Clinical characteristics influence screening intervals for diabetic retinopathy.

AIMS/HYPOTHESIS: Most guidelines recommend annual screening for diabetic retinopathy (DR) but limited resources and the slow progression of DR suggest that longer recall intervals should be considered if patients have no detectable lesions. This study aimed to identify the cumulative incidence and time of development of referable DR in patients with no DR at baseline, classified by clinical characteristics. METHODS: Analysis was performed of data collected prospectively over 20 years in a screening clinic based in a teaching hospital according to a consensus protocol. The cumulative incidence, time of development and relative risk of developing referable retinopathy over 6 years following a negative screening for DR were calculated in 4,320 patients, stratified according to age at onset of diabetes (<30 or ≥ 30 years), being on insulin treatment at the time of screening and known duration of diabetes (<10 or ≥ 10 years). RESULTS: The 6 year cumulative incidence of referable retinopathy was 10.5% (95% CI 9.4, 11.8). Retinopathy progressed within 3 years to referable severity in 6.9% (95% CI 4.3, 11.0) of patients with age at onset ≥ 30 years, who were on insulin treatment and had a known disease duration of 10 years or longer. The other patients, especially those with age at onset <30 years, on insulin and <10 years duration, progressed more slowly. CONCLUSIONS/INTERPRETATION: Screening can be repeated safely at 2 year intervals in any patient without retinopathy. Longer intervals may be practicable, provided all efforts are made to ensure adherence to standards in procedures and to trace and recall non-attenders.

Primary hepatic carcinoid: a case report and literature review.

Carcinoids are tumors derived from neuroendocrine cells and often produce functional peptide hormones. Approximately 54.5% arise in the gastrointestinal tract and frequently metastasize to the liver. Primary hepatic carcinoid tumors (PHCT) are extremely rare; only 95 cases have been reported. A 65-year-old man came to our attention due to occasional ultrasound findings in absence of clinical manifestations. His previous medical history, since 2003, included an echotomography of the dishomogeneous parenchymal area but no focal lesions. A computed tomography scan performed in 2005 showed an enhanced pseudonodular-like lesion of about 2 cm. Cholangio-magnetic resonance imaging identified the lesion as a possible cholangiocarcinoma. No positive findings were obtained with positron emission tomography. Histology suggested a secondary localization in the liver caused by a low-grade malignant neuroendocrine tumor. Immunohistochemistry was positive for anti chromogranin antibodies, Ki67 antibodies and synaptophysin. Octreoscan scintigraphy indicated intense activity in the lesion. Endoscopic investigations were performed to exclude the presence of extrahepatic neoplasms. Diagnosis of PHCT was established. The patient underwent left hepatectomy, followed by hormone therapy with sandostatine LAR. Two months after surgery he had a lymph nodal relapse along the celiac trunk and caudate lobe, which was histologically confirmed. The postoperative clinical course was uneventful, with a negative follow-up for hematochemical, clinical and radiological investigations at 18 mo post-surgery. Diagnosis of PHCT is based principally on the histopathological confirmation of a carcinoid tumor and the exclusion of a non-hepatic primary tumor. Surgical resection is the recommended primary treatment for PHCT. Recurrence rate and survival rate in patients treated with resection were 18% and 74%, respectively.

Common bile duct schwannoma: a case report and review of literature.

Schwannoma is a myelin sheath tumor complicated with neurofibroma, neurofibromatosis and neurogenic sarcoma. Peripheral nerve sheath tumors represent 2%-6% of gastrointestinal tract stromal tumors (GIST), but there are deficient data about location of neurogenic tumors in the biliary system and only nine cases of schwannoma of the extrahepatic biliary tract have been reported. These tumors are clinically non-specific. They are usually symptomatic by compressing the close or adjacent structures when being retroperitoneal, and their preoperative diagnosis is extremely difficult. This paper reviews the literature data and describes a case of schwannoma of the common bile duct associated with cholestasis in a healthy young woman, diagnosed and treated in our department. This case is of interest on account of the complexity of its diagnosis and the atypical macroscopic growth pattern of the tumor.