Appropriateness of the indication for colonoscopy: is the endoscopist the 'gold standard'?

BACKGROUND

The appropriate selection of patients for colonoscopy is crucial for an efficient use of endoscopy. The role of endoscopist in filtering out inappropriate referrals is largely unknown.

METHODS

A multicentre, prospective study was performed in which consecutive patients referred for colonoscopy during a 1-month period were enrolled. Before colonoscopy, the endoscopist assessed appropriateness of the endoscopic referral without directly consulting official guidelines, also collecting clinical and demographic variables. Appropriateness of the indication was eventually assessed by a group of experts based on the American Society for Gastrointestinal Endoscopy guidelines, representing the gold standard. Outcomes of the study were the inappropriateness rate and the main related causes, as well as the concordance rate between the endoscopists and the experts. A multivariate analysis was performed to identify predictors of inappropriateness.

RESULTS

One thousand seven hundred ninety-nine patients were enrolled in 20 centres, of which 1489 outpatients were included in the final analysis. According to the American Society for Gastrointestinal Endoscopy guidelines, 432 referrals were inappropriate, corresponding to an inappropriateness rate of 29%. At multivariate analysis, prescription of a repeated colonoscopy (≥2 colonoscopies in the same patient) was strongly associated with the inappropriateness of the indication (odds ratio: 8.8; 95% confidence interval: 6.2, 12.7). Postpolypectomy or post-colorectal cancer surveillance accounted for 77% of the inappropriate control procedures. A 79% concordance rate between endoscopist and expert assessment was found. Among the 317 discordant cases, postpolypectomy or post-colorectal cancer surveillance accounted for 51% of the cases, the endoscopists mistakenly classifying it as appropriate in 55% to 61% of the inappropriate cases.

CONCLUSIONS

Inappropriateness in outpatient colonoscopy referrals remains high, surveillance procedures representing the most frequent source of inappropriateness.

Burden of Crohn's disease: economics and quality of life aspects in Italy

Background

This was a prospective observational study designed to evaluate direct and indirect costs and quality of life for patients with Crohn’s disease in Italy from the perspectives of the National Health System and of society.

Methods

A total of 162 male and female subjects aged 18–70 years with Crohn’s disease in the active phase and a Crohn’s Disease Activity Index score ≥150 were included in the study. Subjects were recruited from 25 Italian centers on a consecutive basis. The study consisted of four visits undertaken every 6 months with a follow-up period of 18 months. The study started on September 1, 2006 and was completed on April 12, 2010. Multivariate analyses were carried out on demographic characteristics, treatment costs based on the prescribed daily dose, resource use and other cost parameters, and changes in quality of life using the EQ5D questionnaire.

Results

Cost of illness per subject with Crohn’s disease in Italy was estimated to be €15,521 per year, with direct costs representing 76% of total costs. Nonhealth care costs and loss of productivity accounted for 24% of total costs. Societal costs during the first months of enrolment were higher compared with costs in the final months of the study. Quality of life measured by the EQ-5D was 0.558 initially and then increased to 0.739, with a mean value of 0.677 during the enrolment period. The cost of illness was not correlated with age or gender.

Conclusion

The cost of illness was correlated with quality of life; Crohn’s disease had a negative impact on subjects’ quality of life, and higher costs corresponded to a lower quality of life as measured with the EQ5D. Drug treatment may improve quality of life and reduce hospitalization costs. Our results appear to be in line with the results of other international cost-of-illness studies.

Kaposi sarcoma of the stomach: a case report

A 60-year-old man presented with persistent dysphagia and weight loss of 2-months duration. An upper GI endoscopy revealed mycotic oesophagitis and chronic gastritis with two ulcers of the gastric body and antrum. Repeat endoscopy was performed after medical treatment failed, and histological examination on new biopsy samples led to a diagnosis of Kaposi sarcoma of the stomach. HIV infection was not known at this time; however, the patient was tested after the diagnosis of Kaposi sarcoma was made and found to be HIV positive. An adequate biopsy sampling was required for histological diagnosis and the use of immunohistochemical markers, especially human herpesvirus 8 (HHV8) antibodies, supplied valid diagnostic support. This case underlines the importance of an accurate evaluation of vascular proliferation in gastrointestinal biopsies even in patients without clinical evidence of HIV-related pathology.

Analysis of factors predicting survival in patients with hepatocellular carcinoma treated with percutaneous laser ablation

BACKGROUND/AIMS

The factors which predict the long-term outcome in patients with hepatocellular carcinoma who are treated with percutaneous laser ablation (PLA) are not well established.

METHODS

We prospectively analyzed treatment and survival parameters of 148 cirrhotic patients with nonsurgical hepatocellular carcinoma who had undergone PLA at a single institution during an 11-year period.

RESULTS

Single tumors were seen in 129 of 148 (87%) patients, and 2-3 nodules were seen in 19 (13%) patients, for a total of 169 tumors. The median overall time survival was 39 months (95% confidence interval [CI], 30-47 months). The 1-, 2-, 3-, 4-, and 5-year cumulative survival rates were 89, 75, 52, 43, and 27%, respectively. From multiple regression analysis, the independent predictors of survival were found to be tumor grading (P=0.002; risk ratio [RR] 0.37, 95% CI 0.20-0.70), bilirubin levels < or =2.5mg/dl (P=0.014; RR 1.58, 95% CI 1.09-2.28), and the achievement of complete tumor ablation (P=0.020; RR 0.53, 95% CI 0.31-0.90). An initial complete tumor ablation was the only factor associated with longer survival in patients with Child-Turcotte-Pugh class A cirrhosis (P=0.012; hazard ratio [HR] 0.48, 95% CI 0.23-1.03).

CONCLUSIONS

A complete tumor ablation results in improved survival in all patients with nonsurgical hepatocellular carcinoma. Ideal candidates for PLA are those with a well-differentiated histology, and normal bilirubin levels.

Percutaneous laser ablation in the treatment of hepatocellular carcinoma with small tumors: analysis of factors affecting the achievement of tumor necrosis

PURPOSE

To identify the factors that affect the achievement of tumor necrosis with percutaneous laser ablation (PLA) in patients with hepatocellular carcinoma (HCC) and tumor size no larger than 4.0 cm.

MATERIALS AND METHODS

Ultrasound-guided biopsy results were retrospectively studied in 99 lesions (range, 0.5-4.0 cm; mean, 2.7 cm) from 82 patients (44 men, 38 women; age range, 50-80 years; median, 68 y) who had undergone PLA.

RESULTS

Complete tumor ablation was obtained in 90 lesions (90.9%). Of the nine cases in which complete tumor necrosis was not achieved, six had tumors located in sites that did not allow the optimal placement of fibers, and five of these had a tumor diameter greater than 3 cm. Early discontinuation of PLA as a result of decompensation of liver cirrhosis was the reason for not achieving a complete tumor ablation in three other cases. There was a clear relationship between the energy delivered and the volume of necrosis achieved (r = 0.56; P < .001) regardless of the initial size of HCC tumors. The number of illuminations required, and consequently the amount of energy delivered, was also affected by tumor location. In fact, lesions adjacent to large vessels (> or = 3 mm) required a greater number of illuminations than the other lesions to achieve complete ablation (2.9 +/- 1.4 vs 2.3 +/- 0.9; P = .043). The eight cases with undifferentiated histology required more illuminations than the cases with other histologic types (3.4 +/- 0.9 vs 2.2 +/- 0.9; P < .001). However, these cases were located in sites that did not allow the optimal placement of fibers, therefore requiring multiple treatments.

CONCLUSION

PLA is a highly effective treatment in HCC with a tumor size of 4.0 cm or smaller. In this setting, two variables, tumor size and tumor location, affect the achievement of complete tumor ablation and the number of treatments required to obtain tumor necrosis.

Electrogastrography

Electrogastrography (EGG) is the recording and the interpretation of gastric electrical activity. Recordings can be made from the gastrointestinal mucosa, serosa, or skin surface. Because of its ease of use, cutaneous EGG has gained wide acceptance. Many technical problems have been solved to obtain a good graph. The EGG is usually evaluated in terms of changes in the EGG waves amplitude and frequency. Deviations from the normal frequency of 3 cycles per minute may be referred to as brachy- or tachyarrhythmia. The clinical use of EGG has been most widely evaluated in patients with gastroparesis and functional dyspepsia. Scintigraphic gastric emptying is considered the gold standard test for evaluating gastroparesis and 13C-octanoate breath test an ideal alternative because does not use ionizing radiation. While gastric emptying evaluates the efficiency of gastric emptying, EGG focuses on the underlying myoelectrical activity. Using both EGG and 13C-octanoate breath test will be possible to detect many subset of dyspeptic patients and to understand the underlying problem.

Helicobacter pylori eradication in the management of patients with idiopathic thrombocytopenic purpura

PURPOSE

To investigate the relation between Helicobacter pylori infection and the clinical features of idiopathic thrombocytopenic purpura (ITP), and to examine the effects of H. pylori eradication on platelet counts.

METHODS

A(13)C urea breath test for H. pylori infection was performed in a cohort of 137 consecutive patients with ITP. Patients who tested positive received standard eradication therapy if their platelet count was <50 x 10(9)/L or if they had symptoms of dyspepsia.

RESULTS

H. pylori infection was detected in 64 patients (47%), and was not associated with dyspepsia or other clinical or laboratory features. Eradication therapy was successfully administered to 52 patients. Platelet responses were observed in 17 (33%) of these patients, which lasted for more than 1 year in 11 patients. Duration of ITP was shorter among responders than nonresponders. Only one response was observed among patients with severe thrombocytopenia (platelet count <30 x 10(9)/L).

CONCLUSION

The prevalence of H. pylori infection in patients with ITP is similar to that found in the general population. Infection is not associated with distinctive features of the disease. H. pylori eradication may improve the platelet counts in adults in whom the ITP is of recent onset and in those with less severe degrees of thrombocytopenia, but was not effective in patients with chronic severe ITP.

Campylobacter jejuni enterocolitis presenting as inflammatory bowel disease

We report a case of Campylobacter jejuni enterocolitis presenting as inflammatory bowel disease in a 19-year old woman. After a useless course of corticosteroids, ceftazidime and metronidazole, she was successfully treated with erythromicin. Campylobacter species represent an important cause of gastroenteritis in children and adults. The rate of Campylobacter isolation is 5-6 per 100,000 persons. This rate, however, grossly understimates the actual number of Campylobacter infections. In most cases, Campylobacter enteritis is a self-limiting disease, rarely associated with severe complications. Our case demonstrates the difficulty in distinguishing inflammatory bowel disease (Crohn's disease or ulcerative colitis) at onset from atypical infectious colitis. Unfortunately, corticosteroids (necessary for the treatment of inflammatory bowel disease) may exacerbate infectious etiologies. Campylobacter jejuni should be ruled out when assessing inflammatory bowel diseases at onset (as during flare-ups), especially if corticosteroids or immunosuppressive therapies are required.

Hepatopulmonary syndrome. A review of the literature

The majority of cirrhotic patients present dyspnea, but most of the time this is a consequence of ascites, hepatic hydrothorax or cardiopulmonary disease. Very few of these patients undergo the hepatopulmonary syndrome, an infrequent complication of chronic liver disease, especially when associated with portal hypertension and cirrhosis. Hepatopulmonary syndrome is characterised by dyspnea and, consequently, arterial hypoxemia, due to intrapulmonary vasodilation and shunting. The real pathogenesis of this vasodilation is still unknown, although many hypotheses have been suggested. Furthermore, no medical therapy appears to be really useful in the treatment of hepatopulmonary syndrome. At the present time, the only treatment that is efficacious for the resolution, or for the improvement of blood gas oxygenation abnormalities, is orthotopic liver transplantation.

[Physiopathologic approach in esophageal motor disorders: from the diagnosis to therapeutic implications]

Motor disorders are an important chapter in esophageal pathology; from a clinical point of view, these disorders are characterised by dysphagia, non-cardiac chest pain, pyrosis and regurgitation. It is important to underline that chest pain and dysphagia are not specific to motility disorders; in fact, they are also present in other pathologies like peptic or infective esophagitis. In order to attribute these symptoms to a functional cause, it is first of all is necessary to exclude an organic pathology; this can be done with the help of radiological and endoscopical examination when the symptoms are dysphagia, pyrosis and regurgitation, or with electrocardiography or angiography, when the symptom is chest pain. The functional pathology is marines studied by manometric and pH-metric techniques. The manometric technique represents an important instrument for diagnosing esophageal motor disease. The aim of this study, after a review of the literature, is to describe the principal esophageal motor disorders and the physiopathological approach, that have important implications in diagnosis and therapy.

[Whipple's disease: progress in the diagnosis and review of the literature]

Whipple's disease is a rare, chronic, multisystemic disease characterized by the presence of fever, diarrhea, weight loss and malabsorption, preceded by arthritis. Although Whipple's disease almost always includes involvement of the small intestine and the presence of malabsorption, it commonly affects other organs, especially the heart, brain, eyes and joints. Whipple's disease greately mimics other diseases and is caused by a cultivation-resistant bacterium. The disease is fatal unless patients are treated with antibiotics. The diagnosis of Whipple's disease can be made by histologic analysis of small-intestinal biopsy specimens. Identification of Whipple bacterium, Tropheryma whippelii, has led to the development of the polymerase chain reaction This technique can be used to detect the bacterium in many organs and fluids, including synovial tissue and fluid. Affected patients tend to have dilated intestinal villi that are infiltrated with foamy macrophages.

Laser thermal ablation in the treatment of small hepatocellular carcinoma: results in 74 patients

PURPOSE

To evaluate the safety, local effectiveness, and long-term results of laser thermal ablation (LTA) in the treatment of small hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Ninety-two biopsies proved small HCCs (range, 0.8-4.0 cm) in 74 patients who were treated percutaneously with LTA in an outpatient clinic. A laser at a power of 5.0 W was coupled with one to four fibers that were advanced through 21-gauge needle(s) for 6-12 minutes. All lesions were evaluated with computed tomography (CT) for changes in size and vascular pattern, recurrence rates, and cumulative survival rates. Patients were examined for complications.

RESULTS

No major complications occurred in 117 LTA sessions, with an average of 1.3 sessions per tumor. At 3 months, CT scans showed a nonenhancing area (complete necrosis) in 89 (97%) of 92 lesions. During follow-up (range, 6-66 months; mean, 25.3 months), 84 tumors (91%) decreased in size. The local recurrence rates (range, 1-5 years) ranged from 1.6% to 6.0%. Recurrence rates (range, 12-60 months) in other liver segments ranged from 24% to 73%. Cancer-free survival rates (range, 1-4 years) ranged from 73% to 24%. Overall survival rates were 99%, 68%, and 15% at 1, 3, and 5 years, respectively. Twenty-one patients (28%) died.

CONCLUSION

LTA is a safe and effective treatment for small HCC.

Hepatocellular Carcinoma: Long-term Results of Combined Treatment with Laser Thermal Ablation and Transcatheter Arterial Chemoembolization

PURPOSE

To determine the potential long-term effectiveness of laser thermal ablation (LTA) followed by transcatheter arterial chemoembolization (TACE) in the percutaneous ablation of large hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Thirty large HCCs 3.5-9.6 cm in diameter (mean diameter, 5.2 cm) and 15 small HCCs 0.8-3.0 cm (mean diameter, 1.9 cm) were treated with ultrasonographically guided LTA with TACE and with LTA alone, respectively, in 30 patients: 19 with a solitary large HCC, and 11 with one to three additional synchronous small HCCS: A 1.064-microm neodymium yttrium-aluminium-garnet (Nd-YAG) laser at a power of 5.0 W was coupled with one to four quartz optic fibers that were advanced through 21-gauge needles. Segmental TACE was performed 30-90 days after LTA. All lesions were evaluated for change in size at computed tomography (CT), alpha-fetoprotein (AFP) levels, recurrence rates, and cumulative survival rates.

RESULTS

No major complications occurred in 127 LTA sessions. CT showed complete tumor necrosis in 27 (90%) of 30 large HCCS: Twenty-eight patients were followed up for 6-41 months (mean, 17.1 months). In 25 patients, all lesions appeared stable or smaller at CT. AFP levels decreased to the normal range in all patients with high pretreatment values. The 1-, 2-, and 3-year local recurrence rate was 7% in large HCCS: Complete tumor necrosis was achieved in all 15 (100%) small HCCs; none of them recurred locally. The 1-, 2-, and 3-year cumulative survival rates were 92%, 68%, and 40%, respectively.

CONCLUSION

LTA followed by TACE is an effective palliative therapy in treating large HCCS:

Severe thyrotoxicosis due to hyperfunctioning liver metastasis from follicular carcinoma: treatment with (131)I and interstitial laser ablation

Liver metastases from differentiated thyroid tumors are unusual clinical findings, and are only rarely hyperfunctioning. We report a case of thyrotoxicosis caused by a huge and surgically unresectable liver metastasis from follicular thyroid cancer, unresponsive to treatment with large doses of thionamides. To avoid the hazardous side effects of (131)I treatment in a severely thyrotoxic patient, a preliminary debulking of the liver mass was performed by means of percutaneous interstitial laser photocoagulation. Three treatments (total energy delivery: 7200 J) were performed under ultrasound guidance, with no serious complications, during a 2-week period. One month later, serum thyroid hormones had decreased, general condition was improved, and magnetic resonance evaluation revealed large and well-defined areas of necrosis of metastatic tissue. During the following 10 months, the patient underwent 3 radioiodine treatments. Eighteen months after diagnosis, thyroid hormones were within normal levels, liver mass decreased, and the clinical condition markedly improved. The combination of percutaneous interstitial laser photocoagulation treatment and radioiodine therapy made possible the effective management of a hyperfunctioning and surgically untreatable liver metastasis from thyroid follicular carcinoma, avoiding the side effects of (131)I therapy in a thyrotoxic patient and increasing the effectiveness of radioiodine-induced neoplastic tissue ablation.

[Pelvic floor dyssynergia: videoproctographic analysis and pathologic associations in defecation obstruction syndrome]

INTRODUCTION

Pelvic floor dyssynergia is included pathophysiologically in the functional dyschezia group. It is characterized by the paradoxical contraction or lack of relaxation of the puborectal muscle and/or external sphincter during defecation, with consequent functional outlet obstruction. The diagnosis is not always easy because there is no really specific test, nor any diagnostic gold standard; also, many pathophysiologic and epidemiologic findings are still unknown. We tried to define the diagnostic criteria of this condition with the statistical analysis of the main defecographic parameters and to assess the radiologic correlation between functional forms and "mixed" forms, that is those associated with other anorectal disorders.

MATERIAL AND METHODS

We reviewed 121 videoproctographic examinations performed January, 1995, to December, 1996, in patients with clinical and instrumental signs suggestive of pelvic floor dyssynergia and compared the findings with those of a control group of 20 patients with no defecation disorders. We also assessed the frequency of the major anorectal disorders associated with pelvic floor dyssynergia relative to the pure form.

RESULTS

Initiation time (11 s versus 1 s; p < .05), evacuation time (47 s versus 10 s; p < .01) and the rate of residual contrast material (57 versus 7) were on average greater in dyssynergia patients. These parameters provide important information on the degree and rapidity of rectal voiding. 81% of our dyssynergia patients had rectal voiding time > 30 s, with final residual contrast material 1/3 to 2/3 of the initial volume. Posterior anorectal angle measurements showed significant differences on strain and evacuation and in anorectal angle excursion at rest/on evacuation (4 +/- 17 degrees; p < .01). Anorectal angle excursion < 15 degrees or its paradoxical reduction was associated with anal diameter < 12 mm during voiding in 85% of cases. We subdivided our population into 4 groups: group A (15 patients: median age: 38 +/- 14 years) with dyssynergia only: group B (22 patients; median age: 54 +/- 23 years) with dyssynergia associated with a functional megarectum); group C (66 patients; median age: 52 +/- 14 years) with mixed pathophysiological patterns such as megarectum, rectocele, intrarectal intussusception, mucosal prolapse and perineal descent; group D (18 patients; median age: 52 +/- 16 years) with the same characteristics as in group C but also with hemorrhoids and anal fissures.

DISCUSSION AND CONCLUSIONS

At first (digital radiography) and second level (videoproctography), the diagnosis of pelvic floor dyssynergia is based manly on dynamic parameters (initiation and evacuation times) correlated with the residual contrast agent volume. At baseline, the diagnosis is based on the reduced/no excursion of the anorectal angle between rest and evacuation, together with a narrowed anal eanal. The rate of pure pelvic floor dyssynergia was lower (12.4%) than that of the pathophysiologically mixed patterns and the median age of this group of patients was 38 +/- 14 years, which is statistically lower than that of the other groups (52 +/- 14). Comparing the frequency of purely functional forms in the age range < 40 years, we observed a statistically significant difference (p < .001), which suggests that this disorder is always the first cause of the outlet obstruction syndrome.

Evaluation of the vascular pattern of hepatocellular carcinoma with dynamic computed tomography and its use in identifying optimal temporal windows for helical computed tomography

The aim of this work was to study the vascularization of hepatocellular carcinoma (HCC) by means of dynamic CT and to demonstrate the existence of optimal temporal windows for visualization of HCC in order to develop new protocols for helical CT of the liver. We studied, by means of dynamic CT, 42 histologically proved HCCs in 30 patients after injecting contrast medium (100 ml, 3 ml/s). We performed a time-density analysis of the aorta, liver, portal vein, spleen and lesion. We identified three temporal curves of attenuation of the neoplastic tissue. Curve 1 was three-phasic: hyperattenuation, isoattenuation and hypoattenuation; curve 2 was two-phasic: hyperattenuation and isoattenuation; curve 3 was two-phasic: isoattenuation and hypoattenuation. Thirty-two lesions were homogeneous (curve 1 in 22 cases, 68.7 %; curve 2 in 7 cases, 21.8 %; curve 3 in 3 cases, 9.4 %), whereas 10 lesions were non-homogeneous. Two optimal temporal windows were identified: the first, with predominantly hyperattenuating lesions (range 29-65 s, 90.4 % sensitivity); the second, with predominantly hypoattenuating lesions (range 132.1-360 s, 76.1 %). There is an interposed time range of reduced visualization (range 62-127 s, 54.7 %) in which lesions are isoattenuating. Combined CT study during the first and second temporal windows improves the detection of HCCs especially for homogeneous and small lesions. The intermediate isoattenuation time range does not increase lesion detection rate.

[Interstitial photocoagulation with laser in the treatment of liver metastasis]

Interstitial laser photocoagulation (ILP) causes tumor necrosis with local hyperthermia produced by laser light energy. We treated with US-guided ILP 14 patients (7 men and 7 women; mean age: 67 years) and 20 metastases: 9 of them were < 3 cm in max. diameter and 11 were > 3 cm (mean diameter: 2.9 cm); 14 metastases were from colon carcinoma, 5 from breast cancer and 1 from lung cancer. ILP was performed with 300 and 600 microns quartz fiberoptic guides advanced in 21-18G Chiba needles and a continuous-wave Nd: YAG laser with 1064 nm wavelength. We used single expositions of 5-6 minutes with an irradiation power of 5 watts and scheduled 3 treatment sessions, performing CT scans and biopsies at the end of each session. The extent of induced necrosis was classified as follows on the basis of CT findings: grade 1 = 100% necrosis; grade 2 = necrosis > 50%; grade 3 = necrosis < 50%. The average follow-up was 6 months. After the 3 scheduled treatment sessions, CT showed grade 1 necrosis in all the lesions < 3 cm in diameter and in 4/9 (44%) lesions > 3 cm and grade 2 and 3 necrosis in the remaining cases (necrosis > 50% in 95% of the lesions and 92% of the patients). The cytologic findings were in agreement with CT results in all grade 2 and 3 cases, but in one grade 1 necrosis cytology showed residual viable tumor. To conclude, ILP is a safe and well-tolerated procedure. Maximum efficacy was observed in the lesions < 3 cm, while lesion volume was markedly reduced in the lesions > 3 cm. US is a useful tool in the real-time monitoring of this procedure and CT is the most accurate imaging technique to assess treatment efficacy.

A randomized trial of ultrasound-guided anterior subcostal liver biopsy versus the conventional Menghini technique

An ultrasound-guided double pass biopsy technique using a large bore cutting needle via an anterior subcostal route (USAB) is described. The diagnostic adequacy of this biopsy procedure was evaluated in comparison with the traditional Menghini technique in 200 cases of suspected chronic liver disease randomly assigned to the two different procedures. Retrieval rate was better in the USAB group. The sample length was less than 15 mm in four cases in the USAB group and in 19 cases in the Menghini group. In three cases in the USAB group the second pass modified the diagnosis of the first specimen from chronic active hepatitis to active cirrhosis. In order to evaluate the safety and discomfort of the two procedures 340 patients assigned to the different techniques had liver ultrasound scans 6 and 24 h following percutaneous biopsy. USAB was associated with a reduced frequency of complications (one out of 170 patients vs. seven out of 170 patients who had the intercostal Menghini procedure). In our study, USAB seems to offer better sampling and size of individual samples, together with reduced frequency of major and minor complications.

[Fine needle aspiration biopsy (FNAG) guided with tomodensitometry of pulmonary and mediastinal masses. Personal experience]

CT-guided fine-needle aspiration biopsy (FNAB) was performed on the patients with pulmonary or mediastinal masses to obtain material for cytologic/histologic diagnosis. Diagnostic accuracy and safety of the technique were evaluated in 75 patients affected with thoracic lesions still undiagnosed after thorough radiological and endoscopic investigations. The cytologic and/or microhistologic samples allowed a correct diagnosis to be made in 61 cases (81%), with no false positives and 7 false negatives (9%). The samples were inadequate for diagnostic purposes in 7 cases (9%). Specificity, sensitivity, and diagnostic accuracy were 68%, 76%, and 81%, respectively. No major complication was recorded and a case of asymptomatic pneumothorax resolved spontaneously within 48 hours. CT-guided FNAB of space-occupying lesions in the lung and mediastinum is therefore a rapid and valuable diagnostic tool and is quite safe when performed by skilled operators.