Strain ratio ultrasound elastography increases the accuracy of colour-Doppler ultrasound in the evaluation of Thy-3 nodules. A bi-centre university experience.

OBJECTIVES: To assess whether ultrasound elastography (USE) with strain ratio increases diagnostic accuracy of Doppler ultrasound in further characterisation of cytologically Thy3 thyroid nodules. METHODS: In two different university diagnostic centres, 315 patients with indeterminate cytology (Thy3) in thyroid nodules aspirates were prospectively evaluated with Doppler ultrasound and strain ratio USE before surgery. Ultrasonographic features were analysed separately and together as ultrasound score, to assess sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Receiver operating characteristic (ROC) curves to identify optimal cut-off value of the strain ratio were also provided. Diagnosis on a surgical specimen was considered the standard of reference. RESULTS: Higher strain ratio values were found in malignant nodules, with an optimum strain ratio cut-off of 2.09 at ROC analysis. USE with strain ratio showed 90.6% sensitivity, 93% specificity, 82.8% PPV, 96.4% NPV, while US score yielded a sensitivity of 52.9%, specificity of 84.3%, PPV 55.6% and NPV 82.9%. The diagnostic gain with strain ratio was statistically significant as proved by ROC areas, which was 0.9182 for strain ratio and 0.6864 for US score. CONCLUSIONS: USE with strain ratio should be considered a useful additional tool to colour-Doppler US, since it improves characterisation of thyroid nodules with indeterminate cytology. KEY POINTS: • Strain ratio measurements improve differentiation of thyroid nodules with indeterminate cytology • Elastography with strain ratio is more reliable than ultrasound features and ultrasound score • Strain ratio may help to better select patients with Thy 3 nodules candidate for surgery.

Intragastric balloon for obesity treatment: results of a multicentric evaluation for balloons left in place for more than 6 months.

BACKGROUND: Obesity is a major risk factor for several chronic diseases. The BioEnterics(®) Intragastric Balloon (BIB(®)) is used worldwide as a short-term (6 months) treatment in morbid obese patients. However, removal of BIB(®) past 6 months is a common occurrence in clinical practice often as a result of patient factors. The aim of the present Italian multicentre cohort study was to evaluate the safety and efficacy of the BIB(®) left in situ for more than 6 months. MATERIALS AND METHODS: A total of eight Italian centres participated in the study. Participating centres received a standardised questionnaire designed to capture safety and efficacy data. Weight loss data, as well as date, and reason for removal of the BIB(®) after 6 months were recorded. Adverse events, including mortality and complications, operators' subjective technical notes and findings, and difficulties during removal procedure were also collected. RESULTS: Six hundred and eleven patients were included. In the majority of cases, patient extended BIB(®) treatment due to satisfactory weight loss (44 %). At 6 months, all patients achieved a BMI statistically lower than the initial BMI (p < 0.001). There was a non-significant trend towards greater BMIL % in patients who underwent removal up to 15 months versus the results achieved up to 6 months. No major complications were recorded. CONCLUSION: Extending the duration of BIB(®) use up to 14 months safely maintains weight loss and satiety with greater results than that up to 6 months, without complications.

Total or near-total thyroidectomy versus subtotal thyroidectomy for multinodular non-toxic goitre in adults.

BACKGROUND: Total thyroidectomy (TT) and subtotal thyroidectomy (ST) are worldwide treatment options for multinodular non-toxic goitre in adults. Near TT, defined as a postoperative thyroid remnant less than 1 mL, is supposed to be a similarly effective but safer option than TT. ST has been shown to be marginally safer than TT, but it may leave an undetected thyroid cancer in place. OBJECTIVES: The objective was to assess the effects of total or near-total thyroidectomy compared to subtotal thyroidectomy for multinodular non-toxic goitre. SEARCH METHODS: We searched the Cochrane Library, MEDLINE, PubMed, EMBASE, as well as the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was 18 June 2015 for all databases. No language restrictions were applied. SELECTION CRITERIA: Two review authors independently scanned the abstract, title or both sections of every record retrieved to identify randomised controlled trials (RCTs) on thyroidectomy for multinodular non-toxic goitre for further assessment. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality utilising the GRADE instrument. We calculated the odds ratio (OR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. A random-effects model was used for pooling data. MAIN RESULTS: We examined 1430 records, scrutinized 14 full-text publications and included four RCTs. Altogether 1305 participants entered the four trials, 543 participants were randomised to TT and 762 participants to ST. A total of 98% and 97% of participants finished the trials in the TT and ST groups, respectively. Two trials had a duration of follow-up between 12 and 39 months and two trials a follow-up of 5 and 10 years, respectively. Risk of bias across studies was mainly unknown for selection, performance and detection bias. Attrition bias was generally low and reporting bias high for some outcomes. In the short-term postoperative period no deaths were reported for both TT and ST groups. However, longer-term data on all-cause mortality were not reported (1284 participants; 4 trials; moderate quality evidence). Goiter recurrence was lower in the TT group compared to ST. Goiters recurred in 0.2% (1/425) of the TT group compared to 8.4% (53/632) of the ST group (OR 0.05 (95% CI 0.01 to 0.21); P < 0.0001; 1057 participants; 3 trials; moderate quality evidence). Re-intervention due to goitre recurrence was lower in the TT group compared to ST. Re-intervention was necessary in 0.5% (1/191) of TT patients compared to 0.8% (3/379)of ST patients (OR 0.66 (95% CI 0.07 to 6.38); P = 0.72; 570 participants; 1 trial; low quality evidence). The incidence of permanent recurrent laryngeal nerve palsy was lower for ST compared with TT. Permanent recurrent laryngeal nerve palsy occurred in 0.8% (6/741) of ST patients compared to 0.7% (4/543) of TT patients (OR 1.28, (95% CI 0.38 to 4.36); P = 0.69; 1275 participants; 4 trials; low quality evidence). The incidence of permanent hypoparathyroidism was lower for ST compared with TT. Permanent hypoparathyroidism occurred in 0.1% (1/741) of ST patients compared to 0.6% (3/543) of TT patients (OR 3.09 (95% CI 0.45 to 21.36); P = 0.25; 1275 participants: 4 trials; low quality evidence). The incidence of thyroid cancer was lower for ST compared with TT. Thyroid cancer occurred in 6.1% (41/669) of ST patients compared to 7.3% (34/465)of TT patients (OR 1.32 (95% CI 0.81 to 2.15); P = 0.27; 1134 participants; 3 trials; low quality evidence). No data on health-related quality of life or socioeconomic effects were reported in the included studies. AUTHORS' CONCLUSIONS: The body of evidence on TT compared with ST is limited. Goiter recurrence is reduced following TT. The effects on other key outcomes such as re-interventions due to goitre recurrence, adverse events and thyroid cancer incidence are uncertain. New long-term RCTs with additional data such as surgeons level of experience, treatment volume of surgical centres and details on techniques used are needed.

Spider surgical system versus multiport laparoscopic surgery: performance comparison on a surgical simulator.

BACKGROUND: The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS). METHODS: Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system. RESULTS: Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER. Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005). Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007). Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task. CONCLUSIONS: Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience.

Q-elastosonography of solid thyroid nodules: assessment of diagnostic efficacy and interobserver variability in a large patient cohort.

OBJECTIVE: Evaluation of the diagnostic efficacy and interobserver agreement of Q-elastography in the differentiation of benign from malignant thyroid nodules. METHODS: A total of 344 thyroid nodules in 288 patients were examined with grey-scale and colour Doppler ultrasound (CDUS) and Q-elastography by two independent operators. Nodules with hypoechogenicity, poorly defined margins, microcalcifications, and intralesional vascularity were classified as suspicious. Diagnostic performances of CDUS features and Q-elastography for predicting thyroid malignancy were estimated using ROC analysis. Cytology or histopathology was the reference standard. Interobserver agreement in the evaluation of CDUS and Q-elastography was assessed using Cohen's k-statistic. RESULTS: Q-elastography showed excellent diagnostic performance for the prediction of thyroid malignancy, with sensitivity of 93 % and specificity of 92 % for operator 1 (best cutoff at 2.02), and sensitivity of 84 % and specificity of 79 % for operator 2 (best cutoff at 1.86). Performance of Q-elastography was superior to that of CDUS. Reproducibility of the findings was excellent for both Q-elastography and CDUS features as assessed with Cohen's k, which was highest for strain ratio measurements (0.95) and lowest for the echogenicity score (0.83). CONCLUSIONS: Q-elastography showed excellent performance. It is a valid and reproducible diagnostic method as well as a promising tool for identifying suspicious solid thyroid nodules needing cytological assessment and surgery. KEY POINTS: • Elastography is an additional tool for optimal characterisation of malignant thyroid nodules. • The use of semiquantitative elastographic evaluation increases the diagnostic performance, • The interobserver agreement of quantitative elastography can be considered to be good.

Can virtual reality simulators be a certification tool for bariatric surgeons?

BACKGROUND: Construct validity of virtual laparoscopic simulators for basic laparoscopic skills has been proposed; however, it is not yet clear whether the simulators can identify the actual experience of surgeons in more complex procedures such as laparoscopic Roux-en-Y gastric bypass. This study tested the ability of the Lap Mentor simulator to recognize the experience in advanced laparoscopic procedures and to assess its role in the certification of bariatric surgeons. METHODS: Twenty surgeons were divided into two groups according to their experience in laparoscopic and bariatric surgery. The general group included 10 general surgeons performing between 75 and 100 nonbariatric laparoscopic procedures. The bariatric group included 10 bariatric surgeons performing between 50 and 100 laparoscopic bariatric procedures. Participants were tested on the simulator in one basic task (task 1: eye-hand coordination) and in two tasks of the gastric bypass module (task 2: creation of the gastric pouch; task 3: gastrojejunal anastomosis). RESULTS: Comparing the groups, no significant differences were found in task 1. Analyzing the results from the gastric bypass module (bariatric vs. general), in task 2, significant differences (p < 0.05) were found in the median volume of the gastric pouch (21 vs. 48 cm(3)), in the percentage of fundus included in the pouch (8.4 vs. 29.4 %), in the complete dissection at the angle of His (10 vs. 3), and in safety parameters. In task 3, significant differences were found in the size and position of enterotomies. CONCLUSIONS: The Lap Mentor may be proposed as a certification tool for bariatric surgeons because it also recognizes their specific skills in the technical details of the procedure that affect long-term results. Furthermore, the possibility of analyzing the performance in detail can help define areas where the surgeon is lacking. These findings indicate a potential role of the Lap Mentor in tailoring the training to maximize improvement.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note.

BACKGROUND: Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. METHODS: In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. RESULTS: In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). CONCLUSIONS: RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

High tie versus low tie of the inferior mesenteric artery: a protocol for a systematic review.

In anterior resection of rectum, the section level of inferior mesenteric artery is still subject of controversy between the advocates of high and low tie. The low tie is the division and ligation to the branching of the left colic artery and the high tie is the division and ligation at its origin at the aorta. We intend to assess current scientific evidence in literature and to establish the differences comparing technique, anatomy and physiology. The aim of this protocol is to achieve a meta-analysis that tests safety and feasibility of the two procedures with several types of outcome measures.

[Carotid endarterectomy: evaluation of a "combined" technique of general anesthesia]. / Endoarterectomia carotidea: valutazione di una tecnica di anestesia generale "combinata".

INTRODUCTION: The literature suggests several techniques to ensure the optimal anesthetic procedure for carotid surgery. The aim of our study is to combine, in the carotid endarterectomy, a model of general anesthesia with the loco-regional anesthesia in order to test the safety of the method, the eventual brain damage and hemodynamic stability. We also wanted to test whether the immediate postoperative analgesia was adequate. MATERIAL AND METHODS: Seventy eight (78) patients were enrolled in the study (from 60 to 75 years), ASA II-III, candidates for unilateral carotid endarterectomy in a period from June 2008 to January 2009. During the procedure data about perioperative neurologic and hemodynamic complications were collected. At the end of the surgical treatment the pain at the awakening moment through verbal numerical scale VNS was estimated. Data are presented as mean values +/- sd and validated using the chi2 test, when required. Significance was accepted at a value of P < or = 0.05. RESULTS: 85% of patients reported a VNS between 1 and 2 and 10% equal to 3-5. In the study 95% of patients (P<0.05) appreciated the technique and only 3 patients reported their dissatisfaction. There was no mortality and in 5 patients a postoperative morbidity was registered. DISCUSSION: The study demonstrated the advantages in combining loco-regional anesthesia (valid monitoring of neurological and hemodynamic stability) with general anesthesia (complete airways control and patient comfort) during carotid surgery.

Meta-analysis of thyroidectomy with ultrasonic dissector versus conventional clamp and tie.

BACKGROUND: We conducted a systematic review to evaluate the role of Ultrasonic dissector (UAS) versus conventional clamp and tie in thyroidectomy. MATERIALS AND METHODS: We searched for all published RCT in into electronic databases. To be included in the analysis, the studies had to compare thyroidectomy with UAS versus conventional vessel ligation and tight (conventional technique = CT). The following outcomes were used to compare the total thyroidectomy group with UAS versus CT group: operative duration, operative blood loss, overall drainage volume during the first 24 hours, transiet laryngeal nerve palsy, permanent laryngeal nerve palsy, transiet hypocalcaemia and permanent hypocalcaemia. RESULTS: There are currently 7 RCT on this issue to compare thyroidectomy with UAS versus CT. From the analysis of these studies it was possible to confront 608 cases: 303 undergoing to thyroidectomy with UAS versus 305 that were treated with CT. Actually, it was shown a relevant advantage of cost-effectiveness in patients treated with UAS; there is a statistically significant reduction of the operative duration (weighted mean difference [WMD], -18.74 minutes; 95% confidence interval [CI], (-26.97 to -10.52 minutes) (P = 0.00001), intraoperative blood loss (WMD, -60.10 mL; 95% CI, -117.04 to 3.16 mL) (P = 0.04) and overall drainage volume (WMD, -35.30 mL; 95% CI, -49.24 to 21.36 mL) (P = 0.00001) in the patients underwent thyroidectomy with UAS. Although the analysis showed that the patients who were treated with USA presented more favourable results in incidence of post-operative complications (transient laryngeal nerve palsy: P = 0.11; permanent laryngeal nerve palsy: not estimable; transient hypocalcaemia: P = 0.24; permanent hypocalcaemia: P = 0.45), these data didn't present statistical relevance. CONCLUSION: This meta-analysis shown a relevant advantage only in terms of cost-effectiveness in patients treated with UAS; it is subsequent to statistically significant reduction of operation duration, intraoperative blood loss and of overall drainage volume during the first 24 hours. Although the analysis showed that the patients who were treated with UAS presented more favourable results in incidence of post-operative complications (transiet laryngeal nerve palsy; transiet hypocalcaemia and permanent hypocalcaemia), these data didn't present statistical relevance.

[Two strategies of morphine administration on the control of post-surgical pain after anesthesia with remifentanil]. / Due strategie di somministrazione della morfina per il controllo del dolore post-chirurgico dopo anestesia con remifentanil.

AIM: The post-operative pain (POP) is accompanied by autonomic, psychological and behavioural responses which can result in a significant increase in morbidity and mortality. The purpose of this study was to compare the efficacy and safety of intravenous bolus administration of morphine versus subcutaneous administration. MATERIAL OF STUDY: Fifty subjects scheduled for elective abdominal surgery were randomized into a group S (n = 26) and group E (n = 24). The first group was administered morphine (0.35 mg/kg) subcutaneously immediately after induction of anesthesia, while the second group the same drug at a dose of 0.25 mg/kg was administered intravenously 45' before the end of the intervention. All patients received intraoperative remifentanil (0.25-0.50 microg/kg/min), and at the end of surgery paracetameolo 1 g and ondansetron 4 mg. Upon awakening, the DPO has been reviewed by the NRS (numerical scale of pain) at time zero (TO), after 30' (t1), 1h (T2) and 24h (T3). Furthermore, it was annotated request for rescue doses of morphine and the collateral effects. RESULTS: The two study groups did not show significant differences related to the anthropometric characteristics, duration of surgery, type of surgery, ASA class. No difference between the two groups was highlighted during the evaluation of POP through NRS scale and quantity of "rescue" doses requested. In group E there was a single case of respiratory depression. CONCLUSIONS: Our study suggests that whether intravenous or subcutaneous administration of morphine, both simple and economical analgesic techniques, they are able to guarantee the same quality control of POP in patients undergoing abdominal surgery.

[Role of surgery in patients with metastases from melanoma. A case report]. / Ruolo della chirurgia in pazienti con metastasi da melanoma. Un caso clinico.

INTRODUCTION: The prognosis of patients with melanoma varies according to the staging of disease at the moment of diagnosis. Melanoma can metastasize to every organ or tissue, but the most common site involved is locoregional. In selected patients surgery plays a central role with the possibility of changing the prognosis at distance. CASE REPORT: A 65-year-old man with a diagnosis of neoplasm of the left thyroid lobe and metastatic melanoma with unknown primitive localization. Since 2003 the patient has undergone many operations to remove metastatic melanoma. Currently he is in good conditions and performs neoadjuvant palliative treatments. DISCUSSION: The indication for surgery in cases of patients with distant disease (IV stage) or metastases in transit (IIIc stage) is linked to the possibility of surgical removal of individual lesions. In particular are candidates for surgery patients who have a visceral localization less than or equal to 2 sites, a number less than or equal to 8 metastases, in good health and having a melanoma-specific survival estimated more than 3 months; surgical approach requires an accurate and early identification by imaging study. The case report shows that in selected cases, some patients may benefit from aggressive surgery, especially in terms of survival at distance.

Meta-analysis of fibrin glue versus surgery for treatment of fistula-in-ano.

AIM: To evaluate the convenience in terms of recurrence and fecal incontinence rates of fibrin glue versus surgical treatment in the management of fistula-in-ano. MATERIALS AND METHODS: Randomized controlled trials (RCTs) and non-randomized studies (CCTs) comparing conventional surgical treatment versus fibrin glue treatment in patients with perianal fistulae were identified using a predefined search strategy. The post treatment anal incontinence rate and the fistula recurrence rates between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions. The lack of homogeneity of results between the different studies did not allow to analyze other secondary outcomes. Patients with cryptoglandular and Crohn's anal fistula were enrolled in the analysis. The employed fibrin glue came from commercial kits: Beriplast (Aventis Behring, Sussex, United Kingdom) and Tisseal or Tissucol (Baxter, Inc, Mississauga, Ontario). Surgical conventional treatment consisted of fistulotomy, placement of a cutting or loose latex seton and advancement mucosal flap closure. All patients were followed up at 6 and 12 weeks, the longest follow up was 6 months. RESULTS: Two RCTs (106 patients) and 1 non randomized studies (232 patients) were identified. The recurrence rate is higher, although still not statistically significant, in those patients who underwent fibrin glue injection (44/81) versus conventional surgical treatment (108/230), (OR: 0.44; 95 %CI: 0.12-1.68; P = 0.23). Furthermore in the analysis of the subgroup of RCTs alone there were not significant differences with the previous results of RCTs with CCT analysis (OR: 0.33; 95 %CI: 0.03-3.66; P = 0.37). In the same way the analysis of the subgroup of RCTs with complex anal fistulae were not statistically significant and similar to the previous results regarding all type of fistulas (OR: 0.86; 95 %CI: 0.01-72.36; P = 0.95). The analysis of post-operative anal incontinence showed no difference between the group who underwent fibrin glue injection (9/230) and the conventional surgical treatment group (10/81), (OR: 1.00; 95 %CI: 0.43-2.34; P = 1.00). A very low heterogeneity in the analysis was detected (Chi-square = 0.04 - P = 0%). CONCLUSION: Our statistical analysis does not show any significant statistical difference between fibrin glue treatment versus conventional surgical treatment for all perianal fistulae in terms of recurrence (P = 0.23) and anal incontinence (P = 1.00).

Control results on a sample of patients subjected to total thyroidectomy for papillary carcinoma: proposal for a personal diagnostic-therapeutic follow-up.

Well-differentiated thyroid neoplasms may be included among the most frequently occurring thyroid carcinomas. Papillary ca. is without doubt the best behaved type. The aim of the present work is to perform a retrospective case history study to assess patients with con papillary ca. who have been treated surgically over the last 17 years and have been subjected to periodic checks. A sample of patients was therefore extrapolated who had all undergone total thyroidectomy for papillary ca. of the thyroid. The incidence of local recurrence of the disease was verified, together with the results at distance. Furthermore, the assessments performed were evaluated and compared. From the sample of patients observed we inferred that papillary carcinoma of the thyroid can have a good prognosis over time provided periodic random checks are carried out.

Transverse skin crease versus vertical midline incision versus laparoscopy for right hemicolectomy: a systematic review--current status of right hemicolectomy.

PURPOSE: The right hemicolectomy may be conducted through laparoscopic or laparotomic surgery, transverse or midline incisions. The transverse laparotomy offers some advantages compared to the midline laparotomy and laparoscopy. A literature review was performed to evaluate the possible advantages of the transverse incision versus midline incision or laparoscopic right hemicolectomy. METHODS: A systematic research was performed in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, and the Science Citation Index. RESULTS: Laparotomic right hemicolectomy with transverse incision is preferable to laparotomic hemicolectomy with midline incision. A transverse incision offers a lessened postoperative pain following physical activity, a lessened need to administer analgesic therapy during the post-operative time, better aesthetic results, and a better post-operative pulmonary function. Open surgery with transverse or midline incision ensured a shorter operative time, lower costs and a greater length of the incision compared to the laparoscopic. However, there are no differences in the oncological outcomes. CONCLUSIONS: It was not possible to identify significant differences between the open right hemicolectomy with transverse incision versus the open right hemicolectomy with midline incision or laparoscopic hemicolectomy.

Prospective evaluation of acoustic radiation force impulse technology in the differentiation of thyroid nodules: accuracy and interobserver variability assessment.

PURPOSE: The aim of this study is to assess the diagnostic efficacy and interobserver agreement of acoustic radiation force impulse (ARFI) elasticity imaging in differentiating thyroid nodules. METHODS: In our study, 74 consecutive patients (52 females, 22 males; age range 27-77 years, mean: 41 years) with 82 thyroid nodules (60 benign nodules, and 22 malignant) were examined by two radiologists with different experience. Patients underwent either cytology using fine needle aspiration cytology or thyroid surgery. The diagnostic performance of the two operators at ARFI with sensitivity, specificity, positive predictive and negative predictive value, and ROC curves was estimated. Inter-reader variability between the two operators was defined using Cohen's k. RESULTS: According to receiver operating characteristics ROC curves (AUROC = 0.86 for observer 1; 0.81 for observer 2) sensitivity, specificity, PPV and NPV of reader 1 and 2 were respectively: 90, 75, 90.91 and 96.55 %; (cut-off value of shear wave: 2.455 m/s); 90, 72, 90 and 96.90 % (cut-off value shear wave: 2.365 m/s). Concordance between the two operators was good (k = 0.755). CONCLUSIONS: This work is a feasibility study evaluating ARFI imaging. Its results suggest that ARFI imaging is a reproducible method which can be utilized with good diagnostic performance in the thyroid for discriminating benign and malignant nodules using the cut-off value of 2.455 m/s. However, larger studies are needed to validate this method.

Ultrasound elastography in the evaluation of thyroid pathology. Current status.

Thyroid pathology including thyroid nodules and diffuse thyroid diseases represents often a diagnosing challenge for clinicians. US, although highly accurate in identifying thyroid nodules and diffuse thyroid diseases, is still not sufficiently accurate to evaluate them. US-elastography has been introduced in order to further increase US accuracy in many fields and eventually for thyroid disease. The aim of the present paper it to provide an update of the literature on different available techniques and the results reported both for thyroid nodules differentiation and for diffuse thyroid disease evaluation. Advantages and limitations of elastography are also discussed.

Epigenetic-related gene expression profile in medullary thyroid cancer revealed the overexpression of the histone methyltransferases EZH2 and SMYD3 in aggressive tumours.

Epigenetic control of gene expression plays a major influence in the development and progression of many cancer types. Aim of the present study was to investigate the expression of epigenetic regulators in a large cohort of medullary thyroid carcinomas (MTC), correlating the data with the clinical outcome and mutational status of the patients. Taqman Low Density Arrays (TLDAs) were used to analyze expression levels of several genes involved in the epigenetic control of transcription in a series of 54 MTCs. The patients cohort included 13 familial MTCs and 41 sporadic forms; 33 hosted a RET mutation and 13 a RAS somatic mutation. The expression profiling revealed in the more aggressive diseases (i.e. occurrence of metastases; persistent disease; disease-related death) a significant increase of EZH2 and SMYD3 gene expression. The increased levels of EZH2 and SMYD3 did not correlate significantly with mutational status of RET or RAS genes. Thus, the histone methyltransferases EZH2 and SMYD3 mRNA expression may represent useful prognostic biomarkers tailoring the most appropriate follow-up and timing of therapeutic approaches.

Requirement for a standardised definition of advanced gastric cancer.

Each year, ~988,000 new cases of stomach cancer are reported worldwide. Uniformity for the definition of advanced gastric cancer (AGC) is required to ensure the improved management of patients. Various classifications do actually exist for gastric cancer, but the classification determined by lesion depth is extremely important, as it has been shown to correlate with patient prognosis; for example, early gastric cancer (EGC) has a favourable prognosis when compared with AGC. In the literature, the definition of EGC is clear, however, there is heterogeneity in the definition of AGC. In the current study, all parameters of the TNM classification for AGC reported in each previous study were individually analysed. It was necessary to perform a comprehensive systematic literature search of all previous studies that have reported a definition of ACG to guarantee homogeneity in the assessment of surgical outcome. It must be understood that the term 'advanced gastric cancer' may implicate a number of stages of disease, and studies must highlight the exact clinical TNM stages used for evaluation of the study.