Sonoelastography of the distal third of the Achilles tendon in asymptomatic volunteers: correlation with anthropometric data, ultrasound findings and reproducibility of the method.

OBJECTIVE: Evaluating prospectively elastosonographyc (EUS) findings of distal third of Achilles tendon in asymptomatic volunteers and correlating with subject characteristics and ultrasound (US) findings and, subsequently, calculating reproducibility of method. MATERIALS AND METHODS: 70 consecutives Achilles tendons were examined with US and EUS in 35 asymptomatic volunteers. Mean age 42.3 years (±7.6), 22 were female (mean age 41 ± 8.7) and 13 were male (mean age 42.5 ± 11.4). Information about population was collected (anthropometric data, sport activity, taken therapy and associated conditions/pathologies). RESULTS: Statistically significant correlation was found between BMI and EUS findings (p = 0.007) and between EUS aspect and US diagnosis (p = 0.039) both to the right tendon. Possible influence of smoking (p = 0.063 to right) and associated conditions (p = 0. 059 to left), has been found. The multivariate analysis showed that EUS results are correlated only with BMI (high BMI corresponds to the best EUS results), independently from smoke and associated conditions on right side. No correlations have emerged for the left tendon. The 22.8 % of the volunteers took on chronic therapies, none statistically significant correlation. In the past, 80 % of subjects played sports (7.4 % agonistic and 92.6 % non-agonistic). The 22.9 % of volunteers played sporadic or no activity. The 60 % of volunteers has played sports that may lead overload of the Achilles tendon. The 61.5 % of subjects with BMI ≥ 25 was active little or nothing; 63.6 % of the subjects with BMI < 25 is playing sports. US examination showed 57.1 % normal tendons and 42.9 % tendinosic. Rate of tendinosic tendons was similar in both left and right (40 and 45.7 %, respectively). Statistically significant correlation was found between EUS aspect and US diagnosis on the right tendon but not on the left Correlation between thickness and EUS aspect was calculated: no correlation was found. Interoperator correlation was excellent (k = 0.89 for left tendon and k = 0.91 for right tendon). CONCLUSIONS: The EUS is an interesting and useful technique, characterised by a high reproducibility. Its results are related to BMI and US appearance of the tendon, and they are probably influenced by the smoke and associated conditions. However, the flexed ankle position, needed to properly examine the distal third by US, alters the elasticity of the tendon and causes false negative results to EUS. Then, for the EUS study of the distal third, it would be appropriate the relaxed position, with a gel pad to optimise the probe adhesion.

Performance and role of the breast lesion excision system (BLES) in small clusters of suspicious microcalcifications.

PURPOSE: To assess the diagnostic performance of the BLES as a biopsy tool in patients with ≤ 1 cm clusters of BIRADS 4 microcalcifications, in order to possibly avoid surgical excision in selected patients. MATERIALS: This is a retrospective study of 105 patients undergone to stereotactic breast biopsy with the BLES. It excises a single specimen containing the whole mammographic target, allowing better histological assessment due to preserved architecture. RESULTS: Our case series consists of 41 carcinomas (39%) and 64 benign lesions (61%). Cancer involved the specimen margins in 20/41 cases (48.8%) or was close to them (≤ 1 mm) in 14 cases (34.1%); margins were disease-free in only 7 DCIS (17.1%). At subsequent excision of 39/41 malignant cases, underestimation occurred for 5/32 DCIS (15.6%), residual disease was found in 15/39 cancers (38.5%) and no cancer in 19/39 cases (48.7%). For DCIS cases, no residual disease occurred for 66.7% G1-G2 cases and for 35.3% G3 cases (P=0.1556) as well as in 83.3%, 40.0% and 43.8% cases respectively for negative, close and positive BLES margins (P=0.2576). CONCLUSIONS: The BLES is a good option for removal of small clusters of breast microcalcifications, giving better histological interpretation, lower underestimation rates and possibly reducing the need of subsequent surgical excision in selected patients.

Mammographic findings after reshaping with autoprosthesis in women undergoing contralateral breast reconstruction and mastectomy.

AIMS AND BACKGROUND: Breast reduction and mastopexy combined with inferior dermo-lipo-glandular flap (autoprosthesis) gives good breast shape, long-term projection, and upper pole fullness. We assess the impact on breast oncologic surveillance compared to other techniques. METHODS: A total of 105 patients who underwent mastectomy and reconstruction were divided into 3 groups of 35 patients each: groups 1 and 2 include patients with contralateral breast symmetrization performed with and without autoprosthesis technique, respectively. Group 3 is a control group without contralateral breast reshaping. On mammography, edema, skin thickening, architectural distortion, and calcifications were recorded, as well as further diagnostic examinations, biopsies, and surgical treatments required. RESULTS: Statistically significant differences (p<0.001) in the first follow-up mammography between groups 1 and 2 were stromal edema (6% vs 51%) and architectural distortion (74% vs 63%). The latest findings meant architectural distortion also have significant difference (p<0.001) in the last mammography (79% vs 66%). Microcalcification has statistically significant difference (p<0.001) in the latest postsurgical mammography, increased in group 1. Skin thickening had a similar course in either group. Mammography follow-up was not impaired in most cases notwithstanding the parenchyma distortion as compared with mammography after breast-conserving surgery. Four core biopsies were performed in both groups: 3 new breast cancers and 1 benign epithelial hyperplasia were found. CONCLUSIONS: No difficulties were found impairing mammographic evaluation in patients treated with autoprosthesis as compared to other techniques.

Bladder cancer diagnosis: the role of CT urography.

AIMS AND BACKGROUND: To evaluate the diagnostic performance of computed tomography urography (CTU), we first compared it with cystoscopy and subsequently analyzed which CTU phase of acquisition has the highest diagnostic accuracy in identifying bladder cancer. METHODS: In 2013, 177 patients underwent both cystoscopy and CTU. For all acquisition phases, we calculated sensitivity, specificity, diagnostic accuracy, and positive and negative predictive value (PPV and NPV, respectively). We also evaluated the Cohen κ coefficient. RESULTS: Computed tomography urography sensitivity, specificity, diagnostic accuracy, PPV, and NPV were as follows: 96.3%, 86.4%, 92.8%, 92.9%, and 92.7%; concordance calculated with Cohen κ was good: 0.8413. The arterial acquisition phase showed the highest diagnostic accuracy, identifying 93.4% of all lesions. CONCLUSIONS: Computed tomography urography is an accurate examination for the diagnosis of bladder cancer, and the arterial acquisition phase provides the best diagnostic information.

Breast metastasis from cutaneous malignant melanoma mimicking a breast cancer.

INTRODUCTION: Breast metastases are very uncommon, either from solid tumors or malignant melanoma. CASE REPORT: We present the case of a 42-year-old woman with a history of cutaneous melanoma of the shoulder excised 21 years ago. She presented with a palpable lump in the upper outer quadrant of the right breast. Ultrasound demonstrated a solid mass within a cystic lesion. A core biopsy was taken and first histology reported a poorly differentiated primary breast cancer suspected to be triple negative. MRI detected a satellite lesion in the same breast, a focus of suspected enhancement in the other breast, and the extramammary finding of an enhancing pulmonary lesion. Staging computed tomography detected widespread metastases to the lungs, brain, subcutaneous left shoulder, liver, pancreas, and hepatorenal recess. A core biopsy was taken from the left breast lesion and the previous slides were reviewed; histopathology and immunohistochemistry were in keeping with metastasis from melanoma. CONCLUSIONS: The possibility of a metastatic lesion to the breast should be taken into account in any patient presenting with a breast lump and a previous history of melanoma. Breast involvement cannot be considered an isolated finding, as it might be the first manifestation of widespread disease.

Impact of contra-lateral breast reshaping on mammographic surveillance in women undergoing breast reconstruction following mastectomy for breast cancer.

BACKGROUND: The ultimate goal of breast reconstruction is to achieve symmetry with the contra-lateral breast. Contra-lateral procedures with wide parenchymal rearrangements are suspected to impair mammographic surveillance. This study aims to evaluate the impact on mammographic detection of mastopexies and breast reductions for contralateral adjustment in breast reconstruction. PATIENTS AND METHODS: We retrospectively evaluated 105 women affected by uni-lateral breast cancer who underwent mastectomy and immediate two-stage reconstruction between 2002 and 2007. We considered three groups according to the contra-lateral reshaping technique: mastopexy or breast reduction with inferior dermoglandular flap (group 1); mastopexy or breast reduction without inferior dermoglandular flap (group 2); no contra-lateral reshaping (group 3). We assessed qualitative mammographic variations and breast density in the three groups. RESULTS: Statistically significant differences have been found when comparing reshaped groups with non reshaped groups regarding parenchymal distortions, skin thickening and stromal edema, but these differences did not affect cancer surveillance. The surveillance mammography diagnostic accuracy in contra-lateral cancer detection was not significantly different between the three groups (p = 0.56), such as the need for MRI for equivocal findings at mammographic contra-lateral breast (p = 0.77) and the need for core-biopsies to confirm mammographic suspect of contra-lateral breast cancer (p = 0.90). CONCLUSIONS: This study confirms previous reports regarding the safety of mastopexies and breast reductions when performed in the setting of contra-lateral breast reshaping after breast reconstruction. Mammographic accuracy, sensitivity and specificity are not affected by the glandular re-arrangement. These results provide a further validation of the safety of current reconstructive paradigms.

Defaecography and colonic transit time for the evaluation of female patients with obstructed defaecation.

PURPOSE: Colonic transit time and defaecography are well known, commonly used studies for evaluating patients with chronic constipation. The aim of this study was to compare colonic transit time with radiopaque markers and defaecography in female patients with obstructed defaecation. MATERIALS AND METHODS: In a prospective observational study, between January 2010 and December 2012, a total of 30 female patients, mean age 60 years, with symptoms of obstructed defaecation were subjected to colonic transit time and defaecography, and divided into two groups: normal or abnormal colon transit time. The results were statistically compared using the Chi-square test. RESULTS: The comparison of data between colonic transit time and defaecography showed the following groups: group 1 (6/30 = 20 %) with normal colonic transit time but abnormal defaecography, and group 2 (24/30 = 80 %) with abnormal colonic transit time; the latter was further divided into two subgroups: group 2a (4/24 = 17 %), patients with inertia coli; group 2b (20/24 = 83 %), patients with impaired defaecation demonstrated at defaecography. There was a significant statistical difference between the radiological findings in these groups. CONCLUSIONS: This study confirmed the value of both defaecography and colonic transit time in assessing clinically obstructed women. Obstructed defaecation might not always be associated with abnormal colonic transit time. Likewise, not all constipated patients had signs of obstructed defaecation. The differential diagnosis between colonic slow transit constipation and constipation due to pelvic floor disorders is essential for an adequate strategy of care.

Trans-thoracic biopsy of lung lesions: FNAB or CNB? Our experience and review of the literature.

PURPOSE: This study was performed to determine the type and incidence of complications of fine-needle aspiration biopsy (FNAB) and core biopsy (CNB) performed under computed tomography (CT) guidance to characterise lung lesions, and assess the diagnostic accuracy of the two techniques. MATERIALS AND METHODS: In 2009-2011, we performed 124 lung biopsies (66 CNB and 56 FNAB) on 121 patients with a mean age of 72.4 years. Exclusion criteria were pulmonary resection, pleural lesions and/or effusions, and inadequate blood-coagulation profile. All examinations were acquired after contrast-agent administration in a craniocaudal direction from the lung apex to base during a single inspiratory breath-hold, with standardised parameters. Each lesion was scanned with 13-15 slices that could be repeated whenever necessary to document the needle track and for lesion centring, by positioning a metallic marker perpendicular to the centring light to indicate the point of needle access. Unless otherwise clinically indicated, 4 h after the procedure chest radiography was performed. RESULTS: Age was found to be a factor influencing the complications: pneumothorax in young subjects (31 %) and parenchymal haemorrhage in the elderly (30 %), with CNB but not with FNAB. We had more complications with the right lung: 50 % of pneumothorax cases in the upper lobe with CNB and 40 % of cases of haemorrhage in the lower lobe with FNAB. The anterior approach gave rise to more complications with CNB, while the posterior approach with FNAB. CNB had more complications than FNAB for lesions ≤ 3.5 cm (31 vs. 18 % pneumothorax), and >3.5 cm (34 vs. 9 % haemorrhage). There was no significant correlation with lesion histology, needle calibre or number of passes (probably due to the small number of procedures done with needles other than 18 G in CNB or 22 G in FNAB or involving more than one needle pass). The diagnostic accuracy of FNAB, done with a pathologist's extemporaneous assessment of sample adequacy, was 94.83 % against 81.82. % of CNB. CONCLUSIONS: FNAB under CT guidance is subject to a lower rate of complications and, if performed in the presence of the pathologist, has a greater diagnostic accuracy compared to CNB.

Revaluation of breast cytology with pathologist on-site of lesions with suspicious sonographic features.

OBJECTIVE: Evaluating correlation estimation between diagnostic ultrasound (U.S.) of breast lesions and fine needle aspiration cytology (FNAC), and the correlation between cytology and histology (I) of these lesions undergo surgery. MATERIALS AND METHODS: In 2010 we performed 1589 ultrasound breast. We identified 210 suspicious lesions to be subjected to FNAC, which was performed with pathologist on site, and extemporaneous analysis of the sample to assess their appropriateness. We classified the lesions in 5 ultrasound (U) classes according to the criteria defined by Echographic BIRADS Lexicon. The results of cytology were classified in 5 classes (C) according to the guidelines of F.O.N.Ca.M. Then we evaluated the diagnostic correlation between U.S. and FNAC, and between FNAC and Histology. RESULTS: The distribution of lesions in U classes was: 57U2, 55U3, 36U4 and 62U5. The diagnostic concordance between U and FNAC was 96.7%, with a sensitivity of 98%, specificity 93%, negative and positive predictive value respectively of 94.9% and 97.3%, and diagnostic accuracy of 96.6%. The 98 patients with C4-C5 lesions were subjected to surgery and the histology confirmed high-grade malignancy of lesions with a concordance of 99.7%. CONCLUSIONS: Having achieved high diagnostic concordance between U and FNAC, and then between FNAC and histology, we may say that the FNAC, less invasive and traumatic for the patient than needle biopsy (CB), may be still a valid method when performed with pathologist on-site to assess the adequacy of the sample taken.