Expanding the Use of HIPEC in Ovarian Cancer at Time of Interval Debulking Surgery to FIGO Stage IV and After 6 Cycles of Neoadjuvant Chemotherapy: A Prospective Analysis on Perioperative and Oncologic Outcomes

BACKGROUND

Randomized data on patients with FIGO stage III ovarian cancer receiving ≤ 3 cycles of neoadjuvant chemotherapy (NACT) showed that hyperthermic intraperitoneal chemotherapy (HIPEC) after interval debulking surgery (IDS) improved patient's survival. We assessed the perioperative outcomes and PFS of FIGO stage IV and/or patients receiving up to 6 cycles of NACT undergoing IDS+HIPEC.

METHODS

Prospectively collected cases from January 1, 2019 to July 31, 2022 were included. Patients underwent HIPEC if: age ≥ 18 years but < 75 years, body mass index ≤ 35 kg/m2, ASA score ≤ 2, FIGO stage III/IV epithelial disease treated with up to 6 cycles of NACT, and residual disease < 2.5 mm.

RESULTS

A total of 205 patients were included. No difference was found in baseline characteristics between FIGO Stage III and IV patients, whereas rate of stable disease after NACT (p = 0.004), mean surgical complexity score at IDS (p = 0.001), and bowel resection rate (p = 0.046) were higher in patients undergoing delayed IDS. A lower rate of patients with at least one G3-G5 postoperative complications was observed in FIGO stage IV versus FIGO stage III disease (5.3% vs. 14.0%; p = 0.052). This difference was confirmed at multivariable analysis (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.07-0.80; p = 0.02), whereas age, SCS, bowel resection, and number of cycles did not affect postoperative complications. No difference in PFS was identified neither between FIGO stage III and IV patients (p = 0.44), nor between 3 and 4 versus > 4 cycles of NACT (p = 0.85).

CONCLUSIONS

Because of the absence of additional complications and positive survival outcomes, HIPEC administration can be considered in selected FIGO stage IV and patients receiving > 4 cycles of NACT.

Patient satisfaction with ultrasound, whole-body CT and whole-body diffusion-weighted MRI for pre-operative ovarian cancer staging: a multicenter prospective cross-sectional survey

BACKGROUND

In addition to the diagnostic accuracy of imaging methods, patient-reported satisfaction with imaging methods is important.

OBJECTIVE

To report a secondary outcome of the prospective international multicenter Imaging Study in Advanced ovArian Cancer (ISAAC Study), detailing patients' experience with abdomino-pelvic ultrasound, whole-body contrast-enhanced computed tomography (CT), and whole-body diffusion-weighted magnetic resonance imaging (WB-DWI/MRI) for pre-operative ovarian cancer work-up.

METHODS

In total, 144 patients with suspected ovarian cancer at four institutions in two countries (Italy, Czech Republic) underwent ultrasound, CT, and WB-DWI/MRI for pre-operative work-up between January 2020 and November 2022. After having undergone all three examinations, the patients filled in a questionnaire evaluating their overall experience and experience in five domains: preparation before the examination, duration of examination, noise during the procedure, radiation load of CT, and surrounding space. Pain perception, examination-related patient-perceived unexpected, unpleasant, or dangerous events ('adverse events'), and preferred method were also noted.

RESULTS

Ultrasound was the preferred method by 49% (70/144) of responders, followed by CT (38%, 55/144), and WB-DWI/MRI (13%, 19/144) (p<0.001). The poorest experience in all domains was reported for WB-DWI/MRI, which was also associated with the largest number of patients who reported adverse events (eg, dyspnea). Patients reported higher levels of pain during the ultrasound examination than during CT and WB-DWI/MRI (p<0.001): 78% (112/144) reported no pain or mild pain, 19% (27/144) moderate pain, and 3% (5/144) reported severe pain (pain score >7 of 10) during the ultrasound examination. We did not identify any factors related to patients' preferred method.

CONCLUSION

Ultrasound was the imaging method preferred by most patients despite being associated with more pain during the examination in comparison with CT and WB-DWI/MRI.

TRIAL REGISTRATION NUMBER

NCT03808792.

Prediction of the Risk of Malignancy of Adnexal Masses during Pregnancy Comparing Subjective Assessment and Non-Contrast MRI Score (NCMS) in Radiologists with Different Expertise

Ovarian cancer represents 7% of all cancers in pregnant women. Characterising an ovarian mass during pregnancy is essential to avoid unnecessary treatment and, if treatment is required, to plan it accordingly. Although ultrasonography (US) is the first-line modality to characterise adnexal masses, MRI is indicated when adnexal masses are indeterminate at the US examination. An MRI risk stratification system has been proposed to assign a malignancy probability based on the adnexal lesion's MRI, but features of the scoring system require the administration of intravenous gadolinium-based contrast agents, a method that might have a limited use in pregnant women. The non-contrast MRI score (NCMS) has been used and evaluated in non-pregnant women to characterise adnexal masses indeterminate at the US examination. Therefore, we evaluated the diagnostic accuracy of the NCMS in pregnant women, analysing 20 cases referred to our specialised institution. We also evaluated the diagnostic agreement between two radiologists with different expertise. The two readers classified ovarian masses as benign or malignant using both subjective assessment (SA), based on the interpretive evaluation of imaging findings derived from personal experience, and the NCMS, which includes five categories where 4 and 5 indicate a high probability of a malignant mass. The expert radiologist correctly classified 90% of the diagnoses, using both SA and the NCMS, relying on a sensitivity of 85.7% and a specificity of 92.3%, with a false positive rate of 7.7% and a false negative rate of 14.3%. The non-expert radiologist correctly identified patients at a lower rate, especially using the SA. The analysis of the inter-observer agreement showed a K = 0.47 (95% CI: 0.48-0.94) for the SA (agreement in 71.4% of cases) and a K = 0.8 (95% CI: 0.77-1.00) for the NCMS (agreement in 90% of cases). Although in pregnant patients, non-contrast MRI is used, our results support the use of a quantitative score, i.e., the NCMS, as an accurate tool. This procedure may help less experienced radiologists to reduce the rate of false negatives or positives, especially in centres not specialised in gynaecological imaging, making the MRI interpretation easier and more accurate for radiologists who are not experts in the field, either.

Ovarian cancer beyond imaging: integration of AI and multiomics biomarkers

High-grade serous ovarian cancer is the most lethal gynaecological malignancy. Detailed molecular studies have revealed marked intra-patient heterogeneity at the tumour microenvironment level, likely contributing to poor prognosis. Despite large quantities of clinical, molecular and imaging data on ovarian cancer being accumulated worldwide and the rise of high-throughput computing, data frequently remain siloed and are thus inaccessible for integrated analyses. Only a minority of studies on ovarian cancer have set out to harness artificial intelligence (AI) for the integration of multiomics data and for developing powerful algorithms that capture the characteristics of ovarian cancer at multiple scales and levels. Clinical data, serum markers, and imaging data were most frequently used, followed by genomics and transcriptomics. The current literature proves that integrative multiomics approaches outperform models based on single data types and indicates that imaging can be used for the longitudinal tracking of tumour heterogeneity in space and potentially over time. This review presents an overview of studies that integrated two or more data types to develop AI-based classifiers or prediction models.Relevance statement Integrative multiomics models for ovarian cancer outperform models using single data types for classification, prognostication, and predictive tasks.Key points• This review presents studies using multiomics and artificial intelligence in ovarian cancer.• Current literature proves that integrative multiomics outperform models using single data types.• Around 60% of studies used a combination of imaging with clinical data.• The combination of genomics and transcriptomics with imaging data was infrequently used.

The Utility of Contrast-Enhanced Magnetic Resonance Imaging in Uterine Cervical Cancer: A Systematic Review

Correct staging of cervical cancer is essential to establish the best therapeutic procedure and prognosis for the patient. MRI is the best imaging modality for local staging and follow-up. According to the latest ESUR guidelines, T2WI and DWI-MR sequences are fundamental in these settings, and CE-MRI remains optional. This systematic review, according to the PRISMA 2020 checklist, aims to give an overview of the literature regarding the use of contrast in MRI in cervical cancer and provide more specific indications of when it may be helpful. Systematic searches on PubMed and Web Of Science (WOS) were performed, and 97 papers were included; 1 paper was added considering the references of included articles. From our literature review, it emerged that many papers about the use of contrast in cervical cancer are dated, especially about staging and detection of tumor recurrence. We did not find strong evidence suggesting that CE-MRI is helpful in any clinical setting for cervical cancer staging and detection of tumor recurrence. There is growing evidence that perfusion parameters and perfusion-derived radiomics models might have a role as prognostic and predictive biomarkers, but the lack of standardization and validation limits their use in a research setting.

Image-Guided Localization Techniques for Metastatic Axillary Lymph Nodes in Breast Cancer; What Radiologists Should Know

Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.

Radiomics and Radiogenomics of Ovarian Cancer

Ovarian cancer, one of the deadliest gynecologic malignancies, is characterized by high intra- and inter-site genomic and phenotypic heterogeneity. The traditional information provided by the conventional interpretation of diagnostic imaging studies cannot adequately represent this heterogeneity. Radiomics analyses can capture the complex patterns related to the microstructure of the tissues and provide quantitative information about them. This review outlines how radiomics and its integration with other quantitative biological information, like genomics and proteomics, can impact the clinical management of ovarian cancer.

Staging Breast Cancer with MRI, the T. A Key Role in the Neoadjuvant Setting

Breast cancer (BC) is the most common cancer among women worldwide. Neoadjuvant chemotherapy (NACT) indications have expanded from inoperable locally advanced to early-stage breast cancer. Achieving a pathological complete response (pCR) has been proven to be an excellent prognostic marker leading to better disease-free survival (DFS) and overall survival (OS). Although diagnostic accuracy of MRI has been shown repeatedly to be superior to conventional methods in assessing the extent of breast disease there are still controversies regarding the indication of MRI in this setting. We intended to review the complex literature concerning the tumor size in staging, response and surgical planning in patients with early breast cancer receiving NACT, in order to clarify the role of MRI. Morphological and functional MRI techniques are making headway in the assessment of the tumor size in the staging, residual tumor assessment and prediction of response. Radiomics and radiogenomics MRI applications in the setting of the prediction of response to NACT in breast cancer are continuously increasing. Tailored therapy strategies allow considerations of treatment de-escalation in excellent responders and avoiding or at least postponing breast surgery in selected patients.

Beyond N Staging in Breast Cancer: Importance of MRI and Ultrasound-based Imaging

The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0–2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

Association between atherogenic index of plasma and carotid intima-media thickness in a cohort of Mediterranean women

The association between early atherosclerosis (IMT) and Atherogenic index of plasma (AIP), a marker of atherogenicity (log triglycerides/HDL Cholesterol) was evaluated in a population-based cohort study in women, aged 30-69, living in the metropolitan area of Naples, Southern Italy (Progetto ATENA). Serum cholesterol, HDL-cholesterol, LDL-cholesterol, Triglyceride, Insulin, HOMA, Apo B, hs-CPR were measured in 390 menopausal women, as a part of 5.062 participants of the cohort. Women in the second and third tertile of AIP showed an increased common carotid intima-media thickness compared with those in the first tertile: II vs I tertile (O.R. = 2.24, p = 0.007), III vs I tertile (O.R. = 2.29, p = 0.005), adjusted for age and Systolic pressure or II vs I tertile (O.R. = 2.19, p = 0.014), III vs I tertile (O.R. = 2.13, p = 0.026), adjusted for age, Systolic pressure, Body mass index and Apo B. Women in the second and third tertile of AIP compared to those in the first tertile, showed an OR of 2.14 (p = 0.016) and 1.99 (p = 0.033) respectively, of having elevates level of IMT, adjusted for traditional cardiovascular risk factor (age, Systolic Pressure, BMI, LDL Cholesterol, Diabetes diagnosis). This finding shows that in this group of menopausal women increased IMT is associated with elevated AIP independently of age and different cardiovascular risk factors. These results are in line with the hypothesis that AIP may be an useful clinical tools to give additional information in the risk assessment for atherosclerotic disease, in particular in postmenopausal women.

Pearls and Potential Pitfalls for Correct Diagnosis of Ovarian Cystadenofibroma in MRI: A Pictorial Essay

Ovarian cystadenofibroma is a benign ovarian tumor that is characterized by a consistent percentage of masses, which remain indeterminate in ultrasonography and require magnetic resonance (MR) investigation; they may mimic borderline or malignant lesions. Three main morphologic patterns, resembling different ovarian neoplasms, can be identified in cystadenofibromas: multilocular solid lesions, unilocular cystic lesions with parietal thickening, and purely cystic masses. However, a cystoadenofibroma has typical features, such as T2-weighted hypointensity associated with no restrictions in diffusion-weighted imaging (the so-called "dark-dark appearance") and progressive post-contrast enhancement (type I perfusion curve). The purpose of this study was to review the features of ovarian cystadenofibromas in MR imaging and to suggest pearls and pitfalls regarding their correct diagnosis.

Radiologist Checklist for Selecting Patients to Undergo PIPAC (Pressurized IntraPeritoneal Aerosol Chemotherapy)

Peritoneal carcinomatosis frequently occurs in advanced gastrointestinal and gynecological cancers. As factors such as poor drug uptake and distribution cause chemotherapy to be less effective, alternative therapies have been explored. Introduced in 2013, PIPAC (pressurized intraperitoneal aerosol chemotherapy) uses aerosolized chemotherapeutics sprayed into the patient’s peritoneal cavity using a laparoscopic approach. Despite the literature showing encouraging data regarding the tolerability and efficacy of PIPAC, there is a lack of articles on the role that imaging plays in selecting patients suitable for PIPAC. The aim of this study is to combine literature-based evidence and clinical experience to provide information able to support training radiologists, as well as experienced radiologists interested in innovative therapies.

Depiction of periprostatic nerve fibers by means of 1.5 T diffusion tensor imaging

PURPOSE

The knowledge of periprostatic nerve fiber (pNF) is still incomplete by means of conventional MRI. The purpose of our study was to demonstrate if DTI imaging is able to depict anatomical features of pNF.

METHODS

For this retrospective study, fifty-six patients (mean age 63.5 years), who underwent 1.5-T prostate MRI, including 32 directions DTI, were enrolled between October 2014 and December 2018. ANOVA test and Student's t-test were performed between the mean values of the number, FA values, and fiber length of pNF between base and mid-gland, mid-gland and apex, base and apex, right and left side, and anterior and posterior face of the prostate. A qualitative analysis was performed to detect the main orientation of pNF through a colorimetric 3D tractographic reconstruction.

RESULTS

The number of pNF showed a decrease from the base (322) to mid-gland (248) and apex (75) (p < 0.05). The FA values were higher at base and mid-gland (0.435 and 0.456) compared to the apex (0.313) (p < 0.05). The length of pNF was higher at apex (13.4 mm) compared to base (11.5 mm) and mid-gland (11.7 mm) (p < 0.05). The number of pNF was higher on the posterior face compared to the anterior face at base (186 vs 137), (p < 0.001). The FA values were higher on the posterior face compared to the anterior face at base (0.452 vs 0.417), mid-gland (0.483 vs 0.429), and apex (0.42 vs 0.382), (p < 0.05). The length of the pNF was higher in the posterior (14.7 mm) than in the anterior face (12 mm) at apex (p < 0.001). The main orientation of pNF was longitudinal in all patients (56/56, 100%).

CONCLUSIONS

DTI imaging has been demonstrated able to depict anatomical features of pNF.

Prognostic role of sarcopenia in metastatic colorectal cancer patients during first-line chemotherapy: A retrospective study

BACKGROUND

Sarcopenia is a condition characterized by decreased skeletal muscle mass due to physiological ageing or to a concomitant disease such as neoplasia. In cancer patients, a low lean body mass is suggested to be a negative prognostic factor for survival and for the development of dose-limiting chemotherapy toxicities irrespective of disease stage.

AIM

To evaluate the prognostic role of sarcopenia in patients with metastatic colorectal cancer (mCRC) undergoing first-line chemotherapy.

METHODS

Our retrospective analysis included 56 mCRC patients who received first-line chemotherapy from 2014 to 2017 at the Medical Oncology Unit of our hospital. Computerized scans were performed before starting chemotherapy and at the first disease reassessment. Sarcopenia was assessed using the skeletal mass index = muscle area in cm²/(height in m²) calculated at the L3 vertebra. Overall survival and objective response rate were evaluated. Toxicities were analyzed during the first four cycles of therapy and graded according to Common Terminology Criteria for Adverse Events version 4.0. A loss of skeletal muscle mass ≥ 5% was considered indicative of deterioration in muscle condition.

RESULTS

Median age was 67 years and 35.7% of patients were ≥ 70 years old. Fourteen patients (25%) were sarcopenic at baseline computed tomography (CT) scan (7/33 men; 7/23 women); 5/14 sarcopenic patients were ≥ 70 years old. Median follow-up was 26.8 mo (3.8-66.8 mo) and median overall survival was 27.2 mo (95%CI: 23.3-37.3). Sarcopenia was not correlated to overall survival (P = 0.362), to higher toxicities reported during the first 4 cycles of chemotherapy (P = 1.0) or to response to treatment (P = 0.221). At the first disease reassessment, a skeletal muscle loss (SML) ≥ 5% was found in 17 patients (30.3%) 3 of whom were already sarcopenic at baseline CT scan, while 7 patients became sarcopenic. SML was not correlated to overall survival (P = 0.961). No statistically significant correlation was found between baseline sarcopenia and age (P = 1.0), body mass index (P = 0.728), stage at diagnosis (P = 0.355) or neutrophil/lymphocyte ratio (P = 0.751).

CONCLUSION

Neither baseline sarcopenia nor SML affected survival. In addition, baseline sarcopenia was not related to worse treatment toxicity. However, these results must be interpreted with caution due to the limited sample size.

Non-contrast MRI can accurately characterize adnexal masses: a retrospective study

Objective

To determine the accuracy of interpretation of a non-contrast MRI protocol in characterizing adnexal masses.

Methods and materials

Two hundred ninety-one patients (350 adnexal masses) who underwent gynecological MRI at our institution between the 1^st of January 2008 and the 31^st of December 2018 were reviewed. A random subset (102 patients with 121 masses) was chosen to evaluate the reproducibility and repeatability of readers’ assessments. Readers evaluated non-contrast MRI scans retrospectively, assigned a 5-point score for the risk of malignancy and gave a specific diagnosis. The reference standard for the diagnosis was histopathology or at least one-year imaging follow-up. Diagnostic accuracy of the non-contrast MRI score was calculated. Inter- and intra-reader agreement was analyzed with Cohen’s kappa statistics.

Results

There were 53/350 (15.1%) malignant lesions in the whole cohort and 20/121 (16.5%) malignant lesions in the random subset. Good agreement between readers was found for the non-contrast MRI score (к = 0.73, 95% confidence interval [CI] 0.58–0.86) whilst the intra-reader agreement was excellent (к = 0.81, 95% CI 0.70–0.88). The non-contrast MRI score value of ≥ 4 was associated with malignancy with a sensitivity of 84.9%, a specificity of 95.9%, an accuracy of 94.2% and a positive likelihood ratio of 21 (area under the receiver operating curve 0.93, 95% CI 0.90–0.96).

Conclusion

Adnexal mass characterization on MRI without the administration of contrast medium has a high accuracy and excellent inter- and intra-reader agreement. Our results suggest that non-contrast studies may offer a reasonable diagnostic alternative when the administration of intravenous contrast medium is not possible.

Key Points

• A non-contrast pelvic MRI protocol may allow the characterization of adnexal masses with high accuracy.

• The non-contrast MRI score may be used in clinical practice for differentiating benign from malignant adnexal lesions when the lack of intravenous contrast medium precludes analysis with the O–RADS MRI score.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07737-9.

Association between Very Low-Density Lipoprotein Cholesterol (VLDL-C) and Carotid Intima-Media Thickness in Postmenopausal Women Without Overt Cardiovascular Disease and on LDL-C Target Levels

Background: atherosclerotic process inexorably advances in patients reaching low-density lipoprotein cholesterol (LDL-C) targets. An attractive hypothesis is that lipoprotein particles (very low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL)), could contribute to residual risk. The present study aims to investigate the relationship between carotid intima-media thickness (IMT) and different lipoprotein subfractions in a cohort of healthy postmenopausal women. Methods: 75 postmenopausal women, at LDL-C target levels without overt cardiovascular disease, underwent biochemical analyses (including subfraction assay of plasma lipoproteins) and carotid ultrasound examination. Results: a statistically significant correlation between VLDL and carotid IMT (p < 0.001) was found. No significant correlation was found between carotid IMT and LDL-C (p = 0.179), IDL-C (p = 0.815), high-density lipoprotein (HDL) (p = 0.855), and LDL score (p = 0.240). Moreover, IMT is significantly correlated to LDL particle diameter (p = 0.044). After adjusting for age, systolic blood pressure, body mass index, smoking habits, glucose plasma concentration, and Lipoprotein(a) (Lpa) levels, multivariate analysis showed that women in the third tertile of VLDL-C, compared with those in the first tertile, were significantly associated to the highest IMT (p = 0.04). Conclusions: in this cohort of postmenopausal women, VLDL-C was significantly associated to carotid IMT, independent of main cardiovascular risk factors. These findings pave the way for targeting circulating concentrations of VLDL-C to reduce cardiovascular events in patients with target LDL-C levels.

Porto-mesenteric venous gas as a sign of gastric mucosal damage remitted after surgery: a case report

Porto-mesenteric venous gas (PMVG) is a severe sign of abdominal organs damage. Imaging diagnostic criteria allow the detection of PMVG and should be applied in the presence of severe symptoms and signs of abdominal organs damage. Our case had clinical signs of epigastric pain and abdominal tenderness and ultrasonography and computed tomography evidence of PMVG and gastric cancer. The subsequent surgery, without complications, induced PMVG to disappear and the patient to be dismissed from hospital.

Prognostic and Predictive biomarkers in a Mediterranean cohort (Review from Atena Project)

Background

Atena project involved 5,062 women aged 30 to 69 years living in the area of Naples. The purpose of this study is to investigate the causes of those chronic diseases that have a major impact on the female population. As a part of the design (scheduled in 2002-2004). After 10 years, in 228 women, some biochemical measurements were performed.

Methods

This systematic review and meta-analysis biomarkers were evaluated in studies nested into the Atena cohort. Studies were searched using MEDLINE/PubMed. The search was performed by entering individually or in combination: Atena, Mediterranean woman, biomarkers. The preferred reporting of systematic reviews and meta-analysis (PRISMA) guidelines were used for the review. Studies selected for this review are conducted in the Atena project Cohort and reported the study of biomarkers. Disagreements on data extractions between the two investigators were solved by consensus. The extracted data were entered and analyzed using REVMAN software. The original articles were described using forest plot and table. Heterogeneity was computed by Cochran’s Q test.

Results

The search strategy retrieved 13 potential articles, 11 were screened as full text articles and 6 were included in the pooled estimates. Among the articles included, biomarkers chosen as predictors were Lipids, Hcrp, as prognostic where predictive of IMT; and cycle length and LPa as predictive of an augmented LDL cholesterol mean. According to the comparability of data presented, for the first comparison we selected 3 of the 5 studies that assed IMT, for the second we selected 2 of the three studies that analyzed for LDL mean. Results were shown into forrest plots. The pooled estimates verified the potential of biomarkers as predictor of IMT, the significance seemed lower for prediction of LDL cholesterol.

Conclusions

Both results, consistent with the multifactor profile of the CV risk, identify the impact of secondary prevention according to biochemical profiles.

Key messages

Biomarkers studied in nested cohort stufies have predictive potential. pooled estimates may identify the impact of secondary prevention according to biochemical profiles.

Multiple intra-hepatic and abdominal splenosis: an easy call if you know about it

Hepatic splenosis represents the heterotopic implantation of splenic tissue caused by the spillage of cells from the spleen usually after splenectomy or splenic trauma. This condition is usually an incidental finding during surgery and its real incidence is unknown. Splenic implants, which can be placed anywhere in the abdominal cavity, are usually multiple and may be confused with different benign and malignant conditions such as renal tumors, abdominal lymphomas, and endometriosis. We hereby report an unusual case of multiple abdominal splenosis, with a particular intra-hepatic location, that could be misinterpreted as an hepato-cellular carcinoma.

Atherogenic Lipoprotein Subfractions and Carotid Atherosclerosis in Menopausal Women

The aim of the study was to evaluate the relationship between cholesterol contained in very-low-density lipoproteins (VLDL-C), intermediate-density lipoproteins (IDL-C), low-density lipoproteins, high-density lipoproteins, and carotid intima-media thickness (cIMT) and carotid plaques in 228 postmenopausal women (63.1 ± 8.2 years) who participated in the ATENA Project and underwent clinical, biochemical (including the assay of lipoproteins using the Lipoprint system), and carotid ultrasound tests. Very-low-density lipoprotein cholesterol had a statistically significant linear association with cIMT ( P < .001), which remained significant after adjustment for age, smoking, systolic blood pressure, glucose, and body mass index ( r² = .20, P < .05). Higher concentrations of IDL-C and cholesterol contained in triglyceride-rich lipoproteins (TRL-C, ie, VLDL-C + IDL-C) were associated with plaques in the common carotid (tertile III/tertile I: odds ratio [OR] = 2.52, 95% confidence interval [CI] = 1.21-5.32, P < .02; OR = 2.30, 95% CI = 1.05-5.01, P < .05, respectively), after adjustment for main cardiovascular risk factors. In conclusion, high concentrations of VLDL-C and TRL-C are independently associated with the presence of carotid plaques. Their assay represents a useful tool for improving our knowledge on the role of different classes of lipoproteins in atherosclerosis.

Abdominal adiposity is an early marker of pulmonary function impairment: Findings from a Mediterranean Italian female cohort

BACKGROUND AND AIMS

Abdominal adiposity may influence the respiratory function, especially in women. The aim of this prospective study is to evaluate the predictive role of body mass index (BMI) and waist circumference (WC) on lung function in healthy women.

METHODS AND RESULTS

In 600 women randomly selected from the cohort of the "Progetto ATENA," anthropometric measures such as BMI, WC, and weight gain were recorded at baseline, and the spirometric parameters were measured 10 years later. The percentage values of forced expiratory volume in 1 s (FEV1%) and forced vital capacity (FVC%) and the ratio of FEV1/FVC were compared with the anthropometric measures after adjustment for several variables measured at baseline such as age, height, socioeconomic status, smoking habits, and history of respiratory allergies grouped in a basal model. WC is significantly associated with a decreased FVC (p = 0.008) and an increased ratio of FEV1/FVC (p = 0.031) after adjustment for the covariates of the basal model. The association between BMI and spirometric parameters reaches borderline significance only with the ratio of FEV1/FVC (p = 0.052).

CONCLUSIONS

We suggest measuring both BMI and WC to assess the risk of future respiratory impairment.

Predictors of mortality in patients undergoing percutaneous aortic valve implantation

AIM

Transcatheter aortic valve implantation (TAVI) became an attractive alternative to surgery for patients with severe aortic stenosis and high operative risk. The first multicenter randomized trial, conducted in such high risk cohort, showed 20% reduction in mortality in the group treated with TAVI compared to those treated with medical therapy (30.7% vs. 50.7% P=0.001) and a non-inferiority of TAVI compared to traditional valve surgical replacement for all-cause mortality at 1 year with, similar improvement of symptoms and physical performance. However, mortality rate of TAVI remains high (20-30% at one year). The purpose of this prospective single center study was to identify predictors of mortality and adverse events in patients undergoing TAVI in order to be able to select the ones who benefit most from the procedure.

METHODS

Between June 2009 and June of 2011, 118 patients with severe aortic stenosis treated with TAVI at IRCCS Humanitas Clinical Institute were included in a prospective registry. Pre procedural clinical and ecocardiographic evaluations, surgical risk estimation, and procedural complications, defined by VASC criteria, were recorded. Clinical and echocardiographic evaluations were performed at 1, 6 and 12 months after the implants. To investigate the predictors of mortality, clinical and anatomical characteristics of alive patients were compared with those of death ones at one month and one year follow-up.

RESULTS

The procedural success occurred in 92.4% of procedures; vascular complications (33%), bleeding complications (22%), postimplant paravalvolar grade ≥2 AR (20.4%) a new permanent pacemaker implant (19.7%), were the most common complications. Survival for the whole cohort at 30 days was 6.8%, survival at one year was 82.2%. In the logistic regression test, one month mortality was significantly adversely affected by the renal functional status (odd ratio 0.9356), by a previous history of coronary artery bypass grafting (odd ratio 39) and by the mean aortic annular diameter (odd ratio 0.512) (P=0.0005). One year mortality was influenced by high EuroSCORE (odd ratio 1.0399) and the presence of hemodynamically significant prosthetic regurgitation (odd ratio 3.8438).

CONCLUSION

TAVI procedure, in high risk patients with critical aortic stenosis, can be accomplished with low procedural mortality. The worst outcome affects particularly patients with renal insufficiency and previous coronary bypass. However, the long-term mortality remains high due to the poor baseline conditions, mainly related to co-morbidity and to the presence of residual post-procedural aortic insufficiency.

[Anatomy, physiology and clinical relevance of the connecting tubule]

The cortical distal nephron is the site of fine regulation of salt and water excretion by peptide and mineralocorticoid hormones and the site for specific actions of diuretics. Some data suggest that sodium reabsorption and potassium secretion in the distal convoluted tubule and the connecting tubule (CNT) are sufficient to maintain the sodium and potassium balance, with little or no contribution of the collecting duct. The homeostatic role of the sodium and potassium transport systems in the collecting duct can be questioned, especially in conditions where dietary sodium intake is high and potassium intake is low compared with the physiological needs of the organism. The functional expression of epithelial sodium channels (ENaC) in the CNT is sufficient for furosemide-stimulated urinary acidification and identifies the CNT as a major segment in electrogenic urinary acidification. In the outer renal cortex, the CNT returns to the glomerular hilus and contacts the renal afferent arterioles (Af-Art). This morphology is compatible with a cross-talk between the CNT and Af-Art. This novel regulatory mechanism of the renal microcirculation may participate in the vasodilatation observed during high salt intake, perhaps by antagonizing tubuloglomerular feedback. In conclusion, the cortical distal nephron appears to be a complex site for several physiological mechanisms; it is mainly involved in salt and fluid homeostasis and in acid-base balance maintenance. Furthermore, the CNT segment appears to promote a CNT-Af-Art feedback loop.

[Hepatic hemangioma: diagnosis and treatment]

Cavernous hemangioma is the most common benign tumor of the liver. Most patients are asymptomatic and the tumor is discovered incidentally during diagnostics procedures, at laparotomy or at autopsy. Only 10% of hepatic hemangiomas reach dimensions that need surgical treatment. The role of surgical excision in their treatment has not been well defined. We report a careful examination of our casuistry and at the same time a study of the literature.