Brain cortical assessment by MRI in fetuses with left congenital diaphragmatic hernia Brain development in left congenital diaphragmatic hernia

OBJECTIVE

To evaluate fetal brain development using MRI (magnetic resonance imaging) in CDH (congenital diaphragmatic hernia).

METHODS

52 isolated left CDH and 104 control fetuses were imaged using MRI. Brain morphometry (Biparietal diameter - BPD, brain fronto-occipital diameter - BFOD, third ventricle, posterior ventricles, transcerebellar diameter - TCD, anteroposterior and craniocaudal cerebellar vermis diameter - AP and CC) and cortical structures (bilateral cingulate fissure - CF, insular fissure - IF, insular depth - ID) were compared with controls using Mann-Whitney test .

RESULTS

Median gestational age at MRI was comparable (p=0.95), as well as was the median biparietal diameter (p=0.737). Among morphometric parameters only the brain fronto-occipital diameter was significantly smaller in CDH (p= 0.001) and the third ventricle was significantly greater in CDH (<0.0001). Among cortical structures, the cingulate and insular fissure were significantly deeper in CDH fetuses (p<0.0001), as the insular depth ID was smaller in CDH (p< 0.03).

CONCLUSIONS

CDH fetuses have a smaller fronto-occipitaldiameter, reduced insular depth, and deeper cingulate and insular fissure, and greater third ventricle width as compared to controls. These findings suggest that left CDH may have an impact on fetal brain development with an overall reduction of brain volume. This article is protected by copyright. All rights reserved.

Process development and validation of expanded regulatory T cells for prospective applications: an example of manufacturing a personalized advanced therapy medicinal product

BACKGROUND

A growing number of clinical trials have shown that regulatory T (Treg) cell transfer may have a favorable effect on the maintenance of self-tolerance and immune homeostasis in different conditions such as graft-versus-host disease (GvHD), solid organ transplantation, type 1 diabetes, and others. In this context, the availability of a robust manufacturing protocol that is able to produce a sufficient number of functional Treg cells represents a fundamental prerequisite for the success of a cell therapy clinical protocol. However, extended workflow guidelines for nonprofit manufacturers are currently lacking. Despite the fact that different successful manufacturing procedures and cell products with excellent safety profiles have been reported from early clinical trials, the selection and expansion protocols for Treg cells vary a lot. The objective of this study was to validate a Good Manufacturing Practice (GMP)-compliant protocol for the production of Treg cells that approaches the whole process with a risk-management methodology, from process design to completion of final product development. High emphasis was given to the description of the quality control (QC) methodologies used for the in-process and release tests (sterility, endotoxin test, mycoplasma, and immunophenotype).

RESULTS

The GMP-compliant protocol defined in this work allows at least 4.11 × 109 Treg cells to be obtained with an average purity of 95.75 ± 4.38% and can be used in different clinical settings to exploit Treg cell immunomodulatory function.

CONCLUSIONS

These results could be of great use for facilities implementing GMP-compliant cell therapy protocols of these cells for different conditions aimed at restoring the Treg cell number and function, which may slow the progression of certain diseases.

Morphometric Analysis of Brain in Newborn with Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a severe pediatric disorder with herniation of abdominal viscera into the thoracic cavity. Since neurodevelopmental impairment constitutes a common outcome, we performed morphometric magnetic resonance imaging (MRI) analysis on CDH infants to investigate cortical parameters such as cortical thickness (CT) and local gyrification index (LGI). By assessing CT and LGI distributions and their correlations with variables which might have an impact on oxygen delivery (total lung volume, TLV), we aimed to detect how altered perfusion affects cortical development in CDH. A group of CDH patients received both prenatal (i.e., fetal stage) and postnatal MRI. From postnatal high-resolution T2-weighted images, mean CT and LGI distributions of 16 CDH were computed and statistically compared to those of 13 controls. Moreover, TLV measures obtained from fetal MRI were further correlated to LGI. Compared to controls, CDH infants exhibited areas of hypogiria within bilateral fronto-temporo-parietal labels, while no differences were found for CT. LGI significantly correlated with TLV within bilateral temporal lobes and left frontal lobe, involving language- and auditory-related brain areas. Although the causes of neurodevelopmental impairment in CDH are still unclear, our results may suggest their link with altered cortical maturation and possible impaired oxygen perfusion.

Comparison of mediastinal shift angles obtained with ultrasound and magnetic resonance imaging in fetuses with isolated left sided congenital diaphragmatic hernia

Objectives: To compare ultrasound (US) and magnetic resonance imaging (MRI) in the assessment of mediastinal shift angles (MSAs) in fetuses affected by isolated left congenital diaphragmatic hernia (CDH). The use of MRI-MSA and US-MSA as prognostic factor for postnatal survival in fetal left CDH was also explored.Methods: This was an observational study of 29 fetuses with prenatally diagnosed isolated left CDH, assessed with both US and MRI examinations between January 2015 and December 2018. The US-MSA measurements performed within 2 weeks from the MRI assessment were considered for the analysis. The primary outcome was the postnatal survival rate.Results: No significant difference between US and MRI MSAs was detected (p = .419). Among the 29 cases, there were 21 alive infants, for an overall postnatal survival rate of 72.41%. After stratifying for postnatal survival, the best cutoffs with the highest discriminatory power in terms of sensibility and specificity were 42.1° for the US-MSA and 39.1° for the MRI-MSA. The performance of MRI-MSA in predicting postnatal survival was close to that of US-MSA in terms of sensitivity (62.5 versus 50.0%), specificity (80.9 versus 90.5%), positive predictive value (55.6 versus 66.7%), negative predictive value (85.0 versus 82.6%) and accuracy (75.9 versus 79.3%). There was no statistically significant difference between the two modalities (p > .05 for all).Conclusions: MRI and US can be interchangeably used for the assessment of MSA in prenatally diagnosed isolated left CDH. Moreover, MSA measured by both US and MRI was confirmed to be correlated with perinatal outcome in terms of survival.

Fetal MRI assessment of mediastinal shift angle in isolated left congenital diaphragmatic hernia: A new postnatal survival predictive tool?

OBJECTIVE

To quantify the mediastinal shift angle (MSA) in fetuses with isolated left congenital diaphragmatic hernia (CDH) by magnetic resonance imaging and evaluate survival.

METHOD

Fetuses from singleton pregnancies with isolated left CDH were matched for gestational age with controls without thoracic malformations. For all fetuses the MSA was determined by two operators and inter-operator variability and differences between cases and controls were investigated. For all cases total fetal lung volume (TFLV) was calculated and the correlation between MSA and TFLV was assessed, and its predictive value towards survival was determined.

RESULTS

Thirty-four fetuses were included as cases and 42 as controls. The mean gestational age for assessment of CDH fetuses was 32 weeks (range 27-38). Twenty-four fetuses survived until discharge and 10 did not. There was an excellent inter-operator reliability for measuring the MSA and a significant difference between MSA in cases and controls. There was an inverse correlation between MSA values and survival, a correlation between TFLV and survival and an inverse correlation between MSA and TFLV. The area under the ROC curve for MSA in predicting survival was 0.931 (95% CI 0.851-1.000).

CONCLUSION

The MSA measured late in gestation correlates with postnatal survival in patients with isolated left CDH.

Pooled human serum: A new culture supplement for bioreactor-based cell therapies. Preliminary results

BACKGROUND

Bone Marrow MSCs are an appealing source for several cell-based therapies. Many bioreactors, as the Quantum Cell Expansion System, have been developed to generate a large number of MSCs under Good Manufacturing Practice conditions by using Human Platelet Lysate (HPL). Previously we isolated in the human bone marrow a novel cell population, named Mesodermal Progenitor Cells (MPCs), which we identified as precursors of MSCs. MPCs could represent an important cell source for regenerative medicine applications. As HPL gives rise to a homogeneus MSC population, limiting the harvesting of other cell types, in this study we investigated the efficacy of pooled human AB serum (ABS) to provide clinically relevant numbers of both MSCs and MPCs for regenerative medicine applications by using the Quantum System.

METHODS

Bone marrow aspirates were obtained from healthy adult individuals undergoing routine total hip replacement surgery and used to generate primary cultures in the bioreactor. HPL and ABS were tested as supplements to culture medium. Morphological observations, cytofluorimetric analysis, lactate and glucose level assessment were performed.

RESULTS

ABS gave rise to both heterogeneous MSC and MPC population. About 95% of cells cultured in HPL showed a fibroblast-like morphology and typical mesenchymal surface markers, but MPCs were scarcely represented.

DISCUSSION

The use of ABS appeared to sustain a large scale MSC production, as well as the recovery of a subset of MPCs, and resulted a suitable alternative to HPL in the cell generation based on the Quantum System.

Mesenchymal Stromal Cell Culture and Delivery in Autologous Conditions: A Smart Approach for Orthopedic Applications

Human Mesenchymal Stromal Cells (hMSCs) are cultured in vitro with different media. Limits on their use in clinical settings, however, mainly depend on potential biohazard and inflammation risks exerted by xenogeneic nutrients for their culture. Human derivatives or recombinant materials are the first choice candidates to reduce these reactions. Therefore, culture supplements and materials of autologous origin represent the best nutrients and the safest products. Here, we describe a new protocol for the isolation and culture of bone marrow hMSCs in autologous conditions - namely, patient-derived serum as a supplement for the culture medium and fibrin as a scaffold for hMSC administration. Indeed, hMSC/fibrin clot constructs could be extremely useful for several clinical applications. In particular, we focus on their use in orthopedic surgery, where the fibrin clot derived from the donor's own blood allowed effective cell delivery and nutrient/waste exchanges. To ensure optimal safety conditions, it is of the utmost importance to avoid the risks of hMSC transformation and tissue overgrowth. For these reasons, the approach described in this paper also indicates a minimally ex vivo hMSC expansion, to reduce cell senescence and morphologic changes, and short-term osteo-differentiation before implantation, to induce osteogenic lineage specification, thus decreasing the risk of subsequent uncontrolled proliferation.

Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI)

BACKGROUND

Despite progresses in neonatal care, the mortality and the incidence of neuro-motor disability after perinatal asphyxia have failed to show substantial improvements. In countries with a high level of perinatal care, the incidence of asphyxia responsible for moderate or severe encephalopathy is still 2-3 per 1000 term newborns. Recent trials have demonstrated that moderate hypothermia, started within 6 hours after birth and protracted for 72 hours, can significantly improve survival and reduce neurologic impairment in neonates with hypoxic-ischemic encephalopathy. It is not currently known whether neuroprotective drugs can further improve the beneficial effects of hypothermia. Topiramate has been proven to reduce brain injury in animal models of neonatal hypoxic ischemic encephalopathy. However, the association of mild hypothermia and topiramate treatment has never been studied in human newborns. The objective of this research project is to evaluate, through a multicenter randomized controlled trial, whether the efficacy of moderate hypothermia can be increased by concomitant topiramate treatment.

METHODS/DESIGN

Term newborns (gestational age ≥ 36 weeks and birth weight ≥ 1800 g) with precocious metabolic, clinical and electroencephalographic (EEG) signs of hypoxic-ischemic encephalopathy will be randomized, according to their EEG pattern, to receive topiramate added to standard treatment with moderate hypothermia or standard treatment alone. Topiramate will be administered at 10 mg/kg once a day for the first 3 days of life. Topiramate concentrations will be measured on serial dried blood spots. 64 participants will be recruited in the study. To evaluate the safety of topiramate administration, cardiac and respiratory parameters will be continuously monitored. Blood samplings will be performed to check renal, liver and metabolic balance. To evaluate the efficacy of topiramate, the neurologic outcome of enrolled newborns will be evaluated by serial neurologic and neuroradiologic examinations. Visual function will be evaluated by means of behavioural standardized tests.

DISCUSSION

This pilot study will explore the possible therapeutic role of topiramate in combination with moderate hypothermia. Any favourable results of this research might open new perspectives about the reduction of cerebral damage in asphyxiated newborns.

Chest fast MRI: an imaging alternative on pre-operative evaluation of Pectus Excavatum

BACKGROUND

Standard imaging methods in evaluating chest wall deformities, such as Pectus Excavatum (PE) in paediatric and adolescent patients, include baseline 2-view chest radiography and chest CT scan. Only few studies to date investigated the value of fast MRIin the pre operative assessment of patient affected by PE.

OBJECTIVE

To evaluate the efficacy of chest fast MRI in pre-operative management of patient affected by PE. To obtain the Haller Index (HI) and Asymmetry Index (AI) from chest fast MRI protecting patients from radiation exposure.

MATERIALS AND METHODS

We analyzed the data of 42 consecutive patients with severe PE who underwent minimally invasive repair between March 2007 and March 2010. All 42 patients received chest fast MRI, but only the first 5 in view of the results, were studied also with chest ultrafast CT scan. In both examinations, data at the deepest point of the depression were collected.

RESULTS

Severity indices of the deformity using HI and AI, collected from CT scan and fast MRI in the first 5 patients, were comparable. In the remaining 37 fast chest MRI offered good images of the chest wall deformities with no radiation exposure, detailing anatomical information such as displacement and rotation of the heart or great vessels anomalies.

CONCLUSION

This study suggests the use of chest MRI in pre operative workup for patients with PE to obtain severity indices (Haller Index and Asymmetry Index avoiding radiation exposure to paediatric patients.

MRI and DWI: feasibility of DWI and ADC maps in the evaluation of placental changes during gestation

OBJECTIVE

To establish if a correlation exists between apparent diffusion coefficient (ADC) values, obtained by diffusion-weighted imaging (DWI), and placental aging.

METHOD

The study is divided into a retrospective phase and a prospective one.In the first phase, 145 pregnant women underwent fetal magnetic resonance imaging (MRI) for suspected disorders in several organs. We performed DWI (b value 0, 200 and 700 s/mm(2)) in all the fetuses, evaluating the patients in whom the whole placenta was visible.In the prospective phase, 50 women (52 fetuses) underwent MRI. We performed, in the same patient, two echo-planar sequences with b values of 0, 200 and 700, and 50, 200 and 700 s/mm(2), including the whole placenta.The ADC maps were calculated for all fetuses, divided into three groups based on gestational age (GA): group I: 20-26 weeks' gestation, II: 27-33, III: 34-40.

RESULTS

In the retrospective phase, ADC values had a range from 1 to 2.4 mm(2)/s, showing a significant correlation between ADC values and GA.ADC values obtained by DWI with b value 0, 200 and 700 s/mm(2) had a range from 0.8 to 2.5 mm(2)/s, with an inverse correlation between ADC values and GA, whereas the ADC values with b value 50, 200 and 700 s/mm(2) did not show any statistical correlation (range: 1.5-1.7 mm(2)/s).

CONCLUSION

DWI with ADC maps can not be considered markers for placental aging because they are affected by perfusional and circulatory motion.

One-Step Laparoscopic Management of a Female Adnexal Tumor of Wolffian Origin

We report a case of female adnexal tumor of Wolffian origin (FATWO), a rare neoplasm arising from the mesonephric ducts. A 48-year-old woman came first to our center for a recent discovery of a pelvic mass. Transvaginal ultrasonographic findings suggested a solid right para-ovarian mass suspected to be malignant. After thorough counseling, the patient underwent operative laparoscopy for excision of the para-ovarian mass with frozen section (FS) examination resulting in the diagnosis of a poorly differentiated adenocarcinoma. In this case, FS results allowed performing a comprehensive oncological staging, through a totally laparoscopic extrafascial hysterectomy, bilateral adnexectomy, total omentectomy, pelvic wall peritonectomy, and pelvic, parasacral and para-aortic lymphadenectomy. Final pathological and immunohistochemical results confirmed the diagnosis of FATWO. To our knowledge, this is the first case of FATWO managed entirely by a minimally invasive laparoscopic approach in a single surgical session.

Carotid body tumors: radioguided surgical approach

Background

Carotid body tumours (CBTs) are very rare lesions which should be treated as soon as possible even when benign since small tumour size permits easier removal and lower incidence of perioperative complications and recurrence. Malignant forms are rare and they can be identified by lymph node invasion and metastases in distant locations. The need of reliable and effective diagnostic modalities for both primary CBTs and its metastases or recurrence is evident.

The present study reviews our experience and attempt to define the role of colour coded ultrasound (CCU) and Somatostatin receptor scintigraphy (SRS) with Indium-111-DTPA-pentetretide (Octreoscan^®) using both planar and single photon emission tomography (SPECT) technique in the diagnosis and follow-up of these uncommon lesions within a multidisciplinary approach.

Methods

From 1997 to 2008, 12 patients suffering from 16 CBTs (4 bilateral) were investigated by CCU and SRS-SPECT before and after surgery. All tumours were grouped according to Shamblin's classification in order to assess the technical difficulties and morbidity of surgical resection on the ground of their size and relationship with the carotid arteries. Intraoperative radiocaptation by Octreoscan^®) was also carried out in all cases to evaluate the radicality of surgery. All perioperative scans were evaluated by the same nuclear medicine physician.

Results

Preoperatively CCU showed CBTs (four were not palpable) with a sensitivity of 100%. Radioisotope imaging identified the CBTs as chemodectomas in 15 cases while no radioisotopic uptake was detected in 1 vagus nerve neurinoma. No evidence of metastasis or multicentricity were seen by total body radioisotopic scans. Combined data from CCU and SRS-SPECT allowed to determine tumour size in order to select 7 larger tumours which were submitted to selective preoperative embolization.

Intraoperatively Octreoscan demonstrated microscopic tumour leftovers promptly removed in 1 case and an unresectable remnant at the base of the skull in another case.

During follow-up CCI and radioisotope scans showed no recurrence in 14 cases and a slightly enlargement of the intracranial residual as detected during surgery in 1 patient.

Conclusion

CCU may allow an early and noninvasive detection of CBTs and hence safer operations. The combined use of CCU and SRS-SPECT provide useful data to identify those tumours and to evaluate their extent and carotid arteries infiltration. Radioisotope imaging is a sensitive modality to detect metastases and lymph node involvement that are markers of CBT malignancy. After surgery CCU and SRS-SPECT can be accurate modalities for surveillance for an early detection of CBTs recurrence.

Fetal MRI of the cardiovascular system: role of steady-state free precession sequences for the evaluation of normal and pathological appearances

PURPOSE

This study aimed to evaluate the feasibility of fetal magnetic resonance imaging (MRI) with steady-state free precession (SSFP) sequences to visualise the normal and pathological appearances of the cardiovascular system.

MATERIALS AND METHODS

This is a prospective observational study of 83 pregnant women who underwent fetal cardiac MRI: 43 patients (cases) had echocardiographic suspicion of congenital heart disease; 40 patients (controls) did not. Fetal cardiac MRI consisted of a static phase with multiplanar SSFP sequences and a dynamic phase with real-time SSFP sequences. Two radiologists evaluated the diagnostic quality of the SSFP images in both the controls and cases, the MRI morphological and functional features in the controls and the MRI signs of congenital heart disease in the cases.

RESULTS

In both groups, SSFP sequences produced goodquality MR images and good visualisation of morphological features. Functional data appeared to be unavailable due to the current small temporal resolution and the technical impossibility of fetal cardiac triggering. MRI detected direct signs of congenital heart disease in 21 fetuses, indirect signs in six and both signs in 15.

CONCLUSIONS

SSFP sequences are effective in demonstrating the morphological features of the cardiovascular system, whereas dynamic SSFP cine-MRI sequences may provide adjunctive albeit suboptimal functional information.

Infertility in women: combined sonohysterography and hysterosalpingography in the evaluation of the uterine cavity

PURPOSE

To evaluate the diagnostic effectiveness of combined hysterosalpingography (HSG) and sonohysterography (SHG) in the study of infertile women.

MATERIALS AND METHODS

208 women affected by primary (184) or secondary sterility (24) were divided in two random groups. Group 1 underwent only HSG and group 2 underwent simultaneous HSG and SHG. The results obtained in the two groups were correlated with the results of hysteroscopy or laparoscopy, considered Gold Standard. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratio (LR) of HSG alone and combined HSG/SHG were calculated. Results were evaluated with t-test, Pearson's Chi square or Fisher exact test when appropriate and ROC analysis.

RESULTS

In group 1, hysteroscopy revealed no pathology in the uterine cavity in 70/104 patients, but evidenced 47 abnormalities related to the uterine cavity in 34 women. HSG outcome was in accordance with hysteroscopy in 27/34 cases of abnormalities, and in 64/70 cases of normal outcome. Sensitivity 0.79, specificity 0.91, PPV 0.82, NPV 0.90, LR+ 9.26. In group 2, hysteroscopy revealed no pathology in the uterine cavity in 64/104 patients but 52 abnormalities related to the uterine cavity in 40 women. HSG and SHG outcomes were confirmed by hysteroscopy in 39/40 cases of abnormalities of the uterine cavity and in 60/64 cases of normal uterine cavity. Sensitivity 0.97, specificity 0.94, PPV 0.91, NPV 0.98, LR+ 15.60. Statistical analysis showed that combined HSG and SHG yielded elevated specificity and LR+ and therefore few cases of false positive outcome.

CONCLUSION

Combined performance of HSG and SHG can shorten diagnostic investigation time and reduce the discomfort to the patient as the injector is fed into the cervix only once. This may also reduce the patient's anxiety level as one of the causes of infertility.

Practical application of contrast-enhanced magnetic resonance mammography [CE-MRM] by an algorithm combining morphological and enhancement patterns

The purpose of this article is to report our practical utilization of dynamic contrast-enhanced magnetic resonance mammography [DCE-MRM] in the diagnosis of breast lesions. In many European centers, was preferred a high-temporal acquisition of both breasts simultaneously in a large FOV. We preferred to scan single breasts, with the aim to combine the analysis of the contrast intake and washout with the morphological evaluation of breast lesions. We followed an interpretation model, based upon a diagnostic algorithm, which combined contrast enhancement with morphological evaluation, in order to increase our confidence in diagnosis. DCE-MRM with our diagnostic algorithm has identified 179 malignant and 41 benign lesions; final outcome has identified 178 malignant and 42 benign lesions, 3 false positives and 2 false negatives. Sensitivity of CE-MRM was 98.3%; specificity, 95.1%; positive predictive value, 98.9%; negative predictive value, 92.8% and accuracy, 97.7%.

Tamoxifen in women with breast cancer and mammographic density

PURPOSE OF INVESTIGATION

To evaluate the effect of tamoxifen on mammographic density using a qualitative and a semiquantitative method.

METHODS

Mammograms from 148 women treated for breast cancer before and after surgery were reviewed: 68 were administered tamoxifen; 80 did not receive tamoxifen. The mammograms were classified in one of the four BIRADS density categories by two radiologists blinded to the treatment and by a computer-assisted method after digitizing images.

RESULTS

At mammographic one-year-follow-up density was reduced in both groups and remained stable in the following years. A comparison of mammograms performed before surgery and after one year showed a statistically significant difference in density reduction between the tamoxifen and the non-tamoxifen-treated group. Good agreement was obtained between the qualitative and semiquantitative method.

CONCLUSION

Breast density reduction observed in women treated with tamoxifen may help in the detection of small tumors in dense breasts by means of reducing the masking effect of parenchyma.

MRI with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) assessment in the evaluation of normal and abnormal fetal kidneys: preliminary experience

OBJECTIVE

To investigate apparent diffusion coefficient (ADC) mapping with the measurement of renal tissue ADC value of normal and pathological fetal kidneys at various gestational ages (GAs).

METHODS

Fifty pregnant women underwent magnetic resonance images (MRI) after ultrasound (US) for suspected fetal genitourinary disorders (16) or for suspected disorders in other organs (34). A multiplanar study of urinary system was obtained by using conventional T2-weighted sequences and echo planar imaging (EPI); Diffusion-weighted images and ADC maps were evaluated. The renal tissue ADC value was measured for all normal and abnormal fetuses and related to GA.

RESULTS

MRI confirmed urinary anomalies in 15 fetuses [2 renal developmental variants, 2 nephropathies, 4 multicystic dysplastic kidneys (MCDK), 7 renal tract dilatations] and detected normal kidneys in the remaining 35 fetuses. Normal renal parenchyma showed bright signal on diffusion-weighted images with ADC values ranging from 1,065 to 1,327 microm(2)/s with a tendency to decrease over GA. A pathological ADC was detected in cases of bilateral MCDK, huge dilatations and in cases of nephropathies.

CONCLUSION

Diffusion-weighted imaging (DWI) with ADC mapping can be used in the evaluation of fetal renal parenchyma and may become a tool of assessing function of the fetal kidney by means of measurement of renal tissue ADC values.

Diagnostic utility of combined ultrasonography and mammography in the evaluation of women with mammographically dense breasts

PURPOSE

To assess the diagnostic utility and additional cost of combined breast ultrasonography and mammography in the evaluation of asymptomatic women with mammographically dense breasts.

MATERIALS AND METHODS

Of 5108 asymptomatic women, who underwent mammography, 1754 had dense breasts (BI-RADS 3 or 4) and negative mammographic outcome. They were divided in 4 subgroups according to their age (<40 yrs; 40-49 yrs; 50-59 yrs; >59 yrs). Breast ultrasonography was performed immediately after mammography. Lesions detected at ultrasonography were examined cytologically/histologically. Mammograms from women, who were diagnosed carcinoma at ultrasonography, were reviewed by an external radiologist. Costs per diagnosed carcinoma and per examined woman were calculated on the basis of current regional charges.

RESULTS

Mammographies (5108) were performed, 67 cancers were detected (cancer detection rate 13.1‰): mammography identified 55 carcinomas and ultrasonography performed in women with dense breasts identified 12 cancers (17.9% of all cancers detected, overall cancer detection rate 6.8‰). Ultrasonography identified a benign condition in 1567 out of 1754 women (89.3%) (in 925 absence of focal lesions; 438 simple cysts; 56 ductal ectasia; 148 benign solid lesions); 97 complex cysts, 52 lesions that could not be differentiated as liquid or solid lesions, and 38 solid lesions suspicious for malignancy in the remaining 187 out of 1754 patients (10.7%). Cytology/histology confirmed carcinoma in 12 women (overall biopsy rate 26.2‰, benign biopsy rate 19.4‰). The additional costs were: € 6,123.45 per detected cancer, € 41.89 per examined woman.

CONCLUSION

Breast ultrasonography immediately after mammography in women with dense breasts is useful to avoid diagnostic delays and inconvenient medico-legal implications even though this procedure involves increased costs.

Adjunctive diagnostic value of ultrasonography evaluation in patients with suspected ductal breast disease

PURPOSE

The purpose of this study was to evaluate the adjunctive diagnostic value of breast ultrasonography (US) in the study of benign ductal breast disease.

MATERIALS AND METHODS

Fifty-two patients underwent US examinations for bloody nipple discharge, palpable retroareolar masses, retroareolar opacities or ductal pattern on mammography. US enabled visualisation of mammary-duct ectasia (simple or pseudocystic, retroareolar and/or peripheral) and focal masses (endoluminal or periductal, with ill-defined or regular margins). All patients with nipple discharge underwent cytological evaluation. After the US examination, all focal masses with ill-defined margins underwent fine-needle aspiration biopsy (FNAB), if necessary. The benign alterations were followed up.

RESULTS

In 38/52 cases, US diagnosed mammary-duct ectasia and in 30/52 cases, the presence of focal masses (mean size 7 mm). In the nine women who underwent biopsy, histopathological evaluation diagnosed five solitary papillomas, one solitary papilloma with a focal area of ductal carcinoma in situ (DCIS), two multiple papillomas of the nipple and one papillomatosis.

CONCLUSIONS

High-frequency US plays an important role in the detection of benign ductal disease both for the diagnosis and classification of focal masses and mammary-duct ectasia. US can be used as a complementary imaging method to galactography or as a valuable alternative when galactography is not available.

Evaluation of normal brain development by prenatal MR imaging

PURPOSE

The aim of this study was to describe the normal pattern of development and maturation of the foetal brain with respect to gestational age as assessed with magnetic resonance imaging (MRI) and to provide an overview of the possibilities of the technique.

MATERIALS AND METHODS

Foetal cerebral MRI was performed on 56 pregnant women between 19 and 37 weeks of gestation. Half-Fourier single-shot turbo spin-echo (HASTE), true fast imaging with steady precession (FISP), T1-weighted fast low angle shot (FLASH) two-dimensional (2D) and diffusion-weighted (DW) sequences with apparent diffusion coefficient (ADC) were obtained. Biometric parameters and developmental areas of the cerebral cortex were correlated to gestational age by using the Spearman rank correlation test.

RESULT

We found a negative correlation between the germinal matrix/biparietal diameter ratio and gestational age and a positive correlation between the germinal and cortical matrix when expressed as external intraocular diameter ratio (R=0.452, p=0.02). The cortical mantle was correlated with biometric parameters, such as the biparietal diameter and the frontooccipital diameter, and with gestational age. The interhemispheric fissure, the parietooccipital fissure and the sylvian fissure were detectable by the 22nd week. In the grey matter, the mean ADC values varied from 1.76 x 10(-3) mm(2)/s (at week 19) to 0.89 x 10(-3) mm(2)/s (at week 37), whereas in the white matter, the values varied from 2.03 x 10(-3) mm(2)/s (at week 19) to 1.25 x 10(-3) mm(2)/s (at week 37).

CONCLUSIONS

MRI provides a reliable valuation of brain maturation during pregnancy.

Sonohysterography: is the hysterosalpingographic vacuum cup a valid alternative device for cannulation of the cervical Os?

PURPOSE

To determine whether sonohysterography (SHG) should be performed with Plexiglas hysterosalpingographic vacuum cups instead of standard catheters.

MATERIALS AND METHODS

In a prospective setting, 226 women randomly classified into 2 groups underwent SHG. The method used for cervical cannulation was a two-way catheter in the first group (n = 108) and a Plexiglas hysterosalpingographic vacuum cup in the second one (n = 118). Diagnostic reliability, easy applicability for the physician, discomfort for the patients and cost of the instruments were assessed for both devices.

RESULTS

226/226 (100 %) complete sonohysterographic examinations were performed. As regards uterine cavity distension the same diagnostic reliability was reported for vacuum cups and two-way catheters. The standard catheter obscured the cervical canal because of the dilation of the balloon. Both methods were judged as easy to use, and no statistically significant difference was found as far as the time required for cervical cannulation (p > 0.05). A little more discomfort was recorded by women who underwent sonohysterography with standard balloon catheters but a greater interpersonal variability was noticed in this group (SD 3.65 vs. 1.13 in the vacuum cup group). Vacuum cups were by far the most economical devices (unit cost: 16.70 euro vs. catheter unit cost 46.20 euro).

CONCLUSION

Vacuum cups allow sonohysterography to be correctly performed. As they are inexpensive, easy to use, better tolerated by the patients and more helpful for visualisation of the lower third of the uterine cavity, vacuum cups should be considered a serious alternative to standard catheters in the performance of SHG.

Novel splicing and missense mutations in autosomal dominant polycystic kidney disease 1 (PKD1) gene: expression of mutated genes

Autosomal dominant polycystic kidney disease (ADPKD) is a common disorder mostly characterized by cyst formation in kidney tubules. The majority of ADPKD cases is caused by mutations in the PKD1 gene, but no prevalent mutation has been reported. By heteroduplex analysis of the 3' single-copy region of the gene, we have searched for mutations in subjects from 40 ADPKD families of Northern Italy. Seven novel polymorphisms and three novel disease-associated mutations (R3718Q, L3851P and IVS45+56del25) were identified. Both missense mutations are located in the major extracellular loop of polycystin-1. The 25 bp deletion inside intron 45 did not affect 5' and 3' consensus splicing sites, but caused a 56 nucleotide out of frame-deletion due to activation of a cryptic 3' splice site in exon 46. The mutated RNA should produce a truncated polycystin 1 at the G binding peptide in the intracellular C-terminal end of the protein. RT-PCR analysis showed that the disease-associated mutations were present in transcribed sequences. In particular, RNA analysis of BHK cells transfected with PKD1 genomic DNA, including the deleted intron, showed that no normal transcript is produced by the deleted gene. This intronic mutation, found in a large pedigree, seems to be associated with a prevalence of cerebrovascular disease.

[Long-term clinical assessment of single-lead VDD electric stimulation]

BACKGROUND

During the last decade single lead VDD pacing has been progressively affirmed as an electrotherapy of choice in patients with advanced atrioventricular block without alterations of the sinus function. It combines the benefits of P-synchronous ventricular pacing with an easy implant procedure when compared to the conventional DDD approach. The aim of this study was to evaluate the validity of such an approach in a large population of patients, all implanted in a single center.

METHODS

From 1987 up to now, 317 patients, all affected by advanced atrioventricular block and without sinus node dysfunction, were implanted in our center with a single lead VDD pacemaker. During follow-up the persistence of a proper atrioventricular synchronization was assessed and evaluated.

RESULTS

The mean follow-up was 3.9 +/- 2.7 years/patient (range 6-138 months). The 94.6% of implanted systems maintained the normal VDD pacing function. Permanent reprogramming in VVI mode was necessary in 17 patients (5.36%); in 12 (3.78%) because of chronic atrial fibrillation and in 5 (1.63%) for loss of atrial sensing. The percentage of atrial synchronization was optimal (> 98%) and acceptable (> 95%) in 81% and 19% of patients, respectively. Episodes of paroxysmal atrial fibrillation occurred in 3 patients. Neither inhibition by myopotentials nor occurrence of sinus node disease was observed during follow-up. These results are in accordance with those reported by previous studies, performed on a smaller population or on a multicenter basis, and are comparable with the results reported for conventional DDD pacemaker.

CONCLUSIONS

Our results confirm the high reliability of the single lead VDD pacing system concerning the long-term persistence of a proper atrioventricular synchronization. Data showed above enforce our opinion that this pacing approach should be considered the treatment of choice in patients with advanced atrioventricular block and preserved sinus node function.

Bifascicular block complicating blunt cardiac injury. A case report and review of the literature

A thirty-five-year-old horse trainer presented to the emergency room of the authors' hospital with minimal nonpenetrating chest injury after having been kicked by a horse. No rib or sternum fractures were demonstrated. The admission ECG demonstrated a right bundle branch block and a left anterior hemiblock that were previously absent. The authors are aware of only two similar reports, but analogous conduction disturbances might have been classified as intraventricular conduction defects. The rarity of these defects may be explained by the anatomic pathways of the bundle of His and its bifurcations.

Average life expectancy of heterozygous beta thalassemic subjects

In order to define the lifespan of heterozygous beta thalassemic subjects as compared to non thalassemic subjects, the authors prospectively studied all patients deceased during a period of 76 months at St. Camillo Hospital of Comacchio (Ferrara), located in the Po delta, a region with high prevalence of thalassemia minor. No statistically significant differences were found in the average life expectancy between the thalassemic and non thalassemic groups.