Role and efficacy of intraoperative evaluation of resection adequacy in conservative breast surgery.

In the present study we considered the histology of 51 patients who have undergone breast conservative surgery and the related 54 re-excisions that were performed in the same surgical procedure or in delayed procedures, in order to evaluate the role of intraoperative re-excisions in completing tumor removal. In 13% of the cases the re excision obtained the resection of the target lesion. In this study, the occurrence of residual neoplastic lesions in intraoperative re-excisions (24%) is lower than in delayed re-excisions (62%; P = .03). The residual lesions that we could find with definitive histology of re excision specimens are related with lesions with ill defined profile. In 77% of the cases of re excision with tumoral residual the lesion was close to the new resection margin, thus the re-excisions couldn't achieve an adequate ablation of the neoplasm. Invasive or preinvasive nature of the main lesion resected for each case and the approach to the evaluation of the first resection specimen adequacy (surgical or radiological) don't affect the rate of tumoral residual in intraoperative re-excisions. In conclusion, our data are consistent with a low efficacy of intraoperative re excision in obtaining a complete removal of the tumor; intraoperative radiologic evaluation of the first resection specimen is however imperative in defining the effective removal of the target lesion.

Radiography of the surgical specimen in early stage breast lesions: diagnostic reliability in the analysis of the resection margins.

PURPOSE: The purpose of this study was to evaluate the diagnostic reliability of specimen radiography in the assessment of the status of resection margins in early stage breast lesions. MATERIALS AND METHODS: The study involved 123 consecutive patients who underwent breast-conserving surgery for early stage breast lesions. Specimen radiography in the two orthogonal views and with direct magnification was obtained in all cases to assess presence or absence of the lesion, position of the lesion within the surgical specimen and direction in which to extend the excision in cases of lesions located close to the margin. Diagnostic reliability was evaluated for only 102 patients with malignant lesions. RESULTS: Comparison between the radiological and histological diagnoses before immediate reexcision had 66% sensitivity, 86% specificity, 74% positive predictive value and 81% negative predictive value. Definitive histological assessment of margin status, including status after reexcision, was infiltrated margins in 23 patients (23%) and clear margins in 79 patients (77%). Definitive histological assessment in 12/19 patients (63.15%) with intraoperative reexcision, confirmed margin infiltration of the first specimen. Twenty patients (20%) underwent a second surgical procedure. CONCLUSIONS: Specimen radiography was reliable in identifying clear margins (74% positive predictive value) and reduced the rate of reintervention from 31% to 20%. Better results will be provided by digital mammographic equipment.

Sonographic appearance of aggressive angiomyxoma of the bladder.

Aggressive angiomyxoma is a rare, benign but locally aggressive mesenchymal neoplasm. We report the sonographic findings in a case of histologically proven aggressive angiomyxoma of the bladder. Sonography revealed a solid polypoid mass 2 cm in diameter with sharply demarcated borders, a heterogeneous echotexture, and a slightly hyperechoic rim.

[Role of endorectal ultrasonography and CT in preoperative staging of rectal cancer. Personal experience]. / Ruolo dell'ecotomografia endorettale e della TC nella stadiazione preoperatoria del cancro del retto. Esperienza personale.

We report our personal experience on endorectal US and CT in the preoperative staging of rectal carcinoma. Our series includes 64 cases (38 male and 26 female) evaluated with intrarectal sonography; 38 of these patients underwent also CT-study of the lower abdomen. Using both imaging techniques infiltration of the rectal wall and adjacent structures and lymph node involvement were studied. The results of our study refer to 58 patients who underwent endorectal US, 31 of whom studied also with CT. Referring to the T-parameter with ultrasound 41 correct diagnosis were obtained, in 13 cases the lesion was over-staged and in 4 cases understaged. The sensitivity, specificity and diagnostic accuracy was respectively 89.5%, 60% and 79.3%. With CT 23 diagnosis were correct, in 1 case the lesion was overstaged and in 7 cases understaged; sensitivity, specificity and diagnostic accuracy concerning rectal wall infiltration were respectively 72%, 83.3% and 74.2%. The evaluation of the N-parameter demonstrated low value of sensitivity with both US (15.8%) and CT (42.9%). Considering the results of our series, we feel that it is necessary to use both imaging techniques because results obtained are complementary referring to the T-parameter, although N-parameter were a little significant.

[Integration of B-mode and color Doppler ultrasonography in the preoperative diagnosis of thyroid lesions. Preliminary experience in 91 cases]. / Integrazione ecografica B-mode e color-Doppler nella diagnosi preoperatoria di lesioni tiroidee. Esperienza preliminare in 91 casi.

Ninety-one patients affected with thyroid diseases (97 lesions) were examined with conventional B-mode and color-Doppler US. To verify if color-Doppler is able to provide additional elements in the US diagnosis, for each lesion were expressed two diagnosis: the first found on conventional US patterns and the second on color-Doppler patterns. US diagnosis was compared with histologic findings that identify 73 benign lesions and 24 malignant lesions. With conventional B-mode US the diagnosis was correctly expressed in 62/73 benign lesions (85%) and in 18/24 malignant lesions (75%) while it misdiagnosed as positives 11/73 case (15%) and as negatives 6/24 cases (25%). If we completed the conventional US diagnosis with color-Doppler patterns, the false negative reduced to 4% and false positive to 6.8%. On the whole, although any correlation between color-Doppler patterns and different histological types was found, the color-Doppler had a high predictive value of benignity in patterns I, II, and IV while pattern III is not peculiar because it includes either malignant or benign lesions.

[The diagnostic reliability of percutaneous biopsy specimens obtained under instrumental guidance using 4 different types of needles]. / Attendibilità diagnostica dei prelievi bioptici percutanei eseguiti con guida strumentale utilizzando quattro diversi tipi di aghi.

To assess if the effectiveness of biopsy sampling, whose usefulness is widely recognized, can be influenced by different cutting mechanisms, we compared four different types of needles (A, B, C, D) in 76 patients, each needle being of the same length (15 cm) and calibre (18 G) but with different tip shapes. Forty biopsy samples were obtained with each type of needle for a total of 160 samples in 76 patients; 61 samples were acquired under CT guidance and 99 under US guidance. The results were subdivided in 6 categories based on biopsy result: PI (diagnosis histotype in malignant lesions), PN (diagnosis of malignancy in neoplastic lesions), P (correct diagnosis in benign lesions), S (suspicion of neoplastic lesion), E (misdiagnosis), NI (insufficient material). The results, respectively, for each needle type are: 32.5%, 30%, 2.5%, 7.5%, 12.5% and 15% with needle A; 35%, 30%, 7.5%, 0%, 15% and 12.5% with needle B; 27.5%, 17.5%, 10%, 7.5%, 22.5% and 15% with needle C; 30%, 15%, 7.5%, 15%, 17.5% and 15% with needle D. The sensitivity and specificity for each needle type were, respectively, 84.4% and 85.29% for needle A; 86.66% and 88.57% for needle B; 70% and 73.52% for needle C; 77.41% and 79.41% for needle D. No statistically significant difference was found in the effectiveness of the four needles (chi 2); on the contrary, lesions's size can affect sampling quality.

[Percutaneous gastrostomy. Personal experience in 137 cases]. / La gastrostomia percutanea. Esperienza personale in 137 casi.

Percutaneous gastrostomy is reported to be an effective alternative to total parenteral feeding or long-term nasogastric tube in the treatment of mechanical or functional dysphagia. The authors report their personal experience with 137 percutaneous gastrostomies performed on 98 men and 39 women from January 1986 through December 1993. All the maneuvers were performed under fluoroscopic guidance in the patients with head or neck cancer, neoplastic, vascular or post-traumatic neuropathy and upper GI tract cancer. To avoid left hepatic lobe trauma, percutaneous gastrostomy needs to be performed under US guidance. A 7F nasogastric tube is used to fill the stomach with air. After distending the gastric cavity, with the Seldinger technique under local anesthesia, fascial dilators of progressively increasing caliber are introduced into the gastric cavity and the final 12F gastrostomy catheter is positioned under fluoroscopic guidance. No major complications, such as hemorrhage or peritonitis, occurred. In one case, during the maneuver, the patient complained of severe epigastric pain which regressed with no further problems two hours later. In three cases the gastrostomy catheter fell out of place and was replaced by running the fistolous tract with a venous cannula and then a guidewire for gastrostomy repositioning. With this type of treatment, the patient can be given enteral feeding the following day. The maneuver requires approximately 10 minutes to perform and is well tolerated by the patient as it requires no general anesthesia. Percutaneous gastrostomy is more cost-effective than surgery or endoscopy and hospitalization is shorter. The only contraindications to this maneuver are hepatomegaly (because of the risk of liver trauma during percutaneous maneuvers), ascites (because of the risk of infection) and finally the complications resulting from gastric resection.

[The reliability of echotomographic diagnosis in assessing thyroid lesions. A comparison with cytology and histology]. / Attendibilità della diagnosi ecotomografica nella valutazione delle lesioni della tiroide. Confronto con la citologia e l'istologia.

The authors report their personal experience in 160 patients affected with thyroid conditions examined with US and fine needle aspiration (FNA). Benign nodular hyperplasia, cystic-colloid nodular hyperplasia, colloid cyst, hemorrhagic cyst, adenoma, thyroiditis, follicular and malignant lesions were studied. The latter consisted of 5 papillary carcinomas, 6 follicular carcinomas, 1 medullary carcinoma, 1 Hürthle cell carcinoma, 1 lymphoma and 1 metastatic lesion. The following US patterns were observed: 69.2% of the malignant lesions were hypoechoic, 15.4% were hyperechoic and 7.7% isoechoic. Most of the malignant lesions (84.6%) had inhomogeneous echo texture; 46.1% of them exhibited peripheral microcalcifications. US diagnoses were compared with cytologic and/or histologic findings to assess US accuracy. In the surgical patients US accuracy reached 78.6% in benign lesions and 61.5% in malignant lesions. Since US alone fails to yield enough pieces of information for an accurate diagnosis to be made, especially when malignant lesions are concerned, FNA should be used, while trying to define the actual role of color-Doppler US.

[Endoscopic and intraoperative ultrasonography in staging of stomach neoplasms]. / Ecografia perendoscopica ed intraoperatoria nella stadiazione delle neoplasie gastriche.

In Japan a better prognosis of gastric cancer has been achieved by early diagnosis and wide, careful lymphectomy. This is not true in western countries. Thus the Authors believe that rational surgical strategy and the careful use of advanced diagnostic tools would produce a better outcome. The Authors report the new diagnostic methods that they adopt in every case of gastric neoplasm: endoscopic ultrasonography, which also proved useful in submucosal tumors, like lymphomas; parenteral nutrition, immune status assessment for a possible use of immune response modulators, single-dose antimicrobial prophylaxis, antithrombotic prophylaxis, autologous blood storage, in order to reduce transfusion-linked risks. Surgical strategy is also reported, which includes wide resection with adequate margins, R2 lymphectomy and intraoperative assessment of disease extension by ultrasonography.

[Role of ultrasonography in the assessment of lymphoma localized in the abdomen]. / Ruolo dell'ecotomografia nella valutazione delle localizzazioni addominali di linfoma.

Both prognosis and treatment of lymphomas depend strictly on both clinical staging and histologic classification. The role of US was investigated in the evaluation of patients affected with abdominal lymphoma. To this purpose, 52 patients affected with abdominal lymphoma underwent US and CT studies during staging, treatment, or follow-up. A comparison of the results of the two methods shows that the systematic use of US allows 5% of lymph nodes missed at CT to be demonstrated, together with hepatic and splenic involvement also undetected by CT. It is true, however, that the limited number of cases does not allow this result to be correlated with the histopathologic type of lymphopathy. US has also been the examination of choice to evaluate response to chemotherapy and to study suspected relapses. In the authors' opinion, US should become a complementary technique to CT in the staging of abdominal lymphomas.

[Critical evaluation of preoperative instrumental staging of rectal tumors. Research on the adequate use of US, CT and MR]. / Valutazione critica della stadiazione strumentale preoperatoria dei tumori del retto. Ricerca di un impiego adeguato di US, TC e RM.

Both traditional exams (rectal exploration, rectoscopy, barium enema, CEA) and advanced imaging (31 US, 40 CT and 11 MR) were performed for preoperative evaluation of rectal carcinoma in order to assess the accuracy of radiological imaging in the T and N staging. The results obtained have not been considered satisfactory and it is felt that US, CT and MR should not be employed routinely for rectal staging. Indeed accuracy of US, CT and MR is respectively 64%, 75% and 81% in the T evaluation and 64%, 70% and 64% in the N staging. In order to evaluate the effective usefulness of these three latter imaging techniques a double therapeutical choice was proposed. The first treatment option was suggested on the basis of traditional staging while a second choice was given considering US, TC and MR data also. Operatory findings subsequently allowed a definitive judgement on the influence of the different techniques on treatment selection. US has furnished useful data that could have allowed us to modify treatment in one case while in 5 other cases diagnostic error would have influenced treatment negatively. CT was useful in 5 cases while in 7 cases it would have influenced treatment choice negatively. MR would have been useful in one case and harmful in another. It is concluded that only patients with large neoplasms (stages T3 and T4) benefit from CT and MR staging with the exception of those cases that have tumors above the peritoneal fold or in strict relation with the sphincter structures. US was useful only in evaluating relations of neoplasms of the anterior rectal wall with nearby pelvic structures.

[Percutaneous biopsy (PB) of solid thoraco-abdominal formations with instrumental guidance. The authors' experience]. / Biopsia percutanea (BP) di formazioni solide toraco-addominali con guida strumentale. Esperienza personale.

The results are reported of 283 percutaneous biopsies performed on solid thoracic and abdominal masses. Indications to biopsy are examined at first, which are relatively limited in number if compared to other authors' opinion on the subject--i.e., when the tumor cannot be characterized with any other methodology, or in case of neoplasms whose histological type is to be known in order to plan therapy. The techniques employed are then evaluated, with a special emphasis on the needle caliber and the guidance method (US, radioscopy and CT). Correct samplings have been obtained in more than 90% of cases. Minor complications were observed in less than 10% of cases, while major complications were totally absent. In conclusion, percutaneous biopsy proves useful in those cases where exam indication is respected and an accurate selection is previously performed.

[Evaluation of the usefulness of ultrasonics in the diagnosis of cancerous cirrhosis. Comparison with CT]. / Valutazione dell'utilità dell'ecotomografia nella diagnosi della cancro-cirrosi. Confronto con la TC.

Cirrhotic liver hepatocellular carcinoma (HCC) was evaluated with both US and CT. In a group of 600 cirrhotic patients 64 had HCC, which was confirmed at histology in 24 cases, and by disease evolution in the other 40; single focal degeneration was proven in 40 patients, multiple (2, 3 focal lesions), or diffuse degeneration (more than 3 focal lesions) in the remaining 24. Sixteen patients had associated portal thrombosis. US recognized 38/40 single HCC, 22/24 multiple or diffuse lesions, and 11/16 portal vein thromboses. Degeneration was most frequently hypo/isoechoic in small tumors, hyperechoic and mixed in large lesions. When small lesions are hyperechoic their differentiation from both hemangiomas and regeneration noduli is extremely difficult. In such cases CT is mandatory. US diagnostic accuracy is by far superior to that of CT: 95% vs 85% in single lesions and 91.6% vs 87.5% in diffuse forms. Overall accuracy is 93.7% for US and 85.9% for CT. The authors believe that US should be performed every 6 months on cirrhotic patients, so as to allow HCC to be detected in time for radical surgery, while CT should be performed only when doubts persist.

[X-ray computed tomography in latero-cervical lymph nodes, clinically undetectable, in preoperative staging of malignant neoplasms of the larynx]. / Valutazione tomodensitometrica dei linfonodi latero-cervicali, clinicamente non apprezzabili (N0), nella stadiazione preoperatoria delle neoplasie maligne della laringe.

Postoperative CT of the latero-cervical lymph nodes was carried out in 25 patients suffering from laryngeal cancer. The surgically removed lymph nodes themselves were measured and examined histologically. 529/621 removed lymph nodes (about 85%) were recognisable with CT. The metastasized lymph nodes were clearly identified because of the presence of hypodense, poorly vascularised central foci. Some lymph nodes with a diameter of more than 15 mm on CT investigation proved free from metastatic lesions. This criterion should therefore be considered inadequate for diagnostic purposes. The CT cannot be held to be sufficiently precise to avoid conservative functional latero-cervical emptying as it is probably not able to recognise metastases without capsular rupture, not present in this series.

[Ultrasound and CT evaluation of non-lymphomatous splenic focal lesions]. / Valutazione US e TC delle lesioni focali spleniche non linfomatose.

Differential diagnosis problems are caused by the increased, at time occasional, detection of benign and malignant spleen focal lesions in routine superior abdomen ultrasound (US). The following pathologic conditions were reported in 29 patients with focal lesions (excepted systemic diseases): 6 plain cysts, 1 cystic lymphangioma, 3 echinococcus cysts, 3 abscesses, 7 hematomas and 9 metastases. US examination and clinical data together have permitted the differentiation of cysts from solid nodules but has limits in the characterisation of lesions and in the diagnosis of abscesses. Metastases did non present specific US or CT aspects and have been correctly characterized only with aid of anamnestical data and for the coexistence of hepatic lesions. CT has proven superior specificity, compared to US, only in the diagnosis of abscesses and should thus be utilized only in selected cases.

[Is it still useful to integrate cholecystography with direct radiography in the cholecystokinetic test?]. / E tuttora utile integrare la colecistografia con la radiografia diretta e la prova colecistocinetica?

There are discordant opinions in literature on the techniques of execution of the cholecystography. The authors have examined 104 consecutive patients with the clinical suspicion of gallstones in order to verify the usefulness of the plain radiogram and of the cholecystokinetic test. All the patients have been studied systematically with the plain radiogram of the hepatic region, with cholecystography completed by cholecystokinetic test and with ultrasound. In two cases of radiopaque gallstones (7.1%) the plain radiogram was indispensable for the diagnosis while the cholecystokinetic test has permitted to visualize, in one patient (3.5%), a small radiopaque gallstone previously hidden by the gallbladder opacity. In one subject (50%) the cholecystokinetic test has permitted the identification of a small adenomyoma later confirmed by ultrasound. As a conclusion, the diagnostic accuracy of the cholecystography is inferior to that of ultrasound (in the diagnosis of gallbladder stones and adenomyoma) if the first one is not integrated both with the plain radiogram and with the cholecystokinetic test; the Authors consider on the other side, that this last procedures can be substituted if cholecystography is systematically associated to ultrasound examination.

[Cholecystography and ultrasound compared in the radiological diagnosis of chronic cholecystitis]. / Colecistografia e US a confronto nella diagnosi radiologica di "colecistite cronica".

In 50 patients awaiting cholecystectomy, both cholecystography and cholecystosonography have been performed (or repeated), in order to examine the gallbladder wall implementing both examinations with the cholecystokinetic test. The results, related to the surgical, anatomical- and histo-pathological reports, show that, to detect gallbladder parietal lesions, the two studies are complementary in the diagnosis of cholecystitis: consequently, in the authors' opinion, they should always be carried out in association, with the exception of cases when cholecystography may not be possible either because of radiation protection reasons or because of jaundice. Although further experiments are required, it is suggested that the cholecystokinetic test be revalued.