Utility of Ocular Motility Tests in Orbital Floor Fractures with Muscle Entrapment That is Not Detected on Computed Tomography

Purpose

Determine the usefulness of ocular motility testing to detect the presence of muscle entrapment.

Materials and Methods

Cross-sectional study of patients with symptoms of diplopia secondary to facial trauma. Inclusion criteria: age between 20 and 80 years; symptoms of diplopia following facial trauma; presence of orbital floor fracture confirmed radiologically; presence of muscle entrapment confirmed at the time of surgery; best-corrected visual acuity of 0.6 or more. Exclusion criteria: muscle entrapment visible on computed tomography; candidate for immediate surgical correction; prior history of strabismus surgery. Outcome measures: Abnormal Head Position (AHP), Hirschberg Corneal Reflexes (CR), Cover/Uncover and Alternating Cover Test, Hertel exophthalmometry, Near Point of Convergence (NPC), Kestenbaum Limbus test, Red Filter test, and Hess screen test.

Results

Forty-six subjects (38 males, 8 females, mean age 27 ± 3.3 SD years). Pre-operative assessment: forty-six (100%) reported diplopia on the Red Filter test and showed some degree of abnormality on the Hess Screen test. Forty-two (91%) showed AHP. Forty-one (89%) had exophthalmometry values that differed 2 mm or more between the two eyes and insufficient NPC. Thirty-two (69.6%) showed deficits of 3 mm or more on the Kestenbaum Limbus test. Sixteen (35%) had abnormal Hirschberg corneal reflexes. Eleven (24%) demonstrated constant or intermittent strabismus.

Conclusion

Ocular motility testing can differentiate non-invasively, pre-operatively, and cost-effectively the presence of muscle entrapment even when this is not visible on computed tomography.

An unusual infraclavicular mass in the thoracic compartment. Literary Review

Haemangiopericytoma (HPC) is a rare vascular tumor comprising 1% of all vascular neoplasms and was first described by Stout and Murray in 1942. They are highly vascularized tumours located in any part of the body. Malignant HPCs represent <1% of all vascular tumours and around 5% of all sarcomatous tumours. The majority has a relatively indolent behaviour with presenting symptoms being vague for several months and not specific. Surgical excision is the mainstay of treatment. We present the case of a 65-year old male with HPC of left infraclavicular region with no associated lymphadenopathy. Surgical management included en bloc excision. The patient did not require any adjuvant therapy and showed no signs of recurrence at 1-year follow up. KEY WORDS: Haemangiopericytoma, Extracranial, Surgical excision, Vascular tumor.

An unusual location of hand, foot and mouth disease

Hand, foot, and mouth disease (HFMD) is a childhood febrile disease. Oral lesions and papulovesicular lesions on the hands and feet are the clinical signs of the disease. In our case, a 17-year-old boy presented to the emergency department, where he was diagnosed with HFMD. After 6 days, he felt intense pain in his right testicle, and therefore an ultrasound (US) examination was performed. US detected a hypoechoic mass-like area in the right testis. Viral etiology was suspected, and no therapy was prescribed. After a little more than 3 months, US examination showed a reduced lesion size. Viral epididymo-orchitis should be suspected in young men with a recent history of HFMD and testicular pain.

Chronic obstructive Eustachian tube dysfunction: CT assessment with Valsalva maneuver and ETS-7 score

Chronic obstructive Eustachian tube dysfunction (ETD) is a common disorder of the middle ear. In recent years, two main diagnostic tools have become available: Eustachian tube score (ETS-7) and computed tomography (CT) combined with Valsalva maneuver. The aim of this study is to evaluate the outcomes of ETS-7 and CT in a group of patients affected by middle ear atelectasis with a strong suspicion of ETD. Three males and nine females, affected by middle ear atelectasis with retraction of the TM were enrolled. Each patient underwent to Eustachian tube dysfunction evaluation adopting the ETS-7 score and a temporal bone CT with Valsalva maneuver. The ears analyzed at steady state were divided into 2 groups: ETS<7 group and ETS≥ 7 group. The same division was applied for the ears analyzed after the Valsalva maneuver: ETS<7 group and ETS≥ 7 group. ETs were categorized as “well defined” (WD) and “not defined” (ND). The results of the analysis of the ETS-7 score in all 24 ears showed that 42% presented ETS ≥7, while 58% had ETS <7, indicating a diagnosis of ETD. In the ETS<7 group after Valsalva, ET was visualized in 33% of patients. In the ETS≥7 group it was WD in 29% after the Valsalva manoeuver. In both groups the comparison between the visualization of the ET before and after the Valsalva manoeuver did not present a statistical difference. No correlation emerged between ET evaluation with CT scan during Valsalva maneuver and ETS-7 score. It confirms that there is not a gold standard for the study of ET dysfunction.

New 3D Cone Beam CT Imaging Parameters to Assist the Dentist in Treating Patients with Osteogenesis Imperfecta

(1) Background: The aim of the work is to identify some imaging parameters in osteogenesis imperfecta to assist the dentist in the diagnosis, planning, and orthodontic treatment of Osteogenesis Imperfecta (OI) using 3D cone beam Computed Tomography (CBCT) and the Double Energy X-ray Absorptiometry (DEXA) technique. (2) Methods: 14 patients (9 males and 5 females; aged mean ± SD 15 ± 1.5) with a clinical-radiological diagnosis of OI were analyzed and divided into mild and moderate to severe forms. The patients' samples were compared with a control group of 14 patients (8 males and 6 females; aged mean ± SD 15 ± 1.7), free from osteoporotic pathologies. (3) Results: The statistical analysis allowed us to collect four datasets: in the first dataset (C1 sick population vs. C1 healthy population), the t-test showed a p-value < 0.0001; in the second dataset (C2 sick population vs. C2 healthy population), the t-test showed a p-value < 0.0001; in the third dataset (parameter X of the sick population vs. parameter X of the healthy population), the t-test showed a p-value < 0.0001; in the fourth dataset the bone mineralometry (BMD) value detected by the DEXA technique compared to the C2 value of the OI affected population only) the Welch-Satterthwaite test showed a p-value < 0.0001. (4) Conclusions: The research has produced specific imaging parameters that assist the dentist in making diagnostic decisions in OI patients. This study shows that patients with OI have a characteristic chin-bearing symphysis, thinned, and narrowed towards the center, configuring it with a constant "hourglass" appearance, not reported so far in the literature by any author.

ENT-MS-12 questionnaire: A novel tool to investigate otolaryngology symptoms in patients with relapsing-remitting multiple sclerosis. Results from a pilot study

BACKGROUND

Multiple sclerosis (MS) is associated with otolaryngology-related manifestations including vestibular or auditory symptoms; facial motor or sensory disorders; voice or swallowing impairment; and snoring/sleep apnea. Because these symptoms are nonspecific, their significance in MS is seldom recognized by patients with MS and their physicians; yet, presence of these symptoms may be a harbinger of impending relapse or disease progression. We developed and investigated a survey instrument, the ENT-MS-12, to standardize reporting of otolaryngology symptoms in patients with MS, correlating its scoring with disability and lesions.

METHODS

The ENT-MS-12 was administered to 40 patients with relapsing-remitting MS in different phases of their disease. We collected data using the Expanded Disability Status Scale (EDSS) and analyzed patient brain MRIs to evaluate the state (active or non-active) of brain lesions based on gadolinium enhancement. Odds ratios for diverse otolaryngology symptoms across the EDSS scores and brain lesions were calculated.

RESULTS

Higher EDSS scores were associated with auditory and vestibular symptoms (Odd Ratio (OR): 3.06; p: 0.0003); voice and swallowing symptoms (OR: 6.8; p=0.007); and snoring/sleep apnea (OR: 5.1; p=0.03). Presence of active brain lesions was also associated with auditory and vestibular symptoms (OR: 6.7); voice and swallowing symptoms (OR: 5.7); and snoring/sleep apnea (OR: 5).

CONCLUSIONS

The ENT-MS-12 survey instrument standardizes reporting of otolaryngology symptoms in patients with MS and documents association between symptoms and phase of disease in this series. Because ear, nose and throat (ENT)- related symptoms (i.e., sensory symptoms, such as numbness) are under-reported in MS, further investigation is warranted, as such data may improve clinical management of MS.

Public hygiene and funeral rituals during the Risorgimento: mummies and ashes

Starting in 1865, regulations pursuant to public hygiene issued by the Unitary Government provided for administrative and political control of the funerary practice. Specifically, they regulated the management of cemeteries and the burials, increasingly drawing the funeral rituals from the control of the Church and of Catholicism, therefore secularising death for the construction of a new political religion. Hygiene became fundamental in order to promulgate cremation as a system of preserving the integrity of the bodies, preserving the ashes as a tangible and indestructible product of body matter and as a measure to protect public health by eliminating the risk of miasmatic pollution of the air caused by the cadaveric fumes. In the early 1870s, the practice of cremation began to spread, especially in the territories of Lombardy-Veneto and Savoy, as an expression of the progressive policies of the new Italian state, antagonistic to the old Catholic religious traditions. This paper intends to highlight the key aspects of the political significance that the cremation took on during the Risorgimento period, while also illustrating the methods adopted by important authors from that time period regarding incineration techniques and cremation methods.

Digital imaging techniques applied to a case of concha bullosa from an early medieval funerary area in central Italy

OBJECTIVE

Concha bullosa is a rather common condition of the nasal turbinates, rarely reported in archaeological skeletal collections. This paper examines a case of concha bullosa as seen in a female cranium from a burial in central Italy, dated to the Longobard domination in the Peninsula (mid-7th- early 8th century CE).

MATERIALS

The individual under investigation (T86/17) comes from the funerary area of Selvicciola, located near the town of Viterbo in northern Latium, Italy.

METHODS

The skeleton was macroscopically examined. We analyzed the CT-scans of the defect by applying innovative R-based virtual tools.

RESULTS

It was possible to calculate the inner volume of the concha bullosa and to provide a 3D visual assessment of its shape.

CONCLUSIONS

Its size and shape suggest that the individual had this condition for a considerable period of time, during which its presence may have had affected her daily activities and health status.

SIGNIFICANCE

An under-represented paleopathological defect is examined for the first time through a virtual approach aimed at visualizing its shape and the assessment of its volume. New methods of 3D based virtual assessment can increase the informative value of defects.

SUGGESTIONS FOR FURTHER RESEARCH

Techniques used in this assessment should be considered as an evaluative tool for other conditions when macroscopic and radiographic imaging are limited.

Medico legal considerations on refractive surgery

This study is a summary of legal issues that occurred over time in Italy, concerning the evaluation of the professional responsibility of the health damage caused by refractive surgery, also in the light of the diagnostic elements obtained from the new techniques relating to diagnostic tests for preoperative surgical correction of the main ametropia.

Effects of Repeated Intravitreal Injections of Dexamethasone Implants on Intraocular Pressure: A 4-Year Study

Purpose

Dexamethasone and other corticosteroids are administered intravitreally to treat a variety of retinal diseases. As a side effect, they can alter intraocular pressure (IOP). The purpose of this study is to describe the incidence, severity, and management of ocular hypertension following the administration of multiple intravitreal injections of dexamethasone implants.

Materials and Methods

A total of 78 eyes of 78 subjects (males 62%; females 38%; mean age 67 ± 13 years SD) received a total of 152 intravitreal injections of 0.7 mg dexamethasone implants over 4 years. Indications included retinal vein occlusion (87%), diabetic macular edema (9%), wet-type age-related macular degeneration (4%). Ocular hypertension was defined as intraocular pressure above 23 mmHg or any pressure increase of 10 mmHg or more from baseline values. IOP was measured by applanation tonometry before the injection (T0), as well as one week (T1), one month (T2), and three months (T3) afterwards.

Results

Five percent (4/78) of subjects developed ocular hypertension after the 1st injection. On the second and third rounds, additional 7.2% (3/42) and 4.2% (1/24) of subjects developed the same side effect. Among the 8 subjects who received a fourth injection, none was found with OHT. Pressure elevations were detected at T2 and T3. In all patients, topical medical therapy was sufficient to lower the IOP below threshold. Mean pressure variations following the first injection as compared to previous recorded values were +0.97 mmHg (T1), +0.92 mmHg (T2), and -0.41 mmHg (T3) (p < 0.05). Mean pressure variations following the second injection were +0.54 mmHg (T1), +0.23 mmHg (T2) and -0.66 mmHg (T3) (p < 0.05).

Conclusion

Ocular hypertension is a recognized side effect of intravitreal dexamethasone. Some patients develop it right after the first injection, while others develop it subsequently, on the 2nd or 3rd round. This side effect becomes most apparent 30-90 days following the implantation procedure and responds well to topical pressure-lowering medications.

Role of Leptin in Neoplastic and Biliary Tree Disease

BACKGROUND/AIM

Leptin is a small hormone of protein nature, it is strongly involved in the regulation of lipid metabolism and its functioning mechanism is not yet well known or whether or not it is actually secreted by cholangiocytes, nor if the biliary tree expresses its receptors. In the past, various studies have tried to correlate leptin levels with certain neoplasms. The aim of this study was to demonstrate that serum leptin values can become a new sensitive and specific serum marker for cholangiocarcinoma.

MATERIALS AND METHODS

Seventy-two patients with gallbladder stones, hepatolithiasis with benign biliary stenosis, cholangiocarcinoma, and a group of patients without hepato-biliary diseases were enrolled in the study. In all cases blood and bile samples were collected for evaluation of leptin levels and liver biopsies were performed to confirm diagnosis. In all patients, both ultrasound and cholangio-magnetic resonance imaging (MRI) were performed to complete the diagnostic procedure.

RESULTS

Twenty-two patients were affected by cholangiocarcinoma, 50 by benign biliary disease (35 cholelithiasis and 6 hepatolithiasis and 9 by inflammatory biliary stenosis). The mean values of serum leptin in patients with cholangiocarcinoma were 19.28±8.76 ng/ml, significantly higher than those observed in non-neoplastic biliary diseases.

CONCLUSION

Serum leptin levels might be a useful marker to differentiate patients with cholangiocarcinoma from those with biliary lithiasis and inflammatory stenosis.

US-Elastography for Breast Lesion Characterization: Prospective Comparison of US BIRADS, Strain Elastography and Shear wave Elastography

PURPOSE

 To evaluate the diagnostic performance of strain elastography (SE) and 2 D shear wave elastography (SWE) and SE/SWE combination in comparison with conventional multiparametric ultrasound (US) with respect to improving BI-RADS classification results and differentiating benign and malignant breast lesions using a qualitative and quantitative assessment.

MATERIALS AND METHODS

 In this prospective study, 130 histologically proven breast masses were evaluated with baseline US, color Doppler ultrasound (CDUS), SE and SWE (Toshiba Aplio 500 with a 7-15 MHz wide-band linear transducer). Each lesion was classified according to the BIRADS lexicon by evaluating the size, the B-mode and color Doppler features, the SE qualitative (point color scale) and SE semi-quantitative (strain ratio) methods, and quantitative SWE. Histological results were compared with BIRADS, strain ratio (SR) and shear wave elastography (SWE) all performed by one investigator blinded to the clinical examination and mammographic results at the time of the US examination. The area under the ROC curve (AUC) was calculated to evaluate the diagnostic performance of B-mode US, SE, SWE, and their combination.

RESULTS

 Histological examination revealed 47 benign and 83 malignant breast lesions. The accuracy of SR was statistically significantly higher than SWE (sensitivity, specificity and AUC were 89.2 %, 76.6 % and 0.83 for SR and 72.3 %, 66.0 % and 0.69 for SWE, respectively, p = 0.003) but not higher than B-mode US (B-mode US sensitivity, specificity and AUC were 85.5 %, 78.8 %, 0.821, respectively, p = 1.000).

CONCLUSION

 Our experience suggests that conventional US in combination with both SE and SWE is a valid tool that can be useful in the clinical setting, can improve BIRADS category assessment and may help in the differentiation of benign from malignant breast lesions, with SE having higher accuracy than SWE.

Septal Nasal Extramedullary Plasmacytoma: A Rare Tumor in an Unusual Area

We present an extreme rare case of extramedullary nasal plasmacitoma that arise from nasal septum. The mass surgically removed was analyzed by a pathologist who diagnosed an extramedullary nasal plasmacytoma. The patient did not present systemic involvement. A short cycle of radiotherapy was performed after the surgery. At 9-month follow-up, the patient is recurrence free.

High ligation of sapheno-femoral junction and thermal ablation for lower limb primary varicosity in day hospital setting

AIM

The traditional surgical treatment for lower limb primary varicosity has been for a long time high ligation of sapheno-femoral junction and stripping of great saphenous vein. Surgery, however, has been frustrated by postoperative pains and discomfort and recurrences so that it has been challenged by minimally invasive endovenous techniques such as laser treatment and radiofrequency ablation. The aim of the article is to assess the feasibility, in a day hospital setting, of a combined approach to greater saphenous vein reflux: high ligation of sapheno-femoral junction and thermal treatment of the great sapenous vein.

METHODS

A retrospective analysis on 95 patients treated with high ligation and thermal ablation at our institution from January 2009 to July 2017 was performed, assessing duration of surgery, post-operative pain and analgesics requirements, early complications and resumption of activities.

RESULTS

Two patients (2.74%), in the laser group experienced skin burns in the course of the GSV. Moderate ecchymosis, by laser fibre-induced perforation of the vein wall, were observed in another two patients (2.74%). Four limbs (5.48%) in the EVLT group developed transient paraesthesias. Analgesic requirement on POD 3 was nil for RFA group; conversely half of the EVLT patients did take analgesics, either 2 or 3 tabs were required. On POD 7, the patients of RFA group continued to not ask for any analgesics, but the same half of the patients in EVLT group still needed 1-2 tabs to carry out their normal activities smoothly. On POD 15, no patient did require analgesics. Resumption of routine activities was earlier for RFA group patients than for those in the EVLT group. The RFA group resumed their activities within 3 days, whereas EVLT group in 8-9 days. High ligation of the SFJ didn't add too much time or morbidities.

CONCLUSION

Catheter delivery of thermal energies for saphenous ablation, even when combined with high ligation of saphenous femoral arc, demonstrated to be minimally invasive, easy to learn and easy to perform in day hospital setting, with early return to normal activity. EVLT achieved similar results to RFA and both techniques were considered equally effective and safe; the results we obtained were not statistically significant but RFA showed less pain, ecchymosis and haematomas, as well as provided better short-term quality of life.

KEY WORDS

Day Hospital setting, Endovenous laser treatment, High ligation ablation of the saphenous vein, Radiofrequency ablation.

Sensory block in Day Surgery

BACKGROUND

The aim of our research is to evaluate the effectiveness of the spinal anesthesia versus Local Anesthesia within the context of Day Surgery.

MATERIALS AND METHODS

This study is a clinical trial. 140 patients were enrolled (60 female, 80 male). Some parameters have been evaluated with scales ASA, Bromage Scale, Hollmen Scale, Numerical Rate Scale, and Patient Satisfaction that are now internationally recognized as valid to assess both the degree of anesthesia and the patient benefit.

RESULTS

Data is mostly matching between the two groups, even though there are some differences. Every patient from the group SUB underwent a single sensory block due to the fact that everyone had a Bromage Score under 2 and Hollmen score between 2 and 3 CONCLUSIONS: Results showed the versatility of the SUB blockage in a Acute postoperative pain is associated to the surgical treatment and is still today unavoidable. We always tried to keep in check or even avoid the pain, thinking it is useless and ethically inacceptable. It is considered dangerous since it starts neurovegetative and neuroendocrinal cascade which lead to delayed functional and psychophysical recoverywider population, compared to the LAs, the better surgical planning, but mostly a better analgesia over the following 24 hours and a better satisfaction. Despite all these findings the patients continue to prefer the local anesthesia.

KEY WORDS

Analgesia, Epidural, Post-operative, Ultrasound.

The influence of preoperative MRI in early breast cancer: gold standard

BACKGROUND

Aim of this study was to evaluate the impact of presurgical breast MRI on the surgical management of selected patients with early-stage breast cancer, who were candidates for BCT.

MATERIALS AND METHODS

The trial was built up according to the major European Breast Society. In additional foci classified as BI-RADS 3-4 (4a, 4b, and 4c), a targeted second-look US study was performed.

RESULTS

A total of 123 patients underwent presurgical breast MRI. Therapeutic strategy established based on MRI was appropriate in 83.8% of cases. Analysis carried out on the subgroup of patients with dense breast showed that additional foci were found in 41.9% and a greater local extension of the index lesion in 6.4%.

CONCLUSION

The results obtained in the subgroup of patients with high breast density suggest the importance of a sensitive tool such as MRI in the local staging of breast cancer before treatment planning.

KEY WORDS

Breast cancer, BI-RADS, Histological diagnosis, Mammography MRI.

Double Ring in Cochlear Otosclerosis: A Limit to Cochlear Implantation? The Solution Is the Surgical Approach

We present a case of a 50-year patient with a severe form of otosclerosis (double ring) that was successfully implanted. We used a bone-anchored hearing implant for restoring the hearing in the right side and a cochlear implant in the left side; both surgeries did not show any complications. For reducing the risk of a secondary bone ossification related to the trauma of cochleostomy for electrode's insertion, we used a round window approach. The patient recovered a normal auditory threshold and normal speech perception capacity both in silence and noise conditions 1 year after surgery.

Groin hernia containing bladder diverticula Report of two cases and review of the literature

We report two cases of groin herniation of bladder diverticula with different clinical presentation and evolution; bladder diverticula are rarely involved in the pathogenesis of groin hernias. A differential diagnosis is to be made mainly with a common groin hernia. A correct anamnesis, a careful physical examination and a correct diagnostic pattern, including cystography, CT and US scans, are needed. Surgery is recommended when specific symptoms appear, or if an urothelial cancer grows within a diverticulum. KEY WORDS: Diverticulum, Groin hernia, Uretheral cancer.

Aortic arch pseudoaneurysm on penetrating ulcer: delayed closure after endovascular treatment. A case report

Standard open repair of true or false aneurysms of the aortic arch usually require cardiopulmonary bypass, hypothermia and circulatory arrest, associated with increased mortality and morbidity rates. Thus, an alternative strategy that avoids cardiopulmonary bypass (CPB) and hypothermic circulatory arrest would benefit the patient. Endovascular stent-grafting has developed as a safe and effective treatment for descending aortic pathologies.5,6 We share our experience with the endovascular approach to pseudoaneurysm of the aortic arch in a patient with high risk for aortic arch replacement under extracorporal circulation. KEY WORDS: Aortic arch, Endoprosthesis, Evar, Penetrating ulcer.

Multiparametric MRI Versus Multiparametric US in the Detection of Prostate Cancer

BACKGROUND/AIM

The aim of the study was to compare the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI), multiparametric ultrasound (mpUS) and US/MRI fusion imaging techniques in the detection of prostate cancer.

PATIENTS AND METHODS

A total of 82 patients with persistently high prostate specific antigen (PSA) levels after medical therapy were prospectively evaluated. All patients underwent digital rectal examination, mpMRI, mpUS and prostate biopsy.

RESULTS

Histological outcome was positive for prostate cancer (PCa) in 46/82 patients (56.1%). MpMRI detected 54/82 lesions; histological analysis confirmed PCa in 44 lesions (sensitivity 91.3% and specificity 66.7%). Ratio estimation with semiquantitative elastography, between lesions and the peripheral portion showed a higher sensitivity and specificity compared to strain ration (SR) evaluation between lesions and adenomas (sensitivity 84.8% vs. 78.3%; specificity 66.6% vs. 61.1%). Quantitative analysis of contrast-enhanced ultrasound (CEUS) showed 40.0% sensitivity and 97.2% specificity. A total of 54 lesions detected by mpMRI and MRI/TRUS fusion targeted biopsy had a high number of positive samples (81.5%).

CONCLUSION

mpMRI is more accurate than mpUS which still remains a valuable technique used after MRI for prostate fusion-guided biopsy.

Multiparametric ultrasound in the evaluation of kidney disease in elderly

After the age of 30 years, GFR progressively declines at an average rate of 8 mL/min/1.73 m/decade. A problem of advanced age is that the evaluation of renal function on the basis of indicators valid in young adults, such as creatininemia, is unreliable. In fact, many patients with chronic renal failure may have serum creatinine levels within the normal range even if they have a significant reduction in renal function. Ultrasound has become a routine method of investigation in renal disease: kidney size and parenchymal echogenicity are considered markers of renal function, so US is useful in assessing the presence and degree of renal failure. CEUS is useful in the evaluation of kidney disease in the elderly: the increased hemodynamic resistance of renal microvessels reduces perfusion in the renal cortex, so fewer microbubbles enter the renal cortex. EcoColor and EcoDoppler are also useful in the evaluation of senile alterations: here, the distribution of color-signals, as compared to that in the young adult population, appears more attenuated, limited to intersegmental and interlobar districts. Among the ecoDoppler parameters, the resistance index can be considered a marker of renal damage progression, with attention needing to paid to possible concomitant confounding factors. Ultrasonography, color-Doppler and CEUS are a non-invasive and convenient modality for managing kidney disease; their integration with anamnestic, objective and laboratory data permits fast and reliable clinical, diagnostic, and therapeutic classification. It also allows early therapeutic intervention and, ultimately, improvements in patient management.

Unusual presentation of metastatic thyroid cancer without a primary: role of diagnostic imaging in a daily clinical setting

Papillary thyroid carcinoma (PTC) is the most common mali gnancy of the thyroid gland. In 21-90% of the patients occult lymph node metastases may occur. The case reported here describes a woman who underwent a total thyroidectomy for multinodular goiter and who presented an enlarged lymph node on the left side of the neck, which showed a metastasis from PTC. The patient underwent imaging investigation with CT and FNAB. The pathological examination diagnosed a papillary thyroid cancer metastases. The pT underwent a I131 total body scan, negative for secondary localization.