Preoperative MRI accuracy after neoadjuvant chemoradiation for locally advanced rectal cancer.

Background and aims: To evaluate the performance of magnetic resonance imaging (MRI) in restaging locally advanced rectal cancers (LARC) after neoadjuvant chemoradiotherapy (nCRT), with pathologic correlation. Methods: 80 patients with LARC treated with neoadjuvant therapy, with restaging MRI and surgery, were enrolled and prospectively reviewed. The diagnostic accuracy of the restaging MRI was assessed for tumor (ymrT), nodal status (ymrN), circumferential resection margin (ymrCRM), extramural vascular invasion (ymrEMVI) and tumoral deposits (ymrN1c) by calculating the sensitivity (Se), specificity (Sp), negative predictive values (NPV) and positive predictive values (PPV). Response to treatment was classified as good response (complete/near complete) vs. poor response (poor/partial response). The agreement between the tumor regression grade at MRI (mrTRG) and pathology (pTRG) was reported, as well the performance of mrTRG to identify good responders. The correlation between restaging MRI and histopathology was assessed by Spearman correlation coefficient. Results: The MRI accuracy ranged between 63.8% and 92.5% for T stage and was 81.3% for N stage. All MRI parameters evaluated at restaging were statistically significant correlated with histopathology evaluation, but EMVI. There was moderate correlation for N and N1c and a positive strong correlation for T, CRM and TRG (Spearman correlation coefficient of 0.390 for mrN1c-pN1c, 0.428 for mrN-pN, 0.522 for mrCRM-pCRM, 0.550 for mrT-pT and 0.731 for mrTRG-pTRG). Diagnostic accuracy of anal sphincter invasion was 91.3%, with a negative predictive value (NPV) of 100%. Accuracy rate varied between 70% for partial response to 93.75% for complete response after nCRT. Conclusions: MR imaging had good accuracy in restaging LARCs after nCRT. Our results showed high MRI accuracy in detecting anal sphincter involvement for low rectal tumors, with high NPV to exclude tumoral invasion. Restaging MRI predicted well the tumor regression grade, with good diagnostic performance in differentiating good responders from poor/partial responders. The accuracy was high for detecting complete response.

Artificial Intelligence for Personalised Ophthalmology Residency Training.

Residency training in medicine lays the foundation for future medical doctors. In real-world settings, training centers face challenges in trying to create balanced residency programs, with cases encountered by residents not always being fairly distributed among them. In recent years, there has been a tremendous advancement in developing artificial intelligence (AI)-based algorithms with human expert guidance for medical imaging segmentation, classification, and prediction. In this paper, we turned our attention from training machines to letting them train us and developed an AI framework for personalised case-based ophthalmology residency training. The framework is built on two components: (1) a deep learning (DL) model and (2) an expert-system-powered case allocation algorithm. The DL model is trained on publicly available datasets by means of contrastive learning and can classify retinal diseases from color fundus photographs (CFPs). Patients visiting the retina clinic will have a CFP performed and afterward, the image will be interpreted by the DL model, which will give a presumptive diagnosis. This diagnosis is then passed to a case allocation algorithm which selects the resident who would most benefit from the specific case, based on their case history and performance. At the end of each case, the attending expert physician assesses the resident's performance based on standardised examination files, and the results are immediately updated in their portfolio. Our approach provides a structure for future precision medical education in ophthalmology.

Association of Parathyroid and Differentiated Thyroid Carcinomas: A Narrative Up-To-Date Review of the Literature.

Aim: Parathyroid carcinoma (PC) is a rare endocrine malignancy that represents 0.005% of all malignant tumors. Associated PC and differentiated thyroid carcinoma (DTC) is an exceptionally rare condition, and the preoperative diagnostics and proper treatment are challenging. Almost all PCs and the majority of DTCs are diagnosed postoperatively, making correct surgical treatment questionable. Specific guidelines for parathyroid and thyroid carcinomas association treatment are lacking. The purposes of our study were to identify the association between parathyroid and thyroid carcinomas, to analyze the available published data, and to evaluate the possible relationship between preoperative diagnostic and surgical decision-making, and outcome-related issues. Material and methods: We performed a literature review of several databases from the earliest records to March 2022, using controlled vocabulary and keywords to search for records on the topic of PC and WDTC pathological association. The reference lists from the initially identified articles were analyzed to obtain more references. Results: We identified 25 cases of PC and DTC association, 14 more than the latest review from 2021. The mean age of patients was 55, with a female to male ratio of about 3:1. Exposure to external radiation was identified in only one patient, although it is considered a risk factor the development of both PC and DTC. The preoperative suspicion of PC was stated by the authors in only 25% of cases, but suspicion based on clinical, laboratory, ultrasound (US), and fine needle aspiration (FNA) criteria could have been justified in more than 50% of them. With neck ultrasound, 40% of patients presented suspicious features both for PC and thyroid carcinoma. Intra-operatory descriptions of the lesions revealed the highest suspicion (83.3%) of PC, but en bloc resection was recommended and probably performed in only about 50% of the cases. Histopathological examinations of the thyroid revealed different forms of papillary thyroid carcinoma (PTC) in most cases. Postoperative normocalcemia was achieved in 72% of patients, but follow-up data was missing in about 25% of cases. Conclusion: Associated PC and DTC is an exceptionally rare condition, and the preoperative diagnostic and treatment of the patients is a challenge. However, in most cases pre- and intraoperative suspicious features are present for identification by a highly specialized multidisciplinary endocrine team, who can thus perform the optimal treatment to achieve curability.

SERS Liquid Biopsy Profiling of Serum for the Diagnosis of Kidney Cancer.

Renal cancer (RC) represents 3% of all cancers, with a 2% annual increase in incidence worldwide, opening the discussion about the need for screening. However, no established screening tool currently exists for RC. To tackle this issue, we assessed surface-enhanced Raman scattering (SERS) profiling of serum as a liquid biopsy strategy to detect renal cell carcinoma (RCC), the most prevalent histologic subtype of RC. Thus, serum samples were collected from 23 patients with RCC and 27 controls (CTRL) presenting with a benign urological pathology such as lithiasis or benign prostatic hypertrophy. SERS profiling of deproteinized serum yielded SERS band spectra attributed mainly to purine metabolites, which exhibited higher intensities in the RCC group, and Raman bands of carotenoids, which exhibited lower intensities in the RCC group. Principal component analysis (PCA) of the SERS spectra showed a tendency for the unsupervised clustering of the two groups. Next, three machine learning algorithms (random forest, kNN, naïve Bayes) were implemented as supervised classification algorithms for achieving discrimination between the RCC and CTRL groups, yielding an AUC of 0.78 for random forest, 0.78 for kNN, and 0.76 for naïve Bayes (average AUC 0.77 ± 0.01). The present study highlights the potential of SERS liquid biopsy as a diagnostic and screening strategy for RCC. Further studies involving large cohorts and other urologic malignancies as controls are needed to validate the proposed SERS approach.

Cervical Lymph Node Dissection for Papillary Thyroid Cancers: A Decade Experience of a Single Surgical Team.

Background: All patients undergoing thyroid operations should be subjected to preoperative neck ultrasound (US) followed by fine needle aspiration cytology (FNAC) of suspicious lesions. In Western countries, thyroid surgeons routinely perform neck ultrasound. The role of prophylactic central neck dissection (PCND) remains a topic of debate. For treatment of papillary thyroid carcinoma (PTC), in 2014 we introduced two new adjuncts: PCND based on criteria of the European Society of Endocrine Surgeons (ESES) consensus group and surgeon-performed US (S-US). Methods: In order to better understand the role of these two adjuncts in our shift of strategy we aimed to evaluate the outcomes of our patients in two successive 5-year time periods based on a retrospective analysis of our prospectively maintained database (total of 286 patients were included in this study). Results: The two groups were similar regarding epidemiological and clinical data. FNAC was done in only 21.66% of all PTC cases. PTC diagnosis was done in the majority of suspicious cases by FS. S-US guided the selective lateral node dissections (LND), leading to more lymph node metastases detections and it also surpassed endocrinologist performed US (E-US) in terms of PPV. PCND rate of complications was significantly higher due only to transient hypoparathyroidism. Conclusions: Preoperative surgeon-performed ultrasonography is a useful tool in the arsenal of PTC treatment. The systematic preoperative FNAC diagnosis and intraoperative frozen sections in uncertain cases are mandatory. PCND is a safe method of treatment and staging in PTC.

Near infrared light examination as part of the management of sporadic pancreatic head insulinoma: Case report.

INTRODUCTION: We report the case of a 77-year-old female patient with the diagnosis of pancreatic head insulinoma, in whom we used near infrared light (NIR) to detect synchronous pancreatic tumors and potential secondary lymph node or liver involvement. The patient presented with hypoglycemia manifesting by lipothymia. With the diagnosis of secretory neuroendocrine tumor (insulinoma) of the pancreatic head, cephalic pancreatoduodenectomy with the preservation of the pylorus was performed after NIR visualization of the pancreatic tumor mass. At 6, 12, 18 months postoperatively, the patient no longer had hypoglycemia and her general state was good. CONCLUSION: NIR with indocyanine green (ICG) evidences pancreatic neuroendocrine tumors, as well as possible synchronous tumors and secondary lymph node or liver involvement.

Multimodality treatment strategies have changed prognosis of peritoneal metastases.

For a long time, treatment of peritoneal metastases (PM) was mostly palliative and thus, this status was link with "terminal status/despair". The current multimodal treatment strategy, consisting of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), has been strenuously achieved over time, but seems to be the best treatment option for PM patients. As we reviewed the literature data, we could emphasize some milestones and also, controversies in the history of proposed multimodal treatment and thus, outline the philosophy of this approach, which seems to be an unusual one indeed. Initially marked by nihilism and fear, but benefiting from a remarkable joint effort of human and material resources (multi-center and -institutional research), over a period of 30 years, CRS and HIPEC found their place in the treatment of PM. The next 4 years were dedicated to the refinement of the multimodal treatment, by launching research pathways. In selected patients, with requires training, it demonstrated a significant survival results (similar to the Hepatic Metastases treatment), with acceptable risks and costs. The main debates regarding CRS and HIPEC treatment were based on the oncologists' perspective and the small number of randomized clinical trials. It is important to statement the PM patient has the right to be informed of the existence of CRS and HIPEC, as a real treatment resource, the decision being made by multidisciplinary teams.

Dynamic perfusion assessment during perforator flap surgery: an up-to-date.

Flap monitoring technology has progressed alongside flap design. The highly variable vascular anatomy and the complexity associated with modern perforator flaps demands dynamic, real-time, intraoperative information about the vessel location, perfusion patterns and flap physiology. Although most surgeons still assess flap perfusion and viability based solely on clinical experience, studies have shown that results may be highly variable and often misleading. Poor judgment of intraoperative perfusion leads to major complications. Employing dynamic perfusion imaging during flap reconstruction has led to a reduced complication rate, lower morbidity, shorter hospital stay, and an overall better result. With the emergence of multiple systems capable of intraoperative flap evaluation, the purpose of this article is to review the two systems that have been widely accepted and are currently used by plastic surgeons: Indocyanine green angiography (ICGA) and dynamic infrared thermography (DIRT).

Primary peritoneal serous psammocarcinoma: a case report.

BACKGROUND: Psammocarcinomas (PCas) are rare epithelial tumors, usually originating in the ovaries or the peritoneum. These tumors are morphologically characterized by extensive psammomatous calcifications, invasiveness and low-grade cytological features. CASE REPORT: We present the case of a 54-year-old woman who was referred to our department with an umbilical tumor and increasing abdominal girth. The patient had had an umbilical hernia for more than 20 years. The CA 125 level was normal. The CT scan showed small peritoneal nodules at the level of the Douglas pouch, including the posterior wall of the uterus, and the entire colon, as well as large nodules located on the caecum and the sigmoid colon. We performed partial enterectomy, total colectomy with ileo-rectal anastomosis, omentectomy, total histerectomy and bilateral adnexectomy, pelvic peritonectomy of the Douglas pouch. Pathology findings were consistent with F.I.G.O. stage IIIC peritoneal PCa. The patient received adjuvant chemotherapy with Taxol and Carboplatin. To date, twelve months after surgery, the follow-up shows no evidence of disease. CONCLUSION: Standardized treatment protocols are hindered by the rarity of the PCas. However, literature concludes that optimal debulking is mandatory, whereas the efficacy of adjuvant chemotherapy remains to be elucidated.

Surface plasmon resonance-induced photoactivation of gold nanoparticles as mitochondria-targeted therapeutic agents for pancreatic cancer.

BACKGROUND: Noble metal nanoparticles such as gold nanoparticles can strongly absorb light in the visible region by inducing coherent collective oscillation of conduction band electrons in strong resonance with visible frequencies of light. This phenomenon is frequently termed as surface plasmon resonance (SPR). OBJECTIVES: The main objective was to study the effects of laser photoactivated gold nanoparticles (by means of SPR) on human pancreatic cancer cells. RESULTS: Gold nanoparticles obtained using standard wet chemical methods (with sodium borohydride as a reducing agent) underwent photoexcitation using 2w 808 nm laser and further administered to 1.4E7 pancreatic cancer cell lines. Flow cytometry, transmission electron microscopy, phase contrast microscopy, quantitative proteomics and confocal microscopy combined with immunochemical staining were used to examine the interaction between photo excited gold nanoparticles and pancreatic cancer cells. CONCLUSION: The study shows that phonon-phonon interactions following laser photoexcitation of gold nanoparticles exhibit increased intracellular uptake, as well as mitochondrial swelling, closely followed by mitochondrial inner membrane permeabilization and depolarization. This unique data may represent a major step in mitochondria-targeted anticancer therapies using laser-activated gold nanoparticles.

Language, culture and international exchange of virtual patients.

BACKGROUND: Language and cultural differences could be a limiting factor for the international exchange of Virtual Patients (VPs), especially for small countries and languages of limited circulation. Our research evaluated whether it would be feasible to develop a VP based educational program in our Romanian institution, with cases in English and developed in a non-Romanian setting. METHOD: The participants in the research comprised 4th year Romanian medical students from the Faculty of Medicine in Cluj-Napoca, Romania, with previous training exclusively in Romanian, good English proficiency and no experience with VPs. The students worked on eight VPs in two identical versions, Romanian and English. The first group (2010) of 136 students worked with four VPs developed in Cluj and the second group (2011) of 144 students with four VPs originally developed at an US University. Every student was randomly assigned two different VPs, one in Romanian and another in English. Student activity throughout the case, the diagnosis, therapeutic plan and diagnosis justification were recorded. We also compared student performance on the two VPs versions, Romanian and English and the student performance on the two sets of cases, originally developed in Romania, respectively USA. RESULTS: We found no significant differences between the students' performance on the Romanian vs. English version of VPs. Regarding the students' performance on the two sets of cases, in those originally developed in Romania, respectively in the USA, we found a number of statistically significant differences in the students' activity through the cases. There were no statistically significant differences in the students' ability to reach the correct diagnosis and therapeutic plan. CONCLUSION: The development of our program with VPs in English would be feasible, cost-effective and in accordance with the globalization of medical education.

Current state of knowledge on neuroendocrine small bowel tumours: non-systematic review of the literature based on one case.

More than 60% of neuroendocrine tumours, also called carcinoids, are localised within the gastrointestinal tract. Small bowel neuroendocrine tumours have been diagnosed with increasing frequency over the past 35 years, being the second most frequent tumours of the small intestine. Ileal neuroendocrine tumours diagnosis is late because patients have non-specific symptoms. We have proposed to illustrate as an example the case of a patient, and on its basis, to make a brief review of the literature on small bowel neuroendocrine tumours, resuming several recent changes in the field, concerning classification criteria of these tumours and new recommendations and current advances in diagnosis and treatment. This patient came to our emergency department with a complete bowel obstruction, along with a 2-year history of peristaltic abdominal pain, vomits and diarrhoea episodes. During emergency laparotomy, an ileal stricture was observed, that showed to be a neuroendocrine tumour of the small bowel.

Cervical lymphadenopathy: metastasis of papillary carcinoma or ectopic thyroid tissue?

Papillary thyroid carcinoma frequently metastasises to the regional neck lymph nodes. However, cervical lymph node metastases as sole manifestation of occult papillary thyroid carcinoma are observed rarely. The authors report the case of a 52-year-old man presenting for slowly enlarging neck region and shortness of breath, with an insidious history for 15 years. Thyroid imaging showed a goitre predominantly of the right lobe, but histopathological finding revealed a multi-centric thyroid papillary carcinoma with lymph node metastasis.

Cross-cultural use and development of virtual patients.

Three major issues drive the cross-cultural use of virtual patients (VPs): an increased mobility of healthcare professionals, students and patients; limited resources for developing VPs; and emerging standards for the exchange of VPs across institutions. Many students are trained in countries other than where they were born. In addition, healthcare professionals often move between countries and are today meeting more and more patients from cultures different from their own. VPs can be used both for learning a new "medical" language as well as for illustrating different perspectives on illness in the new culture. Therefore, it may be important to develop cases reflecting patients from a wide variety of regions and cultures to prepare these professionals to understand both the background of these patients as well as the different medical conditions they may present. However, the benefits of using VPs may be limited at many universities by insufficient resources to develop all the VPs needed for their curricula. The option to acquire VPs from other universities may therefore be appealing, but as these may only be available in English, it is important to consider whether VPs reflecting the local illness panoramas and medical procedures are needed.

Staging laparoscopy in gastric cancer. Accuracy and impact on therapy.

BACKGROUND: Surgical therapy remains the most effective treatment modality in gastric cancer. The importance of multimodal treatment for advanced gastric cancer has contributed to the development of more accurate preoperative staging strategies. We examined the diagnostic accuracy of staging laparoscopy (SL) for abdominal metastases and the predictive value of SL for tumor resectability. MATERIAL AND METHOD: This is a prospective, cohort, observational study of 98 patients with primary gastric adenocarcinoma admitted at a tertiary referral hospital over a three year period. Extended SL, laparoscopic ultrasonography and peritoneal cytology were performed in 45 patients with gastric cancer without distant metastases on pre-therapeutic imaging staging. Of the 45 patients, 17 (37.8%) had distant metastases on SL and were offered palliative therapy and/or supportive care. Open laparotomy and gastrectomy was performed in the patients without distant metastases or with uncertain resectability on SL. RESULTS: An unnecessary laparotomy was avoided in 17 (37.8%) patients. The overall SL sensitivity for distant metastases was 89%, specificity 100% and diagnostic accuracy 95.5%. The sensitivity for lymph node metastases was 54.5%, the specificity 100% and the diagnostic accuracy 64.3%. The SL positive predictive value for resectability was 96% and the negative predictive value was 50%. The morbidity of SL was 2.2% and the mortality 0. CONCLUSION: Staging laparoscopy is a safe and effective staging modality in patients with gastric carcinoma. It avoids unnecessary laparotomies in a significant number of patients and should be mandatory if neoadjuvant treatment is planned.

Staging laparoscopy in digestive cancers.

BACKGROUND. Laparoscopy and laparoscopic ultrasonography may assist in the more accurate staging of digestive cancers. We assessed the diagnostic value of staging laparoscopy in patients with cancers of lower esophagus, stomach, liver, biliary tract, pancreas and colon. MATERIAL AND METHOD. Extended staging laparoscopy, laparoscopic ultrasonography and peritoneal cytology were performed in 165 patients with primary digestive cancers, admitted between January 2006 and December 2008 at three tertiary referral hospitals participating in the study. Staging laparoscopy was immediately followed by open surgery in 63 patients without distant metastases or with uncertain primary tumor resectability, and in 20 colorectal cancer patients with resectable hepatic metastases. The sensibility, sensitivity and diagnostic accuracy of staging laparoscopy for distant metastases and tumor resectability were assessed against the findings on open surgery and the final pathological report. RESULTS. An unnecessary laparotomy was avoided in 36 of the 99 patients (36.4%) without distant metastases on imaging pre-therapeutic staging. The staging laparoscopy sensitivity for distant metastases varied between 66% and 100% and the diagnostic accuracy between 87% for the lower esophageal cancer and 100% for the biliary tract tumors. The overall morbidity of staging laparoscopy was 2.5% and the mortality 0. CONCLUSION. Staging laparoscopy avoids unnecessary laparotomies and changes the therapeutic plan in a significant number of patients. It can be performed just before the planned surgery or as a separate diagnostic procedure. The laparoscopy indications in digestive cancers are changing fast, with ongoing new developments in cancer treatment and laparoscopic technology.

Pancreatic hamartoma and SAPHO syndrome: a case report.

We report the first case of an association of pancreatic hamartoma with SAPHO syndrome mimicking disseminated bone metastases. A 46 year old male with intermittent back pain for 10 years, relieved by NSAIDs and desquamation erythemathous palmo-plantar eruption one year before, presented with symptoms of duodenal stenosis, a cystic tumor at the head of the pancreas and osteoformative (hyperostosis) and osteodestructive (osteitis) lesions of the clavicle, mandible, lumbar spine. The bone lesions resembled bone metastases, but an inflammatory infiltrate and fibrosis were found on the excisional biopsy of left clavicle, compatible with the SAPHO syndrome. The pancreatic tumor grew rapidly and showed a histological aspect of malignancy at laparoscopy. A cephalic duodenopancreatectomy was performed, but the histological findings established the diagnosis of pancreatic hamartoma. Several months later, the bone Tc99m scintigraphy was normal.

Host-related predictive factors for anastomotic leakage following large bowel resections for colorectal cancer.

AIM: To identify the risk, the host-related prognostic factors and their predictive value for anastomotic leakage after colorectal resections following cancer. METHOD: 993 patients who underwent large bowel resection and primary anastomosis above 12 centimeters from the anal verge, without a temporary or permanent stoma at the Surgical Hospital No.3 (Cluj-Napoca, Romania) were retrospectively reviewed. RESULTS: 32 (3.22 percent) anastomotic leaks were confirmed. Univariate analysis showed that the preoperative variables significantly associated with anastomotic leakage included: weight loss, smoking, cardiovascular disease, lung disease, hypoproteinemia, diabetes, anemia, leukocytosis, presence of two or more underlying diseases. Alcohol use, cerebrovascular disease, bowel preparation, type of anastomosis, tumor location, stage and histology were not significant variables. Hypoproteinemia (total serum protein level < or = 6 g/dl) and anemia (serum hemoglobin level < or = 11 g/dl) remained significant in the logistic regression model. The prognostic role of serum hemoglobin and proteins for the anastomotic leak was assessed using ROC curve analysis. For the cut-off value of serum protein level = 5.5 g/dl, a sensitivity of 61.6 percent and a specificity of 84.2 percent were calculated. The area under the curve was 0.703 (p= 0.0024). The area under the curve for serum hemoglobin was 0.616 (p=0.028). A sensitivity of 64.0 percent and a specificity of 64.7 per cent were obtained for a cut-off value of 9.4 g/dl. CONCLUSION. A serum protein level lower than 5.5 g/dl and serum hemoglobin lower than 9.4 g/dl could be considered as host-related predictive markers for anastomotic leak in large bowel resections for cancer.