Enhancing Anatomy Education Throu€gh Flipped Classroom and Adaptive Learning A Pilot Project on Liver Anatomy.

OBJECTIVES: Anatomy education plays a critical role in medical practice, and the level of anatomical knowledge among students and physicians significantly impacts patient care. This article presents a pilot project aimed at exploring the effectiveness of the Area9's Rhapsode platform, an intelligent tutoring system that uses artificial intelligence (AI) to personalize learning and collect data on mastery acquisition. METHODS: The study focused on liver anatomy (microscopic and macroscopic anatomy, embryology, clinical anatomy) and employed a flipped classroom approach, incorporating adaptive learning modules and an interactive in-class session. A total of 123 first-year medicine students (55 M/68F) participated to the study. Content and resources of the module were adaptable to various digital devices. Statistics were compiled based, on the one hand, on the measurement of mastery for every single learning objective provided automatically by the platform via the student interactions with the system probes (questions); on the other hand, metacognition data were worked out by crossing mastery data with the self-awareness declared in every question and learning resource by each learner. RESULTS AND CONCLUSIONS: At the outset of the study, students displayed a 18.11% level of conscious incompetence and a 19.43% level of unconscious incompetence. Additionally, 50.86% of students demonstrated conscious competence. By the conclusion of the learning module, the level of conscious incompetence had decreased to 1.87%, and 98.73% of students exhibited conscious mastery of the materials. The results demonstrated improved learning quality, positive repurposing of study time, enhanced metacognitive awareness among students, with most students demonstrating conscious mastery of the materials and a clear understanding of their level of competence. This approach, by providing valuable insights into the potential of AI-based adaptive learning systems in anatomy education, could address the challenges posed by limited teaching hours, shortage of anatomist, and the need for individualized instruction.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children.

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

Diagnostic Accuracy of Endoscopic Ultrasonography in Selecting Patients for Endoscopic Submucosal Dissection for Early Gastrointestinal Neoplasms.

Tumor invasion depth and lymph node metastasis determine the prognosis of gastrointestinal (GI) neoplasms. GI neoplasms limited to mucosa (m1 or m2) and superficial submucosa (sm1) can be treated effectively with minimally invasive endoscopic therapy, while the deep invasion of the submucosa (sm2 or sm3) is associated with lymph node metastasis, and surgical resection is required. Correct staging is therefore crucial for preoperative evaluation and planning. Endoscopic ultrasonography (EUS) can be used to detect the depth of invasion due to its close proximity to the lesion. The diagnostic accuracy of EUS, when compared to conventional endoscopic staging, is debated as it can under- or overstage the lesion. We aim in this study to determine if EUS can accurately differentiate mucosal from submucosal GI neoplasms to select patients with early GI lesions for endoscopic submucosal dissection (ESD) or surgery. From March 2014 to February 2022, 293 patients with early superficial GI neoplasms were admitted to our endoscopic unit for EUS staging. To evaluate the accuracy of EUS, we compared the preoperative EUS findings with the definitive histopathologic findings on the resected specimen. Overall, 242 of 293 lesions were correctly staged by EUS (82.59%). In the evaluation of submucosal invasion or deeper, EUS understaged 38 of 293 (12.96%) and overstaged 13 of 293 (4.43%) lesions. EUS has excellent accuracy in staging superficial GI neoplasms; its use is highly recommended before ESD since it can also detect lymph node metastases around the lesions, thus changing the indication from ESD to surgery.

Laparoscopic Microwave Ablation: Which Technologies Improve the Results.

Liver resection is the best treatment for hepatocellular carcinoma (HCC) when resectable. Unfortunately, many patients with HCC cannot undergo liver resection. Percutaneous thermoablation represents a valid alternative for inoperable neoplasms and for small HCCs, but it is not always possible to accomplish it. In cases where the percutaneous approach is not feasible (not a visible lesion or in hazardous locations), laparoscopic thermoablation may be indicated. HCC diagnosis is commonly obtained from imaging modalities, such as CT and MRI, However, the interpretation of radiological images, which have a two-dimensional appearance, during the surgical procedure and in particular during laparoscopy, can be very difficult in many cases for the surgeon who has to treat the tumor in a three-dimensional environment. In recent years, more technologies have helped surgeons to improve the results after ablative treatments. The three-dimensional reconstruction of the radiological images has allowed the surgeon to assess the exact position of the tumor both before the surgery (virtual reality) and during the surgery with immersive techniques (augmented reality). Furthermore, indocyanine green (ICG) fluorescence imaging seems to be a valid tool to enhance the precision of laparoscopic thermoablation. Finally, the association with laparoscopic ultrasound with contrast media could improve the localization and characteristics of tumor lesions. This article describes the use of hepatic three-dimensional modeling, ICG fluorescence imaging and laparoscopic ultrasound examination, convenient for improving the preoperative surgical preparation for personalized laparoscopic approach.

Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review.

Lower urinary tract symptoms (LUTS) and hematuria are common symptoms in men with neoplasms, mainly affecting the elderly population. Prostatic arterial embolization (PAE) is a minimally invasive procedure that has shown promising results in managing LUTS and massive intractable prostatic hematuria in patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa). A few studies, however, have provided valuable insights into the durability and efficacy of PAE focusing on the long-term effectiveness, quality of life, and cancer-specific control of hemostasis and urinary symptoms. As a result of concomitant cardiovascular conditions, these patients often take anticoagulants or antithrombotics, which can worsen their hematuria and clinical status. Transurethral resection of the prostate (TURP) is considered a very high-risk procedure, even without massive bleeding, and requires discontinuation of vitamin K antagonists and antiplatelet therapies. Such patients usually have their surgery postponed, and PAE should be considered a safe alternative treatment. We aimed to report a narrative review from 1976 to June 2023 of the current state of PAE for massive and intractable hematuria, highlighting recent developments in this technique, including prospective cohort studies, and focusing on long-term outcome, safety, and complication management of patients with prostatic neoplasms who develop significant hemorrhagic symptoms. Additionally, we present a case report and a simple algorithm for treating intractable bleeding in a 92-year-old man with PCa and massive hematuria.

Congenital Esophageal Atresia Long-Term Follow-Up-The Pediatric Surgeon's Duty to Focus on Quality of Life.

Esophageal atresia (EA) is the most common congenital esophageal malformation. An improvement in survival led to a focus on functional outcomes and quality of life (QoL). We analyzed the long-term outcomes and QoL of patients submitted to surgery for EA. Perinatal characteristics, surgical procedures, gastrointestinal and respiratory current symptoms and QoL were investigated. Thirty-nine patients were included. Long Gap patients had a higher rate of prematurity and low birth weight. The prevalent surgical procedure was primary esophageal anastomosis, followed by gastric pull-up. Twenty-four patients had post-operative stenosis, while gastroesophageal reflux (GER) required fundoplication in eleven cases. Auxological parameters were lower in Long Gap patients. The lowest scores of QoL were in the Long Gap group, especially in younger patients, which was the group with the highest number of symptoms. In the long term, the QoL appeared to be more dependent on the type of esophageal atresia rather than on associated malformations. Surgical management of GER was indicated in all patients with Long Gap EA, supposedly due to the prevalence of gastric pull-up for this type of EA. The assessment of QoL is part of surgeon's management and needs to be performed in each phase of a child's development.

Developing Virtual Reality Head Mounted Display (HMD) Set-Up for Thoracoscopic Surgery of Complex Congenital Lung MalFormations in Children.

Video assisted thoracoscopic surgery (VATS) has been adopted in pediatric age for the treatment of congenital lung malformations (CLM). The success of VATS in pediatrics largely depends on the surgeon's skill ability to understand the airways, vascular system and lung parenchyma anatomy in CLM. In the last years, virtual reality (VR) and 3-dimensional (3D) printing of organ models and VR head mounted display (HMD) technologies have been introduced for completion of preoperative planning in adult patients. To date no reports about the use of VR HMD technologies in a pediatric setting are available. The aim of this report is to introduce a VR HMD model in VATS procedure to improve the quality of care in children with CLM. VR HMD set-up for planning thoracoscopic surgery was performed in a series of pediatric patients with diagnosis of CLM. The preoperative VR HMD evaluation allowed a navigation into the malformation with the aim to explore, interact, and make the surgeon more confident and skilled to answer to the traps. A development of surgical simulations models and teaching program dedicated to education and training in pediatric VATS is suitable among the pediatric surgery community. Further studies should demonstrate all the benefits of such technology in pediatric patients submitted to VATS procedure.

Hybrid Additive Fabrication of a Transparent Liver with Biosimilar Haptic Response for Preoperative Planning.

Due to the complexity of liver surgery, the interest in 3D printing is constantly increasing among hepatobiliary surgeons. The aim of this study was to produce a patient-specific transparent life-sized liver model with tissue-like haptic properties by combining additive manufacturing and 3D moulding. A multistep pipeline was adopted to obtain accurate 3D printable models. Semiautomatic segmentation and registration of routine medical imaging using 3D Slicer software allowed to obtain digital objects representing the structures of interest (liver parenchyma, vasculo-biliary branching, and intrahepatic lesion). The virtual models were used as the source data for a hybrid fabrication process based on additive manufacturing using soft resins and casting of tissue-mimicking silicone-based blend into 3D moulds. The model of the haptic liver reproduced with high fidelity the vasculo-biliary branching and the relationship with the intrahepatic lesion embedded into the transparent parenchyma. It offered high-quality haptic perception and a remarkable degree of surgical and anatomical information. Our 3D transparent model with haptic properties can help surgeons understand the spatial changes of intrahepatic structures during surgical manoeuvres, optimising preoperative surgical planning.

Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis.

BACKGROUND: Ampullary tumors, although relatively uncommon, are increasingly diagnosed due to ongoing progress in imaging technology and the diagnostic accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography. Endoscopic ampullectomy (EA) has become the preferred treatment option over surgery due to its lower morbidity for benign ampullary adenomas. This study aims to evaluate the efficacy, safety, and outcome of EA in 30 patients with benign-appearing ampullary lesions with particular emphasis on the accuracy of preampullectomy histology and technical details of the pancreatic duct drainage to prevent postprocedural pancreatitis. MATERIALS AND METHODS: Data from a cohort of 30 patients who underwent EA were retrospectively analyzed. Histologic characteristics of the ampullomas, accuracy of histology of pre-EA biopsy specimen, safety of the procedure, recurrence rate, as well as the clinical outcome of all patients, are analyzed and discussed. RESULTS: Endoscopic resection was successful as a definitive treatment in 25 patients (83.3%). Five patients required additional surgery. In 8 patients, a definitive histologic specimen revealed an adenocarcinoma (3 in situ and 5 invasive). The diagnostic accuracy obtained by preresection biopsy specimen was low (0.70). Pancreatic duct stent placement after snare resection was unsuccessful in 9 patients, and 3 of them developed pancreatitis after EA. CONCLUSIONS: EA appears to be a relatively safe alternative to surgery as the first therapeutic option for selected patients with benign-appearing ampullary adenomas. A correct preoperative evaluation by endoscopic ultrasound and magnetic resonance cholangiopancreatography can help to define the anatomy of the pancreatic duct to improve the success rate of pancreatic stent placement which seems to offer a protective role in the prevention of postprocedural pancreatitis.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review.

BACKGROUND: Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries. METHODS: Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints. RESULTS: A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT. CONCLUSIONS: EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Clinical relevance of the left brachiocephalic vein anatomy for vascular access in dialysis patients.

INTRODUCTION: Most hemodialysis patients start renal replacement therapy with a central venous catheter (CVC). The left internal jugular vein (LIJV) is the second-choice vein for CVC positioning, after the right IJV. However, to reach the right atrium, the CVC must pass through the left brachiocephalic vein (LBV), which also drains blood from the left arm through the subclavian vein. The purpose of this study is to describe how the anatomy of the central venous system and in particular that of the LBV affects vascular access in hemodialysis patients. MATERIALS AND METHODS: Three-dimensional (3D) virtual model reconstructions of the central thoracic veins of three hemodialysis patients were obtained from contrast-enhanced computed tomography scans acquired in the venous phase. The images were exported as DICOM files and loaded on open-source software for visualizing and analyzing the medical imaging (3D Slicer, Windows version 4.8.1). RESULTS: As expected, the 3D reconstructions showed that the LBV has a tortuous path with three main angulations that could be associated with external compression and stenosis. These could determine the difficulties and increased risks of venous injury during CVC placement, and an increased risk of medium to long-term catheter-associated vein thrombosis and stenosis. CONCLUSIONS: The anatomical features of the LBV indicate that the path of a CVC from the LIJV to the right atrium is tortuous and can easily be complicated by vein injury, negatively affecting the creation of future arterio-venous vascular accesses in the left arm.

Grade IV Liver Injury Following Mechanical Cardiopulmonary Resuscitation with Postoperative Three-dimensional Evaluation.

A 48-year-old female presented to the emergency department with chest pain and collapsed at the front desk. She was reanimated with mechanical chest compression, and after coronary angiography, a left anterior descending/diagonal bifurcation mini-crush stenting was performed. Few hours after the procedure, the patient showed severe hypotension. Abdominal ultrasound and computed tomography (CT) scan evidenced a massive subcapsular liver hematoma (Grade IV, American association for the surgery of trauma (AAST) liver injury scale) of the right lobe with extrahepatic blushing. Transhepatic embolization was attempted but without benefit, so the patient underwent emergency laparotomy for damage control surgery with perihepatic packing. After hemodynamic stabilization, right hepatectomy was performed with a favorable outcome and full recovery. The patient CT scan was retrospectively processed to obtain a virtual model visualizable through a head-mounted display. The virtual reconstruction could improve the comprehension of the injury and the liver surgical anatomy for educational purpose, and it could represent a new tool for preoperative planning.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades.

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic fluid collections (PFCs) due to the better experience and significant progress using newer stents and access devices during last decade. This study aimed to evaluate the role of the evolving experience and possible influence of new technological devices on the outcome of patients evaluated for PFCs and submitted to EUS-guided drainage during two different periods: the early period at the beginning of experience when a standardized technique was used and the late period when the increased experience of the operator, combined with different stents quality were introduced in the management of PFCs. METHODS: We retrospectively analyzed the clinical data of a cohort of 91 consecutive patients, who underwent EUS-guided drainage of symptomatic PFCs from October 2001 to September 2017. Demographic, therapeutic results, complications, and outcomes were compared between early years' group (2001-2008) and late years' group (2009-2017). RESULTS: Endoscopic treatment was successfully achieved in 55.6% (20/36) of patients in the early years' group, and in 96.4% (53/55) in the late years' group. Eighteen patients (12 in early years' and 6 in the late year's group) required additional open surgery. Procedural complications were observed in 5 patients, 4 in early years' and 1 in late years' group. Mortality was registered in two patients (2.2%), one for each group. CONCLUSIONS: During our long-term survey using EUS-guided endoscopic drainage of PFCs, significantly better outcomes in term of improved success rate and decrease complications rate were observed during the late period.

A Virtual Reality Environment to Visualize Three-Dimensional Patient-Specific Models by a Mobile Head-Mounted Display.

INTRODUCTION: With the availability of low-cost head-mounted displays (HMDs), virtual reality environments (VREs) are increasingly being used in medicine for teaching and clinical purposes. Our aim was to develop an interactive, user-friendly VRE for tridimensional visualization of patient-specific organs, establishing a workflow to transfer 3-dimensional (3D) models from imaging datasets to our immersive VRE. MATERIALS AND METHODS: This original VRE model was built using open-source software and a mobile HMD, Samsung Gear VR. For its validation, we enrolled 33 volunteers: morphologists (n = 11), trainee surgeons (n = 15), and expert surgeons (n = 7). They tried our VRE and then filled in an original 5-point Likert-type scale 6-item questionnaire, considering the following parameters: ease of use, anatomy comprehension compared with 2D radiological imaging, explanation of anatomical variations, explanation of surgical procedures, preoperative planning, and experience of gastrointestinal/neurological disorders. Results in the 3 groups were statistically compared using analysis of variance. RESULTS: Using cross-sectional medical imaging, the developed VRE allowed to visualize a 3D patient-specific abdominal scene in 1 hour. Overall, the 6 items were evaluated positively by all groups; only anatomy comprehension was statistically significant different among the 3 groups. CONCLUSIONS: Our approach, based on open-source software and mobile hardware, proved to be a valid and well-appreciated system to visualize 3D patient-specific models, paving the way for a potential new tool for teaching and preoperative planning.

Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm.

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign. METHODS: Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters. RESULTS: En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups. CONCLUSIONS: Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.

Analysis of histological and immunohistochemical patterns of benign and malignant adrenocortical tumors by computerized morphometry.

Diagnosis of benign and purely localized malignant adrenocortical lesions is still a complex issue. Moreover, histology-based diagnosis may suffer of a moment of subjectivity due to inter- and intra-individual variations. The aim of the present study was to assess, by computerized morphometry, the morphological features in benign and malignant adrenocortical neoplasms. Eleven adrenocortical adenomas (ACA) were compared with 18 adrenocortical cancers (ACC). All specimens were stained with H&E, cellular proliferation marker Ki-67 and reticulin. We generated a morphometric model based on the analysis of volume fractions occupied by Ki-67 positive and negative cells (nuclei and cytoplasm), vascular and inflammatory compartment; we also analyzed the surface fraction occupied by reticulin. We compared the quantitative data of Ki-67 obtained by morphometry with the quantification resulting from pathologist's visual reading. The volume fraction of Ki-67 positive cells in ACCs was higher than in ACAs. The volume fraction of nuclei in unit volume and the nuclear/cytoplasmic ratio in both Ki-67 negative cells and Ki-67 positive cells were prominent in ACCs. The surface fraction of reticulin was considerably lower in ACCs. Our computerized morphometric model is simple, reproducible and can be used by the pathologist in the histological workup of adrenocortical tumors to achieve precise and reader-independent quantification of several morphological characteristics of adrenocortical tumors.

Predictive value of computerized morphometric analysis of steatosis in donor livers.

OBJECTIVE: To describe, by computerized morphometry, the degree and the type of steatosis in liver transplants that developed primary nonfunction and to compare the results with the quantification by pathologist. STUDY DESIGN: Twelve patients who developed primary nonfunction after liver transplantation were matched with 23 transplanted patients with a regular postoperative clinical course. Morphology of the liver biopsy included many stereological parameters; all cases were evaluated by an operator blinded to the diagnosis and to the clinical history. The assessment of steatosis by morphometry was compared with the pathologist's evaluation. Moreover, to assess the reproducibility of the morphometric model, another operator applied the morphometric model in a blinded fashion to a randomly selected sample of cases. RESULTS: The percentage of hepatocytes with microsteatosis and the ratio of macro/microsteatosis were higher in primary nonfunction. The pathologist's evaluation of steatosis showed a marked overestimation when compared to morphometry. Lastly, the comparison between the results of 2 blinded operators of morphometric analysis showed a high reproducibility with a low interobserver variability. CONCLUSION: Our quantitative estimation of the degree and the quality of steatosis avoids interobserver interpretations. Moreover, our analysis shows that the quantification of steatosis in liver transplantation by the current assessment must be reviewed in order to reevaluate the real impact of steatosis.

Endoscopic ultrasound-guided fine-needle aspiration for suspected malignancies adjacent to the gastrointestinal tract.

AIM: To investigate the impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in association with a multidisciplinary team evaluation for the detection of gastrointestinal malignancies. METHODS: A cohort of 1019 patients with suspected malignant lesions adjacent to the gastrointestinal tract received EUS-FNA after a standardized multidisciplinary team evaluation (MTE) and were divided into 4 groups according to their specific malignant risk score (MRS). Patients with a MRS of 0 (without detectable risk of malignancy) received only EUS without FNA. For patients with a MRS score ranging from 1 (low risk) - through 2 (intermediate risk) - to 3 (high risk), EUS-FNA cytology of the lesion was planned for a different time and was prioritized for those patients at higher risk for cancer. The accuracy, efficiency and quality assessment for the early detection of patients with potentially curable malignant lesions were evaluated for the whole cohort and in the different classes of MRSs. The time to definitive cytological diagnosis (TDCD), accuracy, sensitivity, specificity, positive and negative predictive values, and the rate of inconclusive tests were calculated for all patients and for each MRS group. RESULTS: A total of 1019 patients with suspected malignant lesions were evaluated by EUS-FNA. In 515 patients of 616 with true malignant lesions the tumor was diagnosed by EUS-FNA; 421 patients with resectable lesions received early surgical treatment, and 94 patients received chemo-radiotherapy. The overall diagnostic accuracy for the 1019 lesions in which a final diagnosis was obtained by EUS-FNA was 0.95. When patients were stratified by MTE into 4 classes of MRSs, a higher rate of patients in the group with higher cancer risk (MRS-3) received early treatment and EUS-FNA showed the highest level of accuracy (1.0). TDCD was also shorter in the MRS-3 group. The number of patients who received surgical treatment or chemo-radiotherapy was significantly higher in the MRS-3 patient group (36.3% in MRS-3, 10.7% in MRS-2, and 3.5% in MRS-1). CONCLUSION: EUS-FNA can effectively detect a curable malignant lesions at an earlier time and at a higher rate in patients with a higher cancer risk that were evaluated using MTE.

Morphometric analysis of hepatocellular nodular lesions in HCV cirrhosis.

We generated a computerized morphometric model to evaluate and quantify the morphological features in large regenerative nodules (LRN), high-grade dysplastic nodules (HGDN) and hepatocellular carcinoma (HCC). Sixteen LRN, 10 HGDN and 16 HCC in HCV-cirrhotic livers were stained with H&E, smooth muscle actin, CD34, CD31 and reticulin to evaluate volume and surface fractions. On H&E stains, the most discriminatory features between LRN, HGDN and HCC were volume fraction and the number of hepatocyte nuclei in unit volume and hepatocyte nuclear/cytoplasmic ratio. On immunohistochemistry, volume fractions of capillarised sinusoids, capillary units and isolated arteries were significantly different among all groups and highest in HCC; surface fraction of reticulin was markedly decreased in HCC. Our morphometric model is an objective method for quantification of the morphological changes of the nodular lesions, and it could be applied to studies involving histological evaluation of the spectrum of nodular lesions arising in the cirrhotic liver.