Proposal for a systematic preoperative assessment of pelvic endometriosis.

AIM: Severe endometriosis represents one of the most challenging clinical and surgical cases in gynecology. Preoperative assessment of the extension of the disease is of key relevance to opt for medical or surgical therapy and, sometimes, to plan a multidisciplinary approach. METHODS: A systematic diagnostic approach is proposed and evaluated in a tertiary referral centre. It is based on an initial clinical evaluation and a second level ultrasound of the pelvis. Further exams, whenever required, have to be aimed at demonstrating specific involvements of organs other than ovaries and peritoneum such as bowel, urinary tract and nerves. RESULTS: The application of the proposed protocol has led to a reduction of the number of non-radical surgical procedures due to incomplete consent associated with missed diagnosis over the years (P<0.001). CONCLUSION: Our findings support the efficacy of a systematic diagnostic approach to endometriosis. This allows a correct planning of therapy with a multidisciplinary approach when necessary.

Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging.

BACKGROUND: The purpose of the study was to compare the accuracy of double-contrast barium enema (DCBE) and magnetic resonance imaging (MRI) in the diagnosis of intestinal endometriosis using the histological examination on resected specimen as comparative standard. METHODS: Eighty-three consecutive patients with suspected intestinal endometriosis, resected between 2005 and 2007, were prospectively evaluated. All of the women underwent preoperative DCBE and MRI on the same day. We evaluated number, site (rectum, sigmoid, cecum), and size of the lesions. The imaging findings were correlated with those resulting at pathology. RESULTS: Among the 65 women who underwent surgery, 50/65 (76.9%) were found to have bowel endometriosis, with 9/50 (18%) patients presenting two lesions; DCBE allowed to detect 50/59 (84.7%) lesions. MRI allowed to detect 42/59 (71.1%) lesions. DCBE showed sensibility, specificity, PPV, NPV, and accuracy of respectively 84.7, 93.7, 98.0, 62.5, and 86.6%, MRI of 71.1, 83.3, 93.3, 46.8, and 74.6%. CONCLUSION: DCBE is more accurate than unenhanced MRI in the diagnosis of bowel endometriosis, and should be preferred in the preoperative management of this disease, since it usually enables a proper surgical planning.

Stenting unprotected left main coronary artery stenosis in heart transplant patients--the good, bad, and the ugly.

The major cause of late death following orthotopic heart transplantation is coronary artery vasculopathy. Approximately 50% of heart transplant patients have coronary artery vasculopathy 5 years post-transplantation. With advances in interventional cardiology technology, heart transplant patients with selected lesions are now undergoing intravascular stenting with acute-gain and late-loss rates similar to stenting in non-transplanted patients. We describe 3 consecutive cases of stenting unprotected left main coronary artery disease in orthotropic heart transplant patients. With follow-up to 3 years and no evidence of restenosis, these results suggest that stenting unprotected left main coronary artery lesions in heart transplant patients can be performed with excellent immediate and long-term results.

Autoimmune pancreatitis: possibilities of CT characterization.

BACKGROUND: Pancreatitis is defined as an inflammatory disease of the pancreas, leading to morphological and pathological changes. Recently, an autoimmune pathogenesis of this disease has been proposed. This type of pancreatitis should be differentiated from other pancreatic diseases, since appropriate therapy is effective and morphological changes and pancreatic function can recover to normal levels. AIM OF THE STUDY: To assess the possibility of distinguishing autoimmune pancreatitis from other pancreatic diseases with an analogous clinical presentation on the basis of CT findings alone. METHODS: The CT images of 7 patients with proven autoimmune pancreatitis, along with those of 20 patients with other pancreatic diseases, but with an analogous clinical presentation, were retrospectively evaluated in a blinded fashion by 2 radiologists. In particular, the radiologists had to search for the typical signs of autoimmune pancreatitis. Discordant cases were further analyzed in the presence of a 3rd radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The sensitivity, specificity, positive and negative predictive values of CT were calculated against each of the diseases (autoimmune pancreatitis; other pancreatic diseases), in order to evaluate the diagnostic value of the scan. RESULTS: After the consensus evaluation, the correct diagnosis was reached in 25/27 (92.5%) cases, with only 2/27 wrong diagnoses (autoimmune pancreatitis diagnosed as another pancreatic disease and vice versa). The sensitivity and specificity of CT against autoimmune pancreatitis were 86 and 95%, respectively. The positive and negative predictive values were 89 and 93%, respectively. CONCLUSION: Patients with autoimmune pancreatitis demonstrate imaging findings that enable the correct diagnosis by dynamic CT, even in the presence of nonspecific clinical symptoms. The precise classification of the disease is extremely important, since simple steroid therapy then represents the correct treatment, and leads to complete recovery.

Characterization of cystic tumors of the pancreas: CT accuracy.

PURPOSE: The purpose of this work was to evaluate the capabilities of CT to accurately characterize cystic tumors of the pancreas. METHOD: Two observers retrospectively evaluated the CT exams of 100 cystic masses of the pancreas, with pathological confirmation. The two observers, blinded about clinical information and the final diagnosis, tried to categorize the lesions according to well established morphologic features. Statistical analysis was performed to measure the agreement between each radiologist and the consensus diagnosis and to evaluate the usefulness of certain CT findings in differentiating one type of cystic pancreatic neoplasm from another. RESULTS: Serous cystadenoma was better diagnosed by CT [Youden misclassification index (Ymi) = 0.72] than mucinous cystic tumor (Ymi = 0.44) and solid pseudopapillary tumor (cystic variant) (Ymi = 0.47). CONCLUSION: As patients with previous history of pancreatitis were excluded from the study, CT findings allowed correct characterization of only 60% of cystic pancreatic masses. Among the remaining 40%, 15-20% of the wrong diagnoses could not be corrected by means of CT, given the patterns shown by the tumors. In 20-25% of the cases, a nonspecific diagnosis of cystic mass was made.

Intraductal papillary mucinous tumor of the pancreas: a pictorial essay.

Intraductal papillary mucinous tumor (IPMT) of the pancreas was identified and classified only recently. IPMT has a primarily intraductal, papillomatous growth pattern, which is associated with excessive mucin secretion and results in progressive ductal dilatation or cyst formation. The tumor occurs in four forms: segmental or diffuse involvement of the main pancreatic duct and macrocystic or microcystic involvement of a branch duct. In the past, many IPMTs may have been misdiagnosed as chronic pancreatitis because of their generally benign behavior. The correct diagnosis, once achieved only with endoscopic retrograde cholangiopancreatography (ERCP), can now be made with noninvasive imaging modalities, particularly computed tomography (CT) and magnetic resonance (MR) imaging. ERCP remains the imaging modality of choice for diagnosis of IPMT. With ERCP, the communication between the cystically dilated ductal segment or branch duct and the main pancreatic duct is easily demonstrated. However, reflux of contrast material due to an excess of mucin or an enlarged papillary orifice hinders filling of the ductal tree. Filling defects due to mucin globs or mural nodules are also important clues to the diagnosis. Bulging of the papilla into the duodenal lumen is virtually pathognomonic of IPMT and is well demonstrated with CT or MR imaging.

Endovascular stenting of an unprotected left main coronary artery stenosis in a heart transplant patient.

Endoluminal revascularizaion of left main coronary artery vessels is considered to be relatively contraindicated because of a high procedural mortality and restenosis rate. This report describes the first successful case of endovascular stenting in an unprotected left main coronary artery stenosis in a heart transplant patient.

[Morphologic imaging of thyroid carcinoma]. / L'imaging morfologico del carcinoma tiroideo.

Ultrasonography (US) is the choice morphological imaging modality in the study of thyroid carcinomas. The present technological evolution (high frequency probes, development of Colour-Doppler) allows the detection of small non-palpable nodules, being able to define, in a high percentage of cases, features pointing to the malignant character of a thyroid mass, although the definite assessment of malignancy (invasion of adjacent structures, metastatic cervical nodes) is quite rare. From a diagnostic viewpoint US is required to identify nodules with suspect features, to be submitted to fine needle aspiration biopsy. Moreover, US plays a basic role in the staging--at the cervical level--of carcinomas as well as in the post-operative follow-up. The other imaging modalities (Computed Tomography, Magnetic Resonance Imaging) play a limited role in both staging and post-operative follow-up.

Relative performance of specific and nonspecific fluorescence polarization immunoassay for cyclosporine in transplant patients.

The analytical performance of specific and nonspecific fluorescence polarization immunoassays (FPIAs, Abbott Laboratories) for cyclosporine was compared. Both specific and nonspecific FPIAs demonstrated excellent between-run coefficients of variation (5.9% vs. 3.9%) at three levels of control, and a high degree of between-center reproducibility (r2 greater than 0.96). In addition, the correlation between cyclosporine levels measured by specific and nonspecific FPIAs was statistically significant, though imperfect, in both renal (r2 = 0.70) and cardiac transplant patients (r2 = 0.55). In kidney transplant patients, the nonspecific/specific ratio was significantly higher in patients with serum bilirubin concentration exceeding 3 mg/dl (5.9 +/- 2.6 vs. 2.8 +/- 1.1), due to impaired elimination of cyclosporine metabolites in the bile. The nonspecific/specific ratio was also significantly higher in heart transplant patients early (less than 1 month) posttransplant compared with patients in the late posttransplant period (3.4 +/- 0.8 vs. 2.9 +/- 0.8). The Abbott FPIA provides a highly precise method for measuring cyclosporine, with a turnaround time of 15-20 min. The specific monoclonal FPIA has the additional advantage of measuring primarily unchanged cyclosporine and thus has an imperfect correlation with the nonspecific polyclonal FPIA. Together with clinical data, the use of FPIAs may help to improve the efficiency of cyclosporine therapeutic drug monitoring.

Surgical treatment of 200 consecutive patients with left main coronary artery disease.

Two hundred consecutive patients underwent myocardial revascularization for left main coronary artery disease between January, 1975, and December, 1981. The mean age of this group was 64 +/- 8 years, and 78.5% of the patients were men. The anginal pattern was chronic stable in 6% of the patients and progressive or unstable in the remainder. Resting electrocardiograms showed prior myocardial infarction in 45.5%. Left ventricular end-diastolic pressure was elevated in 145 patients, and ejection fraction was less than 50% in 40 patients. The mean number of bypass grafts per patient was 3.2 +/- 1.4 (standard deviation). Seventeen patients underwent major concomitant cardiovascular procedures. The operative mortality was 3.5%, and the incidence of perioperative infarction was 3%. Factors associated with reduced operative survival were increased age; unstable angina, or acute myocardial infarction, or both; female sex; circumflex-dominant circulation; and major concomitant procedures. Late mortality at a mean follow-up of 33.5 months was 6%, and 91% of the surviving patients assessed their quality of life as "excellent" or "good."

Arrhythmias detected by ambulatory monitoring. Lack of correlation with symptoms of dizziness and syncope.

The correlation of symptoms (SX) with major arrhythmias (ARS) occurring during 24-hour ambulatory monitoring (AM) was investigated in a goup of patients referred because of dizziness or syncope. Ninety-eight consecutive patients, ages 25 to 82, who had adequate diaries of activities and SX, wre included. The ARS considered to be major were ventricular and supraventricular ectopy grade 2, 3, and 4 (Lown classification), sinus arrest and block, atrioventricular block, and sinus bradycardia less than or equal to 40/minute. Although all patients were referred because of dizziness and/or syncope, only 41 (42%) had their symptoms during the recording period. The ARS were recorded in 63 (64%). There was no statistically significant difference in the incidence or in the type of ARS in the group with, and the group without, symptoms (x2 = 1.64). Of the 23 subjects with both major ARS and recorded SX, only two had SX and ARS occurring concomitantly. It is concluded that (1) this is a group with a high prevalence of major ARS, (2) there was correlation between major ARS recorded and SX reported in a very small percent of cases (2%), (3) treating the ARS in the others could not be expected to abolish the SX, and (4) the high cost of monitoring should be considered in this context.