Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study.

OBJECTIVE: The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio. METHODS: We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed. RESULTS: Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8 mm, p = 0.019). CONCLUSIONS: Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy. CLINICAL RELEVANCE STATEMENT: Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions. KEY POINTS: • Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

Male Breast: A Review of the Literature and Current State of the Art of Diagnostic Imaging Work-Up.

Pathological conditions affecting the male breast (MB) share some similarities with those found in women, while others are specific to men. The first part of this review provides an overview of MB disorders, exploring the most common types of MB diseases. The second part then emphasizes the state-of-the-art approaches proposed in the literature for screening and follow-up with MB cancer patients, which highlights the importance of tailored strategies for diagnosis, follow-up, and identifying high-risk populations. Considering the increasing attention in recent years on the topic, transgender individuals are also included in this review. Together with the MB, it is an understudied category thus far. This review aims to raise awareness among radiologists that MBs should be approached differently from female breasts, contributing to the advancement of medical knowledge, improving patient outcomes, and promoting early detection of MB disorders. The review also provides an update on breast cancer and screening in the transgender population.

RadioLOGIC, a healthcare model for processing electronic health records and decision-making in breast disease.

Digital health data used in diagnostics, patient care, and oncology research continue to accumulate exponentially. Most medical information, and particularly radiology results, are stored in free-text format, and the potential of these data remains untapped. In this study, a radiological repomics-driven model incorporating medical token cognition (RadioLOGIC) is proposed to extract repomics (report omics) features from unstructured electronic health records and to assess human health and predict pathological outcome via transfer learning. The average accuracy and F1-weighted score for the extraction of repomics features using RadioLOGIC are 0.934 and 0.934, respectively, and 0.906 and 0.903 for the prediction of breast imaging-reporting and data system scores. The areas under the receiver operating characteristic curve for the prediction of pathological outcome without and with transfer learning are 0.912 and 0.945, respectively. RadioLOGIC outperforms cohort models in the capability to extract features and also reveals promise for checking clinical diagnoses directly from electronic health records.

Image-Guided Localization Techniques for Metastatic Axillary Lymph Nodes in Breast Cancer; What Radiologists Should Know.

Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.

Surgical Planning after Neoadjuvant Treatment in Breast Cancer: A Multimodality Imaging-Based Approach Focused on MRI.

Neoadjuvant chemotherapy (NACT) today represents a cornerstone in the treatment of locally advanced breast cancer and highly chemo-sensitive tumors at early stages, increasing the possibilities of performing more conservative treatments and improving long term outcomes. Imaging has a fundamental role in the staging and prediction of the response to NACT, thus aiding surgical planning and avoiding overtreatment. In this review, we first examine and compare the role of conventional and advanced imaging techniques in preoperative T Staging after NACT and in the evaluation of lymph node involvement. In the second part, we analyze the different surgical approaches, discussing the role of axillary surgery, as well as the possibility of non-operative management after-NACT, which has been the subject of recent trials. Finally, we focus on emerging techniques that will change the diagnostic assessment of breast cancer in the near future.

Staging Breast Cancer with MRI, the T. A Key Role in the Neoadjuvant Setting.

Breast cancer (BC) is the most common cancer among women worldwide. Neoadjuvant chemotherapy (NACT) indications have expanded from inoperable locally advanced to early-stage breast cancer. Achieving a pathological complete response (pCR) has been proven to be an excellent prognostic marker leading to better disease-free survival (DFS) and overall survival (OS). Although diagnostic accuracy of MRI has been shown repeatedly to be superior to conventional methods in assessing the extent of breast disease there are still controversies regarding the indication of MRI in this setting. We intended to review the complex literature concerning the tumor size in staging, response and surgical planning in patients with early breast cancer receiving NACT, in order to clarify the role of MRI. Morphological and functional MRI techniques are making headway in the assessment of the tumor size in the staging, residual tumor assessment and prediction of response. Radiomics and radiogenomics MRI applications in the setting of the prediction of response to NACT in breast cancer are continuously increasing. Tailored therapy strategies allow considerations of treatment de-escalation in excellent responders and avoiding or at least postponing breast surgery in selected patients.

Can Medical Devices Help Mitigate Global Environmental Change Effects on Human and Animal Health? A Pilot Study.

Globalization and urbanization are new challenges for the ability to protect public health. Indeed, the anthropogenic impact is changing the environment on a global scale. These changes can have direct and indirect health effects on both human and animal populations, introducing new diseases. Heat waves and floods are an example of these changes. Global Environmental Change (GEC) consequences on human health and well-being are stronger in urban areas, which are inhabited by 70% of the European population. In this context, the use of appropriate medical devices can also help mitigate the effects of climate change. Studies into lifestyle, environment quality and potential fields of application can be useful tools to identify possible types of medical device that could help to support the therapeutic needs and the prevention of health both in everyday life, and in the case of environmental alerts. A study was carried out on the potential role of medical devices (MDs) in mitigating the effects of GEC on human and animal health, by issuing two different questionnaires to specific professional clusters: the first to doctors, pharmacists, and veterinarians, the second to MD manufacturers. The data obtained from this study confirm the strong connection between GEC and the increase in the use of some MDs. Results obtained from questionnaires circulated to MD manufacturers confirmed this trend. MD manufacturers also declared that there are no longer any seasonal trends in market demand for some medical devices. This is a pilot study to consider MDs as a mitigation tool for CEGs.

Efficacy and Accuracy of Using Magnetic Seed for Preoperative Non-Palpable Breast Lesions Localization: Our Experience with Magseed.

In this retrospective study we share our single-center experience using a magnetic seed for the preoperative localization of non-palpable breast lesions. Patients who underwent a preoperative localization with Magseed® (Endomagnetics, Cambridge, UK) placement between 2020 and 2022 were enrolled. Indications to Magseed placement have been established during multidisciplinary meetings prior to surgery and all patients underwent breast-conserving surgery (BCS). 45 patients were included. Magnetic seeds have been introduced under ultrasound guidance in 40 patients (88.9%) and under stereotactic guidance in 5 patients (11.1%). We registered a highly successful placement rate (97.8%), with only one case of migration (2.2%). After BCS, all the magnetic seeds were recovered (100% retrieval rate). The re-excision rate for positive margins was 0%. Our experience, with a highly successful placement and retrieval rate and a re-excision rate equal to 0%, is consistent with the encouraging literature published on Magseed so far, suggesting this technique to be extremely effective. Moreover, our single case of seed migration supports the existing data stating that Magseed migration is rare. In conclusion, despite acknowledging Magseed limitations, we highly value the advantages linked to this technique, and we, therefore, uphold its use.

Beyond N Staging in Breast Cancer: Importance of MRI and Ultrasound-based Imaging.

The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0-2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience.

BACKGROUND: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). METHODS: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. RESULTS: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. CONCLUSIONS: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.

Supine versus Prone 3D Abus Accuracy in Breast Tumor Size Evaluation.

Breast-conserving surgery (BCS) with negative resection margins decreases the locoregional recurrence rate. Breast cancer size is one of the main determinants of Tumor-Node-Metastasis (TNM) staging. Our study aimed to investigate the accuracy of supine 3D automated breast ultrasound (3D ABUS) compared to prone 3D ABUS in the evaluation of tumor size in breast cancer patient candidates for BCS. In this prospective two-center study (Groups 1 and 2), we enrolled patients with percutaneous biopsy-proven early-stage breast cancer, in the period between June 2019 and May 2020. Patients underwent hand-held ultrasound (HHUS), contrast-enhanced magnetic resonance imaging (CE-MRI) and 3D ABUS-supine 3D ABUS in Group 1 and prone 3D ABUS in Group 2. Histopathological examination (HE) was considered the reference standard. Bland-Altman analysis and plots were used. Eighty-eight patients were enrolled. Compared to prone, supine 3D ABUS showed better agreement with HE, with a slight tendency toward underestimation (mean difference of -2 mm). Supine 3D ABUS appears to be a useful tool and more accurate than HHUS in the staging of breast cancer.

Angiostrongylus vasorum in foxes (Vulpes vulpes) and wolves (Canis lupus italicus) from Abruzzo region, Italy.

In Europe wildlife animals such as the red fox (Vulpes vulpes) are considered the main reservoir for Angiostrongylus vasorum as well as a potential threat for domestic dog infection. Though this parasite is endemic in fox populations, data on A. vasorum infection in wolves (Canis lupus italicus) are still scant, having only recently been described in Northwestern Spain, in Italy, in Croatia and in Slovakia. Based on the rising number of cases of canine lungworm infection in Central Italy (Abruzzo region), the aim of the present study was to investigate the infection by A. vasorum in fox and wolf populations sharing the same geographical area of dogs. From October 2008 to November 2019, A. vasorum specimens were collected, through routine post-mortem examination, from 56 carcasses (44 foxes and 12 wolves). Adult parasites were searched for in the right side of the heart and in pulmonary artery of all carcasses. First stage of larvae (L1) was searched in faeces using the Baermann technique and in lungs by tissue impressions. Overall, 230 adult specimens were collected and identified on a morphological basis. To confirm the morphological identification, 4 adult specimens (n = 3 from fox, n = 1 from wolf) were molecularly identified as A. vasorum by amplification of partial fragment of nuclear 18S rRNA (~1700 bp) genes. The anatomo-pathological and parasitological examinations indicated the presence of A. vasorum in 33 foxes (75%) and in 8 wolves (66.7%). The level of prevalence of infested wolves was higher than the previous one reported in other European countries. Interestingly, the prevalence of infection in foxes herein recorded was higher than that described in dogs (8.9%) living in the same geographical area. This result may confirm the hypothesis that the spread of canine angiostrongylosis is linked to fox populations infection.

Conventional CT versus Dedicated CT Angiography in DIEP Flap Planning: A Feasibility Study.

The deep inferior epigastric perforator (DIEP) flap is used with increasing frequency in post-mastectomy breast reconstruction. Preoperative mapping with CT angiography (CTa) is crucial in reducing surgical complications and optimizing surgical techniques. Our study's goal was to investigate the accuracy of conventional CT (cCT), performed during disease staging, compared to CTa in preoperative DIEP flap planning. In this retrospective, single-center study, we enrolled patients scheduled for mastectomy and DIEP flap breast reconstruction, subjected to cCT within 24 months after CTa. We included 35 patients in the study. cCT accuracy was 95% (CI 0.80-0.98) in assessing the three largest perforators, 100% (CI 0.89-100) in assessing the dominant perforator, 93% (CI 0.71-0.94) in assessing the perforator intramuscular course, and 90.6% (CI 0.79-0.98) in assessing superficial venous communications. Superficial inferior epigastric artery (SIEA) caliber was recognized in 90% of cases (CI 0.84-0.99), with an excellent assessment of superficial inferior epigastric vein (SIEV) integrity (96% of cases, CI 0.84-0.99), and a lower accuracy in the evaluation of deep inferior epigastric artery (DIEA) branching type (85% of cases, CI 0.69-0.93). The mean X-ray dose spared would have been 788 ± 255 mGy/cm. Our study shows that cCT is as accurate as CTa in DIEP flap surgery planning.

Radial Scar: a management dilemma.

Radial scar (RS) or complex sclerosing lesions (CSL) if > 10 mm is a benign lesion with an increasing incidence of diagnosis (ranging from 0.6 to 3.7%) and represents a challenge both for radiologists and for pathologists. The digital mammography and digital breast tomosynthesis appearances of RS are well documented, according to the literature. On ultrasound, variable aspects can be detected. Magnetic resonance imaging contribution to differential diagnosis with carcinoma is growing. As for the management, a vacuum-assisted biopsy (VAB) with large core is recommended after a percutaneous diagnosis of RS due to potential sampling error. According to the recent International Consensus Conference, a RS/CSL lesion, which is visible on imaging, should undergo therapeutic excision with VAB. Thereafter, surveillance is justified. The aim of this review is to provide a practical guide for the recognition of RS on imaging, illustrating radiological findings according to the most recent literature, and to delineate the management strategies that follow.

Image-Guided Localization Techniques for Surgical Excision of Non-Palpable Breast Lesions: An Overview of Current Literature and Our Experience with Preoperative Skin Tattoo.

Breast conserving surgery has become the standard of care and is more commonly performed than mastectomy for early stage breast cancer, with recent studies showing equivalent survival and lower morbidity. Accurate preoperative lesion localization is mandatory to obtain adequate oncological and cosmetic results. Image guidance assures the precision requested for this purpose. This review provides a summary of all techniques currently available, ranging from the classic wire positioning to the newer magnetic seed localization. We describe the procedures and equipment necessary for each method, outlining the advantages and disadvantages, with a focus on the cost-effective preoperative skin tattoo technique performed at our centre. Breast surgeons and radiologists have to consider ongoing technological developments in order to assess the best localization method for each individual patient and clinical setting.

Automated breast volume scanner (ABVS) compared to handheld ultrasound (HHUS) and contrast-enhanced magnetic resonance imaging (CE-MRI) in the early assessment of breast cancer during neoadjuvant chemotherapy: an emerging role to monitoring tumor response?

OBJECTIVES: To investigate the role of automated breast volume scanner (ABVS) compared to handheld ultrasound (HHUS) and contrast-enhanced magnetic resonance imaging (CE-MRI) in the early detection of patients with locally advanced breast cancer who are more likely to reach a complete pathological response (pCR) during neoadjuvant chemotherapy (NAC). METHODS: A single-institution prospective study was performed in patients with histological diagnosis of invasive breast cancer, eligible for NAC, and who were to undergo surgery in our Hospital. Imaging examinations with ABVS, HHUS and CE-MRI were performed at diagnosis (basal time) and after 3 months of chemotherapy (middle time). The tumor size of each lesion was measured at the basal and middle times, and the dimensional variation was reported. Based on this, patients were divided dichotomously by the median value, obtaining "good responders" (goodR) versus "poor responders" (poorR). The results were correlated with the histological assessment (pCR versus No-pCR) with the use of the intergroup comparison of categorical data (Fisher's exact test). RESULT: A total of 21 patients were included; 5 obtained a pCR (23%). Both the ABVS and the CE-MRI found all 5 patients with pCR in the group of goodR (10 patients), while none of the poorR (11 patients) obtained a pCR [correlation was statistically significant (p 0.01)]. In the HHUS, goodR (10 patients) 1 obtained a pCR while in the poorR (11 patients) 4 obtained a pCR [correlation not statistically significant (p 0.31)]. CONCLUSIONS: ABVS could be a useful tool, appearing to be more reliable than HHUS, and as accurate as CE-MRI, in early detection of patients who could reach a pCR after NAC.

An evaluation of the objectivity and reproducibility of shear wave elastography in estimating the post-mortem interval: a tissue biomechanical perspective.

Cadaveric rigidity-also referred to as rigor mortis-is a valuable source of information for estimating the time of death, which is a fundamental and challenging task in forensic sciences. Despite its relevance, assessing the level of cadaveric rigidity still relies on qualitative and often subjective observations, and the development of a more quantitative approach is highly demanded. In this context, ultrasound shear wave elastography (US SWE) appears to be a particularly well-suited technique for grading cadaveric rigidity, as it allows non-invasive quantification of muscle stiffness in terms of Young's modulus (E), which is a widely used parameter in tissue biomechanics. In this pilot study, we measured, for the first time in the literature, changes in the mechanical response of muscular tissues from 0 to 60 h post-mortem (hpm) using SWE, with the aim of investigating its applicability to forensic practice. For this purpose, 26 corpses were included in the study, and the muscle mechanical response was measured at random times in the 0-60 hpm range. Despite the preliminary nature of this study, our data indicate a promising role of SWE in the quantitative determination of cadaveric rigidity, which is still currently based on qualitative and semiquantitative methods. A more in-depth study is required to confirm SWE applicability in this field in order to overcome some of the inherent limitations of the present work, such as the rather low number of cases and the non-systematic approach of the measurements.

Contagious Bovine Pleuropneumonia: A Comprehensive Overview.

Contagious bovine pleuropneumonia (CBPP) is a respiratory disease of cattle that is listed as notifiable by the World Organization for Animal Health. It is endemic in sub-Saharan Africa and causes important productivity losses due to the high mortality and morbidity rates. CBPP is caused by Mycoplasma mycoides subsp. mycoides (Mmm) and is characterized by severe fibrinous bronchopneumonia and pleural effusion during the acute to subacute stages and by pulmonary sequestra in chronic cases. Additional lesions can be detected in the kidneys and in the carpal and tarsal joints of calves. Mmm infection occurs through the inhalation of infected aerosol droplets. After the colonization of bronchioles and alveoli, Mmm invades blood and lymphatic vessels and causes vasculitis. Moreover, Mmm can be occasionally demonstrated in blood and in a variety of other tissues. In the lung, Mmm antigen is commonly detected on bronchiolar and alveolar epithelial cells, in lung phagocytic cells, within the wall of blood and lymphatic vessels, inside necrotic areas, and within tertiary lymphoid follicles. Mmm antigen can also be present in the cytoplasm of macrophages within lymph node sinuses, in the germinal center of lymphoid follicles, in glomerular endothelial cells, and in renal tubules. A complete pathological examination is of great value for a rapid presumptive diagnosis, but laboratory investigations are mandatory for definitive diagnosis. The purpose of this review is to describe the main features of CBPP including the causative agent, history, geographic distribution, epidemiology, clinical course, diagnosis, and control. A special focus is placed on gross and microscopic lesions in order to familiarize veterinarians with the pathology and pathogenesis of CBPP.

External Validation of a Risk Stratification Score for B3 Breast Lesions Detected at Ultrasound Core Needle Biopsy.

OBJECTIVE: The aim of this study was to externally validate the feasibility and robustness of a risk-stratification score for B3 lesions based on clinical, pathological, and radiological data for improved clinical decision making. METHODS: 129 consecutive histologically confirmed B3 lesions diagnosed at ultrasound-guided biopsy at our institution were included in this retrospective study. Patient- and lesion-related variables were independently assessed by two blinded breast radiologists (R1, R2), by assigning each feature a score from 0 to 2 (maximum sum-score of 5). Sensitivity, specificity, positive and negative predictive values were calculated at two different thresholds (≥1 and 2). Categorical variables were compared using Chi-squared and Fisher exact tests. The diagnostic accuracy of the score to distinguish benign from malignant B3 lesions was assessed by receiver operating characteristic (ROC) analysis. RESULTS: Surgery was performed on 117/129 (90.6%) lesions and 11 of these 117 (9.4%) lesions were malignant. No cancers were found at follow-up of at least 24 months. Area under the ROC-curve was 0.736 (R1) to 0.747 (R2), with no significant difference between the two readers (p = 0.5015). Using a threshold of ≥1, a sensitivity, specificity, PPV, and NPV of 90%/90% (R1/R2), 39%/38% (R1/R2), 11%/12% (R1/R2) and 97%/98% (R1/R2) were identified. Both readers classified 47 lesions with a score ≤1 (low risk of associated malignancy). Of these, only one malignant lesion was underdiagnosed (Ductal carcinoma in situ-G1). CONCLUSIONS: In our external validation, the score showed a high negative predictive value and has the potential to reduce unnecessary surgeries or re-biopsies for ultrasound-detected B3-lesions by up to 39%.

Efficacy and safety of honeybee and wasp tyrosine-adsorbed venom immunotherapy.

INTRODUCTION: It is acknowledged that any claim of efficacy of allergen immunotherapy must be done for each specific product, and this remains true also for venom immunotherapy (VIT). Thus, we evaluated the efficacy and safety of a specific tyrosine-adsorbed VIT for vespula spp. and honeybee in real-life. METHODS: Consecutive patients diagnosed with hymenoptera allergy, and receiving VIT for either vespula or honeybee with a tyrosine-adsorbed preparation were observed to evaluate the grade of reaction (according to Muller) at the first field re-sting. A modified ultra-rush protocol was used. RESULTS: A total of 247 patients (73 female) were observed (102 honeybee, group H, 145 vespula, group V). Seventy-five patients in group H had a re-sting, and 74/75 had a lower grade reaction at re-sting as compared to the pre-VIT reaction. Considering systemic reactions, protection was achieved in 89% of patients. In group V 118 patients were re-stung, and 76/118 patients with previous grade III-IV reaction had no more systemic reaction under VIT. Overall, considering systemic reactions, protection was achieved in 92% of subjects. Of note, in both groups there was a clear inverse correlation between the severity of pre-VIT and during VIT reactions. The duration of VIT at the time of re-sting did not affect the efficacy. The safety was overall good, with 18% ad 15.4% local reactions in groups H and V, respectively. DISCUSSION: Modified extracts, including tyrosine-absorbed, have the aim of improving the safety of VIT still yet maintaining the efficacy. Field re-sting is the best way to assess the efficacy in real life. In this observational study we could confirm the protective efficacy of the tyrosine-adsorbed extract, with a good safety expecially in the build-up using a modified-rush protocol. CONCLUSION: The tyrosine-adsorbed VIT used herein is a viable and advantageous form of treatment for hymenoptera allergy.