Serendipitous Adrenal Hyperplasia in Patients Admitted to the Emergency Department for Suspected SARS-CoV-2 Infection is Linked to Increased Mortality.

BACKGROUND: Few data are available on adrenal morphology in patients with acute diseases, although it is known that endogenous glucocorticoids are essential for survival under stress conditions and that an adequate response is driven by activation of the hypothalamic-pituitary-adrenal (HPA) axis. AIMS: The aim of this study was to assess adrenal morphology in patients with acute disease compared with patients with non-acute disease. METHODS: This cross-sectional study included: 402 patients admitted to the emergency department (ED) for suspected SARS-CoV-2 infection (March-May, 2020) [main cohort]; 200 patients admitted to the ED for acute conditions (December 2018-February 2019) [control group A]; 200 outpatients who underwent radiological evaluation of non-acute conditions (January-February 2019) [control group B]. Chest and/or abdominal CT scans were reviewed to identify adrenal nodules or hyperplasia. RESULTS: In the main cohort, altered adrenal morphology was found in 24.9% of the patients (15.4% adrenal hyperplasia; 9.5% adrenal nodules). The frequency of adrenal hyperplasia was higher both in the main cohort (15.4%) and control group A (15.5%) compared to control group B (8.5%; p = 0.02 and p = 0.03, respectively). In the main cohort, 14.9% patients died within 30 d. According to a multivariate analysis, adrenal hyperplasia was an independent risk factor for mortality (p = 0.04), as were older age (p <0.001) and active cancer (p = 0.01). CONCLUSIONS: The notable frequency of adrenal hyperplasia in patients with acute diseases suggests an exaggerated activation of the HPA axis due to stressful conditions. The increased risk of short-term mortality found in patients with adrenal hyperplasia suggests that it may be a possible hallmark of worse prognosis.

Three-dimensional Virtual Models' Assistance During Minimally Invasive Partial Nephrectomy Minimizes the Impairment of Kidney Function.

Three-dimensional virtual models (3DVMs) are nowadays under scrutiny to improve partial nephrectomy (PN) outcomes. This report aims to analyze their impact on renal function preservation after minimally invasive PN. A total of 100 patients treated with minimally invasive PN with contrast-enhanced computed tomography from which a 3DVM was obtained, and having undergone baseline and 3rd month postoperative renal scans were prospectively enrolled and compared with a control group of 251 patients without 3DVMs. Weighted differential of pre- and postoperative renal scan-based effective renal plasmatic flow (b-WD ERPF) was calculated, according to the availability of 3DVMs and PADUA risk category. Multivariable logistic regression (MLR) models predicting a significant loss of renal function (LORF; ERPF drop >20%) were performed, overall and according to PADUA risk categories. The b-WD ERPF of the 3DVM group showed significantly lower LORF (-10%) than that of the control group (-19.6%, p = 0.02). In MLR, the availability of a 3DVM was found to be the only protective factor against a significant LORF (odds ratio [OR] = 0.3, p = 0.002). Moreover, after stratification as per tumor surgical complexity, this protective role was observed in both PADUA 8-9 and ≥10 category risk patients (OR = 0.3, p = 0.03 and OR = 0.1, p = 0.01). PATIENT SUMMARY: The drop in operated kidney function was significantly lower in surgeries assisted by three-dimensional virtual models (3VDMs), indicating that the availability of a 3VDM is the only protective factor against a significant functional damage.

Angiographic control versus ischaemia-driven management of patients undergoing percutaneous revascularisation of the unprotected left main coronary artery with second-generation drug-eluting stents: rationale and design of the PULSE trial.

BACKGROUND: The role of planned angiographic control (PAC) over a conservative management driven by symptoms and ischaemia following percutaneous coronary intervention (PCI) of the unprotected left main (ULM) with second-generation drug-eluting stents remains controversial. PAC may timely detect intrastent restenosis, but it is still unclear if this translated into improved prognosis. METHODS AND ANALYSIS: PULSE is a prospective, multicentre, open-label, randomised controlled trial. Consecutive patients treated with PCI on ULM will be included, and after the index revascularisation patients will be randomised to PAC strategy performed with CT coronary after 6 months versus a conservative symptoms and ischaemia-driven follow-up management. Follow-up will be for at least 18 months from randomisation. Major adverse cardiovascular events at 18 months (a composite endpoint including death, cardiovascular death, myocardial infarction (MI) (excluding periprocedural MI), unstable angina, stent thrombosis) will be the primary efficacy outcome. Secondary outcomes will include any unplanned target lesion revascularisation (TLR) and TLR driven by PAC. Safety endpoints embrace worsening of renal failure and bleeding events. A sample size of 550 patients (275 per group) is required to have a 80% chance of detecting, as significant at the 5% level, a 7.5% relative reduction in the primary outcome. TRIAL REGISTRATION NUMBER: NCT04144881.

Prostate cancer management at an Italian tertiary referral center: does multidisciplinary team meeting influence diagnostic and therapeutic decision-making process? A snapshot of the everyday clinical practice.

BACKGROUND: Multidisciplinary team (MDT) management decision-making process appears as an interesting tool to answer most aspects of prostate cancer (PCa) diagnosis and treatment, allowing a fairer choice of therapies. The aim of this study to prospectively investigate the impact on prostate cancer clinical management of the uro-oncology MDT meeting at an Italian tertiary referral center. METHODS: All cases discussed over an 18-months period at San Luigi Hospital uro-oncology MDT were prospectively evaluated for the impact of the MDT discussion on PCa clinical decision-making. Dilemma and management plan in the monodisciplinary visit before and/or after primary treatment were recorded. Subsequently, the MDT discussed the case and reached a consensus decision, which was also recorded. Changes in diagnostic assessment and patient management from pre- to post-MDT meeting were evaluated by a consultant urologist. RESULTS: Overall, 201 patients, of which 99, 81 and 21 with local, advanced and metastatic disease respectively, were selected for MDT evaluation. The most frequent reasons for MDT approach after either PCa diagnosis or primary treatment were metastatic disease or locally advanced disease/positive surgical margins/biochemical recurrence, respectively. Patients with local, advanced and metastatic disease had a significative change of diagnostic/therapeutic management in 23.2%, 46.9% and 33.4%, respectively (P<0.001). Multimodal treatment was recommended in 25.3%. CONCLUSIONS: The uro-oncology MDT meeting alters management plans in at least one-quarter of patients reaching almost 50% of cases in locally advanced disease.

The role of radiology in the evaluation of the immunotherapy efficacy.

In the last years, a great interest has arisen on immunotherapy for the treatment of advanced non-small cell lung cancer (NSCLC). Check-point inhibitor drugs are now considered clinical practice standard in different settings and their use is expected to increase significantly in the near future. As treatment options for lung cancer advance and vary, the different patterns of radiological response increase in number and heterogeneity. To correctly evaluate the radiological findings after and during these treatments is of paramount importance, both in the clinical and sperimental setting. In consideration of their peculiar mechanism, immunotherapies can determine unusual response patterns on imaging, that cannot be correctly evaluated with the traditional response criteria such as World Health Organization (WHO) and Response Evaluation Criteria in Solid Tumours (RECIST). Therefore, during these years, several response criteria [immune-related response criteria (irRC), irRECIST and iRECIST] were proposed and applied in clinical trials on immunotherapies. The aim of this review is to describe the radiological findings after immunotherapy, to critically discuss the different response criteria and the imaging of immune-related adverse events.

Radiofrequency ablation of thoracic tumours: lessons learned with ablation of 100 lesions.

PURPOSE: Our aim was to analyse the results of our first 100 radiofrequency ablation (RFA) procedures, of primary (nonsmall-cell lung cancers, NSCLC) and secondary (MTS) lung cancers to assess what lessons could be learned from our experience. MATERIALS AND METHODS: We analysed 100 lesions (mean size 23 mm) in 81 patients (25 NSCLC/56 MTS). On the basis of the clinical-radiological evolution, we analysed complete ablation (CA) versus partial ablation (PA) at the first computed tomography (CT) scan and during the follow-up (mean 23 months), time to progression (TTP) and survival. Possible predictive factors for local effectiveness and survival were sought. RESULTS: At the first CT scan CA was obtained in 88 %; the difference between the mean diameter of lesions achieving CA and PA was significant (20 versus 38 mm; p = 0.0001). A threshold of 30 mm (p = 0.0030) and the histological type (NSCLC 75 %/MTS 94 %; p = 0.0305) were also predictive of CA. A total of 18.4 % of the CA recurred (average TTP 19 months). Survival at 1, 2 and 3 years was 84.5, 65.4 and 51.5 %, respectively. The predictors of survival at 3 years were the coexistence of other MTS (p = 0.0422) and a diameter <20 mm (p = 0.0323), but not the local effectiveness of RFA. CONCLUSION: RFA for thoracic malignancies is accurate for lesions up to 30 mm, especially if metastatic; survival is more closely related to staging factors than to the local effectiveness of RFA.

T1a as the sole selection criterion for RFA of renal masses: randomized controlled trials versus surgery should not be postponed.

PURPOSE: To evaluate the long-term effects of radiofrequency ablation (RFA) of renal masses (RM) and compare them with surgery. METHODS: A total of 203 RM (193 malignant; mean size 30 mm) in 137 patients (95 male subjects; average age 64 years) underwent RFA. Complications and technique effectiveness were evaluated. Overall survival, cancer-specific survival, and disease-free survival were calculated (mean follow-up time 39 months). Predictors for complications, technique effectiveness, and survival were investigated. RESULTS: Seventeen (8.4 %) adverse events were recorded (2 % major complications). Exophytic development and smaller size were protective against adverse events. Complete ablation was obtained in 87 % RM (93 % ≤3 cm, 89 % ≤4 cm). T1a threshold was a positive predictor for complete ablation and central location a negative one. Three- and 5-year overall survival were 84 and 75 %; cancer-specific survival 96 and 91 %; and disease-free survival 80 and 75 %. Considering only the 79 patients with newly diagnosed renal cell carcinoma, T1a disease stage resulted a positive predictor for both overall survival (87 and 83 % at 3 and 5 years) and cancer-specific survival (100 % at 5 years). CONCLUSION: RFA of noncentral small RM is safe and effective, and it provides favorable long-term oncological outcomes. Selection criteria for RFA can also include T1a renal cell carcinoma in patients without surgical contraindications, even though randomized controlled trials are needed to establish the best treatment.

Radiofrequency thermal ablation (RFA) of hepatic metastases (METS) from breast cancer (BC): an adjunctive tool in the multimodal treatment of advanced disease.

PURPOSE: The study was done to analyse the results of a series of radiofrequency ablation (RFA) procedures performed on hepatic metastases (METS) from breast cancer in order to evaluate the clinical impact of this therapy. MATERIALS AND METHODS: We analysed 45 patients (mean age 55 years) with 87 METS (mean size 23 mm), in terms of adverse events (AE), complete ablation (CA) at initial follow-up assessment and during the subsequent follow-up (mean 30 months), time to progression, and survival. The correlation between local effectiveness and METS size was investigated. Possible predictors of 3-year survival, including the local effectiveness of RFA (complete ablation maintained at 1-year versus treatment failure) were analysed. RESULTS: Nine AE occurred (two major complications, 2.3 %). CA at initial follow-up was obtained in 90 %; 19.7 % CA relapsed, with a time to progression of 8 months. The difference between the mean diameter of maintained CA (22 mm) and that of the treatment failures (30 mm) was highly significant (p = 0.0005), as was the 30 mm threshold (p = 0.0062). Overall survival at 1-3 years was 90, 58 and 44 %. At univariate analysis, the local effectiveness of RFA did not reach statistical significance. CONCLUSION: RFA of hepatic METS from breast cancer has high local effectiveness in tumours up to 30 mm, but it is not relevant in determining survival.

Early response to chemotherapy in patients with non-small-cell lung cancer assessed by [18F]-fluoro-deoxy-D-glucose positron emission tomography and computed tomography.

BACKGROUND: This study aimed to demonstrate that patients who exhibit a tumor metabolic response to first-line chemotherapy seen on FDG-PET and computed tomography (CT) would survive longer than those who did not show such a response, comparing this evaluation with the morphologic response seen on CT. PATIENTS AND METHODS: Images were acquired in 22 consecutive patients with advanced non-small-cell lung cancer (NSCLC) randomized to receive carboplatin/paclitaxel/sorafenib or placebo. FDG-PET was performed within 4 weeks before (PET1) and 2 weeks after starting treatment (PET2). Similarly, CT (CT1) was performed at baseline and then every 2 cycles (6 weeks) during treatment (CT2). Responders and nonresponders were identified with FDG-PET, and metabolic response was then compared with morphologic changes detected by spiral CT. RESULTS: Twenty-one of 22 patients completed this study. In terms of progression-free survival (PFS) (45 vs. 22.2 weeks) and overall survival (OS) (77 vs. 47.7 weeks), we observed a trend that was not statistically significant for patients whose response after 2 weeks of treatment was seen on FDG-PET (P = .22 for PFS; P = .15 for OS). CONCLUSION: Patients with advanced NSCLC who had a positive outcome, as evidenced by prolonged survival, were those who showed a tumor metabolic response seen on FDG-PET.

Imaging of benign solitary fibrous tumor of the pleura: a pictorial essay.

Solitary fibrous tumor of the pleura (SFTP) is a mesenchymal tumor that tends to involve the pleura, and is also described in other thoracic and extrathoracic sites. SFTP usually presents as a peripheral mass abutting the pleural surface, to which it is attached by a broad base or by a pedicle that allows it to be mobile. SFTPs exist in benign and malignant forms. A precise pre-operative diagnosis can be arrived at with a cutting-needle biopsy, although most cases are diagnosed with postoperative histology and immunohistochemical analysis. In this pictorial essay, we review a large series of cases, with emphasis on the radiographic appearance of these lesions and their findings from computed tomography, magnetic resonance imaging, ultrasonography and positron emission tomography.