasive imaging modality in the detection of early microstructural and functional changes of different organs. DW-MRI is an imaging technique with a high sensitivity for the detection of a large variety of diseases in the urogenital tract. In kidneys, DW-MRI has shown promise for the characterization of solid lesions. Also in focal T1 hyperintense lesions DW-MRI was able to differentiate hemorrhagic cysts from tumours according to the lower apparent diffusion coefficient (ADC) values reported for renal cell carcinomas. Promising results were also published for the detection of prostate cancer. DW-MRI applied in addition to conventional T2-weighted imaging has been found to improve tumour detection. On a 3 T magnetic resonance unit ADC values were reported to be lower for tumours compared with the normal-appearing peripheral zone. The combined approach of T2-weighted imaging and DW-MRI also showed promising results for the detection of recurrent tumour in patients after radiation therapy. DW-MRI may improve the performance of conventional T2-weighted and contrast-enhanced MRI in the preoperative work-up of bladder cancer, as it may help in distinguishing superficial from muscle invasive bladder cancer, which is critical for patient management. Another challenging application of DW-MRI in the urogenital tract is the detection of pelvic lymph node metastases. As the ADC is generally reduced in malignant tumours and increased under inflammatory conditions, reduced ADC values were expected in patients with lymph node metastases.

Perfusion CT in solid body-tumours. Part II: Clinical applications and future development.

Perfusion computed tomography (CTP) has shown great potential in diagnosing tumours and evaluating and predicting treatment response and has been the subject of numerous experimental and clinical studies. Its increasing availability and simplicity allow it to be performed alongside morphological imaging to complete the evaluation of neoplastic lesions. The aim of this paper is to describe our personal experience and review the literature on the applications of CTP in tumours of different body regions, with particular regard to fields of development for new research. Increased clinical application is desirable, especially in relation to a wider use of antiangiogenic drugs. Additional and ideally multicentre studies are necessary to define the role of this technique.

CT perfusion in solid-body tumours. Part I: Technical issues.

Functional imaging is becoming increasingly important in both research and clinical diagnostic radiology. Perfusion computed tomography (CTP) is a readily available and widely used tool that allows an objective measurement of tissue perfusion through the mathematical analysis of data obtained from repeated scans performed after administration of contrast agent. Recently, CTP has been increasingly used in the oncological field, being studied as a potential marker of neoplastic angiogenesis, which is one of the main targets of new tumour therapies. The aim of this paper was to provide the theoretical background and practical guidance for accurately performing CTP and interpreting results of examinations in solid-body tumours. CTP could be a valid tool for functional imaging of tumours if the acquisition technique is robust, if image and data analysis is accurate and if interpretation of results is adequately inserted within a clinical context.

CT perfusion in oncology: how to do it.

Robust technique and accurate data analysis are required for reliable computed tomography perfusion (CTp) imaging. Multislice CT is required for high temporal resolution scanning; 16-slice (or 64-slice) scanners are preferred for adequate volume coverage. After tumour localization, the volume of CTp imaging has to be positioned to include the maximum visible area of the tumour and an adequate arterial vessel. Dynamic scans at high temporal resolution (at least 1-s gantry rotation time) are performed to visualize the first pass of contrast agent within the tumour; repeated scans with low temporal resolution can be planned for late enhancement assessment. A short bolus of conventional iodinated contrast agent, preferably with high iodine concentration, is power injected at a high flow rate (>4 ml/s) in the antecubital vein. The breath-hold technique is required for CTp imaging of the chest and upper abdomen to avoid respiratory motion; free breathing is adequate for CTp imaging of the head, neck and pelvis. Using dedicated software, a region of interest (ROI) has to be placed in an adequate artery (as arterial input) to obtain density-time curves; according to different kinetic models, colour maps of different CTp parameters are generated and generally overlaid on CT images. Additional ROIs can be positioned in the tumour, and in all other parts of the CTp volume, to obtain the values of the CTp parameters within the ROI.

Intra- and interobserver agreement and impact of arterial input selection in perfusion CT measurements performed in squamous cell carcinoma of the upper aerodigestive tract.

BACKGROUND AND PURPOSE: CT Perfusion (CTP) has shown potential for assessing head and neck tumors. Our purposes were to assess the inter- and intraobserver agreement of CTP measurements and to investigate whether the selection of arterial input, ipsilateral versus contralateral to the tumor or left-versus-right external carotid artery (ECA), may affect CTP measurements in patients with squamous cell carcinoma (SCCA) of the upper aerodigestive tract. MATERIALS AND METHODS: Twenty-six patients with SCCA were enrolled in this prospective study and underwent CTP. Data were analyzed by 2 expert readers and by an inexperienced reader for interobserver agreement and by the 2 expert readers for intraobserver agreement assessment, by using the ECA ipsilateral to tumor site as arterial input. All 3 readers repeated their analysis by using the ECA contralateral to tumor site as arterial input. Inter- and intraobserver agreement was assessed by using the Bland-Altman approach; CTP measurements by using ipsilateral-versus-contralateral or left-versus-right ECA were compared by using the Wilcoxon signed rank test. RESULTS: The geometric mean of the ratios (95% limits of agreement) for inter- and intraobserver agreement ranged from 0.96 (0.75-1.23) to 1.00 (0.92-1.10) for blood flow (BF), from 0.88 (0.63-1.21) to 1.00 (0.88-1.14) for blood volume (BV), from 0.96 (0.64-1.44) to 0.98 (0.76-1.27) for mean transit time (MTT), and from 0.85 (0.41-1.76) to 1.14 (0.70-1.86) for permeability surface area product (PS). Significantly higher tumor PS and MTT for 2 readers and lower tumor BF for 1 of 3 readers were observed when the arterial input was placed in the left ECA. CONCLUSIONS: BF, BV, and MTT demonstrated higher inter- and intraobserver agreement than PS. The selection of arterial input, right-versus-left ECA, may determine changes in CTP measurements in patients with SCCA of the upper aerodigestive tract.

Local staging of penile cancer using magnetic resonance imaging with pharmacologically induced penile erection.

PURPOSE: This study was undertaken to compare the local staging of penile cancer by magnetic resonance imaging (MRI) combined with pharmacologically induced penile erection (PIPE), with clinical examination and pathology, and to verify whether MRI-PIPE led to changes in treatment planning in our cohort. MATERIALS AND METHODS: Thirteen patients with untreated penile cancer underwent local staging by clinical examination and MRI-PIPE obtained by intracavernosal injection of 10 mug prostaglandin E1. Transverse, sagittal and coronal T2-weighted and T1-weighted (before and after intravenous gadolinium injection) images were obtained with a four-channel phased-array coil. Tumours were treated according to stage, as defined by MRI-PIPE and clinical examination. Stage T1 tumours underwent laser ablation and stage T2 or T3 tumours partial or total penectomy. RESULTS: Twelve penile cancers were squamous cell carcinomas and one was a sarcoma. MRI-PIPE correctly staged 12 out of 13 patients, failing to detect one in situ carcinoma. Clinical examination correctly staged eight out of 13 patients, over-staging two patients (one Tis was over-staged as T1 and one T1 as T2) and under-staging three patients (two T2 as T1 and one T3 as T2). CONCLUSION: MRI-PIPE performed better than the clinical examination and changed treatment planning in three patients.

Heparin-bonded expanded polytetrafluoroethylene grafts for infragenicular bypass in patients with critical limb ischemia: 2-year results.

AIM: The use of prosthetic grafts in below-knee (BK) bypasses may be necessary in patients with no available autologous vein and critical limb ischemia not amenable to angioplasty. Such conduits, however, have generally yielded disappointing results. METHODS: A new heparin-bonded expanded polytetrafluoroethylene graft (Gore-Tex Propaten Vascular Graft) designed to provide resistance to thrombosis may be associated with decreased early graft failure and increased patency. This graft was implanted in 27 limbs (26 patients; 18 men; mean age 71 years; Rutherford class 4 to 6 disease) in a BK femoropopliteal and femorodistal location, without perioperative complications and with immediate graft patency. RESULTS: During a mean follow-up time of 24 months, 4 cases of thrombosis occurred, all at least 6 months postoperatively: 2 cases resolved after fibrinolytic treatment, 1 required surgical revision and in 1 case, amputation was required because of a delay in seeking treatment for thrombosis. Two patients died of cardiac disease during follow-up. The 2-year primary and secondary patency rates for the BK bypasses were 85% and 93%, respectively; the limb-salvage rate was 96%. CONCLUSION: These results are encouraging for a prosthetic graft, especially in the light of the severity of the vascular disease in the limbs treated.

Surgical 'damage control' treatment of a large retroperitoneal liposarcoma encasing a horseshoe kidney.

Damage control is a surgical strategy for severely compromised trauma patients based on speed control of life-threatening injuries that aims to rapidly resuscitate patients in an intensive care unit (ICU). We report on the use of such therapeutic strategy in a patient affected by a retroperitoneal sarcoma concomitant to a horseshoe kidney, a relatively rare anatomical malformation.

[Anaplastic carcinoma of the thyroid: diagnosis and treatment]. / Il carcinoma anaplastico della tiroide: inquadramento diagnostico e attuali possibilità terapeutiche.

Anaplastic thyroid carcinoma (ATC), accounting for 5% to 15% of primary malignant thyroid neoplasm, is one of the most aggressive solid tumors in humans. It is rapidly fatal, with a mean survival of 6 months after diagnosis. Multimodality treatment with surgery and/or external beam radiotherapy and chemotherapy are of fundamental importance for local control of disease and to enhance survival. Molecular biology studies have shown that ATC is associated with a p 53 mutation. ATC usually does not concentrate radioiodine or express thyroglobulin. It is essential to verify the diagnosis histologically because insular thyroid cancer, lymphomas, and medullary thyroid cancer are occasionally confused with undifferentiated neoplasms. Immunohistochemical study is helpful in establishing the diagnosis. Multimodal therapy and development of effective systemic chemotherapy agents would provide to result in improvements in survival although no single agent has yet been identified. Aggressive multimodality treatment regimens show promise in improving local control in patients with ATC. Survival rates however remain low. Despite intense applications of such integrated therapy, no standardized successful treatment protocol has yet been established.

Duodenal leiomyosarcoma.

Malignant stromal tumours of the duodenum are rare. The efficacy of surgical resection for duodenal leiomyosarcoma was assessed in 5 patients treated over an 11-year period, probably the largest series treated by a single surgeon. There were 3 women and 2 men with an age range of 27-52 years. Tumours were large (8.5-21 cm diameter) and partly cystic (4 cases). They arose from the second (2), third (2) and fourth parts of the duodenum. Resection was a major undertaking and comprised either partial duodenectomy (n = 4) or Whipple resection. Two patients required a right hemicolectomy in addition. Two patients with positive resection margins had adjuvant radiotherapy. Operative time ranged from 4.0 to 6.25 h and blood loss from 1.8 to 4.5 litres. Two patients developed complications: a transient low-output biliary fistula and an infected haematoma requiring percutaneous drainage. The 2 patients with incomplete resection died of recurrent disease at 3 and 15 months. The 3 survivors are free of disease at 24, 60 and 66 months. The results support a policy of aggressive resection despite the technical difficulties posed by these large and vascular tumours.

[The immediate reconstruction of the breast after a mastectomy for carcinoma. Our experience]. / Ricostruzione immediata della mammella dopo mastectomia per carcinoma. Nostra esperienza.

The authors surgically treated 281 consecutive women with breast cancer by breast conservation techniques (45.2%) or by mastectomy (38.8%), during a four-year period. Forty-five of these 281 patients (16%) were treated in the same period of time by mastectomy and immediate reconstruction (IR) of the breast. IR of the breast was performed by inserting a submuscular tissue expander at the same time of mastectomy (first stage of reconstruction). A second operation allowed the replacement of the expander with a prosthesis (second stage of reconstruction) and the simultaneous symmetrization of the contralateral breast (not always performed, however). In some cases nipple-areola complex was eventually reconstructed with a delayed surgical procedure (third stage of reconstruction). In the present paper the authors analyze the results and outline the advantages of IR. This easy and safe technique slightly increased the average operative time of a mastectomy, did not interfere with routine oncological follow-up, did definitely reduce patient's psychological trauma following mastectomy. The authors conclude that IR of the breast undoubtedly plays a major role in the so called "onco-plastic"" surgical management of breast cancer.

[Intracystic papillary carcinoma of the breast. Personal experience]. / Carcinoma papillare intracistico della mammella. Esperienza personale.

The Authors, on the base of three cases of intracystic papillary carcinoma of the breast, discuss about the diagnostic means and the modalities of treatment of such rare cancer. They stress the value of cytology by fine needle aspiration, which gives more detailed informations than mammography or ultrasonography. As far as the treatment concerns, the Authors, according to the data of the literature, suggest for this tumor, still at an "in situ" stage, a conservative surgical treatment such as a quadrantectomy or tumorectomy plus lymphadenectomy followed both by radiotherapy. Finally, they remark that the intracystic papillary carcinoma of the breast, mainly arising in old women (7th, 8th decade), was found within their series (two out of three) in young women in the 5th decade of life.

[Biliary surgery in the aged]. / La chirurgia biliare nell'anziano.

Between 1980 and 1995 in the Section of General and Oncological Surgery of the Department of Surgery of the University of Catania, on a total of 1715 biliary surgical procedures, 926 were performed on the elderly patients, 287 of which in emergency. Cholelithiasis (469 cases) morbidity 4.5%, mortality 0.4%; acute colecystitis, (247 cases) morbidity 21%, mortality 12%. Choledocholithiasis (122 cases) surgical treatment (51 cases) morbidity 21.6%, mortality 3.9%; endoscopic treatment (71 cases) morbidity 9.4%, mortality 0%. Neoplasms of the biliary tract (48 cases) diagnostic laparotomises 9, surgery (27 cases) morbidity 37%, mortality 11%; endoscopy (12 cases) morbidity 33%, mortality 0%. Acute obstructive cholangitis (34 cases), surgical drainage (9 cases) morbidity 55%, mortality 33%; endoscopic drainage (22 cases) morbidity 14%, mortality 4.8%; transhepatic drainage (3 cases) morbidity 66%, mortality 33%. Acute biliary pancreatitis (6 cases) surgery (2 cases) morbidity 100%, mortality 50%; endoscopy (4 cases) morbidity 25%, mortality 0%. This experience confirms that in elderly patients the treatment of choice for cholelithiasis is cholecystectomy and for acute colecystitis is early cholecistectomy. The preferred treatment of choledocholithiasis and severe acute biliary pancreatitis is endoscopic sphincterectomy. Endoscopic or radiologic drainages are the choice for acute biliary pancreatitis. In conclusion elderly patients with surgical biliary problems should be treated by a surgical, endoscopic and radiological team, taking in account all the available procedures.

[Treatment of the residual pancreatic stump after pancreatoduodenectomy: pancreatogastrostomy]. / Trattamento del moncone pancreatico residuo dopo duodenocefalopancreatectomia: la pancreatogastrostomia.

In the last few years more and more often the use of pancreaticogastrostomy (PG) for reconstruction after pancreatoduodenectomy (PD) has been reported. Aim of this paper is to review pertinent Literature and to try to define, on the basis of Authors' experience, the role this technique may have in reducing morbidity and mortality of PD. From January 1993 to June 1995 nine pancreaticogastrostomies were performed. Five patients had an adenocarcinoma of the papilla, two had a carcinoma of the distal choledochus and two had a carcinoma of the head of the pancreas. Major complications in this series were one operative death unrelated to PG and a massive bleeding from the gastric site of the anastomosis occurred 3 days after the operation, associated to a partial dehiscence of the anastomosis, treated surgically. Reported results after pancreaticogastrostomy seem to demonstrate a dramatic decrease in morbidity and mortality after PD, however, the real value of this technique will be established only after a greater clinical experience and, when possible, wider randomized prospective studies.

[Abdominal wall metastasis of pancreatic adenocarcinoma following laparoscopy]. / Metastasi della parete addominale da adenocarcinoma del pancreas in seguito a laparoscopia.

Wound recurrence after oncologic surgery is known since 1885, but nowadays we deal with a new problem after the rapid diffusion of laparoscopically assisted surgery and the 22 cases of trocar site metastases already reported in literature. Aim of this paper is to present a case of cutaneous seeding of adenocarcinoma of the pancreas, in two trocar sites, after laparoscopy for lithiasis of the gallbladder. Diagnosis of neoplasia was made intraoperatively for the presence of peritoneal and omental carcinomatosis; no cholecystectomy was performed and after biopsy and postoperative TC-scan a chemotherapeutic treatment was started. Five months after the operation parietal seeding was evident and treated with local radiotherapy; the patient died one month later for further dissemination of the disease. The etiopathogenesis of tumor recurrence in the abdominal scar tissue is still unknown, local (trauma) and general (decreased immunologic defences) factors could be responsible. The apparent higher incidence after laparoscopic surgery could presuppose the presence of further specific risks: more tissue manipulation (increased cellular exfoliation), contact between trocar and abdominal wall for the whole operative period (malignant cell carrier), pneumoperitoneum. In conclusion, as 50% of the patients with cutaneous metastases die within 6 months after the operation and almost nobody is still alive after 4 years, it is necessary to establish if a real additional risk, due to the laparoscopic procedure, exists to contrast eventual benefits of the mini-invasive procedure.

[Role of ultrasonography in abdominal surgical emergencies. Our experience]. / Ruolo dell'ultrasonografia nelle urgenze chirurgiche addominali. Nostra esperienza.

OBJECTIVE: To assess the sensitivity, specificity, and predictive value of ultrasonography in surgical patients in abdominal emergency in regard to the indication for immediate operation, delayed abdominal exploration, or conservative treatment. DESIGN: A retrospective study was conducted after consecutive sampling of 98 patients in a control trial. SETTING: The study was conducted at the University Hospital of Catania (Italy), which serves as a general community hospital. PATIENTS: All patients with acute upper abdominal pain or blunt abdominal trauma were eligible for the study. A total of 110 patients were observed from 1990 to 1994, after plain X-ray of the abdomen in 12 patient was diagnosed visceral perforation and they went for immediate operation. The remaining 98 patients were divided into two groups: acute upper abdominal pain (56 patients) and blunt abdominal trauma (42 patients). INTERVENTION: Ultrasonography in the emergency department. MAIN OUTCOME MEASURES: Conservative or operative treatment based on ultrasonographic and clinical findings. RESULTS. Ultrasonography showed a sensitivity of 100%, a specificity of 52.6%, a positive predictive value of 100%, and a negative predictive value of 100% in regard to the indication for surgery in cases of surgical abdominal emergency. CONCLUSION: Ultrasonography saves time and money, can be performed in the emergency department, shows high sensitivity and specificity, and is the method of first choice in the evaluation of blunt trauma.