Computerized tomography texture analysis of pheochromocytoma: relationship with hormonal and histopathological data.

OBJECTIVES: Pheochromocytomas are rare tumors which can present with heterogeneous secretion profiles, clinical manifestations, and radiologic appearance. Under a histopathological point of view, they can be characterized as more or less aggressive with the Pheochromocytoma of the Adrenal gland Scaled Score (PASS) and the Grading system for Adrenal Pheochromocytoma and Paraganglioma (GAPP) score. The aim of this study is to analyze the texture analysis characteristics of pheochromocytoma and identify whether the texture analysis can yield information aiding in the diagnosis and the characterization of those tumors. METHODS: Radiological, biochemical, and histopathological data regarding 30 consecutive patients with histologically confirmed pheochromocytoma were analyzed. Images obtained in the unenhanced, late arterial, venous, and delayed phases were used for the texture analysis. RESULTS: Urinary epinephrine and metanephrine levels showed a significant correlation (R2 = 0.946; R2 = 699) in the multivariate linear model with texture features, as well as Ki-67 (R2 = 0.397), PASS score (R2 = 0.182), GAPP score (R2 = 0.705), and cellularity showed a significant correlation (R2 = 0.389). The cluster analysis based on radiomic features resulted in 2 clusters, with significative differences in terms of systolic and diastolic blood pressure values at the time of diagnosis (p = 0.025), GAPP score (4 vs 6, p = 0.05), histological pattern (1-2, p = 0.039), and comedonecrosis (0% vs 50%, p = 0.013). CONCLUSION: In conclusion, our study provides the proof of concept for the use of texture analysis on contrast-enhanced CT images as a noninvasive, quantitative tool for helping in the characterization of the clinical, biochemical, and histopathological features of pheochromocytoma.

Radiologically defined lipid-poor adrenal adenomas: histopathological characteristics.

BACKGROUND: Adrenal lipid-poor adenomas (LPA) are defined by high unenhanced density (≥ 10 HU), and absolute and relative contrast medium washout > 60% and > 40%, respectively, at computerized tomography (CT). To date, no thorough histopathological characterization has been performed in those frequent lesions (one-third of adrenal adenomas). Our aim was to analyze the histopathological characteristics of adrenal LPA. METHODS: Patients with LPA (n = 57) were selected among consecutive subjects referred for an adrenal incidentaloma or ACTH-independent Cushing syndrome. FluoroDeoxyGlucose-Positron Emission Tomography (FDG-PET) was performed in 37 patients. In patients treated by adrenalectomy (n = 17), Weiss score and Lin-Weiss-Bisceglia score (in tumors composed entirely or predominantly of oncocytes) were calculated. RESULTS: Radiological parameters did not differ among patients with ACTH-independent Cushing syndrome (n = 6) and those with adrenal incidentalomas associated with primary aldosteronism (n = 2), autonomous cortisol secretion (n = 14), or non-functioning (n = 35). Patients treated by adrenalectomy had larger tumors (28.9 ± 11.2 vs 17.3 ± 8.4 mm, P < 0.001), higher CT unenhanced density (29.1 ± 11.0 vs 23.1 ± 9.0 HU, P = 0.043), and FDG-PET adrenal uptake (9.0 ± 6.4 vs 4.4 ± 2.3 SUV, P = 0.003) than non-operated ones. Oncocytic features > 75% of the tumor were detected in 12/17 cases (70.6%). Five of those showed borderline-malignant histopathological characteristics by Lin-Weiss-Bisceglia score. Among remaining non-oncocytic tumors, 1/5 had a Weiss score ≥ 3. Overall, 6/17 tumors (35.3%) had borderline-malignant potential. Radiological parameters were similar between patients with benign and borderline-malignant tumors. CONCLUSIONS: Adrenal LPA are a heterogeneous group of tumors, mostly composed of oncocytomas. Up to 1/3 of those tumors may have a borderline-malignant potential at histopathology.

Use of high-dose cytarabine in autologous bone marrow transplantation in acute myeloid leukemia.

Autologous bone marrow transplantation is widely used as late intensification therapy for patients with AML in remission without an HLA identical donor or who are older than 40-45 years. We report our experience in 21 AML patients in 1st or 2nd CR transplanted with a regimen including HD-ARA-C in addition to Cyclophosphamide (CY) and TBI. The median age was 32 years (3-50). Fourteen patients were transplanted in 1st CR and 7 in 2nd CR. In all but one patient BM harvesting and ABMT were done in the same remission status and after at least 3 courses of consolidation therapy. Two patients (9.5%) died from treatment related toxicity on Day +15 and Day +31. The median time to reach 1000 WBC and 50,000 platelets per cmm was 23 (13-55) and 55 (22-790) days respectively. Only 4 (21%) of the 19 evaluable patients (median observation time of 32 months) relapsed, at 3, 8, 18 and 26 months from ABMT. The projected event free survival curve shows survival of 67% at 96 months with a relapse rate of 26%.

Traumatic pathology of the thoracic aorta. Personal experience based on 42 cases.

Between 1974 and 1989, 42 patients have been operated on at the Istituto di Chirurgia Generale e Cardiovascolare of University of Milan, for traumatic pathology of the thoracic aorta: in 14 cases it occurred an acute rupture at the level of aortic isthmus and in 28 cases a posttraumatic fals aneurysm. We had an operative mortality of 28% (4 cases) in the acute rupture: 3 patients died for neurological complications which were present at hospitalization. In one case appeared a serious ARDS. We had no surgical deaths in patients operated on for the posttraumatic false aneurysm. In 15 cases, the patients suffered for a postoperative paraplegia. Surgical indications are discussed, overall for the posttraumatic false aneurysms. The authors consider the advantage and the risks of the use of ECC and of total heparinization of the patients.

Surgical treatment of abdominal aortic aneurysm. A ten-year experience (1980-1989) referred to 1725 patients operated on.

The authors' experience of surgical management of abdominal aortic aneurysms (AAA), in 1725 consecutive patients, operated on in a ten years period (1980-1989) is presented. Surgical indications, operative technique, and outcome of elective and emergency procedures are analyzed. A ten years follow-up period is also presented. This shows a significantly better survival rate in surgically treated patients than in nonoperated cases.

Acute aortic dissection. Personal experience.

Aortic dissection is a catastrophic event with a high mortality rate for untreated patients. One hundred and thirteen patients with acute aortic dissection were observed in the IInd Surgical Department of Milan University from 1974 to 1985; 55 had type I and II aortic dissection and 58 had type III aortic dissection. All patients with type I and II and about 50% of patients with type III aortic dissection underwent surgical correction. In the second type III group the aortic lesion was surgically corrected only when visceral ischaemia or ischaemia of the lower limb was recognized. In the other type III cases, medical treatment was preferred. The mortality rate was lower after medical treatment (15%) than after surgical treatment (37%). Follow-up was performed for the majority of patients and was recently completed with non-invasive techniques like Magnetic Resonance. It accurately shows the residual dissection and follows, the development of occlusion of the false lumen without any risk to the patients.

Acute ruptures of the thoracic aorta. Personal experience.

The statistical incidence, etiopathogenesis, diagnostics and surgical treatment of acute ruptures of the thoracic aorta are described. A personal series of 7 cases is reported; surgical techniques, benefits and risks of extracorporeal circulation during surgical treatments are analysed and discussed.

Surgical treatment of thoracic aortic aneurysms. Personal experience.

A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.

Cystic lymphangioma of the pancreas: anatomoclinical, diagnostic and therapeutic considerations regarding three personal observations and review of the literature.

Cystic lymphangioma is a very rare pathology and the pancreatic ones represent an exceptional report that must be considered in the differential diagnosis with others and more frequent cystic lesions of the pancreas. In this paper we describe three cases of cystic lymphangiomas of the pancreas observed in our Institute and we report on the literature review. Anatomopathological, clinical and therapeutics aspects of pancreatic cystic lymphangioma were analyzed for a better knowledge of this cystic lesion and to recognize some specific findings that could allow a preoperative diagnosis and, subsequently, a proper treatment.

[Hypertensive emergency during large vessel surgery]. / L'emergenza ipertensiva nella chirurgia dei grossi vasi.

The effectiveness of a new alpha-blocking agent with additional mechanism of action was evaluated during intraoperative hypertensive crises. Urapidil was administered both in bolus form and as a continuous infusion in order to compare the two routes of delivery. During the study systolic, diastolic, mean pressure and heart rate were measured, and results were evaluated using statistical methods. The study showed that urapidil clearly possesses a rapid (bolus route) and long-lasting (continuous infusion) hypotensive function. In conclusion, given its efficacy in hypertensive crises and the absence of side-effects in this study. Urapidil may be considered one of the best choices during intraoperative hypertension crises.

Atypical picture of cervico-vaginal condylomatosis in a patient submitted to hepatic transplant. A case report.

A case is presented of diffused cervico-vaginal condylomata in a 32-year-old woman who had undergone hepatic transplant and successive immunosuppressive therapy, treated with DTC and beta IFN for topical use.

[The use of methylprednisolone in the therapy of renal transplants from cadavers]. / L'uso del metilprednisolone nella terapia del trapianto renale da cadavere.

The role of steroids, and specifically of methylprednisolone, in the pharmacological treatment of cadaver kidney transplants is discussed. The action mechanisms of the substance, and the modalities for its use in basic treatment of the transplanted organ and in rejection crisis are described. Finally, the results obtained in 147 transplanted patients, the complications involved and the measures taken to eliminate, or at least reduce, the problems of prolonged steroid therapy are reviewed.

[Use of the Kimray-Greenfield filter in the prevention of pulmonary embolism. Personal experience]. / L'uso del filtro Kimray-Greenfield nella prevenzione dell'embolia polmonare. Esperienza personale.

Personal experience in the use of intra-caval filters in the prevention of pulmonary embolisms is reported. The advantages and the indications for positioning of the K.G. filter are analysed on the basis of a series of 31 patients operated on with this method.

Institutionalizing district level infant death review: an experience from southern India.

BACKGROUND: An Infant Death Review (IDR) programme was developed and implemented in two districts of Karnataka. OBJECTIVE: We explored the processes that led to the development of the IDR programme with a view to improving the existing pilot programme and to ensuring its sustainability. METHODS: A sequential mixed-methods design was followed in which quantitative data collection (secondary data) was followed by qualitative data collection (in-depth interviews). Quantitative data were entered using EpiInfo (version 3.5.1) software and qualitative data were analysed manually. RESULTS: Apart from ascertaining the cause of infant deaths, the IDR Committee discusses social, economic, behavioural and health system issues that potentially contribute to the deaths. As a result of the IDR programme, key actors perceived an improvement in infant death reporting at district level, the development of a rapport with the local community, and elaboration of a feedback system for corrective actions. This has led to improved health care during pregnancy. CONCLUSIONS: We found that involvement of the different stakeholders in planning and implementing the IDR programme offered a platform for collective learning and action. Impediments to the success of the programme need to be addressed by corrective actions at all levels for its future sustainability.

Chimeric superficial temporal artery based skin and temporal fascia flap plus temporalis muscle flap - An alternative to free flap for suprastructure maxillectomy with external skin defect.

Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery.

Institutionalizing district level infant death review: an experience from southern India

Background: An Infant Death Review (IDR) programme was developed and implemented in twodistricts of Karnataka.Objective: We explored the processes that led to the development of the IDR programme with aview to improving the existing pilot programme and to ensuring its sustainability.Methods: A sequential mixed-methods design was followed in which quantitative data collection(secondary data) was followed by qualitative data collection (in-depth interviews). Quantitativedata were entered using EpiInfo (version 3.5.1) software and qualitative data were analysedmanually.Results: Apart from ascertaining the cause of infant deaths, the IDR Committee discusses social,economic, behavioural and health system issues that potentially contribute to the deaths. As aresult of the IDR programme, key actors perceived an improvement in infant death reporting atdistrict level, the development of a rapport with the local community, and elaboration of a feedbacksystem for corrective actions. This has led to improved health care during pregnancy.Conclusions: We found that involvement of the different stakeholders in planning and implementingthe IDR programme offered a platform for collective learning and action. Impediments to thesuccess of the programme need to be addressed by corrective actions at all levels for its futuresustainability

[Therapy of shock]. / Terapia dello shock.

Shock therapy is a problem which readily leads to considerations of a practical nature. Routine clinical experience is the basis for all evaluations of results. Drugs, doses, therapeutical tactics are of value only in so far as experience has successfully made use of them.