Twinkle, twinkle little stone: an artifact improves the ultrasound performance!

AIMS: Ultrasound is a noninvasive method used for the diagnosis of urinary lithiasis. When the length of the stone is less than 5 mm, its detection may be difficult. The twinkling artifact (TwA) is an intense alternating color signal behind calcifications and stones in different organs. The aim of this paper was to evaluate the importance of the TwA in detecting kidney stones less than 5 mm in length. MATERIAL AND METHODS: We examined 230 patients with lumbar pain or a history of kidney stones. We excluded patients with stones larger than 5 mm. 174 patients corresponded to the inclusion criteria. We performed color Doppler ultrasound and we noticed the presence of the twinkling artifact. The gold standard for the diagnosis was either computed tomography (CT) scan, intravenous urography (IVU) or the spontaneous elimination of the stones. RESULTS: We found renal stones in 123 patients. The twinkling artifact was present in 113 cases and absent in the rest of 10 patients. In two patients the artifact was present but the stones were not confirmed by CT. The twinkling artifact had sensitivity, specificity, positive predictive value and negative predictive value of 99.12%, 90.91%, 99.12%, and 90.91% respectively. CONCLUSIONS: The twinkling artifact is a very useful color Doppler ultrasound tool for the detection of small urinary stones. We suggest the routine use of color Doppler in all suspicious cases in order to avoid unnecessary irradiating and expensive radiological methods.

Cerebral lesions of multiple sclerosis: is gadolinium always irreplaceable in assessing lesion activity?

PURPOSE: We aimed to identify imaging characteristics on conventional magnetic resonance imaging that could predict multiple sclerosis (MS) brain lesion activity without contrast media administration. MATERIALS AND METHODS: Magnetic resonance data sets of forty-two patients with relapsing-remitting MS who presented symptoms or signs suggestive of new disease activity were retrospectively reviewed. We classified the MS lesions into three types according to different patterns present on T2-weighted images and evaluated their relationship with the contrast uptake. Evolving aspects of each type of lesion were observed in 18 patients during a follow-up period ranging from nine to 36 months. RESULTS: On T2-weighted images, only the pattern consisting of a thin border of decreased intensity compared with the lesion's center and perifocal edema (Type II) reached diagnostic accuracy in terms of its relationship with gadolinium enhancement (P = 0.006). The sensitivity was 0.461, and the specificity was 0.698. In contrast, enhancement was not significantly related to the pattern consisting of a lesion center that was homogeneously brighter than its periphery (Type I) or less-hyperintense T2 focal lesions with either homogeneous or inhomogeneous center (Type III) (P > 0.05 for both). CONCLUSION: The assessment of MS lesion activity should include a careful evaluation of T2-weighted images in addition to contrast enhancement assessment. The presence of an accompanying peripheral thin rim of hypointensity on T2-weighted images related best with contrast enhancement and subsequent lesion activity and may represent an additional pattern for disease activity assessment when gadolinium examination is contraindicated or influenced by prior therapy.

Malignant transformation of adenomyoepithelioma of the breast by a monophasic population: a report of two cases and review of literature.

Two cases of adenomyoepithelioma of the breast with malignant transformation by monophasic population of cells are presented. The underlying benign adenomyoepithelioma with typical biphasic architectural pattern was identified and represented at least 30% of the tumor in each case. In both cases, malignant portion of tumor was composed of relatively uniform monophasic population of highly atypical cells. The malignant component in case 1 was positive for pan cytokeratin, myoepithelial markers, and basal-type cytokeratins and also focally positive for luminal-type of cytokeratins, but negative for hormone receptors (estrogen and progesterone) and HER-2/neu protein overexpression. The malignant component in case 2 was positive for spectrum of myoepithelial markers but negative for luminal cytokeratins, hormone receptors and HER-2/neu protein overexpression. The bilinear immunophenotype in the case 1 suggests that the malignant tumor may have developed from precursor multipotent cells that can differentiate into both luminal epithelial and myoepithelial cells, although malignant component in case 2 appears to be the of pure myoepithelial phenotype.

[Prognostic factors in breast cancer]. / Factori prognostici în cancerul mamar.

UNLABELLED: Survival in breast cancer is determined by many factors, their influence is different. The aim of the study is to assess the impact on survival of various prognostic factors. MATERIAL AND METHODS: We studied a total of 198 cases of histologically confirmed breast cancer patients, and we evaluated the impact of prognostic factors on survival. RESULTS: The most important factor influencing survival is the preset of axillary metastasis(p: 0.0001). Other important prognostic factors are: tumor size (p: 0.003), tumor grading (p: 0.0025), N stage (p: 0.0001.) lymphovascular invasion (p 0.0005) and Nottingham Prognostic Index (p: 0.0109). The factors with no impact on survival were: histological type (p: 0.82), number of lymph nodes affected(p: 0.23), tumor necrosis(p: 0.49) and inflammatory infiltration (p: 0.2). CONCLUSIONS: The most important prognostic factors are: axillary metastasis followed by tumor grading, NPI and lymphovascular invasion.

Multiple renal infarctions due to thromboembolism. Importance of ultrasound in diagnosis. Case report.

We present the case of a woman with known risk factors for embolism with multiple kidney infarctions. She was admitted with left renal colic, discrete hematuria and subfebrility. She was under acenocumarolum treatment but without efficient anticoagulation. Ultrasound performed at the emergency room revealed smaller right kidney (congenital hypoplasia) and moderately enlarged left kidney with hypoechoic areas in the parenchyma. Computer tomography scan with contrast agent revealed multiple avascular areas within the left kidney. Evolution was favorable after efficient anticoagulation. Contrast enhanced ultrasound performed two weeks later revealed only one residual avascular area. Differential diagnosis was made with acute pyelonephritis, cholesterol embolism and acute tubular necrosis in a diabetic patient.

The evaluation of the sentinel lymph nodes status in breast carcinoma using microscopic, immunohistochemical and cytomorphometric methods in order to establish new stadializations and therapeutic schemes.

The state of axillary lymph nodes represents the most important prognostic parameter in patients with breast carcinoma. The biopsy and examination of sentinel lymph nodes, the former one containing metastases originating in mammary carcinoma, allows a better stadialization of the tumor but also the avoiding of the extirpation of the axilla, associated with a series of complications and high costs of hospitalization. In establishing the tumoral prognosis, not only the diameter but also the localization of the metastasis in the lymph nodes is utterly important. The evaluation of the metastases was carried out through the serial examination of the sentinel lymph node correlated to immunohistochemical examinations with AE1/AE3. Of the 570 patients with breast carcinoma evaluated in this research, 250 had macrometastases, 93 micrometastases, only 23 had isolated tumor cells, and in the case of 204 no metastases were found. The technique of computerized cytomorphometry allowed a better evaluation of the diameter and localization of the metastases in the lymph nodes than the examination through optical microscope. The tumoral prognosis in the case of patients with macrometastases is poorer than that of patients with micrometastases. The patients in whom only the presence of isolated tumoral cells was demonstrated have a similar prognosis with those who do not have metastases. As far as the localization of micrometastases in the sentinel lymph nodes is concerned, those with a subcapsular localization are associated with a poorer prognosis than those with an intraparenchymatous localization. As well as this, the subcapsular localization of micrometastases was also associated with the diameter of the primary tumor extending between 2-5 centimeters, a high microscopic grade, the presence of lymph vascular emboli and microscopic type of the primary tumor associated with poor prognosis. On the other hand, the presence of isolated tumoral cells was associated with tumors of a small diameter lacking the presence of lymph vascular emboli and with a low microscopic grade. All these data are essential in establishing the therapeutic management of the patients with breast carcinoma; consequently, we recommend their inclusion in future stadializations of this lesion and the evaluation of tumoral prognosis.

Two-step hepatectomy with right portal branch ligature for a right lobe metastasis.

Hepatic resection is the only treatment with possible curative effect both for primary and secondary tumors. An increase of the rate of resectability for tumors considered inoperable at first, and a decrease of the postoperative morbidity and mortality can be realized by right portal branch ligature and two-step hepatectomy. We would like to present the case of a patient with left bowel cancer with a hepatic metastasis. Right portal branch ligature was performed which was followed by systemic postoperative chemotherapy. The right portal branch occlusion was followed by right lobe atrophy and left lobe hypertrophy, confirmed by CT scanning. Three months after the portal occlusion the patient underwent a right lobe hepatectomy. The postoperative evolution was favorable, eight days of hospitalization were necessary. The portal branch ligature can be made in several cases of hepatic tumors to increase the resectability rate.

[Telescopic anastomosis in colorectal surgery]. / Anastomoza prin telescopare in chirurgia colonului.

UNLABELLED: The most frequent postoperative morbidity and mortality in the colorectal surgery is caused by the failure of the anastomosis. On the base of the statistics the postoperative mortality caused by the failure of the anastomosis can rise up to 20%. In the last decade a lot of types of anastomoses was initiated, for example: telescopic anastomosis, mechanical anastomosis with stapler, anastomosis with a bio-fragmentary ring. In the technique of the telescopic anastomosis, introduced from the beginning of 20th century, many changes had made. The experimental and the operative results shown that the telescopic anastomosis is a secure, fast and cheap procedure in the surgery of the colon. CONCLUSIONS: the telescopic anastomosis is applicable also in emergency, with a short septic time , easy procedure and doesn't need special instruments.

[The surgical treatment of the parastomal hernia using prolene mesh]. / Tratamentul chirurgical a eventratiilor parastomale cu plasa prolen.

UNLABELLED: Parastomal herniation is a frequent complication in enterostomy. The therapeutic strategy consists in three approaches: local fascial repair, relocation of the stoma, local repair of the parietal defect using nonabsorbable meshes. In our clinic between 1997-2002 we used monofilament meshes placed in sublay position at four patients with parastomal herniation. At three patients we used midline laparotomy placing the mesh round the colostomy on preperitoneal space, after preparing the hernia sack. The size of the mesh goes beyond the parastomal parietal defect with 3-5 cm. At the fourth patient we placed the mesh round the preperitoneal segment of the colon using a combined intraperitoneal and parastomal procedure, the size of the mesh going beyond parastomal parietal defect in this case too with 3-5 cm. The immediately and delayed results was favorable. CONCLUSIONS: The parastomal herniation's surgical repair applying prolen mesh can be a therapeutic alternative with good results.