Petrous Bone Cholesteatoma: Facial and Hearing Preservation

Objectives: Petrous bone cholesteatoma (PBC) is a rare condition of the petrous portion of the temporal bone. Treatment of choice consists of radical surgical removal, paying attention to protect the facial nerve and inner ear as far as possible. The aim of the present study was to evaluate the efficacy of modified translabyrinthine techniques in preserving hearing function and the use of the adjuvant endoscopic techniques in a group of PBC patients. Methods: This study comprised 16 cases of PBCs surgically treated in our Department. Pre- and post-operative hearing status was assessed with pure tone audiometry and speech discrimination and graded according to the Gardner- Robertson classification system. Facial function was based on the House Brackman (HB) classification. PBCs were grouped using Sanna's classification. The choice of surgical technique was based on the above findings together with preoperative evidence. Post-operative follow-up ranged from 1 to 10 years and also included Computed Tomography and Magnetic Resonance Imaging assessment. Results: PBCs were classified as follows: 37.5% infralabyrinthine; 43.75% supralabyrinthine; and 18.75% massive. Preservation of the bone conduction threshold was feasible in 62.5% of patients. For supralabyrinthine PBCs a subtotal petrosetomy was performed in all cases and hearing preservation was possible in 57% of them: an adjuvant endoscopic approach was performed in 43%. Infralabyrinthine PBCs were treated using a modified translabyrinthine approach with preservation of bone conduction in 83% of patients; an adjuvant endoscopic approach was performed in 50% cases. One patient with a massive cholesteatoma was treated by modified translabyrinthine approach, preserving a serviceable level of hearing. In all massive cases, an adjuvant endoscopic approach was performed. In 2 patients with preoperative palsy, facial nerve function showed an improvement. The follow-up period revealed evidence of limited recurrence at CT imaging in 2 patients. Conclusions: The introduction of modified surgical approaches, able to preserve the anatomical-functional structures, have shown an improvement of post-operative hearing outcomes.

A new 3D-printed temporal bone: 'the SAPIENS'-specific anatomical printed-3D-model in education and new surgical simulations

PURPOSE

Otology and neuro-otology surgeries pose significant challenges due to the intricate and variable anatomy of the temporal bone (TB), requiring extensive training. In the last years 3D-printed temporal bone models for otological dissection are becoming increasingly popular. In this study, we presented a new 3D-printed temporal bone model named 'SAPIENS', tailored for educational and surgical simulation purposes.

METHODS

The 'SAPIENS' model was a collaborative effort involving a multidisciplinary team, including radiologists, software engineers, ENT specialists, and 3D-printing experts. The development process spanned from June 2022 to October 2023 at the Department of Sense Organs, Sapienza University of Rome. Acquisition of human temporal bone images; temporal bone rendering; 3D-printing; post-printing phase; 3D-printed temporal bone model dissection and validation.

RESULTS

The 'SAPIENS' 3D-printed temporal bone model demonstrated a high level of anatomical accuracy, resembling the human temporal bone in both middle and inner ear anatomy. The questionnaire-based assessment by five experienced ENT surgeons yielded an average total score of 49.4 ± 1.8 out of 61, indicating a model highly similar to the human TB for both anatomy and dissection. Specific areas of excellence included external contour, sigmoid sinus contour, cortical mastoidectomy simulation, and its utility as a surgical practice simulator.

CONCLUSION

We have designed and developed a 3D model of the temporal bone that closely resembles the human temporal bone. This model enables the surgical dissection of the middle ear and mastoid with an excellent degree of similarity to the dissection performed on cadaveric temporal bones.

Pembrolizumab-based first-line treatment for PD-L1-positive, recurrent or metastatic head and neck squamous cell carcinoma: a retrospective analysis

BACKGROUND

The KEYNOTE-048 trial showed that pembrolizumab-based first-line treatment for R/M HNSCC led to improved OS in the PD-L1 CPS ≥ 1 population when compared to the EXTREME regimen. However, the R/M HNSCC real-world population is generally frailer, often presenting with multiple comorbidities, worse performance status and older age than the population included in phase III clinical trials.

METHODS

This is a retrospective, single-centre analysis of patients with R/M HNSCC treated with pembrolizumab-based first-line treatment.

RESULTS

From February 2021 to March 2023, 92 patients were treated with pembrolizumab-based first-line treatment. Patients treated with pembrolizumab-based chemoimmunotherapy had better ECOG PS and younger age than those treated with pembrolizumab monotherapy. Median PFS and OS were 4 months and 8 months, respectively. PFS was similar among patients treated with pembrolizumab-based chemoimmunotherapy and pembrolizumab monotherapy, while patients treated with pembrolizumab monotherapy had worse OS (log-rank p =.001, HR 2.7). PFS and OS were improved in patients with PD-L1 CPS > = 20 (PFS: log-rank p =.005, HR 0.50; OS: log-rank p =.04, HR 0.57). Patients with higher ECOG PS scores had worse PFS and OS (PFS, log-rank p =.004; OS, log-rank p = 6e-04). In multivariable analysis, ECOG PS2 was associated with worse PFS and OS.

CONCLUSIONS

PFS in our real-world cohort was similar to the KEYNOTE-048 reference while OS was numerically inferior. A deeper understanding of clinical variables that might affect survival outcomes of patients with R/M HNSCC beyond ECOG PS and PD-L1 CPS is urgently needed.

Radiomic Application for Head and Neck Squamocellular Tumor: Systematic Review

Abstract

Radiomics represents the convergence of artificial intelligence and radiological data analysis, primarily applied in the diagnosis and treatment of cancer. In the head and neck region, squamous cell carcinoma is the most prevalent type of tumor. Recent radiomics research has revealed that specific bio-imaging characteristics correlate with various molecular features of Head and Neck Squamous Cell Carcinoma (HNSCC), particularly Human Papillomavirus (HPV). These tumors typically present a unique phenotype, often affecting younger patients, and show a favorable response to radiation therapy. This study provides a systematic review of the literature, summarizing the application of radiomics in the head and neck region. It offers a comprehensive analysis of radiomics-based studies on HNSCC, evaluating its potential for tumor evaluation, risk stratification, and outcome prediction in head and neck cancer treatment.

A Rare Case of Complete-Immunotherapy-Responsive Metastatic Non-Small Cell Lung Cancer with Long Lasting Progression-Free Survival: A Case Report

BACKGROUND AND INTRODUCTION

Lung cancer is a prevalent and deadly disease globally. Non-small cell lung cancer (NSCLC) is the most common subtype, comprising 85% of cases.

CASE REPORT

A 65-year-old male ex-smoker presented to our facility with a nocturnal cough. Various investigations revealed that he had metastatic NSCLC, for which he underwent chemotherapy with cisplatin and gemcitabine, followed by immunotherapy with Nivolumab. He achieved a complete response to the therapy and has remained free from recurrence for over 7 years since the initial diagnosis.

DISCUSSION AND CONCLUSIONS

The treatment of metastatic NSCLC remains a significant therapeutic challenge, but the implementation of new therapeutic techniques has expanded the possibilities of achieving complete and durable eradication of the disease.

Neuroinflammatory disorders of the brain and inner ear: a systematic review of auditory function in patients with migraine, multiple sclerosis, and neurodegeneration to support the idea of an innovative 'window of discovery'

Background

Hearing can be impaired in many neurological conditions and can even represent a forme fruste of specific disorders. Auditory function can be measured by either subjective or objective tests. Objective tests are more useful in identifying which auditory pathway (superior or inferior) is most affected by disease. The inner ear's perilymphatic fluid communicates with the cerebrospinal fluid (CSF) via the cochlear aqueduct representing a window from which pathological changes in the contents of the CSF due to brain inflammation could, therefore, spread to and cause inflammation in the inner ear, damaging inner hair cells and leading to hearing impairment identifiable on tests of auditory function.

Methods

A systematic review of the literature was performed, searching for papers with case-control studies that analyzed the hearing and migraine function in patients with neuro-inflammatory, neurodegenerative disorders. With data extracted from these papers, the risk of patients with neurological distortion product otoacoustic emission (DPOAE) was then calculated.

Results

Patients with neurological disorders (headache, Parkinson's disease, and multiple sclerosis) had a higher risk of having peripheral auditory deficits when compared to healthy individuals.

Conclusion

Existing data lend credence to the hypothesis that inflammatory mediators transmitted via fluid exchange across this communication window, thereby represents a key pathobiological mechanism capable of culminating in hearing disturbances associated with neuroimmunological and neuroinflammatory disorders of the nervous system.

The Medical Historical Cultural Foundations of Western Nasal Surgery from Ancient Greece to the Middle Ages

The manuscript aims to clarify the origins of Western rhinosurgery through the ancient texts of the greatest physicians of the past, up to the Byzantine Era, focusing on the "exchange of knowledge" between peoples. This excursus is carried out by quoting the texts of the greatest doctors of the past, such as Hippocrates, Galen and Celsus and by analysing the works of Byzantine authors such as Oribasius, Aetius, Antillus, which, more than others, represent the moment of fusion and interpenetration of Ancient Medical knowledge, paving the way for the Medieval Scholae Medicae in the West. The aim, therefore, is to fill that sort of "great gap" (from the foundation of Constantinople in the 4th century AD to the early Arab culture in the 11th century AD) due to the fact that figures such as Branca, Vianeo and, finally, Tagliacozzi, are considered direct actors of a recovery of the "ancient knowledge" of classic authors. This literature tends to less evaluate, instead, that important and huge cultural exchange -literally osmotic- in medical and surgical knowledge between peoples and civilizations, that find a trait d'union in the application of medical knowledge and surgical practical techniques matured in the Byzantine, Arab and Early Medieval period. In final analysis, through the History of Rhinosurgery, this paper aims to highlight how Western medical knowledge is made up of the ensemble of cultures which are apparently distant and different from each other, which merge themselves in a truly universal and transcultural knowledge: the Medical knowledge. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A silent laryngeal trauma case: an unexpected late fracture of the superior portion of the thyroid cartilage superior horn

Attempts to analyze clinical unexpected cases of laryngeal fractures based on mild symptoms and physical findings. Even though a laryngeal fracture is rare in a living patient and when happens it is related to severe airways emergency, this case reported seems important to offer a possible differential diagnosis in patients who present with the same symptoms, if no other causes have been detected, like another one benign laryngeal disease.

Relationship between Salivary Amylase and Xerostomia in Intensity-Modulated Radiation Therapy for Head and Neck Cancer: A Prospective Pilot Study

Purpose. A single-institution prospective pilot study was conducted to the assess correlation between salivary amylase and xerostomia in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiotherapy (IMRT). Methods and materials. Serum saliva amylase, clinician-reported xerostomia (using Common Terminology Criteria for Adverse Events), and patient-reported xerostomia (using 8-item self-reported xerostomia-specific questionnaire) were prospectively collected at baseline, during treatment and thereafter. Correlations between variables were assessed by correlation matrices. Results. Twelve patients with locally advanced HNSCC formed the cohort. Eighty-three percent were male, 75% were smokers, 100% had clinical positive lymph nodes at diagnosis, and 42% received induction chemotherapy. All patients received IMRT with concurrent cisplatin-based chemotherapy. No grade ≥4 xerostomia was observed. Severe (G3) acute and late xerostomia occurred in five cases (41.7%) and two cases (16.7%), respectively. Patient-reported xerostomia scores were highly correlated with the clinician-reported scores (ρ = 0.73). A significant correlation was recorded between the concentration of amylase and the acute (ρ = −0.70) and late (ρ = −0.80) xerostomia. Conclusion. Preliminary results are encouraging. Prospective clinical trials are needed to define the value of salivary amylase in the management of HNSCC tumors.

Benralizumab reduces eosinophils and inflammatory markers in patients with severe eosinophilic asthma and chronic rhinosinusitis with nasal polyps: A pilot real-life study

Chronic rhinosinusitis with nasal polyps (CRSwNP) and Severe Eosinophilic Asthma (SEA) are both frequently sustained by eosinophilic inflammation and are probably the manifestation of a unique disease of upper and lower respiratory tract. We retrospectively observed 11 patients with severe CRSwNP and concomitant SEA under add-on therapy with benralizumab evaluating symptoms using Sino Nasal Outcome Test-22 (SNOT-22), Visual Analogue Scale (VAS), and Asthma Control Test (ACT) and Nasal polyp size by endoscopic and radiological score by Nasal Polyp Score (NPS) and Lund-Mackay Score (LMS). At 6 and 12 months, the expression of cationic eosinophil protein (ECP), Interleukin 17 (IL-17), Interferon gamma (INF-γ), and vascular endothelial growth factor (VEGF) was measured by nasal scraping to assess mucosal inflammation. After 12 months of benralizumab treatment, SNOT-22 decreased from 45 (23-97) to 14 (5-53) (p < 0.05), total VAS of rhinologic symptoms decreased from 30 (17-44) to 9 (5-37) (p ≤ 0.01) and ACT score increased from 10 (5-15) to 24 (20-25) (p ≤ 0.01). NPS decreased from 5 (3-6) to 3 (2-4) after 6 months (p < 0.05) and to 2 (2-3) after one year respectively (p <  0.05) and LMS total score from 21 (15-24) to 17 (8-21) (p ≤ 0.01) after 12 months from starting treatment. Nasal mucosa scraping found differences in INF-γ and VEGF expression in patients compared to 10 healthy subjects, with a normalization of these markers during eosinophils depletion induced by benralizumab. This is the first pilot real-life study conducted with an anti-IL5R monoclonal antibody in severe eosinophilic asthma and severe CRSwNP patients showing that this treatment can induce benefit both diseases not only from the clinical, but also from the inflammatory point of view. Moreover, our research pointed out that INF-γ and VEGF may represent potential response biomarker.

Sporadic diffuse neurofibroma of the retropharyngeal space

Neurofibroma (NF) rarely arises in the retropharyngeal space (RPS) of patients with or without Neurofibromatosis type I (NF-I). The diffuse subtype of NF (DNF) is characterized by an infiltrative growth pattern and typically involves the skin and subcutaneous tissue of the head and neck. We describe the clinic-pathologic features of a DNF involving the RPS of an adult without NF-I. To date, this subtype of NF has never been reported at this site.

Suppressive immune profile in combined positive score positive head and neck cancer patients treated with immunotherapy

e18014

Background: Immunotherapy has revolutionized the landscape of systemic treatment of recurrent or metastatic (R/M HNSCC). However only a small percentage of patients achieve long-term benefit regarding overall response and overall survival from the current immunotherapy. Indeed it has already been demonstrated that HNSCC microenviroment is distinctly immunosuppressive due to the high concentration of several biomarkers such as regulatory T cells (Treg cells) and lymphocyte activation gene 3 (LAG3) . The aim of our study is to investigate if the expression of peculiar biomarkers can affect the therapeutic efficacy of anti-PD-1. Methods: Data from 35 patients with combined positive score (CPS) positive R/M HNSCC receiving first line immunotherapy or immunotherapy in association with chemotherapy, from March 2021 to November 2021 were prospectively reviewed. Treg cells, stromal and intratumoral, and LAG3 expression by cancer cells and CPS expression were evaluated on pre-treatment biopsies. We defined an immune suppressive profile (ISP) as a concomitant presence both of LAG3 and Treg cells. We evaluated the associations between early progression (EP), defines as progression occurred within 3 months, progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and the expression of LAG3 and with the ISP. Results: Twenty-four patients were male (69%), 11 female (31%) and median age was 67 years. Baseline ECOG PS, evaluated before the start of treatment, was 0, 1, and 2 in 14 (40%), 14 (40 %) and 7 (20%) patients, respectively. The primary tumor site was the oral cavity in 19 patients (54 %), the larynx in 13 patients (37 %), hypopharynx in 2 patients (6 %) and sinus in the remaining 1 (3%). Thirteen (37%) patients received pembrolizumab alone while pembrolizumab in association with chemotherapy (carboplatin or cisplatin and 5-fluorouracil) were administered intravenously to 22 (63%) patients. Twenty-eight (80%) patients presented LAG3 expression, whereas Treg cells was reported in the stroma and the tumour in 31 (89%) and 29 (83%) patients respectively. Twenty-three (66%) patients presented both expression of LAG3 and presence of Treg cells. We showed both a statistically significant association between LAG3 expression and EP disease ( p = 0.005) and between ISP and EP ( p = 0.023). We didn’t observed associations between PFS, OS, ORR and LAG3 and Treg status. Conclusions: Our findings showed that in CPS positive R/M HNSCC patients the contemporary expression of Treg cells and LAG3 could better select the patients primary resistant to anti-PD-1. The results of our study identify a novel immunological patients’ profile.

THE ORIGINS OF THE BLOOD TRANSFUSION: EUROPEAN LITERATURE AND ITALIAN DEBATE ON NEW INNOVATIONS (1667-1668)

This paper deals with the literary debate on the first experiments regarding blood transfusion on human beings between 1667 and 1668 in Europe, with particular attention to the less-known experimental research, carried out in Italy. The authors examine the details of the experimental developments, focusing on the techniques and instruments used by physicians involved in this new surgical approach, with special attention to the Italian debate and experimentations. The article suggests that transfusion was considered a part of what we could call "emergency surgery". In this framework, Italian transfusional pioneers played a central role in the improvement and transmission of a discipline that was still in its dawning throughout Europe. Moreover, the manuscript highlights the contribution of the "chirurgia infusoria" as an innovative therapeutic system for an immediate and rapid recovery. From this perspective, blood transfusion represents a surgical practice for reanimation and resuscitation. The objective of this work was to analyze the importance of foreign literature and the English and French disputes presented by Davia in Italy, which made them known. Despite foreign prohibition in Italy, experiments with animal-to-human transfusions continued after 1648. A papal bull excommunicating scientists for conducting such research has never been found.

Labyrinthine Fistula in Cholesteatoma Patients: Outcomes of Partial Labyrinthectomy With “Underwater Technique” to Preserve Hearing

Labyrinthine fistula (LF) is one of the most important complications of cholesteatoma and is defined as an abnormal communication between the inner and the middle ear. This study aims to describe our experience with the partial labyrinthectomy evaluating the post-operative hearing results. Twenty-one patients who presented labyrinthine fistula in the semicircular canals were included in the present study. Hearing impairment was present in 48% of patients (10/21). A pre-operative assessment using the Gardner–Robertson hearing classification showed the following: 52%, Class I; and 48%, Class II. A post-surgical Gardner–Robertson hearing classification evidenced the following: 43%, Class I; and 57%, Class II. The presence of LF is usually considered a negative prognostic factor for hearing preservation. The key point of partial labyrinthectomy surgery is the preservation of structures, keeping them wet with Ringer's solution throughout the procedures, and not performing suction that is close to the opened LF. The bony labyrinth is drilled underwater without suction, removing the entire cholesteatoma matrix and quickly plugging the site before and after the LF. This faster plugging of the labyrinth makes it possible to preserve the peri-lymph and the endo-lymph fluid and the hearing function. This study showed that a partial labyrinthectomy is useful for maintaining serviceable hearing in patients with LF.

Rare localization of tongue vascular lesion detected by multi-parametric magnetic resonance imaging

Hemangiomas are developmental vascular abnormalities that are common in the head and neck (60%), rare in the oral cavity, and uncommon in the tongue. A patient performed a multi-parametric MRI, which characterized the lesion of his tongue, providing relevant information for diagnostic, therapeutic orientation, and realization of slight aggressive surgery with consequent excellent recovery.

The Art of Rhinoplasty: Researching Technical and Cultural Foundations of Western World Rhinosurgery, from the Middle Ages to the Renaissance

The analysis of the written sources allowed to follow the gradual development of every new technique in the field of rhinoplasty but also to understand the value of this surgery in those ancient times, highlighting a deep connection between traumatologic surgery of the nose and the development of modern “aesthetic and reconstructive” Rhinosurgery. Specifically, we analyzed the techniques described by less known surgeons to emphasize their cultural and surgical value. As a matter of fact, the descriptions offered by these authors clearly show the importance of rhinoplasty as a cardinal and autonomous practice since Antiquity, also clarifying the persistence and development of specific techniques for this surgical practice in the History of medicine. In the manuscript, the contributions of the Italian surgeons, such as Brancas and Vianeos families, are highlighted, demonstrating their influence on the progress of this surgical specialty in the Early Modern Age. Finally, we deepen the description of Gaspare Tagliacozzi’s work, pointing out the topics and controversial debates arising from his techniques and innovations in “rhinosurgery” and also in the field of tissue transplantation, laying the foundations of modern Plastic Surgery.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

How can we manage Bezold abscess emergency in COVID-19 pandemic? Blind ceftriaxone and metronidazole treatment to avoid infection spread†

Bezold abscess (BA) can be a rare complication of different forms of otitis media. We describe a rare case of BA determined by Escherichia Coli. Because of COVID-19 restriction, the surgery had to be delayed up to the swab results. To avoid infection spread, the patient was treated by blind antibiotic treatment until the surgical drainage of mastoid and neck. Thanks to the treatment with broad-spectrum antibiotics, the progression and the spread of the infection during COVID-19 investigation was avoided. Delayed surgery could expose the patient to the risk of severe brain infection caused by the E. Coli.

Prediction of Recurrence by Machine Learning in Salivary Gland Cancer Patients After Adjuvant (Chemo)Radiotherapy

BACKGROUND/AIM

To investigate survival outcomes and recurrence patterns using machine learning in patients with salivary gland malignant tumor (SGMT) undergoing adjuvant chemoradiotherapy (CRT).

PATIENTS AND METHODS

Consecutive SGMT patients were identified, and a data set included nine predictor variables and a dependent variable [disease-free survival (DFS) event] was standardized. The open-source R software was used. Survival outcomes were estimated by the Kaplan-Meier method. The random forest approach was used to select the important explanatory variables. A classification tree that optimally partitioned SGMT patients with different DFS rates was built.

RESULTS

In total, 54 SGMT patients were included in the final analysis. Five-year DFS was 62.1%. The top two important variables identified were pathologic node (pN) and pathologic tumor (pT). Based on these explanatory variables, patients were partitioned in three groups, including pN0, pT1-2 pN+ and pT3-4 pN+ with 26%, 38% and 75% probability of recurrence, respectively. Accordingly, 5-year DFS rates were 73.7%, 57.1% and 34.3%, respectively.

CONCLUSION

The proposed decision tree algorithm is an appropriate tool to partition SGMT patients. It can guide decision-making and future research in the SGMT field.

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.

Meckel's diverticulum as an occasional finding during major surgery. What to do? Case report and literature review

Meckel's Diverticulum is the most frequent congenital anomaly of the digestive system in the population, with a prevalence of 2% on results of a postmortem. Clinically, it can remain silent through all life, or it gets complicated in an acute abdomen sight. In emergency, we can find Meckel's Diverticulum much more in childhood than in adult subjects, with a ratio of 2:1, and, therefore, it joins differential diagnosis with other pathologies being able to cause acute abdomen sight. In adult subjects that doesn't happen: usually, we can achieve the diagnosis sureness only during an exploratory laparotomy. The Authors report the clinic case of a Meckel's Diverticulum found in a 78 years old patient during an exploratory laparotomy like accidental discovery. KEY WORDS: Complications, Laparoscopy, Meckel's disease, Diverticulum.

Role of elastosonography in the differentiation between benign and malignant neoformations of the breast and possibility of reducing the number of FNACS for tissue characterization

Introduction

Background The aim of the paper is related to our experience defining the diagnostic accuracy of breast elastosonog-raphy.

Objective

The aim of our study is therefore to define the diagnostic accuracy of breast elastosonography in the differential diagnosis of nodular breast neoformations to improve the characterization of the solid lesion and reduce the number of needle aspiration unnecessary for benign formations.

Material and methods

A total of 88 patients were enrolled, who came to the Department with an ultrasound diagnosis of a breast lesion. Each lesion was subjected to mammography and B-mode ultrasonogra-phy with an evaluation of size, echogenicity, and vascularization pres-ence or absence. The use of the ultrasound machine and the respective probe has made it possible to make the measurements. All nodules were subjected to ultrasound-guided FNAC. These data were compared with the results of elastosonographic examination.

Results

FNAC results were as follows: CIN 1 in 18 nodules, CIN 2 in 22 nodules, CIN 3 in 36 nodules, CIN 4 in 6 nodules, and CIN 5 in 6 nodules. The sensitivity and specificity of elastosonography found in our case series reported values in line with data reported in the literature, confirming the method's high reliability.

Conclusions

The elastosonography could become a complemen-tary technique to mammography and ultrasonography in the future, reducing the costs and risks of additional examinations. Therefore, we believe it is essential to contribute with this additional finding to increasingly accredit this pathway and reduce the discomfort to patients of more invasive methods.

Arachnoid Cysts of the Internal Auditory Canal: Multiplanar Magnetic Resonance Imaging With Audio-Vestibular Correlates

Objectives/Hypothesis

To investigate prevalence, radiological characteristics, and functional correlates of arachnoid cysts (AC) of the internal auditory canal (IAC) region, including associations of nerve compression with auditory/vestibular symptoms and asymmetrical audiogram or vestibular testing.

Study Design

Retrospective study.

Methods

T2‐weighted magnetic resonance imaging (MRI) studies of IACs were retrospectively analyzed from 1247 patients with asymmetric auditory or vestibular symptoms. Patients with radiological findings of AC of the IAC were identified. Multiplanar analysis was used to analyze cyst position in the IAC and assess nerve displacement or compression. Size, position, and presence of nerve compression were correlated with symptoms.

Results

Twenty‐four patients had a cyst in the middle or fundus in the IAC. Diameter (P = .04) and position (P = .002) of AC were associated with symptoms. Sagittal analyses identified displacement versus compression (P = .003) more reliably than axial imaging. Symptom laterality was associated with the site of radiological abnormality. Vestibular nerve compression was associated with vertigo (P = .0001), and cochlear nerve compression was associated with auditory symptoms (P < .0001).

Conclusions

In a retrospective series of patients undergoing MRI of IACs for asymmetric auditory or vestibular impairment, clinical symptom profile correlated with blinded assessment of IAC lesions.

Level of Evidence

4 Laryngoscope, 131:2323–2331, 2021

Correlation Between Onco-suppressors PTEN and NM23 and Clinical Outcome in Patients With T1 Breast Cancer

BACKGROUND

The aim of the present work was to evaluate the prognostic significance in patients with T1 breast cancer of tissue expression of the two oncosuppressors phosphatase and tensin homolog (PTEN) and non-metastatic clone 23 (NM23) as detected by immunohistochemistry.

MATERIALS AND METHODS

We prospectively analyzed 62 patients who underwent surgery for a T1 stage breast cancer. Expression of PTEN and NM23 was tested for correlation with clinical characteristics and clinical outcome.

RESULTS

Of the 62 patients considered for our study, 16 underwent mastectomy and 46 underwent conservative surgical treatment. The surgery was considered radical (R0) in all cases described. PTEN and NM23 expression was higher in patients with no lymph node metastases and no recurrent cancer at a mean follow-up of 36 months (range=6-48 months). This correlation was more evident when both PTNE and NM23 expression were highly expressed (p<0.0001).

CONCLUSION

Low or lack of PTEN and NM23 immunohistochemical expression in cancer tissue is a risk factor for lymph node involvement and recurrent disease. It may represent a valid prognostic factor in planning therapy in patients who had surgery for T1 breast cancer.

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.