Three-dimensional imaging reconstruction and laparoscopic robotic surgery: a winning combination for a complex case of multiple myomectomy.

OBJECTIVE: To demonstrate the intraoperative use of three-dimensional (3D) imaging reconstruction for a complex case of multiple myomectomy assigned to robot-assisted laparoscopic surgery. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: University tertiary care hospital. PATIENT(S): A 36-year-old nulliparous infertile woman with multiple uterine myomas (>20) presented with menorrhagia and pelvic discomfort for many months. Because of the huge number of fibroids present, the patient was considered eligible for laparoscopic robotic-assisted myomectomy. INTERVENTION(S): A robotic-assisted laparoscopic myomectomy was performed with the use of intraoperative 3D imaging reconstruction. After opening the retroperitoneum through the adnexal triangle and identifying the ureters, to reduce intraoperative bleeding, bulldog clamps were used to temporarily reduce uterine vascularization. A multiple myomectomy was then performed with the use of tenaculum and Maryland bipolar forceps. During the intervention, the surgeon used the 3D uterine reconstruction to adapt its surgical strategy. Multilayer running closure was achieved using a bidirectional barbed suture ensuring introflexion of the serosa. Patients' consent was obtained for publication of the case; institutional review board approval was not required for this case report as per our institution's policy. MAIN OUTCOME MEASURE(S): Description of a robotic-assisted myomectomy with the intraoperative use of 3D imaging reconstruction. RESULT(S): The total operative time was 105 minutes. A total of 21 fibroids were removed with 150 mL of intraoperative blood loss. The patient was discharged the day after. CONCLUSION(S): The application of 3D imaging technology could overcome one of the limitations of robot-assisted minimally invasive surgery, the lack of haptic feedback, enabling the surgeon to rapidly locate myomas and guide the intraoperative plan to optimize the results. Additional studies evaluating the clinical impact of this technique and its improvement are required.

Contrast-Enhanced Ultrasound Findings in Patients with Rare Solitary Necrotic Nodule of the Liver - a Multicenter Report.

PURPOSE: This multicenter retrospective study highlights the contrast-enhanced ultrasound (CEUS) findings in a series of histologically proven solitary necrotic nodules (SNN) of the liver, a poorly understood pathologic entity of uncertain origin that mimics malignancy. MATERIALS AND METHODS: 22 patients (M/F 13/9; mean age 59.4 years, SD ±â€Š10.7, range 35-81) with histological diagnosis of SNN and CEUS were selected from clinical, imaging, and pathological archives of 7 US interventional centers, each of which provided 1 to 6 cases (mean 2.8). Pathological diagnosis was made on 20 US-guided biopsies and 2 surgical specimens. 2 patients had 2 SNNs with identical CEUS findings so that imaging analysis was carried out on 24 nodules. RESULTS: SNN was an incidental finding in healthy people in 10 cases (45.5 %), and it was discovered during follow-up for either known extrahepatic malignancies (9 cases = 41 %) or chronic liver disease (3 cases = 13.5 %). SNNs had a mean size of 19.3 mm (SD ±â€Š6.5, range 9-40). On B-mode US, SNNs appeared hypoechoic in 14 cases (66.7 %), "target-like" in 7 cases (29.2 %), and homogeneously hyperechoic in 1 case (4.1 %). On CEUS, all lesions appeared devoid of contrast enhancement ("punched out" aspect) in the arterial, portal venous, and late phases after US contrast agent injection. A uniformly thin, hyperenhancing ring in the early arterial phase and isoenhanced with the surrounding parenchyma in the portal venous and late phases was found in 10 nodules (41.6 %). Clinical and imaging follow-up (mean duration 42.2 months, SD ±â€Š34.9, range 2-108) was available in 15 patients with 16 SNNs: no changes in size and echostructure were seen. CONCLUSION: CEUS can contribute to the diagnosis of SNN when a "punched out" appearance in all vascular phases with or without thin rim enhancement in the very early arterial phase is present in healthy subjects in whom a focal liver lesion is incidentally found. In patients with a history of chronic liver disease or malignancy, US-guided biopsy represents the unavoidable first-line diagnostic modality.

MRI radiomics: A machine learning approach for the risk stratification of endometrial cancer patients.

PURPOSE: To investigate radiomics and machine learning (ML) as possible tools to enhance MRI-based risk stratification in patients with endometrial cancer (EC). METHOD: From two institutions, 133 patients (Institution1 = 104 and Institution2 = 29) with EC and pre-operative MRI were retrospectively enrolled and divided in two a low-risk and a high-risk group according to EC stage and grade. T2-weighted (T2w) images were three-dimensionally annotated to obtain volumes of interest of the entire tumor. A PyRadiomics based and previously validated pipeline was used to extract radiomics features and perform feature selection. In particular, feature stability, variance and pairwise correlation were analyzed. Then, the least absolute shrinkage and selection operator technique and recursive feature elimination were used to obtain the final feature set. The performance of a Support Vector Machine (SVM) algorithm was assessed on the dataset from Institution 1 via 2-fold cross-validation. Then, the model was trained on the entire Institution 1 dataset and tested on the external test set from Institution 2. RESULTS: In total, 1197 radiomics features were extracted. After the exclusion of unstable, low variance and intercorrelated features least absolute shrinkage and selection operator and recursive feature elimination identified 4 features that were used to build the predictive ML model. It obtained an accuracy of 0.71 and 0.72 in the train and test sets respectively. CONCLUSIONS: Whole-lesion T2w-derived radiomics showed encouraging results and good generalizability for the identification of low-risk EC patients.

The Use of Ceus Software with No Contrast Media Administration in the Diagnosis of Pneumoperitoneum.

BACKGROUND: Pneumoperitoneum is defined by the presence of free air in the abdominal cavity; gastrointestinal perforation is an important cause of this pathological condition. In emergency situations, radiology is considered vital in the early detection and identification of the site and cause of the perforation, which is critical for proper surgical planning. AIM: The aim of our study was to evaluate a new diagnostic US tool, based on the US contrast-specific software generally used during contrast-enhanced US examination (CEUS), without the administration of sonographic contrast media, and to describe the specific imaging features in the detection of free intra-peritoneal air. SUBJECTS AND METHODS: One hundred and fifty-seven consecutive and hemodynamically stable patients, who arrived in our E.D. with an acute abdomen between April 2018 and October 2019, underwent US and CT examination, performed by three radiologists (with 5, 5, and 25 years of experience). The US was performed first and divided into two steps, using B-mode US and both B-mode and contrast-specific software US, with no contrast media administration. All the patients underwent CT examination. RESULTS: In 32 out of 157 patients, the surgery confirmed GI perforation. CT correctly detected 31 out of 32 patients; the contrast-specific software US identified 30 perforated patients. CT reached a sensitivity value of 97% and specificity value of 100%; contrast-specific software US demonstrated higher values than B-mode US in sensitivity (93% vs. 70%, respectively) and specificity (98% vs. 88%, respectively). CONCLUSION: the use of contrast-specific software in emergencies improves image quality, and reaches higher levels of sensitivity and specificity with no time delay compared to standard US examination, helping radiologists expedite diagnoses.

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma.

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

Tailored versus fixed scan delay in contrast-enhanced abdominal multi-detector CT: An intra-patient comparison of image quality.

PURPOSE: To perform anintra-patient comparison betweena single-pass protocol (SP) and a portal venous phase (PVP) by means ofboth quantitative and qualitative analysis of image quality. METHODS: Forty patients (31 M; 9F; aged 20-77 years; BMI 23 ± 4 Kg/m2) underwent both a SP and a PVP using a 64-rows multi-detector CT with a median interval time of 56 days (range5-903). All patients underwent i.v. bolus injection (2.0 cc/sec) of 1.7 cc/Kg of a non ionic iodinated contrast-media (370 mgI/ml) with scan delays of 67 ± 8 and 90 s for the SP and the PVP, respectively. Signal- (SNR) and contrast-to-noise ratios (CNR) were calculated for most visceral organs and for both abdominal aorta (AA) and main portal vein (MPV). For qualitative analysis, reproduction of abdominal viscera and vascular structures was blindly evaluated and inter-observer agreement calculated by the weighted Cohen k-analysis. RESULTS: Attenuation values (H.U.) of AA (232 ± 53vs180 ± 36) and MPV (215 ± 39vs187 ± 42) were significantly (p < 0.001) higher in the SP than in PVP, respectively. At qualitative analysis, reproduction of mostabdominal viscerawas also significantly sharper (p < 0.001) with the SP than the PVPwith inter-observer agreement scores (k)ranging from 0.60 to 0.88 for all but one imaging criteria. CONCLUSIONS: As the SP resulted in a significantly higher vascular enhancement and in a sharper reproduction of most abdominal viscera, it may be better suited than a PVP for the CT evaluation of non traumatic acute abdomen.

Mycosis fungoides (CTCL) associated with colorectal adenocarcinoma. A rare case of combined response to neoadjuvant therapy.

Mycosis fungoides (MF) is a well-known and common form of cutaneous T-cell lymphoma (CTCL), composed of malignant proliferation of CD4+CD45Ro+helper memory T cells. In the patient with MF, the incidence of secondary malignancies is higher than general population but very few cases with both MF and colorectal adenocarcinoma have been reported. Herein we describe a case of MF occurring in a 64-year-old man and followed, five months later, by a diagnosis of colorectal adenocarcinoma. Of notice, simultaneous regression of both rectal mass and cutaneous MF manifestations was observed after administration of chemioradiation therapy prior to rectal surgery. The patient is alive and in stable clinical remission at eight years from the diagnosis. KEY WORDS: CTCL, Colorectal adenocarcinoma, Mycosis fungoides, PUVA.

MRI to assess deep myometrial invasion in patients with endometrial cancer:A multi-reader study to evaluate the diagnostic role of different sequences.

OBJECTIVE: The identification of deep myometrial invasion (DMI) represents a fundamental aspect in patients with endometrial cancer (EC) for accurate disease staging. It can be detected on MRI using T2-weighted (T2-w), diffusion weighted (DWI) and dynamic contrast enhanced sequences (DCE). Aim of the study was to perform a multi-reader evaluation of such sequences to identify the most accurate and its reliability for the best protocol. METHODS: In this multicenter retrospective study, MRI were independently evaluated by 4 radiologists (2 senior and 2 novice) with a sequence-based approach to identify DMI. The performance of the entire protocol was also evaluated. A comparison between the different sequences assessed by the same reader was performed using receiver operating curve and post-hoc analysis. Intraclass Correlation Coefficient (ICC) was used to assess inter- and intra-observer variability. RESULTS: A total of 92 patients were included. The performance of the readers did not show significant differences among DWI, DCE and the entire protocol. For only one senior radiologist, who reached the highest diagnostic accuracy with the entire protocol (82,6 %), both DWI (p = 0,0197) and entire protocol (p = 0,0039) were found significantly superior to T2-w. The highest inter-observer agreement was obtained with the entire protocol by expert readers (ICC = 0,77). CONCLUSIONS: For the detection of DMI, the performances of DWI and DCE alone and that of a complete protocol do not significantly differ, even though the latter ensures the highest reliability particularly for expert readers. In cases in which T2-w and DWI are consistent, an unenhanced protocol could be proposed.

Use of Contrast-Enhanced Ultrasound in Ablation Therapy of HCC: Planning, Guiding, and Assessing Treatment Response.

Contrast-enhanced ultrasonography (CEUS) plays an important role in the management of patients treated with ablation therapies, in the diagnostic, therapeutic and monitoring phases. Compared to contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging, CEUS presents several advantages in imaging HCC, including real time imaging capability, high sensitivity for tumor vascularity, absence of renal toxicity, no ionizing radiation, repeatability of injections, good compliance by the patient and low cost. The purpose of this review is to evaluate the role of CEUS in the management of the patients with HCC treated with ablation therapies and describe how in our protocol CEUS is integrated with the other imaging modalities such as contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging.

Early Diagnosis of Liver Metastases from Colorectal Cancer through CT Radiomics and Formal Methods: A Pilot Study.

BACKGROUND: Liver metastases are a leading cause of cancer-associated deaths in patients affected by colorectal cancer (CRC). The multidisciplinary strategy to treat CRC is more effective when the radiological diagnosis is accurate and early. Despite the evolving technologies in radiological accuracy, the radiological diagnosis of Colorectal Cancer Liver Metastases (CRCLM) is still a key point. The aim of our study was to define a new patient representation different by Artificial Intelligence models, using Formal Methods (FMs), to help clinicians to predict the presence of liver metastasis when still undetectable using the standard protocols. METHODS: We retrospectively reviewed from 2013 to 2020 the CT scan of nine patients affected by CRC who would develop liver lesions within 4 months and 8 years. Seven patients developed liver metastases after primary staging before any liver surgery, and two patients were enrolled after R0 liver resection. Twenty-one patients were enrolled as the case control group (CCG). Regions of Interest (ROIs) were identified through manual segmentation on the medical images including only liver parenchyma and eventual benign lesions, avoiding major vessels and biliary ducts. Our predictive model was built based on formally verified radiomic features. RESULTS: The precision of our methods is 100%, scheduling patients as positive only if they will be affected by CRCLM, showing a 93.3% overall accuracy. Recall was 77.8%. CONCLUSION: FMs can provide an effective early detection of CRCLM before clinical diagnosis only through non-invasive radiomic features even in very heterogeneous and small clinical samples.

Role of multidetector computed tomography in the assessment of pancreatic injuries after blunt trauma: a multicenter experience.

Pancreatic injuries can occur from either penetrating or blunt abdominal trauma. While there are rare, especially in the setting of blunt abdominal trauma, they are associated with a mortality of up to 30%, and a morbidity of 60%. Multidetector computed tomography (MDCT) is the preferred imaging modality in patients with acute blunt abdominal trauma and for the detection of acute pancreatic injury. Magnetic resonance (MR) and magnetic resonance cholangiopancreatography (MRCP) plays an important role in the follow-up of pancreatic injury. In this brief review, we discuss the main MDCT acute imaging findings as well as the complications. Finally, we discuss the role of MR and MRCP in follow up of patients with pancreatic injuries.

Obstructing left sided colorectal cancer. A retrospective single Center study.

BACKGROUND: In recent years, with population aging, there has been an increased number of colorectal cancer cases with severe occlusion symptoms. About 75% of obstructions due to malignant colorectal cancer (10-30%) occur distal to splenic flexure. METHODS: The authors evaluated the best surgical therapeutic strategy to be used in cases of left-sided colorectal carcinoma in patients over 65 years old, especially considering the emergency condition, age of patients and efficacy in terms of postoperative morbidity, mortality and 5 years survival rate. RESULTS: The management of left-sided obstructing colorectal carcinoma is controversial. Hartmann's procedure is the best therapeutic choice in elderly patients. However, resection with intraoperative colonic wash-out and primary anastomosis has favorable outcome in low risk patients. CONCLUSIONS: A review of the literature reveals that primary resection and anastomosis for left-sided obstructing CRC is the correct therapeutic strategy in low risk patients with localized, resectable carcinoma, without peritonitis; Hartmann's procedure should be adopted in doubtful cases and in high risk patients.

The Induction of Noble Rot (Botrytis cinerea) Infection during Postharvest Withering Changes the Metabolome of Grapevine Berries (Vitis vinifera L., cv. Garganega).

The natural or induced development of noble rot caused by the fungus Botrytis cinerea during the late stages of grapevine (Vitis vinifera L.) berry ripening is used in some traditional viticulture areas to produce high-quality wines such as Sauternes and Tokaji. In this research, we wanted to verify if by changing the environmental conditions during post-harvest withering we could induce the noble rot development on harvested berries in order to positively change the wine produced from withered Garganega berries. Therefore, we exposed the berries to postharvest withering under normal or artificially humid conditions, the latter to induce noble rot. The presence of noble rot symptoms was associated with the development of B. cinerea in the berries maintained under humid conditions. The composition of infected and non-infected berries was investigated by untargeted metabolomics using liquid chromatography/mass spectrometry. We also explored the effects of the two withering methods on the abundance of volatile organic compounds in wine by yeast-inoculated micro-fermentation followed by targeted gas chromatography/mass spectrometry. These experiments revealed significant metabolic differences between berries withered under normal and humid conditions, indicating that noble rot affects berry metabolism and composition. As well as well-known botrytization markers, we detected two novel lipids that have not been observed before in berries infected with noble rot. Unraveling the specific metabolic profile of berries infected with noble rot may help to determine the compounds responsible for the organoleptic quality traits of botrytized Garganega wines.

The incidence of thyroid carcinoma in the nodules. A retrospective study.

UNLABELLED: Fine-needle aspiration (22G) is the diagnostic procedure chosen to study the nature of suspicious thyroid nodules. In 2008 the SIAPEC-IAP work group issued the results of Italian Consensus about the clinical management of patients with thyroid nodular disease, and introduced diagnostic categories aimed to standardize the diagnostic and therapeutic process of patients affected by thyroid nodules. This retrospective study is aimed to assess the incidence of carcinoma at definitive histological examination after total thyroidectomy of nodules with TIR3 cytological diagnosis. KEY WORDS: CEUS, FNAC, Surgery, Thyroid nodules.

Immunochemical investigation of allergenic residues in experimental and commercially-available wines fined with egg white proteins.

Proteinaceous egg whites are widely used as a fining agent during the production of red wines. Residues of egg white in the final wine could present a risk for individuals allergic to eggs. This study investigated the presence of allergenic residues in both red and white wines fined with egg whites. Experimental and commercially available wines fined with egg whites, with or without subsequent bentonite fining, were studied. Unfined wines were used as negative controls. The physicochemical characteristics of each wine were determined to assess their possible role in enhancing or hindering the elimination of allergenic residues from wine. The amount of egg white protein residues was investigated both by a specifically developed/validated ELISA test and by immunoblotting. Both immunochemical tests used the same anti-total egg white protein antibody and were highly sensitive to the allergen. No egg white protein was detected in the wines studied in either immunochemical test, irrespective of the physicochemical characteristics of the wine, the type and dosage of the fining agent and the oenological process used. The risk of adverse reactions in egg-allergic individuals should therefore be considered negligible, but the exemption from labelling should be allowed only when the absence of residues is confirmed by analytical controls.

Decision making in borderline ovarian tumors: report of a rare case of mesosigma psammocarcinoma.

Psammocarcinoma is a rare variant of serous carcinoma arising either from ovary or peritoneum, characterized by massive psammoma body formation, low-grade of cytologic differentiation and invasiveness. Its clinical behavior is similar to the serous borderline tumors, whose prognosis is significantly better compared to invasive forms, with a 5-year survival in stage I greater than 95%. A typical feature of borderline ovary tumors is the presence, in more than 30% of cases, of borderline peritoneal implants similar to primary ovarian cancer or of invasive forms. We report a case of a 44-years-old woman who referred to our clinic for mesosigmoid mass , accidentally discovered by ultrasonography. Sigmoidectomy with fertility sparing surgery was performed in september 2010. The mass was hystologically characterized by many psammoma bodies and low grade cytological features with diagnosis of psammocarcinoma of mesosigma. One year after the primary surgery, the patient showed with left adnexial mass; optimal debulking surgery was performed including omentectomy, total abdominal hysterectomy, bilateral adnexectomy and appendicectomy. The patient did not receive any adjuvant chemotherapy and to date she is alive and with no evidence of disease. The conclusion is that psammocarcinoma is a very rare tumor that behaves less aggressively than typical serous carcinoma, the mainstay of treatment is surgical debulking , with fertility sparing surgery as possible option in young patients with ovaries macroscopically free of disease.

Absence of allergenic residues in experimental and commercial wines fined with caseinates.

The possible presence of allergenic residues in wines treated with one of the potassium caseinates used as fining agents has been investigated. Samples of experimental (16) and commercial (63) wines that had been fined with caseinates with or without bentonites were studied. The leading physicochemical characteristics of each wine sample were determined to assess their possible role in promoting or hindering the elimination of allergenic residues. The study used a specifically developed ELISA test as well as an immunoblotting technique in which membranes were incubated with specific anti-caseinate antibody, both tests having high sensitivity for allergenic residues. No detectable allergenic residues were found in any of the samples by either immunochemical test, irrespective of the physicochemical characteristics of the wine, the type and dosage of refining agent and the enological process used.