Patterns of Lymph Node Metastasis in Differentiated Thyroid Cancer; Clinical Implications with Particular Emphasis on the Emerging Role of Compartment-Oriented Lymph Node Dissection.

Recent advances in modern imaging allow an accurate identification of involved or suspicious lymph nodes within the nodal compartments of the neck. Careful ultrasonographic lymphatic mapping of the neck by an experienced radiologist allows a targeted, compartment-oriented (or selective) lymph node dissection to be performed instead of the more extensive modified radical lymph node dissection. Compartment-oriented lymph node dissection necessitates the close cooperation of an experienced radiologist with a particular interest in thyroid and neck ultrasonography. There is emerging evidence that this more conservative strategy allows local control of the disease while at the same time morbidity is minimized and a better cosmetic result is achieved. Further investigation is needed to establish the precise role of this interesting surgical approach.

MR imaging features and tumor biomarkers of screen-detected and non-screen detected breast cancers: preliminary results of a comparative study.

PURPOSE: To investigate differences in clinical features, MRI findings and tumor biomarker characteristics in screen-detected (SCD) and non-screendetected (NSCD) cancers. MATERIAL AND METHODS: A total of 62 women (mean age, 48.4 years; range, 33-68 years) with biopsy confirmed breast cancer who underwent preoperative breast MRI were retrospectively evaluated by two expert radiologists. The women were divided into two groups according to the mode of cancer detection (Group A: screen- detected, Group B: non-screen/symptomatic cancer) and clinical, histopathological, MRI characteristics and biomarker features in each group were evaluated. RESULTS: NSCD tumors had significantly greater size (3.5 cm vs. 2.1 cm) and Ki-67 expression (68.4% vs. 41.7%) in comparison to SCD cancers. NSCD cancers were less likely to have strongly positive progesterone receptors (Pr) and more likely to have Ki-67 > 15% or positive nodal status (47.4% vs. 8.3%). Increased breast density (ACR C and D: 78.9% vs. 50%ACR A and B) and intense background parenchymal enhancement (BPE, moderate/marked: 42.1% vs. 8.3% minimal/mild) were significantly more frequent in NSCD cases. CONCLUSION: NSCD cancers had higher prevalence of poor prognostic characteristics in comparison to SCD tumors, including larger tumor size, higher Ki-67 index, and positive nodes. Increased fibroglandular tissue and intense BPE were both strongly associated with NSCD cancers, supporting their use as potential MR biomarkers in breast cancer risk models.

Correlation Between Contrast-enhanced Ultrasound Characteristics (Qualitative and Quantitative) and Pathological Prognostic Factors in Breast Cancer.

BACKGROUND/AIM: Little is known about the correlation between contrast-enhanced ultrasound (CEUS) characteristics and pathological prognostic factors in breast cancer. The aim of this study was to explore the correlation between CEUS characteristics and pathological prognostic factors. PATIENTS AND METHODS: A retrospective study with 34 malignant breast lesions was conducted. CEUS characteristics included qualitative characteristics (e.g. lesion's enhancement degree and order, internal lesion homogeneity etc.) and quantitative characteristics (e.g. peak intensity, time to peak etc.). Also, pathological prognostic factors were included (e.g. tumor grade, estrogen receptor status etc.). RESULTS: Blurred lesion margins were observed more often in tumors of high histological grade (p=0.01) and in estrogen receptor-negative tumors (p=0.049). Furthermore, perilesional enhancement was associated with positive Ki-67 expression (p=0.049), while heterogeneous internal sentinel lymph node enhancement was associated with malignant infiltration of the node (p=0.002). CONCLUSION: CEUS has the potential to provide a prevision of pathological prognostic factors in malignant breast lesions, helping in the better early patient management.

Phase II study of panitumumab combined with capecitabine and oxaliplatin as first-line treatment in metastatic colorectal cancer patients: clinical results including extended tumor genotyping.

This clinical trial assessed the efficacy and toxicity of panitumumab combined with oxaliplatin and capecitabine as first-line treatment in KRAS exon 2 wild-type metastatic colorectal cancer (mCRC) patients. Patients with exon 2 KRAS wild-type mCRC received panitumumab 9 mg/Kg, oxaliplatin 130 mg/m2, and capecitabine 2000 mg/m2 repeated every 3 weeks. The primary endpoint was objective response rate (ORR, minimum 42 responses). We retrospectively assessed mutations in genes implicated in CRC with massively parallel sequencing; ERBB2 and EGFR amplification with fluorescence in situ hybridization, and tumor-infiltrating lymphocyte density. Among 78 patients enrolled, 45 (57.7%) completed 6 cycles. Most common grade 3-4 toxicities were skin rash (19.2%), diarrhea (18%), and neuropathy (6.4%). Among 5 (6.4%) potentially treatment-related deaths, 2 (2.6%) were characterized toxic. Objective response occurred in 43 (55.1%) of the patients (complete 6.4% and partial response 48.7%; stable 17.9% and progressive disease 7.7%), while 3.8% were non-evaluable and 15% discontinued their treatment early. Additional mutations in KRAS/NRAS/BRAF were found in 11/62 assessable (18%) tumors. After 51 months median follow-up, median progression-free (PFS) was 8.1 and overall survival 20.2 months, independently of KRAS/NRAS/BRAF or PI3K-pathway mutation status. Patients with TP53 mutations (n = 34; 55%), as well as those with left colon primary tumors (n = 66; 85%), had significantly better PFS, also confirmed in multivariate analysis. Although the clinical trial met its primary endpoint, according to the current standards, the efficacy and tolerability of the drug combination are considered insufficient. Extended genotyping yielded interesting results regarding the significance of TP53 mutations.ClinicalTrials.gov identifier: NCT01215539, Registration date: Sep 29, 2010.

Should renal color Doppler ultrasonography be a routine test in newly diagnosed hypertensive patient?

: European Society of Hypertension/European Society of Cardiology guidelines recommend calculation of estimated glomerular filtration rate and evaluation of urinary albumin excretion rate as routine tests in the initial evaluation and during the follow-up of all hypertensive patients. However, from a clinical point of view, renal ultrasound - a noninvasive, readily available and cheap imaging modality - could contribute to the better evaluation of a hypertensive patient by identifying common causes of secondary hypertension (HTN) originating from the kidney and more recently by detecting renal injury in severe or long-standing essential HTN by measuring renal resistive indexes. The purpose of this review is to summarize the actual evidence which could support a larger use of renal ultrasound in the work-up of patients with newly diagnosed HTN.

Contrast-Enhanced Color Doppler Ultrasonography for Preoperative Evaluation of Sentinel Lymph Node in Breast Cancer Patients.

BACKGROUND: Sentinel lymph node (SLN) biopsy is the standard of care for breast cancer patients with non-palpable axillary lymph nodes. We evaluated the usefulness of contrast-enhanced ultrasonography in preoperative detection of malignant SLNs. METHODS: 50 patients with breast cancer (median age: 60 years) underwent a color power Doppler ultrasonography with intravenous contrast (Sonovue®) preoperatively, and findings suggestive of metastatic disease to the SLN were documented. The final histopathological report and the radiological preoperative record were compared. Finally, the sensitivity, specificity and diagnostic accuracy of this evolving diagnostic modality were calculated. RESULTS: Contrast-enhanced ultrasound scan identified a negative SLN in the axilla of 27 patients and final histopathology was negative for 30 cases in total, so negative predictive value was calculated as 90% and positive predictive value was 75%. Overall sensitivity was 83.33% and specificity was 84.38%. Moreover, the ability of contrast-enhanced ultrasound to differentiate between SLN status was only statistically significantly correlated with the actual final histopathological report (p < 0.001), while successful ultrasound prediction was not correlated with any factor. CONCLUSIONS: SLN status can be evaluated preoperatively using contrast-enhanced color Doppler ultrasonography with high accuracy.

Diffuse pattern of bone marrow involvement on magnetic resonance imaging is associated with high risk cytogenetics and poor outcome in newly diagnosed, symptomatic patients with multiple myeloma: a single center experience on 228 patients.

Magnetic Resonance Imaging (MRI) and specific cytogenetic abnormalities offer important prognostic information for myeloma patients. However, limited data are available about the association between cytogenetic abnormalities and MRI patterns of marrow infiltration. To address this issue, we analyzed 228 consecutive newly diagnosed, symptomatic patients who were diagnosed and treated in a single center. On bone marrow MR images, 95 (41%) patients had diffuse, 94 (41%) had focal, 35 (15%) were normal, and 4 (1.7%) patients had variegated pattern of marrow infiltration. High risk cytogenetics were more commonly observed with diffuse MRI pattern (50% vs. 31% in focal and normal patterns). Patients with diffuse MRI pattern had poorer survival compared to others and responded better to novel agent-based therapies than to conventional chemotherapy (objective response: 88% vs. 46%, P < 0.001). There was a significant improvement of patients' survival with a diffuse MRI pattern when treated upfront with novel agents compared to conventional chemotherapy (47 vs. 24 months; P < 0.001). Diffuse MRI pattern along with ISS-3 and high risk cytogenetics could identify a very high risk group of patients with extremely poor median survival (21 months) and an only 35% probability of 3-year OS. Our study shows that symptomatic myeloma patients with a diffuse MRI pattern at diagnosis very often show high risk cytogenetic abnormalities and are benefiting from upfront novel agent-based therapies. Diffuse MRI pattern in combination with high risk cytogenetics and ISS-3 can identify a subset of myeloma patients with very poor prognosis who may need innovative treatment strategies and possibly more aggressive therapies.

Ovarian vein thrombosis mimicking acute abdomen: a case report and literature review.

BACKGROUND: Ovarian vein thrombosis (OVT) is a rare, but serious condition that affects mostly postpartum women. A high index of suspicion is required in order to diagnose this unusual cause of abdominal pain. CASE PRESENTATION: A 19-year-old woman at three days postpartum was admitted to our hospital because of severe right lower quandrant abdominal pain and fever 38.5'C. Physical examination revealed an acutely ill patient and right lower quadrant tenderness with positive rebound and Giordano signs. The patient underwent appendectomy which proved to be negative for acute appendicitis. Postoperatively fever and pain persisted and abdominal CT-scan with intravenous contrast agent demonstrated a thrombosed right ovarian vein. The patient was initiated on low-molecular weight heparin (LMWH) and antibiotic treatment and a month later a new abdominal CT-scan showed a patent right ovarian vein. DISCUSSION: Pathophysiologically, OVT is explained by Virchow's triad, because pregnancy is associated with a hypercoagulable state, venous stasis due to compression of the inferior vena cava by the uterus and endothelial trauma during delivery or from local inflammation. Common symptoms and signs of OVT include lower abdomen or flank pain, fever and leukocytosis usually within the first ten days after delivery. The reported incidence of OVT ranges 0,05-0,18% of pregnancies and in most cases the right ovarian vein is the one affected. Anticoagulation and antibiotics is the mainstay of treatment of OVT. Complications of OVT include sepsis, extension of the thrombus to the inferior vena cava and renal veins, and pulmonary embolism. The incidence of pulmonary embolism is reported to be 13.2% and represents the main source of mortality due to OVT. CONCLUSIONS: OVT is a rare condition, usually in the postpartum period. A high index of suspicion is required for the prompt diagnosis and management especially in cases that mimic acute abdomen.

Degenerative endplate changes of the lumbosacral spine: dynamic contrast-enhanced MRI profiles related to age, sex, and spinal level.

PURPOSE: To investigate differences in perfusion profiles between degenerative endplate marrow changes and normal vertebral marrow in relation to spinal level, age, and sex with dynamic contrast-enhanced magnetic resonance imaging (DCE MRI). MATERIALS AND METHODS: Ninety-two consecutive patients referred for evaluation of low back pain or sciatica, without history of malignant or chronic disease, underwent conventional and DCE MRI of the lumbosacral spine. Fifty-two of them demonstrated degenerative endplate marrow changes. Regions of interest were placed on sites of normal marrow (group A) and degenerative changes (group B) on subtracted images. Fitted time-intensity curves (fTICs) were generated and evaluated for curve pattern. Both groups were stratified into upper (L1-L2) and lower (L3-I1) levels, males and females younger or older than 50 years. Perfusion parameters were calculated and statistically compared for both groups and subgroups. Receiver operator curve (ROC) analysis was also performed. RESULTS: Two fTIC patterns were identified. Perfusion parameters of degenerative changes and normal marrow differed significantly, even when groups were stratified for spinal level, age, and sex (P < 0.05). A time to peak value >108 seconds was characteristic for degenerative changes with sensitivity 69.5% and specificity 84.6%. CONCLUSION: DCE MRI profiles of degenerative endplate marrow changes of the lumbosacral spine differ significantly from normal marrow regardless of spinal level, age, or sex.

Combination of right nephrectomy and total pancreaticoduodenectomy for Von Hippel-Lindau disease.

CONTEXT: Von Hippel-Lindau disease is an inherited syndrome of multiorgan neoplasia caused by a germline mutation in the von Hippel-Lindau gene and can include central nervous system tumors, renal cell carcinomas and benign pancreatic cystic tumors. CASE REPORT: We report the case of a 56-year-old patient who had a past history of cerebellar hemangioblastoma and presented with abdominal pain. Imaging revealed renal tumors and multiple pancreatic tumors which caused duodenal and pancreatic duct compression. The patient was treated with a combination of radical right nephrectomy, total pancreaticoduodenectomy and splenectomy. Pathology identified a multifocal unilateral clear cell renal carcinoma which interestingly coexisted with multiple large pancreatic serous microcystic adenomas with infiltration of the fibrous capsule. CONCLUSION: In past cases of von Hippel-Lindau disease, pancreatic adenomas with malignant transformation have not been reported. In our case, the infiltration of the fibrous capsule by parenchymal cells may indicate malignant transformation.

Recurrent pulmonary embolism due to giant hepatic hamangioma treated with hepatectomy under vascular exclusion.

Giant hepatic hemangiomas are benign tumors that measure more than 4 cm and are usually asymptomatic. Pulmonary embolism (PE) is an extremely rare manifestation of giant hepatic hemangiomas. We report a case of a 44-year-old woman who suffered of recurrent pulmonary emboli that, after thorough work up, were attributed to thrombi formation inside a giant hepatic hemangioma. A right hepatectomy under vascular exclusion was performed and the hemangioma, measuring 17 cm, was resected. Two years later the patient remains asymptomatic. The report highlights the value of investigating giant liver hemangiomas in case of PE. In such cases, the hemangioma should be resected preferably under occlusion of the venous outflow of the liver to avoid PE intraoperatively.

Surgical challenges in the treatment of leiomyosarcoma of the inferior vena cava: analysis of two cases and brief review of the literature.

BACKGROUND: Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor of mesenchymal origin. Optimal treatment should include complete resection of the malignant lesion with preservation of venous return. We present our experience from two patients treated in our hospital in the last 3 years. METHODS AND RESULTS: The first case is that of a 54-year-old woman, with a 9 cm a primary IVC leiomyosarcoma extending from the level of the right renal vein to the common iliac veins. The patient underwent radical tumor resection and reconstruction of the IVC with a polytetrafluoroethylene patch. She received adjuvant chemotherapy and is free of recurrence almost 3 years after surgery. The second case is that of a 56-year-old woman presenting with back pain due to an 8-cm retroperitoneal mass in close proximity to the right renal vein. She underwent exploratory laparotomy, where initially the effort of en bloc resection of the mass failed. Eventually, partial resection of the IVC was performed and the defect was primarily repaired. Pathological examination confirmed primary leiomyosarcoma of the IVC. She received adjuvant chemotherapy, but was referred to our hospital with local recurrence 6 months after the operation and is suffering from disseminated abdominal disease almost a year postsurgery. CONCLUSION: Radical surgical en bloc resection is the mainstay of treatment for IVC leiomyosarcomas. Extensive vascular reconstruction techniques may be necessary to restore adequate venous return to the IVC after tumor resection, and combination with adjuvant chemoradiotherapy has been shown to prolong disease-free survival rates.

Primary hepatic neuroendocrine tumor with exophytic growth: report of a case with diagnosis by fine needle aspiration biopsy.

BACKGROUND: Primary hepatic neuroendocrine tumor with exophytic growth is a unique entity. CASE: A 74-year-old man presented to our hospital with abdominal discomfort. Diagnostic imaging procedures revealed a 15 x 10-cm mass in the liver with exophytic growth. The tumor was adjacent to the stomach, and clinical suspicion of gastrointestinal stromal tumor of the stomach was very strong initially. The cytologic and immunocytochemical examination of aspirated material showed features similar to those of neuroendocrine tumor. Systemic staging procedures showed no evidence of metastasis or other primary site. The histopathologic results of the excised tumor confirmed the cytologic diagnosis. CONCLUSION: Primary neuroendocrine tumor with exophytic growth is a rare entity and can be diagnosed with cytology and immunocytochemistry.

Gastric glomus tumor: a case report.

Gastric glomus tumors are rare mesenchymal tumors of the gastrointestinal tract. We describe a 72-year-old patient who presented with episodes of melena and was subsequently investigated for a tumor of the antrum of the stomach. Surgical resection revealed a 2 x 2 x 1.7 cm well circumscribed submucosal tumor, extending into the muscularis propria. The histopathologic examination of the specimen demonstrated a glomus tumor of the stomach. We discuss the preoperative investigation, the diagnostic problems and the surgical treatment of the patient with this rare submucosal lesion.

Plain X-ray, computed tomography and magnetic resonance imaging findings of telangiectatic osteosarcoma: a case report.

An 18-year-old male patient presented with chronic nonspecific pain of three months located at his left proximal tibia. The patient was admitted to our department for plain X-ray, computed tomography and magnetic resonance imaging examination. Plain X-ray and computed tomography revealed a geographic lytic lesion at the medial aspect of the proximal tibia. Biopsy of the lesion showed telangiectatic osteosarcoma. Image findings of all modalities are presented.

Intermittent obstructive jaundice following gastric band placement.

Complications of laparoscopic adjustable gastric banding occur in 10 - 20% of patients. However, hepatobiliary complications of this procedure are very rare. We report a unique case of gastric band misplacement around the hepato-duodenal ligament. The patient developed obstructive jaundice several months after the gastric band placement and suffered recurrent episodes of obstructive jaundice and cholangitis that were initially erroneously attributed to fatty infiltration of the liver. Further diagnostic work-up demonstrated the presence of the gastric band in the hepatic hilum. Exploratory laparotomy confirmed the diagnosis, and the band was removed. Jaundice reversed and hepatic function was restored following removal of the occluding band.