Ambrogio P. Londero

Surgical Treatment and Survival in Patients with Liver Metastases from Neuroendocrine Tumors: A Meta-Analysis of Observational Studies

Introduction. The role of hepatic resection in patients with liver metastases from gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is still poorly defined. Therefore, we examined the results obtained with surgical resection and other locoregional or systemic therapies by reviewing the recent literature on this topic. We performed the meta-analysis for comparing surgical resection of hepatic metastases with other treatments. Materials and Methods. In this systematic review and meta-analysis of observational studies, the literature search was undertaken between 1990 and 2012 looking for studies evaluating the different survivals between patients treated with surgical resection of hepatic metastases and with other surgical or nonsurgical therapies. The studies were evaluated for quality, publication bias, and heterogeneity. Pooled hazard ratio (HR) estimates and 95% confidence intervals (CI.95) were calculated using fixed-effects model. Results. We selected six studies in the review, five of which were suitable for meta-analysis. We found a significant longer survival in patients treated with hepatic resection than embolisation HR 0.34 (CI.95 0.21–0.55) or all other nonsurgical treatments HR 0.45 (CI.95 0.34–0.60). Only one study compared surgical resection with liver transplantation and meta-analysis was not feasible. Conclusions. Our meta-analysis provides evidence supporting the hypothesis that hepatic resection increases overall survival in patients with liver metastases from GEP-NETs. Further randomized clinical trials are needed to confirm these findings and it would be desirable to identify new markers to properly select patients for surgical treatment.

Quantitative elastography of the cervix for predicting labor induction success.

PURPOSE To evaluate the role of quantitative elastography of the cervix in the prediction of successful labor induction compared to the Bishop score (BS) and ultrasound cervical length (CL). MATERIALS AND METHODS A prospective pilot study was conducted between July 2010 and June 2011 in patients without preterm membrane rupture undergoing labor induction with vaginal prostaglandins. Before starting induction, the BS, functional CL and cervical tissue strain (TS) were assessed. TS assessment was performed twice using the Tissue Doppler Imaging (TDI) software. Diagnostic accuracy was evaluated for the prediction of the following endpoints: active labor achievement (success vs. failure, time interval < 24 h and < 48 h), vaginal delivery (success vs. failure, time interval < 36 h and < 72 h) and total amount of prostaglandins used for labor induction (< 6 mg and < 12 mg). RESULTS We analyzed 77 patients with a mean gestational age of 39.7 ± 1.5 weeks of gestation and a mean strain of 0.75 ± 0.17. The TS significantly predicted a failure of labor induction, which occurred in 4 cases, both in mono- and multivariate analysis, independently of the functional cervical length (TS 0.6 ± 0.1). No correlation was found between the TS and other outcomes. The Bishop score and functional cervical length were found to predict only an early response to labor induction (time to active labor < 24 h, time to vaginal delivery < 36 h and PG usage < 6 mg). The diagnostic accuracy was slightly but not significantly improved if both TS and CL were considered. CONCLUSION Preliminary data show the possible usefulness of quantitative cervical elastography in the prediction of labor induction failure.

Reliability of quantitative elastography of the uterine cervix in at - term pregnancies

Abstract Aims: To evaluate the intra-operator reliability of tissue Doppler imaging-based quantitative cervical elastography in at-term pregnancies. Methods: Three series of two cycles of manual gentle compression-relaxation of the cervix were performed by one gynecologist in 11 consecutive at-term pregnancies through the vaginal probe. The compression movements should be sufficient to obtain the maximal compression of the anterior portion of the cervical tissue, until the posterior portion begins to be dislocated. Strain values were assessed on the entire thickness of the anterior cervical lip. The influence of strain type (Lagrangian vs. natural) and the extent of compression exerted (difference among the two cycles of compression-relaxation) were evaluated. Results: Strain measurement was influenced by the extent of compression, as well as by the strain type. The strain measured during the cycle with larger cervical compression, using the natural strain preset, showed a superior reliability [mean strain among patients: 0.68±0.18; mean of differences among three measures: 0.07±0.06; intraclass correlation coefficient (ICC) consistency: 0.90]. The strain measured using the Lagrangian strain preset showed overall a low reliability (ICC consistency: 0.04). Conclusions: Quantitative cervical elastography performed in at-term pregnancies, under standardized conditions, has a high reliability.

Morbus Paget der Vulva: Remission durch Lokalbehandlung mit Imiquimod – Fallbericht und Literaturübersicht

Der Morbus Paget ist eine seltene Erkrankung der Vulva, welche weniger als 1% aller Neoplasien der Vulva ausmacht. Die übliche Therapie besteht in der lokalen chirurgischen Entfernung. Während die invasive Form des Morbus Paget selten ist, stellen die häufigen Lokalzrezidive, welche nicht mehr chirurgisch behandelt werden können, ein bedeutendes klinisches Problem dar. Bei einer 71-jährigen Patientin wurde ein solches Rezidiv erfolgreich mit Imiquimodsalbe behandelt. Die Juckreizsymptome bildeten sich nach kurzer Zeit zurück. Nach 4 Wochen waren die kolposkopisch sichtbaren Hauterscheinungen rückläufig. Innerhalb von 8 Wochen kam es zu einer kompletten klinischen Remission. Die Lokalbehandlung mit Imiquimod ist demnach nicht nur bei der vulvären intraepithelialen Neoplasie erfolgversprechend, sondern stellt auch bei ausgewählten Patientinnen mit rezidivierendem Morbus Paget der Vulva eine konservative Behandlungsalternative dar.

Adiponectin Levels Are Reduced While Markers of Systemic Inflammation and Aortic Remodelling Are Increased in Intrauterine Growth Restricted Mother-Child Couple

Aim of the Study. To investigate the relationships between the adipocytokine levels, markers of inflammation, and vascular remodelling in pregnancies complicated by intrauterine growth restriction (IUGR). Materials and Methods. This was a retrospective study. One hundred and forty pregnant patients were enrolled. Adiponectin, leptin, tumor necrosis factor α (TNFα), interleukin-6 (IL-6), and C reactive protein (CRP) were assessed in IUGR, small for gestational age (SGA), and appropriate for gestational age (AGA) mother-child couples at delivery. IUGR and SGA fetuses were defined as fetuses whose estimated fetal weight (EFW) was below 10th percentile for gestational age with and without umbilical artery (UA) Doppler abnormalities, respectively. Fetal aorta intima media thickness (aIMT) was evaluated by ultrasound in the same fetal groups. Data were analyzed by R (version 2.15.2). Results. There were 37 IUGR mother-child couples, 33 SGA, and 70 AGA. Leptin, TNFα, IL-6, and CRP serum levels were higher in IUGR pregnant patients (P < 0.05). Adiponectin levels were significantly reduced in IUGR fetuses compared to SGA and AGA, while leptin, TNFα, and IL-6 levels were higher in IUGR group (P ≤ 0.05). Fetal aIMT was significantly higher in IUGR (P < 0.05) and in this group there was a negative correlation between aIMT and adiponectin/leptin ratio (A/L ratio) (P < 0.05) and between adiponectin and IL-6 levels (P < 0.05). Conclusions. In conclusion, compared to SGA and AGA, IUGR fetuses had reduced circulating levels of adiponectin and elevated measures of aIMT and several inflammatory markers. Moreover, adiponectin levels were negatively correlated with aIMT in IUGR fetuses suggesting a possible causal link between reduced adiponectin and vessel remodelling.

Menstrual abnormalities and predisposition to pregnancy-related hypertensive disorders: a retrospective study

Objective. Pregnancy-related hypertensive disorders (PRHDs) are a leading cause of maternal and perinatal morbidity and mortality in developed countries. This study investigated a possible association of PRHDs with menstrual abnormalities. Materials and Methods. We contacted all women with PRHDs who delivered in our clinic between 2004 and 2007 as well as a random control cohort without pregnancy complications and asked them about their menstrual cycle characteristics. Statistical analyses were performed using R, with significance set at p < 0.05. Results. We collected data for 237 women with normal pregnancies and 255 women with PRHDs, among whom 143 had gestational hypertension and 70 had mild and 41 severe preeclampsia. By monovariate analysis, PRHDs correlated with dysmenorrhoea, hypermenorrhoea and menstrual irregularity (p < 0.05). By multivariate analysis, the occurrence of PRHDs was influenced by dysmenorrhoea and menstrual irregularity (p < 0.05). Conclusions. PRHDs usually affect women with painful or irregular menstrual cycles, perhaps due to metabolic syndrome or molecular pathways involving vasoactive substances, with clear vascular implications.

Type of Breast Cancer Diagnosis, Screening, and Survival

INTRODUCTION Breast cancer screening is known to reduce mortality. In the present study, we analyzed the prevalence of breast cancers detected through screening, before and after introduction of an organized screening, and we evaluated the overall survival of these patients in comparison with women with an extrascreening imaging-detected breast cancer or those with palpable breast cancers. MATERIALS AND METHODS We collected data about all women who underwent a breast operation for cancer in our department between 2001 and 2008, focusing on type of tumor diagnosis, tumor characteristics, therapies administered, and patient outcome in terms of overall survival, and recurrences. Data was analyzed by R (version 2.15.2), and P < .05 was considered significant. RESULTS Among the 2070 cases of invasive breast cancer we considered, 157 were detected by regional mammographic screening (group A), 843 by extrascreening breast imaging (group B: 507 by mammography and 336 by ultrasound), and 1070 by extrascreening breast objective examination (group C). The 5-year overall survival in groups A, B, and C were, respectively, 99% (95% CI, 98%-100%), 98% (95% CI, 97%-99%), and 91% (95% CI, 90%-93%), with a significant difference between the first 2 groups and the third (P < .05) and a trend between groups A and B (P = .081). CONCLUSION The diagnosis of invasive breast cancer with screening in our population resulted in a survival gain at 5 years from the diagnosis, but a longer follow-up is necessary to confirm this data.

Incidence and risk factors of the intraoperative localization failure of nonpalpable breast lesions by radio-guided occult lesion localization: a retrospective analysis of 579 cases: reply.

Background The radio-guided occult lesion localization (ROLL) technique allows the identification of nonpalpable breast lesions by means of the preoperative, intratumoral injection of a radiotracer. Our study aimed to determine the incidence and risk factors of ROLL failure.

A proposal for a new scoring system to evaluate pelvic masses: Pelvic Masses Score (PMS)

OBJECTIVES Ovarian cancer is the fourth leading cause of death among neoplastic diseases in women. In spite of constant improvement in surgical, chemotherapeutic and immunologic techniques, which can induce long remission periods, the five-year survival rate has not really changed over the past thirty years. We tried to create a sonographic scoring system, called PMS, that could be helpful in diagnosis of pelvic masses. STUDY DESIGN The three most commonly used and validated indexes--Sassone score, Ovarian Tumor Index (OTI), and Risk of Malignancy Index 3 (RMI3)--were applied to a population of 102 women with adnexal masses. We developed a new scoring system, named Pelvic Masses Score (PMS), that takes into account the ultrasound morphological pattern, the Doppler flowmetry of the pelvic mass, the CA125 serum level and the menopausal status. We then applied this scoring system to a population of 160 women for validation of the score. RESULTS Statistical analysis of the data obtained from the new scoring system reveals that sensitivity, specificity, positive and negative predictive values (PPV and NPV) are higher than in the case of data separately derived from the Sassone score, OTI index or RMI index. CONCLUSIONS Our preliminary data showed good results in term of sensitivity, specify and predictive values compared to other old scoring systems. A larger prospective study is required to confirm these preliminary data. The number of cases will be expanded to permit a better evaluation of PMS.

New and old predictive factors for breech presentation: our experience in 14 433 singleton pregnancies and a literature review

Abstract Objective: Breech presentation represents a common indication for primary cesarean section in women presenting for parturition. This study aims to investigate the presence of new and old risk factors for breech presentation and to provide a literature review. Method: In this population-based retrospective cohort study, we collected data from 14 433 consecutive singleton deliveries occurred in a 3rd level hospital setting of northeast Italy between January 2001 and July 2009. Related risk factors and trends in breech presentation prevalence were also considered. Results: Mean maternal age was 31.78 years (±5.17) and mean gestational age at delivery 38.67 weeks (±2.54). Breech presentation prevalence in nullipara and pluripara was respectively 5.36% (415/7743) and 3.53% (236/6689; p < 0.05), and was significantly lower among Sub-Saharan-African women 2.62% (14/535) versus 4.51% (651/14432; p < 0.05). Also advanced maternal age, early gestational age at delivery, neonatal female gender and low weight at delivery resulted associated with a higher prevalence of breech presentation. By multivariate logistic regression, the breech presentation resulted independently predicted by maternal age, ethnicity, parity, gestational age and neonatal weight MoMs at delivery, and neonatal gender. Conclusions: Advanced maternal age, early gestational age, low neonatal weight MoMs at delivery and female gender resulted to be risk factors for fetal breech presentation at delivery, while multiparity and Sub-Saharan-African ethnicity resulted to be protective.