Prospective Evaluation of Semiquantitative Strain Ratio and Quantitative 2D Ultrasound Shear Wave Elastography (SWE) in Association with TIRADS Classification for Thyroid Nodule Characterization.

PURPOSE: To evaluate the diagnostic performance of strain ratio elastography (SRE) and shear wave elastography (SWE) alone and in combination with Thyroid Imaging Reporting and Data System (TIRADS) classification parameters to improve differentiation between benign and malignant thyroid nodules. MATERIALS AND METHODS: In this prospective study benign (n = 191) and malignant (n = 52) thyroid nodules were examined with high-resolution ultrasound (US) features using the TIRADS lexicon and SRE semiquantitative and SWE quantitative findings using histology or cytology as the gold standard with a 12-month follow-up. Sensitivity (Se), specificity (Sp) and the area under the ROC curve (AUROC) were used to evaluate the diagnostic performance of each feature and combinations of the methods. RESULTS: TIRADS score showed a sensitivity of 59.6 %, a specificity of 83.8 % with an AUROC of 0.717, a PPV of 50.0 % and an NPV of 88.4 %. SRE yielded the highest performance with a sensitivity of 82.7 %, a specificity of 92.7 % with AUROC of 0.877, a PPV 75.4 % and an NPV of 95.2 %. SWE (kPa) had a sensitivity and specificity of 67.3 % and 82.7 %, respectively, with an AUROC of 0.750, a PPV of 51.5 % and an NPV of 90.3 %. Differences were significant for SRE only but not for SWE. CONCLUSION: Ultrasound elastography may improve thyroid nodule discrimination. In particular, SRE has a better performance than TIRADS classification, while their combination improves sensitivity.

Strain ratio ultrasound elastography increases the accuracy of colour-Doppler ultrasound in the evaluation of Thy-3 nodules. A bi-centre university experience.

OBJECTIVES: To assess whether ultrasound elastography (USE) with strain ratio increases diagnostic accuracy of Doppler ultrasound in further characterisation of cytologically Thy3 thyroid nodules. METHODS: In two different university diagnostic centres, 315 patients with indeterminate cytology (Thy3) in thyroid nodules aspirates were prospectively evaluated with Doppler ultrasound and strain ratio USE before surgery. Ultrasonographic features were analysed separately and together as ultrasound score, to assess sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Receiver operating characteristic (ROC) curves to identify optimal cut-off value of the strain ratio were also provided. Diagnosis on a surgical specimen was considered the standard of reference. RESULTS: Higher strain ratio values were found in malignant nodules, with an optimum strain ratio cut-off of 2.09 at ROC analysis. USE with strain ratio showed 90.6% sensitivity, 93% specificity, 82.8% PPV, 96.4% NPV, while US score yielded a sensitivity of 52.9%, specificity of 84.3%, PPV 55.6% and NPV 82.9%. The diagnostic gain with strain ratio was statistically significant as proved by ROC areas, which was 0.9182 for strain ratio and 0.6864 for US score. CONCLUSIONS: USE with strain ratio should be considered a useful additional tool to colour-Doppler US, since it improves characterisation of thyroid nodules with indeterminate cytology. KEY POINTS: • Strain ratio measurements improve differentiation of thyroid nodules with indeterminate cytology • Elastography with strain ratio is more reliable than ultrasound features and ultrasound score • Strain ratio may help to better select patients with Thy 3 nodules candidate for surgery.

US Evaluation of Topical Hemostatic Agents in Post-Thyroidectomy.

BACKGROUND: the aim of this study was to describe the ultrasound appearance of topical hemostatics after thyroidectomy. METHODS: we enrolled 84 patients who were undergoing thyroid surgery and were treated with two types of topical hemostats, 49 with an absorbable hemostat of oxidized regenerated cellulose (Oxitamp®) and 35 with a fibrin glue-based hemostat (Tisseel®). All patients were examined using B-mode ultrasound. RESULTS: In 39 patients of the first group (approximately 80%), a hemostatic residue was detected and in some cases confused with a native gland residue, or with cancer recurrence in oncological patients. No residue was detected in patients in the second group. The main ultrasound characteristics of the tampon were analyzed and arranged according to predefined patterns, and suggestions to recognize it and avoid wrong diagnoses were provided. A part of the group of patients with tampon residue was re-evaluated after 6-12 months, ensuring that the swab remained for months after the maximum resorption time declared by the manufacturer. CONCLUSIONS: with equal hemostatic effectiveness, the fibrin glue pad is more favorable in the ultrasound follow-up because it creates reduced surgical outcomes. It is also important to know and recognize the ultrasound characteristics of oxidized cellulose-based hemostats in order to reduce the number of diagnostic errors and inappropriate diagnostic investigations.

The Role of CEUS in the Evaluation of Thyroid Cancer: From Diagnosis to Local Staging.

Ultrasound often represents the first diagnostic step for thyroid nodule evaluation in clinical practice, but baseline US alone is not always effective enough to achieve thyroid nodule characterization. In the last decades new ultrasound techniques, such as CEUS, have been introduced to evaluate thyroid parenchyma as recommended by EFSUMB guidelines, for use in clinical research field, although its role is not yet clear. Several papers show the potential utility of CEUS in the differential diagnosis of benign and malignant thyroid nodules and in the analysis of lymph node involvement in neoplastic pathology. Therefore, we carried out an evaluation of the literature concerning the role of CEUS in three specific areas: the characterization of the thyroid nodule, the evaluation of minimally invasive treatment and loco-regional staging of the lymph node in proven thyroid cancer. According to evidence reported, CEUS can also play an operative role in nodular thyroid pathology as it is able to guide ablation procedures on thyroid nodule and metastatic lymph nodes, to assess the radicality of surgery, to evaluate disease relapse at the level of the margins of ablated regions and to monitor the clinical evolution of necrotic areas in immediate post-treatment setting.

[The surgical tratment of the subperitoneal rectal cancer]. / Trattamento chirurgico del carcinoma del retto sottoperitoneale.

AIM: To value the results of "open" surgery with sphincter preservation, TME nerve-sparing, fast-track, without a protective stoma in a consecutive series of patients with subperitoneal rectal cancer (s.p.r.c.). MATERIALS AND METHODS: In January 1989, we started a prospective, non-randomized study designed to assess when a primary derivative stoma was warranted in a series of consecutive patients electively treated with open low and ultralow AR. The inclusion criteria were: all patients with middle and low rectal cancer who underwent elective low and ultralow AR, including those treated with neoadjuvant therapy. The exclusion criteria were: urgent surgery, incomplete rings in the stapler, a positive hydropneumatic test, preoperative involvement of the external sphincter and/or surrounding structures by the tumor as demonstrated by CT-scan and endorectal MR and/or transrectal ultrasound. Anastomoses between 7 cm and 4 cm from the pectinate line were defined as low colo-rectal anastomoses, while anastomoses lower than 4 cm from the pectinate line were defined as ultralow anastomoses. A fistula or anastomotic dehiscence was suspected when pelvic and/or peritoneal pain, fever, leucocytosis, fecaloid liquid in the drainage and/or perianal erythematosus swelling were present. An anastomotic leak was confirmed by means of angio-CT and/or endoscopy and/or contrast enema depending on the procedure available most promptly. Signs of peritoneal reaction were considered to be indicative of a major dehiscence, regardless of the diameter of the fistula; when diagnosed, a transverse colostomy was immediately performed. Clinically less serious cases were defined as minor dehiscences, for which a "wait and see" strategy or a transcutaneous CT or ultrasound guided drainage of an abscess were used. Sixty-five patients were treated according to a fast-track postoperative protocol. RESULTS: Between 1998 and 2007, 89 patients with s.p.r.c. were treated according to a prospective protocol. One hundred and nineteen patients (69.6%) underwent low anastomoses and 52 patients (30.4%) underwent ultra low anastomoses. Forty-two (24.6%) were treated with traditional AR, 129 (75.4%) with AR and nerve-sparing TME. Forty-six (26.9%) patients underwent neoadjuvant therapy. One hundred and two patients underwent a mechanical end-to-end anastomosis, 67 a double stapled anastomosis, and 2 a colo-anal anastomosis at the pectinate line performed according to our technique. All 6 patients with major dehiscences underwent a protective colostomy within hours of the onset of clinical symptoms immediately after the radiologically- or endoscopically-confirmed diagnosis. The 7 minor dehiscences were successfully treated with conservative therapy (antibiotic and enteral feeding) using an out-patient regimen. Two (28.6%) required percutaneous drainage: one pelvic CT-guided drainage and the other (an ultralow dehiscence) perineal drainage. The 72.6% of the patients survived at 5-years follow-up. The incidence of local recurrences in 2-years followup was 3.2% (on 124 patients). We had no deaths in patients treated with fast-track protocol. CONCLUSION: Open, TME nerve-sparing A.R. with selective use of neoadjuvant therapy, can be successfully performed without a protective stoma in more than 80% of the patients. Fast-track protocol seems to increase quality of p.o. period and decrease hospital stay

[Results of a National Questionnaire on "Treatment of the subperitoneal rectal cancer". Comparision among the international guidelines and metaanalysis]. / Risultati del Questionario Nazionale sulla "Terapia del cancro del retto sottoperitoneale". Confronto con le linee guida internazionali e le metanalisi.

A questionnaire including 20 questions about different aspects of subperitoneal rectal cancer was sent to 2200 fellows of Italian Society of Surgery. The answers were compared with International guidelines and with more recent metaanalyses from the literature. On the whole less than half of Italian surgeons fulfil the terms of the guidelines and the prevalent trend of the International literature. This behaviour concerns the choice of surgical procedure and prevention and diagnosis of anastomotic fistulas.

Computer-aided diagnostic system for thyroid nodule sonographic evaluation outperforms the specificity of less experienced examiners.

PURPOSE: Computer-aided diagnosis (CAD) may improve interobserver agreement in the risk stratification of thyroid nodules. This study aims to evaluate the performance of the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) classification as estimated by an expert radiologist, a senior resident, a medical student, and a CAD system, as well as the interobserver agreement among them. METHODS: Between July 2016 and 2018, 107 nodules (size 5-40 mm, 27 malignant) were classified according to the K-TIRADS by an expert radiologist and CAD software. A third-year resident and a medical student with basic imaging training, both blinded to previous findings, retrospectively estimated the K-TIRADS classification. The diagnostic performance was calculated, including sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve. RESULTS: The CAD system and the expert achieved a sensitivity of 70.37% (95% CI 49.82-86.25%) and 81.48% (61.92-93.7%) and a specificity of 87.50% (78.21-93.84%) and 88.75% (79.72-94.72%), respectively. The specificity of the student was significantly lower (76.25% [65.42-85.05%], p = 0.02). CONCLUSION: In our opinion, the CAD evaluation of thyroid nodules stratification risk has a potential role in a didactic field and does not play a real and effective role in the clinical field, where not only images but also specialistic medical practice is fundamental to achieve a diagnosis based on family history, genetics, lab tests, and so on. The CAD system may be useful for less experienced operators as its specificity was significantly higher.

Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding.

BACKGROUND: Upper and lower acute gastrointestinal bleeding (AGIB) is associated with high rates of mortality and morbidity. The latest computerized tomography (CT) imaging techniques play an important role in the treatment of this pathology. METHODS: Twenty-nine patients with severe AGIB (11 upper, 18 lower), all hemodynamically stable, underwent endoscopy followed by a multi-detector row CT (MDCT) scan. Endoscopic and MDCT accuracy for the anatomical localization and etiology of AGIB was assessed, the diagnosis being considered correct when the two procedures were concordant or when the diagnosis was confirmed by angiographic, surgical, or post-mortem findings. RESULTS: The sensitivity in identifying the site and etiology of bleeding was, respectively, 100% and 90.9% for the MDCT scan, compared with 72.7% and 54.5% for endoscopy in upper AGIB, and 100% and 88.2% for the MDCT scan, compared with 52.9% and 52.9% for endoscopy, in lower AGIB. CONCLUSIONS: Considering the advantages of MDCT over endoscopy, we propose a new diagnostic algorithm for AGIB.

Retrorectal tumors: the choice of surgical approach based on a new classification.

Because retrorectal-presacral tumors differ in histologic origin, symptoms, and prognosis, and often involve various neighboring structures, successful treatment of this heterogeneous group of tumors depends on the surgical approach chosen and the specialist surgeons involved. We investigated whether a new classification of retrorectal tumors based on findings from CT and MRI would simplify presurgical planning. The clinical records of a series of 34 patients who underwent surgeryfor retrorectal tumors from 1989 to 2003 were reviewed. Two radiologists, who were blind to the patients' records, separately reviewed the preoperative CT and MRI findings and classified tumors according to whether they arose from the presacral area (Group 1), sacrum or spinal cord growing anteriorly (Group 2), or rectum growing posteriorly (Group 3). The preoperative CT and MRI findings for the retrorectal tumors yielded the information required to allow surgery to be properly planned (surgical approach and need to involve various specialist surgeons) in nearly all cases: 17 of the 18 patients (94.5%) with tumors arising from the retrorectal space, all 12 of those with tumors arising from the sacrum or spinal cord, and all four of those with rectal tumors. With the findings yielded by currently available CT and MRI techniques, retrorectal tumors can be anatomically and topographically classified preoperatively so as to allow surgery to be adequately planned in advance and thus optimize the surgical resection.

Assessment of guidelines to improve diagnosis and treatment of solid pseudopapillary tumor of the pancreas. A case report and literature review.

AIM: Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm, its preoperative diagnosis is difficult and therefore inappropriate therapy or postoperative complications are frequent. Reviewing the literature, the purpose of this article was to identify guidelines to improve diagnosis and treatment of SPT. CASE REPORT: Authors report a case of SPT of the pancreas in a 27-year-old woman in whom a mistaken radiologic diagnosis made surgical strategy difficult and caused postoperative complications. DISCUSSION/CONCLUSIONS: Clinicians and surgeons should: (1) consider the possible disease of SPT in young females, with pancreatic encapsulated lesion with well-defined borders and variable central areas of cystic degeneration, necrosis or hemorrhage showed on radiological examinations. (2) Intensity of the differentiation of the clinical symptoms, especially during the course of therapy of chronic gastritis and diabetes. (3) Use immunohistochemical stains of alpha-1-antitrypsin, alpha-1-antichymotrypsin, vimentin and neuron-specific enolase. (4) Keep this unusual but potentially curable tumor in mind, following patients who had suffered from acute pancreatitis or abdominal injury. Increasing experience with this tumor leads to a greater awareness of its clinical presentation and pathological features and a lower rate of misdiagnosis. (5) Finally, perform, where technically feasible, conservative surgical treatment, that is safe and effective.

[Surgical treatment of extraperitoneal rectal cancer]. / Trattamento chirurgico del carcinoma del retto extraperitoneale. Chirurgia "open" con conservazione sfinterica, TME nerve-sparing, fast-track, senza stomia di protezione.

The aim of the study was to evaluate the results of open surgery with sphincter preservation and nerve-sparing total mesorectal excision and a fast-track protocol, without a protective stoma in a consecutive series of patients with extraperitoneal rectal cancer. From 1998 to 2007, 89 patients with extraperitoneal rectal cancer were treated according to a prospective protocol. Eight-six patients were submitted to anterior resection with a low or ultra-low anastomosis and nerve-sparing total mesorectal excision. Fifty-four patients received neoadjuvant therapy. Twenty-eight patients were treated according to a fast-track postoperative protocol. Primary protective colostomies were performed in 6 cases (6.9%), while a secondary colostomy was necessary in 3 patients (3.4%). There was just one postoperative death (1.1%) and major morbidity occurred in 12.3%. Seven patients developed anastomotic dehiscence; 3 were successfully treated with a secondary colostomy and 4 were treated conservatively. 68.4% of the patients treated with the fast-track protocol could be discharged on postoperative day 4. 73% of patients were still surviving at a 5-year follow-up (48 patients). The incidence of local recurrences was 3.1%. Anterior resection in the form of open nerve-sparing total mesorectal excision with selective use of neoadjuvant therapy can be successfully performed without a protective stoma in more than 80% of patients. The fast-track protocol seems to increase the quality of the patient's postoperative condition and reduce the hospital stay.

Protective stoma in anterior resection of the rectum: when, how and why?

BACKGROUND: The use of protective stoma in anterior resection (AR) is controversial. Neoadjuvant therapy, TME and laparoscopy seem to increase the rate of anastomotic dehiscences (a.d.). PATIENTS AND METHODS: In a prospective study, 219 patients were submitted to elective open AR (109 patients), open AR+TME nerve-sparing (110 patients), 35 of which had intrasphinteric anastomosis. Fifty-five patients were treated by neoadjuvant therapy. Primary stoma was not performed. RESULTS: We had 15 (6.8%) a.d.: 5 (2.3%) major and 10 (4.4%) minor. In the five major a.d. an immediate colostomy was performed with one death. In the 10 minor the a.d. was cured conservatively. CONCLUSIONS: A protective stoma is necessary in less than 10% of the patients treated with AR, so avoiding further surgery, mortality, morbidity and higher medical costs in most patients.

A rare cause of acute gastrointestinal hemorrhage: ileal lipoma Case report.

Primary small bowel tumors account for 1-6% of all Gastrointestinal (G.I.) tract malignancies. Among these pedunculated lipomas are unusual. We report a case of a 66-year-old male with a history of G.I. hemorrhage and acute anemia, negative upper and lower endoscopies and a pedunculated lipoma in distal ileum, revealed by CT enterography. The patient was successfully treated by open surgery. Patients with G.I. hemorrhage and negative upper and lower endoscopies need an accurate evaluation of small bowel. Multislice CT enterography or Magnetic Resonance enteroclysis/ enterography represent the fastest and more accurate tools to obtain an exhaustive evaluation of small bowel. In case of small bowel tumors this diagnostic procedures can show site and stage and can even suggest histological type of such neoplasms, with a significant impact in the surgical planning, avoiding time consuming surgical exploration. In this patient multislice TC enterography allowed a correct diagnosis of benign lipoma due to its radiological density and absence of infiltration of the intestinal wall and surrounding tissues. KEY WORDS: CT enterography, Gastrointestinal hemorrhage, Lipoma, Small bowel.

Strain US Elastography for the Characterization of Thyroid Nodules: Advantages and Limitation.

Thyroid nodules, with their high prevalence in the general population, represent a diagnostic challenge for clinicians. Ultrasound (US), although absolutely reliable in detecting thyroid nodules, is still not accurate enough to differentiate them into benign and malignant. A promising novel modality, US elastography, has been introduced in order to further increase US accuracy. The purpose of this review article is to assess the thyroid application of US strain elastography, also known as real-time elastography or quasistatic elastography. We provide a presentation of the technique, and of up-to-date literature, analyzing the most prominent results reported for thyroid nodules differentiation. The practical advantages and limitations of strain elastography are extensively discussed herein.

Axillary metastasis as first symptom of occult breast cancer: a case report.

Axillary lymph node metastasis from an occult breast carcinoma is a rare occurrence. We report this condition in a 59-year-old woman who presented with a swelling in the right axilla. No breast mass was clinically evident. Mammography, ultrasonography and multiple random fine-needle breast biopsies yielded no pathological findings. No extramammary primary lesions were present. Axillary sampling was performed and histological examination revealed the presence of metastatic adenocarcinoma in three of the 12 dissected lymph nodes. Estrogen receptors were positive and immunohistochemistry pointed to a breast origin. All these data were suggestive of occult breast cancer. The patient refused any further treatment but accepted clinical and radiological follow-up. Eight years later mammography revealed in the same breast a 10-mm nodule containing microcalcifications, which was not evident at physical examination. The patient underwent a lumpectomy. Intraoperative histology was positive for breast carcinoma and complete axillary clearance was performed. Histological examination revealed a lobular invasive breast carcinoma and the presence of micrometastasis in one of the 23 removed lymph nodes. The patient was given radiotherapy to the breast and axilla and tamoxifen. At present, one year after the appearance of the primary tumor, she is free of disease. Based on this case report we suggest an eclectic approach in the management of patients with axillary metastasis from occult breast cancer, depending on the clinical, pathological and biological findings.

Choledochal cyst mimicking Mirizzi's syndrome: a case report.

Choledochal cysts are cystic dilatations of the intra or extra-hepatic biliary tract with an incidence of 1 case per 150.000 live births. Cysts usually are diagnosed in childhood, but diagnosis can be delayed until adulthood in the 20-50% of cases. Clinical manifestations comprise abdominal pain with biliary or pancreatic features. Mirizzi's syndrome is a late and rare complication, that occurs in 1% of patients with cholelithiasis due to extrinsic compression of the common bile duct by stones impacted either in the gallbladder or in the cystic duct. Clinical symptoms include extrahepatic obstructive jaundice, ascending cholangitis, or, in the later course, cholecystocholedocal fistula. For both pathologies the Endoscopic Retrograde Cholangio Pancreatography and the Magnetic Resonance Cholangio Pancreatography should lead to the diagnosis with a sensibility and a specificity up to 100%. We report the case of a 66 year old patient admitted to the Emergency Department of our hospital for jaundice and abdominal pain, whom both the endoscopic and radiologic examination showed a Mirizzi's syndrome but surgery revealed a type I choledocal cyst.

Choledochal cyst mimicking Mirizzi's syndrome A case report.

Choledochal cysts are cystic dilatations of the intra or extra-hepatic biliary tract with an incidence of 1 case per 150.000 live births. Cysts usually are diagnosed in childhood, but diagnosis can be delayed until adulthood in the 20-50% of cases. Clinical manifestations comprise abdominal pain with biliary or pancreatic features. Mirizzi's syndrome is a late and rare complication, that occurs in 1% of patients with cholelithiasis due to extrinsic compression of the common bile duct by stones impacted either in the gallbladder or in the cystic duct. Clinical symptoms include extrahepatic obstructive jaundice, ascending cholangitis, or, in the later course, cholecystocholedocal fistula. For both pathologies the Endoscopic Retrograde Cholangio Pancreatography and the Magnetic Resonance Cholangio Pancreatography should lead to the diagnosis with a sensibility and a specificity up to 100%. We report the case of a 66 year old patient admitted to the Emergency Department of our hospital for jaundice and abdominal pain, whom both the endoscopic and radiologic examination showed a Mirizzi's syndrome but surgery revealed a type I choledocal cyst.

Effectiveness of clinical guidelines in the management of acute sigmoid diverticulitis. Results of a prospective diagnostic and therapeutic clinical trial.

BACKGROUND: Evidence-based criteria in the therapeutic choice for sigmoid acute diverticulitis (AD) are lacking. It is necessary to differentiate an acute episode of diverticular disease, not complicated (NCAD) and complicated (CAD) because these stages of diverticular disease needs different approach. METHODS: In a prospective study on 377 consecutive patients admitted for AD, 265 had NCAD and 112 CAD diagnosed with CT scan. Thirty-six of 265 with NCAD were operated on due to two or more previous episodes of AD. On 188 patients with NCAD followed-up, 35 had further episodes of NCAD and 2 had CAD. On 112 CAD patients, 61 had Hinchey I and were submitted to colonic resection. Twenty-three of 24 patients with Hinchey II were treated with percutaneous drainage. All Hinchey II patients were operated on. All the 13 patients with Hinchey III and IV had emergency surgery. RESULTS: We had no mortality and respectively 9.8% and 30% morbidity in Hinchey I and II patients. In Hinchey II patients percutaneous drainage was successful in 21 on 23 (91.3%). In 13 Hinchey III and IV patients the mortality rate was 25%. The comparison of CT findings and pathological results showed a sensitivity of 100% and predictive positive value of respectively 94.4, 96.7, 100 and 100% for NCAD, Hinchey I, Hinchey II and Hinchey III-IV. CONCLUSIONS: The therapeutic approach of diverticular disease needs to differentiate among an acute episode, NCAD and CAD. Evidence-based therapeutic choices can be reached only by homogeneous diagnostic criteria obtained by CT scan.

Laparoscopy in Liver Transplantation: The Future has Arrived.

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.

Alpha-fetoprotein and novel tumor biomarkers as predictors of hepatocellular carcinoma recurrence after surgery: a brilliant star raises again.

Alpha-fetoprotein (AFP), des-γ-carboxy prothrombin (DCP), and lens culinaris agglutinin-reactive fraction of AFP (AFP-L3) have been developed with the intent to detect hepatocellular carcinoma (HCC) and for the surveillance of at-risk patients. However, at present, none of these tests can be recommended to survey cirrhotic patients at risk for HCC development because of their suboptimal ability for routine clinical practice in HCC diagnosis. Starting from these considerations, these markers have been therefore routinely and successfully used as predictors of survival and HCC recurrence in patients treated with curative intent. All these markers have been largely used as predictors in patients treated with hepatic resection or locoregional therapies, mainly in Eastern countries. In recent studies, AFP has been proposed as predictor of recurrence after liver transplantation and as selector of patients in the waiting list. Use of AFP modification during the waiting list for LT is still under investigation, potentially representing a very interesting tool for patient selection. The development of a new predictive model combining radiological and biological features based on biological markers is strongly required. New genetic markers are continuously discovered, but they are not already fully available in the clinical practice.