The Therapeutic Intensity Score as Predictor of Clinical Outcomes after Total and Partial Adrenalectomy for Unilateral Primary Aldosteronism: Results of a Multicentric Series.

BACKGROUND: To evaluate the ability of therapeutic intensity score (TIS) in predicting the clinical outcomes of partial (PA) and total adrenalectomy (TA) for UPA. METHODS: Between 2011 and 2022, a four-center adrenalectomy dataset was queried for "unilateral adrenal mass" and "UPA" (n = 90). Preoperative TIS of each antihypertensive medication were individually calculated and merged to create a single, cumulative variable. Probability of complete clinical, partial, and absent pooled success rates according to TIS were assessed for the overall cohort by Kaplan-Meier. Cox analyses were used to identify predictors of complete clinical and partial/absent success, respectively. For all analyses, a two-sided p < 0.05 was considered significant. RESULTS: At a median follow-up of 42 months (IQR 27-54) complete partial, and absent clinical success were observed in 60%, 17.7%, and 22.3%, respectively. On Kaplan-Meier analysis, TIS < 1 predicted higher complete success rates (p < 0.001), while TIS ≥ 1 was predictor of either partial and absent clinical success (p = 0.008). On multivariable analysis, TIS < 1 (HR 0.25; 95% CI 0.11-0.57; p = 0.001) and adenoma size (HR 1.11; 95% CI 1-1.23; p = 0.0049) were independent predictors of complete clinical success, while TIS ≥ 1 (HR 2.84; 95% CI 1.32-6.1; p = 0.007) was the only independent predictor of absent clinical success. CONCLUSIONS: TIS score and adenoma size may help to identify patients who are likely to be at risk of persistent hypertension after surgery.

Minimally Invasive Partial vs. Total Adrenalectomy for the Treatment of Unilateral Primary Aldosteronism: A Systematic Review and Meta-Analysis.

BACKGROUND: This systematic review and metanalysis was conducted to assess differences between perioperative and functional outcomes in patients undergoing minimally-invasive partial (mi-PA) and total adrenalectomy (mi-TA) for unilateral primary aldosteronism (uPHA). MATERIAL AND METHODS: Multiple scientific databases (PUBMED, Web of Science, and Cochrane Library) were searched up to November 2021 for surgical series comparing mi-PA vs. mi-TA for uPHA according to the PRISMA statement. Primary outcomes of interest were perioperative and functional outcomes. RESULTS: Overall, a total of 802 patients from six eligible studies were identified, with mi-PA and mi-TA performed in 40.4% (n = 324) and 59.6% (n = 478) of cases, respectively. No differences were recorded between the two groups according to number of transfusions, EBL and Clavien-Dindo complications ≥2. Similarly, no differences in clinical success, persistence of postoperative hypokalemia and improvement in HTN were reported between mi-PA and mi-TA. CONCLUSIONS: In a uPHA setting, mi-PA and mi-TA provide comparable perioperative and functional outcomes despite the use of mi-PA remains limited to patients with small adenoma size, or hereditary/bilateral disease. Due to limited use of standardized reporting criteria in most of current series, the quest for a superiority of mi-PA over mi-TA in the treatment of uPHA still remains open.

Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism.

BACKGROUND: To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy (n = 90) for unilateral primary aldosteronism (UPA). METHODS: Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2-5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan-Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant. RESULTS: Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07-10.9; p = 0.03). At Kaplan-Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53-5.36; trifecta: HR 2.1; 95% CI 1.13-3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68-8.65; trifecta: HR 4.29; 95% CI 2.08-8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45-5.58; p < 0.01). CONCLUSIONS: Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.

Clinical cure vs a novel trifecta system for evaluating long-term outcomes of minimally-invasive partial or total adrenalectomy for unilateral primary aldosteronism: results of a multicentric series.

Introduction: Several predictive scores to evaluate outcomes of adrenal surgery for unilateral primary aldosteronism (UPA), have been conceived. We compared a novel trifecta that summarizes outcomes of adrenal surgery for UPA with the clinical cure proposed by Vorselaars. Material and methods: Between March 2011 and January 2022, a multi-institutional dataset was queried for UPA. Baseline, perioperative and functional data were collected. Clinical and biochemical complete and partial success rates according to Primary Aldosteronism Surgical Outcome (PASO) criteria were assessed for the overall cohort. Clinical cure was defined either as normotension without antihypertensive medications or normotension with lower or equal use of antihypertensive medications. Trifecta was defined as the coexistence of ≥50% antihypertensive therapeutic intensity score (TIS) reduction (ΔTIS), no electrolyte impairment at 3-months and no Clavien-Dindo (2-5) complications. Cox regression analyses were used to identify predictors of long-term clinical and biochemical success. For all analyses, a two-sided p <0.05 was considered significant. Results: Baseline, perioperative and functional outcomes were analyzed. Out of 90 patients, at a median follow-up of 42 months (IQR 27-54) a complete and partial clinical success was observed in 60% and 17.7% of cases while a complete and partial biochemical success was achieved in 83.3% and 12.3% of cases, respectively. Overall trifecta and clinical cure rates were 21.1% and 58.9%, respectively. On multivariable Cox regression analysis, trifecta achievement (HR 2.87; 95% CI 1.45-5.58; p = 0.02) was the only independent predictor of complete clinical success at long-term follow-up. Conclusions: Despite its complex estimation and more restrictive criteria, trifecta but not clinical cure allows to independently predict composite PASO endpoints on the long run.

Risk factors for nodal involvement in early-stage rectal cancer: a new scoring system based on the analysis of 326 cases.

BACKGROUND: the purpose of this study was to identify which clinicopathological features of early-stage rectal cancer (ESRC) are significantly correlated with the risk of local-regional lymph node metastases (LNM) and to quantify the strength of this association through a novel scoring system. According to several case studies, about 20% of operated ESRC are found with occult lymph nodal metastases at the histological examination. The low frequency of local recurrence in these tumors treated with total mesorectal excision (TME) compared to transanal approaches highlights the role of mesorectal lymph nodes as a site of metastatic location. METHODS: Overall, 386 consecutive patients with ESRC treated with radical resection and TME were examined in a retrospective, observational multi-centric study, operated between 2007 and 2019 in seven centers. Demographic and tumor related clinicopathological characteristics were identified, collected and analyzed. Each variable was specifically weighted based on the strength of its association with the presence of nodal metastases. A scoring system using these weighted variables was developed. RESULTS: Six variables were found to be significantly associated with local regional LNM: lymphatic invasion combined with vascular invasion, poor differentiation (G3), stage T2, age ≥60 years, male sex, perineural invasion. A novel scoring system weighted on the presence of each of these variables able to quantify the risk of LNM in ESRC was developed. CONCLUSIONS: The proposed scoring system is a good predictor of the risk of LNM and should be of help in the decision-making process for ESRC cases diagnosed either by local excision or endoscopic biopsy.

Changes in volumes and severity of surgical urgencies during the first two COVID-19 pandemic waves in a regional hospital network.

Background and aim This study analyses the impact of the first two pandemic waves on surgical urgencies/emergencies and their consequences on an entire provincial hospital network's surgical activities. Methods  Clinical and epidemiological data of urgent/emergent surgical admissions and interventions in the Autonomous Province of Trento's hospital network were collected from the internal common electronic database. The investigation periods were March-May 2019 (reference period), March-May 2020 (phase-I), June - August 2020 (phase-II), and October - December 2020 (phase-III). The same data were divided and grouped for the six most represented diagnoses. Results: The number of admissions for surgical emergencies in the studied periods showed a sinusoidal trend. In the reference period of 2019, 957 patients were admitted in urgency, while in the three pandemic phases, urgent admissions were 511, 888 and 633 respectively (-47% in phase I, - 8% in phase II, -34% in phase III). This trend was also observed by stratifying admissions for single disease, except for gastrointestinal perforations and pancreatitis, which showed a slight increasing trend in phase-I. Among the studied population, the surgical rate was 35.2% in phase-I and 34.3% in phase-III; these data were significantly higher than in 2019 (25.6%).  Conclusions The effect of the COVID pandemic on surgical emergencies and urgencies (SUEs) was mainly indirect, manifesting itself with a significant reduction in the number of surgical admissions, particularly in phases-I and-III. Conversely, in the same phases, the surgical rate showed a significant increase compared to 2019.

The negative effects of COVID-19 and national lockdown on emergency surgery morbidity due to delayed access.

BACKGROUND: The aim of this retrospective comparative study was to assess the impact of COVID-19 and delayed emergency department access on emergency surgery outcomes, by comparing the main clinical outcomes in the period March-May 2019 (group 1) with the same period during the national COVID-19 lockdown in Italy (March-May 2020, group 2). METHODS: A comparison (groups 1 versus 2) and subgroup analysis were performed between patients' demographic, medical history, surgical, clinical and management characteristics. RESULTS: Two-hundred forty-six patients were included, 137 in group 1 and 109 in group 2 (p = 0.03). No significant differences were observed in the peri-operative characteristics of the two groups. A declared delay in access to hospital and preoperative SARS-CoV-2 infection rates were 15.5% and 5.8%, respectively in group 2. The overall morbidity (OR = 2.22, 95% CI 1.08-4.55, p = 0.03) and 30-day mortality (OR = 1.34, 95% CI 0.33-5.50, =0.68) were significantly higher in group 2. The delayed access cohort showed a close correlation with increased morbidity (OR = 3.19, 95% CI 0.89-11.44, p = 0.07), blood transfusion (OR = 5.13, 95% CI 1.05-25.15, p = 0.04) and 30-day mortality risk (OR = 8.00, 95% CI 1.01-63.23, p = 0.05). SARS-CoV-2-positive patients had higher risk of blood transfusion (20% vs 7.8%, p = 0.37) and ICU admissions (20% vs 2.6%, p = 0.17) and a longer median LOS (9 days vs 4 days, p = 0.11). CONCLUSIONS: This article provides enhanced understanding of the effects of the COVID-19 pandemic on patient access to emergency surgical care. Our findings suggest that COVID-19 changed the quality of surgical care with poorer prognosis and higher morbidity rates. Delayed emergency department access and a "filter effect" induced by a fear of COVID-19 infection in the population resulted in only the most severe cases reaching the emergency department in time.

Impact of COVID-19 pandemic waves on changes in surgical urgency volumes and severity in the regional hospital network of Trento (Northern Italy): a descriptive epidemiological analysis.

OBJECTIVES: to analyse both direct and indirect impacts on surgical admissions, surgical rates, and clinical picture severity of the two COVID-19 pandemic waves in a hospital network covering an entire province (Trento, located in Trentino-Alto Adige Region, Northern Italy). DESIGN: retrospective epidemiological study. SETTING AND PARTICIPANTS: data regarding the patient load of the Surgical Urgencies/Emergencies flows (SUEs) of the Local Health Authority of the Autonomous Province of Trento derived from the Hospital Discharge Record (HDR) information flow. The population in study was that of patients hospitalized in the entire Province of Trento. This study compares the volume and characteristics of urgent/emergency surgery during the 2020 COVID-19 pandemic with the homologous period in 2019, subdividing the analysed pandemic period in 3 separated groups: • phase I (March-May 2020); • phase II (June-August 2020); • phase III (October-December 2020). The 3 groups represent, respectively: the 1st pandemic wave proclamation of national lockdown from 9 March to 18 May; the summer pandemic remission; the 2nd pandemic wave with partial restrictions on circulation and commercial activities. Clinical and surgical records of SUE population among these 3 periods (March-May; June-August; October-December) of both 2020 and 2019 were analyzed and compared. MAIN OUTCOME MEASURES: the overall number of admissions and surgical rates for SUEs in the study periods were chosen as primary outcomes. The same outcomes were analysed for the most represented diagnoses in the SUEs population: diverticulitis, intestinal obstruction, appendicitis, cholecystitis, gastrointestinal (GI) perforations, pancreatitis, traumas. To assess the degree of clinical picture severity, variables coming from the hospital discharging charts, commonly associated to worst outcomes in term of mortality and morbidity, such as age, length of hospital stay, DRG weight, and patients not discharged at home were extrapolated from the electronic database. A numerical weight was then assigned to each variable, obtaining a scoring system from 0 to 15 (severity index). RESULTS: the number of admissions for SUEs in the studied period showed a sinusoidal trend, with a dramatic decrease in phase I and III (-46.6% and -31.6%, respectively). This trend was also observed even by stratifying admissions for the most frequent pathologies, except for gastrointestinal perforations and pancreatitis. The surgical rate among hospitalised patients for SUEs was 35.2% in phase, significantly higher than that of 2019 (25.6%). Considering the most frequent diagnoses individually, some had a progressive increase in the surgical rate in phases I and II (diverticulitis, bowel obstructions, cholecystitis), others showed an initial decrease and then settled on values ​​not far from those of 2019 (GI perforations and appendicitis), others again had an initial significant increase and then gradually returned to values ​​similar to those of 2019 in phase III (traumas). The mean patients age was significantly higher in phase I than in 2019 (p-value <0.001) and in phase II (p-value <0.05). Consistently with the trend of the number of urgent admissions, even the severity index calculated on the SUEs population showed a sinusoidal trend with and evident increase during the two pandemic waves. CONCLUSIONS: the effect of the COVID-19 pandemic on SUEs was mainly indirect, manifesting itself with a significant reduction in surgical admissions, particularly in phases I and III. Conversely, in the same phases, the surgical rate showed a significant increase compared to 2019. The stratified analysis confirmed these findings for the most frequent diagnoses except for GI perforations and pancreatitis. The clinical pictures were more severe in the two pandemic waves than in the reference period of 2019. Although with a slight numerical attenuation, in general, the second pandemic wave confirmed the first one findings.

Minimally Invasive Partial Versus Total Adrenalectomy for the Treatment of Primary Aldosteronism: Results of a Multicenter Series According to the PASO Criteria.

BACKGROUND: Determination of success after adrenal-sparing surgery for primary aldosteronism (PA) is limited by the lack of standardized definitions of outcomes. OBJECTIVE: To evaluate the safety and effectiveness of minimally invasive partial adrenalectomy (MIPA) for PA by comparing perioperative and functional outcomes with minimally invasive total adrenalectomy (MITA) according to the Primary Aldosteronism Surgical Outcome (PASO) criteria. DESIGN, SETTING, AND PARTICIPANTS: Between March 2011 and April 2020, a multicenter adrenalectomy dataset was queried for "unilateral adrenal mass, PA, MIPA (n = 29), or MITA (n = 61)"at four participating Institutions. INTERVENTION: MITA and MIPA for PA. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Differences between continuous variables were assessed with the Wilcoxon rank sum test, while Pearson's χ2 test was used for categorical data. Complete, partial, and absent clinical success rates were assessed for the overall cohort and compared between groups. RESULTS AND LIMITATIONS: The median tumor size was significantly higher in the MITA group (4.2 vs 2.7 cm; p = 0.001), while preoperative hypertension rate was significantly higher in the MIPA series (82.8% vs 57.4%, p = 0.01). The median length of hospital stay was increased in the MITA cohort (4 vs 3 d; p = 0.038). Overall, at a median follow-up of 42 mo (interquartile range 27-54 mo), complete, partial, and absent clinical success was observed in 60%, 17.7%, and 22.3% of cases, respectively. The complete clinical success rate was higher in the MIPA group (72.4% vs 54.1%), while a partial clinical success was higher in the MITA series (23% vs 6.8%). The absence of clinical success was comparable between groups (MITA 23% vs MIPA 20.7%). CONCLUSIONS: MIPA showed excellent perioperative results with a complete clinical success rate of 72.4%. Owing to the heterogeneity of the PASO criteria in the assessment of partial or absent success, the quest for a univocal definition of satisfactory clinical outcomes in the treatment of PA remains open. PATIENT SUMMARY: We compared minimally invasive partial adrenalectomy (MIPA) and minimally invasive total adrenalectomy for the treatment of unilateral primary aldosteronism, assessing the outcomes with the Primary Aldosteronism Surgical Outcome (PASO) criteria. MIPA seems to provide comparable perioperative outcomes and midterm clinical success rates.

Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery.

PURPOSE: To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS: All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS: One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION: Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION: ClinicalTrials.gov # NCT03560180.

Teamwork enables high level of early mobilization in critically ill patients.

BACKGROUND: Early mobilization in critically ill patients has been shown to prevent bed-rest-associated morbidity. Reported reasons for not mobilizing patients, thereby excluding or delaying such intervention, are diverse and comprise safety considerations for high-risk critically ill patients with multiple organ support systems. This study sought to demonstrate that early mobilization performed within the first 24 h of ICU admission proves to be feasible and well tolerated in the vast majority of critically ill patients. RESULTS: General practice data were collected for 171 consecutive admissions to our ICU over a 2-month period according to a local, standardized, early mobilization protocol. The total period covered 731 patient-days, 22 (3 %) of which met our local exclusion criteria for mobilization. Of the remaining 709 patient-days, early mobilization was achieved on 86 % of them, bed-to-chair transfer on 74 %, and at least one physical therapy session on 59 %. Median time interval from ICU admission to the first early mobilization activity was 19 h (IQR = 15-23). In patients on mechanical ventilation (51 %), accounting for 46 % of patient-days, 35 % were administered vasopressors and 11 % continuous renal replacement therapy. Within this group, bed-to-chair transfer was achieved on 68 % of patient-days and at least one early mobilization activity on 80 %. Limiting factors to start early mobilization included restricted staffing capacities, diagnostic or surgical procedures, patients' refusal, as well as severe hemodynamic instability. Hemodynamic parameters were rarely affected during mobilization, causing interruption in only 0.8 % of all activities, primarily due to reversible hypotension or arrhythmia. In general, all activities were well tolerated, while patients were able to self-regulate their active early mobilization. Patients' subjective perception of physical therapy was reported to be enjoyable. CONCLUSIONS: Mobilization within the first 24 h of ICU admission is achievable in the majority of critical ill patients, in spite of mechanical ventilation, vasopressor administration, or renal replacement therapy.

Use of floseal hemostatic matrix for control of hemostasis during laparoscopic cholecystectomy for acute cholecystitis: a multicenter historical control group comparison (the GLA study gelatin matrix for acute cholecystitis).

BACKGROUND: In patients with acute cholecystitis undergoing laparoscopic cholecystectomy, bleeding is a common complication that can reduce procedural visibility and worsen outcome. Insufficient hemostasis can also lead to postoperative bleeding that can, in rare cases, be fatal. Topical hemostatic agents are used to ensure adequate hemostasis during laparoscopic cholecystectomy. SUBJECTS AND METHODS: This prospective, open-label, nonrandomized, historical control group study investigated the use of Floseal(®) (Baxter International, Inc., Deerfield, IL) hemostatic matrix as an adjunct to surgical techniques to achieve hemostasis of the resected areas in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. The primary end point was the rate of complete hemostasis 10 minutes after laparoscopic application of Floseal to the gallbladder bed. Secondary end points included complete hemostasis rates at 2, 4, and 6 minutes, surgery time, laparoscopic procedure to open laparotomy conversion rate, postoperative bleeding rate, and mortality and safety outcomes over the entire follow-up period. RESULTS: From April to November 2011, 101 consecutive patients were enrolled (51 men; mean age, 61.5±6.2 years). The historical control group of 100 age- and gender-matched patients with acute cholecystitis had undergone laparoscopic cholecystectomy without hemostatic agent. In the Floseal group, bleeding ceased within 10 minutes after laparoscopic application of the hemostatic agent to the gallbladder bed in all patients. The conversion rate was significantly lower in the Floseal group than in the control group (4 versus 12 patients, P<.05). CONCLUSIONS: Floseal in acute cholecystitis is safe, is effective in controlling bleeding, and results in a lower conversion rate compared with cholecystectomy without hemostatic agents.

Analysis of risk factors for lymph nodal involvement in early stages of rectal cancer: when can local excision be considered an appropriate treatment? Systematic review and meta-analysis of the literature.

Background. Over the past ten years oncological outcomes achieved by local excision techniques (LETs) as the sole treatment for early stages of rectal cancer (ESRC) have been often disappointing. The reasons for these poor results lie mostly in the high risk of the disease's diffusion to local-regional lymph nodes even in ESRC. Aims. This study aims to find the correct indications for LET in ESRC taking into consideration clinical-pathological features of tumours that may reduce the risk of lymph node metastasis to zero. Methods. Systematic literature review and meta-analysis of casistics of ESRC treated with total mesorectal excision with the aim of identifying risk factors for nodal involvement. Results. The risk of lymph node metastasis is higher in G ≥ 2 and T ≥ 2 tumours with lymphatic and/or vascular invasion. Other features which have not yet been sufficiently investigated include female gender, TSM stage >1, presence of tumour budding and/or perineural invasion. Conclusions. Results comparable to radical surgery can be achieved by LET only in patients with T(1) N(0) G(1) tumours with low-risk histological features, whereas deeper or more aggressive tumours should be addressed by radical surgery (RS).

Heterogeneity of large cell carcinoma of the lung: an immunophenotypic and miRNA-based analysis.

Large cell carcinomas (LCCs) of the lung are heterogeneous and may be of different cell lineages. We analyzed 56 surgically resected lung tumors classified as LCC on the basis of pure morphologic grounds, using a panel of immunophenotypic markers (adenocarcinoma [ADC]-specific, thyroid transcription factor-1, cytokeratin 7, and napsin A; squamous cell carcinoma [SQCC]-specific, p63, cytokeratin 5, desmocollin 3, and Δnp63) and the quantitative analysis of microRNA-205 (microRNA sample score [mRSS]). Based on immunoprofiles 19 (34%) of the cases were reclassified as ADC and 14 (25%) as SQCC; 23 (41%) of the cases were unclassifiable. Of these 23 cases, 18 were classified as ADC and 5 as SQCC according to the mRSS. Our data show that an extended panel of immunohistochemical markers can reclassify around 60% of LCCs as ADC or SQCC. However, a relevant percentage of LCCs may escape convincing immunohistochemical classification, and mRSS could be used for further typing, but its clinical relevance needs further confirmation.

Subclassification of the "grey zone" of thyroid cytology; a retrospective descriptive study with clinical, cytological, and histological correlation.

Undetermined thyroid cytology precludes any definitive distinction between malignant and benign lesions. Recently several classifications have been proposed to split this category into two or more cytological subcategories related to different malignancy risk rates. The current study was performed retrospectively to investigate the results obtained separating "undetermined" cytologic reports into two categories: "follicular lesion" (FL) and "atypia of undetermined significance" (AUS). Biochemical, clinical, and echographic features of each category were also retrospectively analyzed. Altogether, 316 undetermined fine-needle aspirated cytologies (FNACs) were reclassified as 74 FL and 242 AUS. Histological control leads to a diagnosis of carcinomas, adenomas, and nonneoplastic lesions, respectively, in 42.2%, 20%, and 37.8% of AUS and in 8.3%, 69.4%, and 22.2% of FL. Among biochemical, clinical, cytological, and echographic outcomes, altered thyroid autoantibodies, multiple versus single nodule, AUS versus FL, and presence of intranodular vascular flow were statistically significant to differentiate adenoma from carcinoma and from nonneoplastic lesions, whereas no significant differences were found between carcinomas and nonneoplastic lesions for these parameters. The results of this retrospective study show that undetermined FNAC category can further be subclassified in AUS and FL, the former showing higher malignancy rate. Further prospective studies are needed to confirm our results.