Francesca Frezzotti

Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: Preliminary experience

PURPOSE To assess the clinical value of quantitative elastosonography compared with multiparametric ultrasound in differentiating the nature of thyroid nodules. METHODS AND MATERIALS Ninety-seven consecutive patients (32 males, 65 females, mean age, 54 years, range 20-81 years) with thyroid nodules previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated quantitative software (Elasto-Q, Toshiba) before surgery. Ultrasound examination and elastosonography were evaluated by two investigators in consensus. US features, color-Doppler pattern, and strain ratio value were evaluated. Sensitivity and specificity of CDUS and sono-elastography were compared using X(2) test and ROC curves. RESULTS Sensitivity and specificity of hypoechogenicity, irregular margins or suspicious halo features, CDUS blood flow pattern, and strain ratio in the diagnosis of malignant nodules were 56.8%, 62.2%, 54.1% and 97.3% and 71.7%, 93.3%, 28.3%, and 91.7%, respectively. Elastosonography was more sensitive and specific than all ultrasonographic features in predicting malignancy of the thyroid nodules (p<0.0001). According to elastosonographic features the lesions characterized by strain ratio ≥ 2 were highly likely to be of malignant nature (p<0.0001, O.R. 396, 95%, CI: 44-3530). CONCLUSIONS The results of the present study suggest that elastosonography with Q system is a valuable tool in the characterization of thyroid nodules and it seems to be far more accurate than CDUS. These findings as well as those of previous studies support its use in selecting patients who are candidates for surgery.

Fibroblast Growth Factor Receptor-2 Expression in Thyroid Tumor Progression: Potential Diagnostic Application

Fibroblast growth factor receptor-2 (FGFR-2) plays an important role in tumorigenesis. In thyroid cancer it has been observed a FGFR-2 down-modulation, but the role of this receptor has not been yet clarified. Therefore, we decided to examine the expression of both FGFR-2 isoform, FGFR-2-IIIb and FGFR-2-IIIc, in different histological thyroid variants such as hyperplasia, follicular adenoma and papillary carcinoma. Immunohistochemistry and quantitative Real-Time PCR analyses were performed on samples of hyperplasia, follicular adenoma and papillary carcinoma, compared with normal thyroid tissue. Thyroid hyperplasia did not show statistically significant reduction in FGFR-2 protein and mRNA levels. Interestingly, in both follicular adenoma and papillary carcinoma samples we observed a strongly reduced expression of both FGFR-2 isoforms. We speculate that FGFR-2 down-modulation might be an early event in thyroid carcinogenesis. Furthermore, we suggest the potential use of FGFR-2 as an early marker for thyroid cancer diagnosis.

Acute abdominal pain in a 24-year-old woman: Fitz- Hugh-Curtis syndrome associated with pyelonephritis

Fitz-Hugh-Curtis syndrome is an inflammatory disease ofthe liver capsule that occurs as a complication of pelvicinflammatory disease in approximately 25% of cases. Themost common etiological agents are Chlamydia trachomatisand Neisseria gonorrhoeae. Classically, it manifests as acuteright upper quadrant pain, which can sometimes beconfused with pyelonephritis or a primitive condition ofhepatobiliary origin or the digestive tract. A correctdiagnosis is often difficult. Ultrasonography and computedtomography (CT) may be helpful in the differentialdiagnosis of other forms of peritonitis localized in the rightabdominal quadrants, and serology, urine cultures andcervical swabs are generally used to isolate the responsibleorganism. The differential diagnosis could include Chilaiditisyndrome (interposition of a colonic segment between theliver and diaphragm with occlusion) or exudative peritoni-tis from salpingitis. We describe the clinical case of a 24-year-old Caucasian woman who presented with acute rightupper quadrant pain, positive Murphy’s sign, neutrophilicleukocytosis, and fever.

True aneurysm of the proximal occipital artery: Case report

Highlights • Aneurysms of the proximal occipital artery may cause symptoms by compressing adjacent structures.• Resection may require intubation by the nose.• Resection if usually followed by regeression of symptoms.

Hybrid treatment of tandem, common carotid/innominate artery and ipsilateral carotid bifurcation stenoses by simultaneous, retrograde proximal stenting and eversion carotid endarterectomy: Preliminary results of a case series

BACKGROUND Tandem stenoses of the internal carotid artery (ICA) and proximal, ipsilateral common carotid artery (CCA) or innominate artery can be treated with a hybrid approach, combining conventional carotid endarterectomy (CEA) and retrograde stenting of the proximal stenosis, through surgical exposure of the carotid bifurcation. The purpose of this study was to evaluate the results of combining eversion CEA with retrograde CCA/innominate artery stenting. MATERIAL AND METHODS From January 2015 to July 2017, 7 patients, 6 men of a mean age of 72 years (range 59-83 years) underwent simultaneous, retrograde stenting of the proximal CCA/innominate artery and an eversion CEA of the ipsilateral ICA, through surgical exposure of the carotid bifurcation, for severe tandem stenoses. The proximal stenosis involved the left proximal CCA in 4 patients, the proximal innominate artery in 2 patients and the right CCA in one patient. The procedure was performed under general anesthesia in a conventional operating room equipped with a mobile C-arm. A covered, balloon expandable stent was deployed over the proximal stenosis via a 6-F sheath directly introduced into the proximal CCA through the obliquely transected carotid bulb. After removing the sheath, debris were flushed through the carotid bulb and eversion CEA completed the procedure. Study endpoints were: postoperative stroke/mortality rate, cardiac mortality and morbidity, peripheral nerve injury, cervical hematoma, overall late survival, freedom from ipsilateral stroke and patency of arterial reconstruction. RESULTS No postoperative mortality or neurologic morbidity was observed in any patient. Cervical hematomas and peripheral nerve injuries were likewise absent. At a mean follow-up of 18 months, all the patients were alive, free from neurologic events of new onset and free from restenosis. CONCLUSION Combined proximal stenting and eversion CEA for tandem lesions seems a valid treatment, with the advantages of eversion CEA over other techniques of carotid bifurcation revascularization.

Results of subclavian to carotid artery bypass for occlusive disease of the common carotid artery: A retrospective cohort study

BACKGROUND Optimal treatment of significant atherosclerosis of the common carotid artery (CCA) is not well-defined. The purpose of this study was to evaluate the long-term results of prosthetic subclavian to carotid bypass for occlusive disease of the CCA. MATERIAL AND METHODS From January 1994 to December 2015, 45 patients, mean age 67 years, underwent an ipsilateral subclavian to carotid bypass for occlusive disease of the CCA. Thirty-eight patients (84%) presented with neurologic symptoms, including transitory ischemic attacks in 29 cases and minor strokes in 9 cases. The graft material consisted of a 7 mm polytetrafluoroethylene conduit, and the distal anastomosis was done on the carotid bulb in 21 patients, on the internal carotid artery in 19 cases, and on the distal CCA in 5 cases. Median length of follow-up was 58 months. Study endpoints were the combined postoperative stroke/mortality rate, graft infection, overall late survival, freedom from ipsilateral stroke, and graft patency. RESULTS Postoperative stroke/mortality rate was 2%. No graft infection was observed throughout follow-up. At 60 months, overall survival, freedom from stroke, and graft patency were 71% (standard error [SE] = 0.07), 98% (SE = 0.02), and 95.5% (SE = 0.06), respectively. CONCLUSIONS Subclavian to carotid bypass allows very good patency rates and excellent protection from postoperative and late stroke, remaining a benchmark for any other treatment method.

Surgical treatment for primary hyperparathyroidism in the elderly: a single- center analysis

BackgroundsThe suspicion of a hyperparatiroidism is mostly guidedby the finding of an increase in serum calcium levels byroutine measurements. Primary hyperparathyroidism is acommon disease occurring in 0.2 to 0.5% of the popula-tion. The incidence in the United States is approxi-mately 100000 new cases per year and increases withage affecting up to 2% of elderly people [1].Materials and methodsFrom January 1995 to December 2009, 172 patientsunderwent operations for Hyperparathyroidism, 130 ofthese were Primary Hyperparathyroidism at our Depart-ment of General Surgery. Patients were divided into twogroups: patients of≤ 69 years old (Group A) andpatients of ≥ 70 years old (Group B). The following vari-ables were studied: demographic characteristics, co-mor-bidities, preoperative symptoms, laboratory values,operative procedures, postoperative complications andanatomo -pathological findings.ResultsGroup A: 110 patients operated 25 were male, 85 werefemale with a M:F ratio of 0.3:1. Mean age at admissionwas52.4(SD±12.9).Wereportedamorbidityrateof5.4% (6 patients) and a mortality rate of 0%. Group B:20 patients operated 6 were male, 16 were female with aM:F ratio of 0.25:1. Mean age at admission was 74.2 (SD±3.7). We reported a morbidity rate of 5% (1 patient)and mortality rate 0%.ConclusionsElderly patients with Hyperparathyroidism present avariety of symptoms that are often different from thoseseen in younger patients. They are more likely to mani-fest fatigue and psychiatric symptoms that are difficultto distinguish from those due to their age, therefore inthe majority of cases the suspicion of hyperparathyroid-ism is guided by the finding of an increase in serum cal-cium levels on a routine measurement. If serum calciumlevel is high or if hypercalcaemia is discovered, measure-ment of PTH confirms the diagnosis [2,3]. Cervicotomyand parathyroidectomy is still to be considered as thetreatment of choice in elderly patients with primaryhyperparathyroidism.