Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk?

Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.

Proliferation in pleomorphic adenoma: Lights and shadow on this parameter, in a neoplasm showing unpredictable behavior-An immunohistochemical study and review of the literature.

BACKGROUND: Pleomorphic adenoma accounts for the majority of benign tumors of the salivary gland. It is also called mixed tumor because it is composed by ductal epithelial and myoepithelial cells, variably intermixed within a chondromyxoid stroma. The recurrence rate is around 3.4% and 6.3%, respectively at 5 and 10 years and, to date, there are no valuable predictive factors. Aim of our study was to assess the role of Ki67 proliferative index in our cases and through meta-analysis. METHODS: Immunohistochemistry with Ki67 antibody was performed on 28 cases. A manual count of the signal was performed, to establish the proliferative activity. Statistical tests were applied to assess the correlation between the score and clinico-pathologic parameters. Further data were extrapolated from studies published on Pubmed, Cochrane and Web of Science database. RESULTS: Higher values of Ki67 were found among cases with larger size (p value = 0.0061) and showing greater cellularity (p value=0.0004). 19 papers were selected from the bibliographic search, concerning a total of 1187 patients affected by pleomorphic adenoma. In most of them, a higher Ki67 was detected among relapsing forms but results were controversial. In each study, several count methods were applied. CONCLUSION: The role of Ki67 in pleomorphic adenoma of the salivary glands remains unclear. The lack of homogeneity of the data makes it very difficult to standardize them in order to draw a conclusion. It would therefore be desirable to carry out a comparison study of the various possible methods of Ki67 counting.

Extraovarian dysgerminoma in a pregnant woman: an extremely rare finding.

Extraovarian germ cell tumors are very rare and their occurrence during pregnancy is exceptional. In this case report an abdominal mass was shown by ultrasonography, during a routine monitoring of a 26-year-old pregnant woman. The patient was left under radiological control in the following months in order to bring the pregnancy to term. A few months after the delivery, the patient underwent surgery and a diagnosis of extraovarian (abdominal) dysgerminoma was made. To the best of our knowledge, there are only 3 other case reports describing an extra-gonadal dysgerminoma occurring during pregnancy. The aim of this study was to report an extremely rare tumor, whose management can be challenging first because this neoplasm has some differences from its ovarian and testicular counterparts. Furthermore, the occurrence during pregnancy makes the multidisciplinary approach mandatory since 3 distinct but not independent entities are involved (tumor, mother and fetus).

The continuing role of breast fine-needle aspiration biopsy after the introduction of the IAC Yokohama System For Reporting Breast Fine Needle Aspiration Biopsy Cytopathology.

BACKGROUND: Ultrasound-guided fine-needle aspiration biopsy (FNAB) (US-guided FNAB) is a rapid and cost-effective procedure for the diagnosis of breast lesions. Our Institution has a long tradition in breast FNAB performed by cytopathologists; recently we adopted both US guidance and a five-tiered classification system similar to that proposed by the International Academy of Cytology (IAC). The aim of this study was to demonstrate the continuing role of US-guided FNAB in the diagnosis of breast lesions, despite the growing adoption of core-needle biopsy (CNB). METHODS: The laboratory information database system was searched to obtain the breast FNAB diagnostic reports recorded from 2010 to 2017 and classified using a five-tiered Classification System; each entry was matched with the available histology. RESULTS: A total of 4624 breast FNAB samples were retrieved. Of these, 1745/4624 cases (37.7%) had histological follow-ups. The risk of malignancy (ROM) was 4.9% for benign, 20.7% for atypical, 78.7% for suspicious of malignancy, and 98.8% for malignant. When the atypical category was evaluated as a negative index, the positive predictive value was 93.73%, and the negative predictive value was 90.78%, reaching an overall diagnostic accuracy of 92.82%. CONCLUSIONS: The IAC Yokohama System for Reporting Breast FNAB Cytopathology clearly identifies different diagnostic categories with increasing ROM. Most of the FNAB samples were classified as benign or malignant (65.3%), warranting prompt management for these patients. Moreover, the inclusion of the atypical category as a low-risk indeterminate category avoided overtreatment of benign lesions. Thus, despite the well-established merits of CNB, US-guided FNAB still represents a cost-effective and rapid nonoperative diagnostic approach.

A New Technological Advancement of the Drug-Induced Sleep Endoscopy (DISE) Procedure: The "All in One Glance" Strategy.

To illustrate a new technological advance in the standard drug-induced sleep endoscopy (DISE) model, a new machine was used, the Experimental 5 Video Stream System (5VsEs), which is capable of simultaneously visualizing all the decisional parameters on a single monitor, and recording and storing them in a single uneditable video. The DISE procedure was performed on 48 obstructive sleep apnea (OSA) or snoring patients. The parameters simultaneously recorded on a single monitor are (1) the pharmacokinetics and pharmacodynamics of propofol (through the target controlled infusion (TCI) pump monitor), (2) the endoscopic upper airway view, (3) the polygraphic pattern, and (4) the level of sedation (through the bispectral index (BIS) value). In parallel to the BIS recording, the middle latency auditory evoked potential (MLAEP) was also recorded and provided. Recorded videos from the 5VsEs machine were re-evaluated six months later by the same clinician and a second clinician to evaluate the concordance of the therapeutic indications between the two. After the six-month period, the same operator confirmed all their clinical decisions for 45 out of 48 videos. Three videos were no longer evaluable for technical reasons, so were excluded from further analysis. The comparison between the two operators showed a complete adherence in 98% of cases. The 5VsEs machine provides a multiparametric evaluation setting, defined as an "all in one glance" strategy, which allows a faster and more effective interpretation of all the simultaneous parameters during the DISE procedure, improving the diagnostic accuracy, and providing a more accurate post-analysis, as well as legal and research advantages.

Primary High-Grade Angiosarcoma of the Breast in a Young Woman With Breast Implants: A Rare Case and a Review of Literature.

Primary angiosarcoma (AS) of the breast is an extremely unusual variant of breast malignancies, and its incidence is about 0.05% of all primary breast tumors. In this article, we present a rare case of a primary AS that developed in a young woman with breast implants. This case report emphasizes importance of early investigation for accurate diagnosis and proper management of the breast AS, along with a correlation of histopathologic, radiologic, and clinical findings.

MRI Radiomics for the Prediction of Fuhrman Grade in Clear Cell Renal Cell Carcinoma: a Machine Learning Exploratory Study.

The Fuhrman nuclear grade is a recognized prognostic factor for patients with clear cell renal cell carcinoma (CCRCC) and its pre-treatment evaluation significantly affects decision-making in terms of management. In this study, we aimed to assess the feasibility of a combined approach of radiomics and machine learning based on MR images for a non-invasive prediction of Fuhrman grade, specifically differentiation of high- from low-grade tumor and grade assessment. Images acquired on a 3-Tesla scanner (T2-weighted and post-contrast) from 32 patients (20 with low-grade and 12 with high-grade tumor) were annotated to generate volumes of interest enclosing CCRCC lesions. After image resampling, normalization, and filtering, 2438 features were extracted. A two-step feature reduction process was used to between 1 and 7 features depending on the algorithm employed. A J48 decision tree alone and in combination with ensemble learning methods were used. In the differentiation between high- and low-grade tumors, all the ensemble methods achieved an accuracy greater than 90%. On the other end, the best results in terms of accuracy (84.4%) in the assessment of tumor grade were achieved by the random forest. These evidences support the hypothesis that a combined radiomic and machine learning approach based on MR images could represent a feasible tool for the prediction of Fuhrman grade in patients affected by CCRCC.

Cytology meets next generation sequencing and liquid biopsy: A case of lung adenocarcinoma presenting as metastasis to the phalanx.

Carcinomas do rarely metastasize to the finger. Non-small-cell lung cancer is most frequently involved. To date, only a few cases have been reported, on histology. Here we describe the cytological features of a metastatic lung adenocarcinoma case to the phalanx of the right forefinger as initial manifestation of the neoplastic disease in a 69-years-old woman. The cytological microscopic findings, complemented by a wide array of ancillary techniques, were confirmed by histology. Neoplastic cells were positive for cytokeratin 7 (CK7) and thyroid transcription factor 1 (TTF-1), harboring, in tissue and in bloodstream samples, an uncommon epidermal growth factor receptor (EGFR) exon 20 p.S768_D760DUP, detected by next generation sequencing (NGS) and liquid biopsy. Cytology corroborated by immunocytochemistry, NGS, and liquid biopsy is a modern approach to provide diagnostic and therapeutic information even in rare and challenging cases.