Pv Lippolis

Is Elastography Actually Useful in the Presurgical Selection of Thyroid Nodules with Indeterminate Cytology

BACKGROUNDnAlthough fine-needle aspiration cytology remains the mainstay of the preoperative workup of thyroid nodules, those with follicular proliferation still represent a diagnostic challenge. Real-time elastography (RTE) estimates the stiffness/elasticity of lesions and is regarded as a promising technique for the presurgical selection of thyroid nodules (including those with indeterminate cytology).nnnAIMnOur aim was to verify the potential role of RTE in the presurgical diagnosis of cancer in a large cohort of consecutive patients with follicular thyroid nodules.nnnPATIENTS AND METHODSnOne hundred two patients were submitted to conventional ultrasonography and RTE evaluation before being operated on for thyroid nodule with indeterminate cytology (54% single nodules). Tissue stiffness on RTE was scored from 1 (greatest elasticity) to 4 (no elasticity).nnnRESULTSnAt conventional ultrasonography examination, the nodules (median diameter 2.2 cm) were solid (cystic areas < 10%); microcalcifications were detected in 56% of them and a hypoechoic pattern in 64%. Elasticity was high in eight cases only (score 1-2) although low in 94 (score 3-4). Cancer was diagnosed in 36 nodules (35%), being associated with microcalcifications (P < 0.0001) and inversely related to nodule diameter (P < 0.01). Malignancy was detected in 50% of the nodules with RTE score 1-2 and in 34% of those with score 3-4. Therefore, either the positive (34%) or the negative predictive value (50%) was clinically negligible.nnnCONCLUSIONSnThe current study does not confirm the recently reported usefulness of RTE in presurgical selection of nodules with indeterminate cytology and suggest the need for quantitative analytical assessment of nodule stiffness to improve RTE efficacy.

Percutaneous ethanol injection treatment of autonomously functioning single thyroid nodules: Optimization of treatment and short term outcome

Twenty-five patients with solitary autonomous thyroid nodules (15 nontoxic, 10 toxic) received percutaneous ethanol injection treatment (PEIT) under sonographic guidance in 4–7 sessions (1–2 weekly). To test different doses, smaller nodules (volume <15 mL) were given 0.75–2.8 mL ethanol/mL nodular tissue while larger nodules received 0.5–1 mL/mL. Except for 1 patient who developed hyperpyrexia, no relevant adverse effects were observed. A slight, asymptomatic increase in serum thyroid hormone levels was observed in both groups during the treatment. Three months after treatment, a biochemical and clinical remission of hyperthyroidism was observed in 8 of 10 patients with toxic nodules. A significant increase of TSH level was seen in both groups (p<0.01). Significant shrinkage of volume (p<0.001) as well as structural alternations of nodules were consistently recorded at sonography. A linear relationship (r=0.98;p<0.0001) between pretreatment volume and volume reduction was found both for large and small nodules, thus suggesting that even limited ethanol doses may be therapeutically effective. A recovery of extranodular parenchyma activity at scintiscan occurred in 16 (64%) of 25 patients. These data confirm that PEIT is effective in obtaining functional ablation and in inducing remission of hyperthyroidism. Adverse effects are infrequent. In spite of the small patient sample, a 0.5–1 mL ethanol dose per each mL of tissue appears as effective as larger doses and seems appropriate for treatment.RésuméOn a injecté de léthanol par voie percutanée (IEP) et sous échographie chez 25 patients ayant un nodule solitaire autonome de la thyroïde (15 non-toxiques, 10 toxiques), à raison de 4–7 séances (1–2 par semaine). Pour évaluer les doses nécessaires en fonction de la taille, les patients ayant un nodule plus petit (volume <15 mL) ont reçu 0.75–2.8 mL deéthanol/mL de tissu nodulaire, alors que ceux porteurs de nodules de plus gros volume ont reçu un volume dose de 0.5 mL/mL. Hormis un cas dhyperpyrexie transitoire, il na pas été observé deffects secondaires notables. On a constaté une augmentation modérée, asymptomatique, des taux hormonaux sériques dans les deux groupes pendant le traitement. Trois mois aprés la fin du traitement, une rémission clinique et biologique a été observée chez 8 des 10 patients ayant un nodule toxique. Une augmentation significative des niveaux de TSH a été notée dans les deux groupes (p<0.01). Une diminution significative du volume (p<0.001), ainsi que des modifications structurales ont toujours été documentées par léchographie. Une corrélation linéaire hautement significative a été retrouvée (r=0.98;p<0.0001) entre le volume pré-opératoire et la réduction tumorale à la fois pour les grands et les petits nodules, suggèrant que même une injection limitée déthanol peut être thérapeutiquement efficace. La récupération dune activité scintigraphique extranodulaire a été observee chez 16 des 25 patients (64%). Ces données confirment que lIPE est un moyen efficace pour obtenir une “ablation fonctionnelle” de la thyroïde et induire une rémission dhyperthyroide. Les effets secondaires apparaissent peu fréquents. Malgré la taille réduite des effectifs dans cette étude, il semble que la dose de 0.5–1 mL déthanol par mL de tissu soit aussi efficace quune dose plus importante.ResumenVeinticinco pacientes con nodulos tiroideos solitarios autónomos (15 no tóxicos, 10 tóxicos) fueron tratados mediante inyección de etanol por vía percutánea (TIEP) bajo guía ultrasonigráfica en 4–7 sesiones (1–2 semanales). Con el objeto de probar diferentes dosis, los nódulos pequeños (volumen<15 mL) fueron tratados con dosis de 0.75–2.8 mL etanol/mL de tejido nodular, en tanto que los nódulos mayores recibieron 0.5–1.0 mL. Aparte de un paciente que exhibió hiperpirexia transitoria, no se observaron efectos adversos. En el curso del tratamiento se registró una leve y asintomática elevación de los niveles séricos de hormona tiroidea en ambos grupos. A los tres meses de efectuado el tratamiento se comprobó remisión bioquímica y clínica del hipertiroidismo en 8 de 10 pacientes tóxicos, y elevación significativa de los niveles de TSH en ambos grupos (p<0.01). En forma consistente la sonografía demostró reducción significativa del volumen (p<0.0001) y alteraciones estructurales de los nódulos. Se encontró una relación linear entre el volumen de la masa anterior al tratamiento y la reducción, tanto para los nódulos grandes como para los pequeños, lo cual sugiere que aún las dosis limitadas de etanol poseen eficacia terapéutica. Se demostró recuperación de la actividad parenquimatosa extranodular en 16 de 25 pacientes (64%). Los datos confirman que el TIEP es efectivo para lograr la ablación funcional y la remisión del hipertiroidismo, cuando éste se encuentra presente; los efectos adversos son muy raros. A pesar de lo pequeno de la muestra de pacientes, parece que una dosis de 0.5–1.0 mL de etanol por cada mL de tejido es tan eficaz como las dosis mayores y que resulta apropiada para el tratamiento de los nódulos solitarios autónomos de la glándula tiroides.

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer? A comparative study

AbstractBackground: Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery.n Methods: We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification.n Results: LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone.n Conclusions: The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy.

Appearance of Graves’ disease after percutaneous ethanol injection for the treatment of hyperfunctioning thyroid adenoma

In this report we describe an unusual patient with hyperfunctioning thyroid adenoma in whom percutaneous ethanol injection (PEI) thera py was followed by typical Graves’ disease. His history revealed the presence of a sister with Hashimoto’s thyroiditis. 99-mTc thyroid scintiscan showed focal uptake in the nodule, with suppression of extranodular parenchyma. PEI therapy was followed by the development of severe hyperthyroidism. One month after a second PEI cycle, recurrence of hyperthyroidism associated with diffuse 99-mTc uptake by the gland was observed. TSH-receptor and thyroglobulin autoantibodies were undetectable before PEI therapy, appeared during the first cycle, and showed a further increase after the second PEI therapy cycle. Though spontaneous switch to Graves’ disease cannot be excluded in patients with toxic nodules, the massive release of thyroid materials from follicular cells, among these TSH-receptor antigenic components partially denatured by ethanol, may indeed trigger an autoimmune response to the TSH-receptor, thus accounting for this observation. Patients with possible autoimmune disposition, as selected by familiar history and/or laboratory markers should be carefully monitored during PEI treatment.

Laparoscopic treatment of pancreatic insulinoma

Laparoscopy and laparoscopic ultrasonography (LUS) have been proposed for the diagnosis and treatment of pancreatic insulinoma. We present for cases of pancreatic insulinoma approached by laparoscopy guided by LUS. In three cases, insulinomas were in the pancreatic body and in one case in the pancreatic head. All lesions were detected preoperatively by abdominal US and confirmed by computed tomography. Laparoscopy was performed under general anesthesia. LUS was performed using a 10-mm flexible probe. In two cases the adenoma was enucleated using scissors and electrocoagulation, major vessels were controlled using clips, and enucleation was completed using a 30-mm endo-GIA. In one case a laparoscopic distal pancreatectomy with spleen preservation was performed. In one case the adenoma was deep in the pancreatic head; minilaparotomy was performed and the adenoma enucleated. Patients were discharged in good health 5–7 days after surgery. The postoperative course was complicated in one case of enucleation by peripancreatic fluid collection that was treated percutaneously. Our experience confirms that accurate localization followed by excision of tumors via the laparoscopic approach constitute a significant advance in the management of insulinoma.

Critical US visibility with tissue harmonic imaging of subcutaneous nodules().

INTRODUCTIONnAssessment of US ability to identify subcutaneous nodular lesions using conventional B mode imaging (CBMI) and tissue second harmonic imaging (THI).nnnMATERIALS AND METHODSnThree different types of equipment were used (Philips Envisor HDC, Philips HD 11 XE and GE Logic E) with 12-13xa0MHz probes and THI probes with variable frequency. One experienced operator studied 31 patients (24 women, 7 men, mean age 49xa0±xa015) with 52 subcutaneous nodular lesions of which 43 were palpable and 9 were nonpalpable. Statistical analysis was carried out using chi-square test.nnnRESULTSn19/52 subcutaneous nodular lesions were hyperechoic, 10/52 were isoechoic and 23/52 were hypoechoic. Of the hyperechoic nodules, 8/19 (42%) (pxa0<xa00.005) were not detected using THI, as they disappeared when THI was activated. Of the isoechoic nodules only 1/10 was not detected using THI, and of the hypoechoic nodules only 2/23 were not detected. Of the nodular lesions detected using CBMI and also using THI (41/52), 16/41 were shown more clearly using THI than using BMCI. No nodule was detected with the exclusive use of THI.nnnCONCLUSIONSnThe statistical significance of the disappearing lesions (pxa0<xa00.005), mainly hyperechoic (42%), at the activation of THI must lead to a reconsideration of routine activation of THI during the entire US examination in the evaluation of subcutaneous lesions in order to avoid the risk of missing important lesions. The present results suggest that both BMCI and THI should be used in the study of subcutaneous lesions.

Ultrasound findings guided a successful hemicolectomy in a leukemic patient with neutropenic enterocolitis.

INTRODUCTIONnNeutropenic enterocolitis (NEC) can be a life-threatening complication of chemotherapy in leukemic patients. Early diagnosis and treatment is therefore crucial.nnnMETHODSnA 38-year-old woman with acute lymphoblastic leukemia and chemotherapy-induced neutropenia suddenly developed symptoms suspicious of NEC. Transabdominal ultrasound showed features consistent with NEC, later confirmed by computed tomography (CT) scan.nnnRESULTSnThe patient was scanned using portable ultrasound (US) equipment (Esaote My Lab 25). US findings showed involvement of the cecum, appendix, ascending colon and proximal middle transverse colon, with features resembling gas containing fissures within the colon wall itself. The risk of colon rupture was confirmed by CT scan. The patient underwent successful hemicolectomy after intravenous treatment with broad spectrum antibiotics, granulocyte-colony stimulating factor (G-CSF), platelets and fresh frozen plasma transfusion.nnnDISCUSSIONnA prompt bedside US examination upon development of symptoms allowed an early diagnosis of NEC and identified features consistent with imminent colon wall rupture, shifting the management of this life-threatening complication from medical to surgical. Multidisciplinary intervention was crucial for a successful hemicolectomy in a severely affected neutropenic patient.