Mean Lesion Size Research Articles

Localized Endometrial Proliferations of Pregnancy are Clonal Glandular Outgrowths Characterized by PTEN Loss and PIK3CA Pathogenic Variants

Gestational endometrium can demonstrate a spectrum of atypical but benign changes. One such lesion is localized endometrial proliferation of pregnancy (LEPP), first described in a series of 11 cases. To understand its biological and clinical importance, we explore the pathologic, immunophenotypic, and molecular features of this entity. Nine cases of LEPP identified in 15 years were retrieved from departmental archives and reviewed. Immunohistochemistry and next-generation sequencing using a comprehensive 446-gene panel were performed when the material was available. Eight cases were identified in curettage specimens performed after first-trimester pregnancy loss, and 1 in the basal plate of a mature placenta. The mean patient age was 35 (range 27–41) years. The mean lesion size was 6.3 (range 2–12) mm. Architectural patterns, often coexisting in the same case, included cribriform (n = 7), solid (n = 5), villoglandular (n = 2), papillary (n = 2), and micropapillary (n = 1). Cytologic atypia was mild in 7 cases and moderate in 2. Mitotic activity was low (up to 3 per 2.4 mm2). All lesions were associated with neutrophils. Background Arias–Stella phenomenon was present in 4 cases. Immunohistochemistry was performed in 7 LEPP, all of which demonstrated wildtype p53, retained MSH6 and PMS2, membranous beta-catenin, and positive estrogen receptor (mean 71%) and progesterone receptor (mean 74%). All were negative for p40 except 1 case (focal weak positivity). PTEN was markedly reduced in background secretory glands in all cases; in 5/7, LEPP foci showed a complete absence of PTEN expression. PIK3CA pathogenic variants were identified in 4/4 cases sequenced; 3/4 had inactivating PTEN mutations. Follow-up, available in 8 patients (mean length = 51 months, range 7–161), was conservative with observation only and showed no persistence or adverse outcomes. LEPP is characterized by intraglandular cribriform/solid architecture, positive estrogen receptor/progesterone receptor, PTEN loss, and PIK3CA and PTEN mutations. Although our findings indicate that LEPP is neoplastic, for now, we advise against diagnosing LEPP as endometrial carcinoma or hyperplasia because LEPP has a particular clinicopathologic context (concurrent gestation), distinct morphology (purely intraepithelial complex growth), and indolent outcome. Thus, it should be distinguished from endometrial intraepithelial neoplasia and carcinoma for which therapeutic interventions are indicated.

V10-11 TIPS AND TRICKS FOR TESTIS SPARING SURGICAL TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V10-11 TIPS AND TRICKS FOR TESTIS SPARING SURGICAL TECHNIQUE Silvia Altomare, Gabriele Tulone, Cristina Minasola, Arjan Bishqemi, Antonio La Rocca, Rosa Giaimo, Nicola Pavan, and Alchiede Simonato Silvia AltomareSilvia Altomare More articles by this author , Gabriele TuloneGabriele Tulone More articles by this author , Cristina MinasolaCristina Minasola More articles by this author , Arjan BishqemiArjan Bishqemi More articles by this author , Antonio La RoccaAntonio La Rocca More articles by this author , Rosa GiaimoRosa Giaimo More articles by this author , Nicola PavanNicola Pavan More articles by this author , and Alchiede SimonatoAlchiede Simonato More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Testis sparing surgery is now a well known surgical technique for small testicular masses. The candidate are patients with normal pre operative testosterone (if fertility preservation is required), small masses (under 2 cm, or not more then 1/3 of the testicular volume), normal value of serum markers for testicular cancer (bHCG, aFP, LDH), testicular masses in monorchid patients and in case of bilateral tumors. METHODS: We conducted a retrospective study including the period from February 2021 to August 2022. Our cohort of patients is composed by 4 patients with small testicular masses who underwent testis sparing surgery. The mean age was 36 years (27-57). BMI was >25 in 50% of patients. One patient reported cryptorchidism history. One patient referred anabolic steroids abuse in the past. None of them had previous history of testicular cancer. A testicular lamp was palpable in 2 patients. The mean lesion size was 0,7 cm (0,5-1,1). 2 patients presented with testicular pain, while two others patient had incidental diagnosis during routinary assessment for infertility and hypogonadotropic hypogonadism. For each patient US scan, tumor markers serum level, were performed. Tumor markers were within the normal limits in 100% of patients. RESULTS: The frozen sections assessment detected correctly benign tumors in 3 out of 4 patients: Adenomatoid tumor 2 (50%), Leydig cell tumor 1 (25%). A single malignant case was correctly identified as seminomatous proliferation in 1 patient; subsequently orchiectomy was performed, histologic examination confirmed Seminoma tumor plus Granulosa Cell Neoplasia In Situ (GCNIS). No one of the four patients developed post-op complications. Each patient is still in a follow-up program that includes periodic imaging surveys and clinical examinations. CONCLUSIONS: Testis sparing surgery is safe and effective in selected patients for small, benign masses and in the setting of bilateral disease or tumor in a solitary testis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e929 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Silvia Altomare More articles by this author Gabriele Tulone More articles by this author Cristina Minasola More articles by this author Arjan Bishqemi More articles by this author Antonio La Rocca More articles by this author Rosa Giaimo More articles by this author Nicola Pavan More articles by this author Alchiede Simonato More articles by this author Expand All Advertisement PDF downloadLoading ...

Bronchoscopic Evaluation of a Steerable Needle for Simulated Tumor Targets in the Lung Periphery: A Feasibility Study (Bullseye)

Background: Peripheral bronchoscopy is often performed to biopsy peripheral pulmonary lesions. Despite technological advancements to improve reach and access to the lung periphery, the diagnostic yield of peripheral bronchoscopy has been inconsistent, and challenging, particularly for lesions that are adjacent to peripheral bronchi. Current biopsy instruments are reliant on the catheter or scope to align properly with targeted lesions. Objectives: This study evaluates the feasibility of using a steerable biopsy needle to gain access to peripheral tumor targets in a cadaveric model. Methods: Simulated tumor targets 10–30 mm in axial diameter were placed into human cadavers. Bronchoscopy was performed using a 4.2 mm OD flexible bronchoscope, CT-anatomic correlation, and multi-planar fluoroscopy for lesion localization. Once at the targeted location, a steerable needle was deployed and the needle position was determined to be in the central zone, peripheral zone, or outside of the lesion by cone beam CT imaging. If the needle position was within the lesion, a fiducial marker was deployed to mark the needle position, and the needle was articulated and/or rotated in an attempt to place another fiducial marker into a different location within the same lesion. If the needle was outside of the lesion, the bronchoscopist was provided with two additional attempts to gain access to the lesion. Results: Fifteen tumor targets were placed with a mean lesion size of 20.4 mm. The majority of lesions were located in the upper lobes. One fiducial marker was placed in 93.3% of lesions and a second fiducial marker was successfully placed in 80% of lesions. A fiducial marker was placed within the central zone in 60% of lesions. Conclusion: The steerable needle was successfully placed within 93% of targeted lesions 10–30 mm in diameter in a cadaveric model, with the ability steer the instrument into another portion of the lesion in 80% of cases. The ability to steer and control needle positioning toward and within peripheral lesions may complement existing catheter and scope technology during peripheral diagnostic procedures.

Diagnostic Performance of Prototype Handheld Ultrasound According to the Fifth Edition of BI-RADS for Breast Ultrasound Compared with Automated Breast Ultrasound among Females with Positive Lumps

(1) Objective: To evaluate the diagnostic performance of prototype handheld ultrasound compared to automated breast ultrasound, according to the fifth edition of BI-RADS categorization, among females with positive lumps. (2) Methods: A total of 1004 lesions in 162 participants who underwent both prototype handheld ultrasound and automated breast ultrasound were included. Two radiologists and a sonographer independently evaluated the sonographic features of each lesion according to the fifth BI-RADS edition. The kappa coefficient (κ) was calculated for each BI-RADS descriptor and final assessment category. The cross-tabulation was performed to see whether there were differences between the ABUS and prototype HHUS results. Specificity and sensitivity were evaluated and compared using the McNamar test. (3) Results: ABUS and prototype HHUS observers found the same number of breast lesions in the 324 breasts of the 162 respondents. There was no significant difference in the mean lesion size, with a maximum mean length dimension of 0.48 ± 0.33 cm. The assessment of the lesion's shape, orientation, margin, echo pattern, posterior acoustic features, and calcification was obtained with good to excellent agreements between ABUS and prototype HHUS observers (κ = 0.70-1.0). There was absolutely no significant difference between ABUS and prototype HHUS in assessment of lesion except for lesion orientation p = 0.00. Diagnostic accuracy (99.8% and 97.7-98.9%), sensitivity (99.5% and 98.0-99.0%), specificity (99.8% and 99.6-99.8%), positive predictive value (98.1% and 90.3-96.2%), negative predictive value (90.0% and 84.4-88.7%), and areas under the curve (0.98 and 0.83-0.92; p < 0.05) were not significantly different between ABUS and prototype HHUS observers. (4) Conclusion: According to the fifth BI-RADS edition, automated breast ultrasound is not statistically significantly different from prototype handheld ultrasound with regard to interobserver variability and diagnostic performance.

Surgical Excision for Refractory Ischiogluteal Bursitis: A Consecutive Case Series of 21 Patients.

A response to conservative treatment is usually obtained in cases of ischiogluteal bursitis. However, the time required to achieve relief of symptoms can vary from days to weeks, and there is a high recurrence rate, thus invasive treatment in addition to conservative treatment can occasionally be effective. Therefore, the aim of this study was to examine surgical excision in cases of refractory ischiogluteal bursitis and to evaluate patients' progression and outcome. A review of 21 patients who underwent surgical excision for treatment of ischiogluteal bursitis between February 2009 and July 2020 was conducted. Of these patients, seven patients were male, and 14 patients were female. Injection of steroid and local anesthetic into the ischial bursa was administered at outpatient clinics in all patients, who and they were refractory to conservative treatment, including aspiration and prescription drugs. Therefore, surgery was considered necessary. Excisions were performed by two orthopedic specialists using a direct vertical incision on the ischial area. A review of each patient was performed after excision, and quantification of the outcomes recorded using clinical scoring systems was performed. The results of radiologic evaluation showed that the mean lesion size was 6.2 cm×4.5 cm×3.6 cm. The average disease course after excision was 21.6 days (range, 15-48 days). Measurement of clinical scores, including the visual analog scale and Harris hip scores, was performed during periodic visits, with scores of 0.7 (range, 0-2) and 98.1 (range, 96-100) at one postoperative month, respectively. Surgical excision, with an expectation of favorable results, could be considered for treatment of ischiogluteal bursitis that is refractory to therapeutic injections, aspirations, and medical prescriptions, particularly in moderate-to-severe cases.

Cartilage Repair of the Tibiofemoral Joint With Versus Without Concomitant Osteotomy: A Systematic Review of Clinical Outcomes.

The extent to which concomitant osteotomy provides an improvement in clinical outcomes after cartilage repair procedures is unclear. To review the existing literature to compare clinical outcomes of patients undergoing cartilage repair of the tibiofemoral joint with versus without concomitant osteotomy. Systematic review; Level of evidence, 4. A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies that directly compared outcomes between cartilage repair of the tibiofemoral joint alone (group A) versus cartilage repair with concomitant osteotomy (high tibial osteotomy [HTO] or distal femoral osteotomy [DFO]) (group B). Studies on cartilage repair of the patellofemoral joint were excluded. The search terms used were as follows: osteotomy AND knee AND ("autologous chondrocyte" OR "osteochondral autograft" OR "osteochondral allograft" OR microfracture). Outcomes in groups A and B were compared based on reoperation rate, complication rate, procedure payments, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale [VAS] for pain, satisfaction, and WOMAC). Included in the review were 5 studies (1 level 2 study, 2 level 3 studies, 2 level 4 studies) with 1747 patients in group A and 520 patients in group B. The mean patient ages were 34.7 and 37.5 years in groups A and B, respectively, and the mean lesion sizes were 4.0 and 4.5 cm2, respectively. The mean follow-up time was 44.6 months. The most common lesion location was the medial femoral condyle (n = 999). Preoperative alignment averaged 1.8° and 5.5° of varus in groups A and B, respectively. One study found significant differences between groups in KOOS, VAS, and satisfaction, favoring group B. The reoperation rates were 47.4% and 17.3% in groups A and B, respectively (P < .0001). Patients undergoing cartilage repair of the tibiofemoral joint with concomitant osteotomy might be expected to experience greater improvement in clinical outcomes with a lower reoperation rate compared with those undergoing cartilage repair alone. Surgeons preparing for cartilage procedures of the knee joint should pay particular attention to preoperative malalignment of the lower extremity to optimize outcomes.

A decade's experience of managing suspected pancreatic adenocarcinoma at a tertiary cancer center.

We present our experience and established management strategy for endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) in diagnosing suspected pancreatic neoplasms at a tertiary referral cancer hospital. Relevant data were extracted from our database for patients who underwent EUS-FNA for suspected pancreatic neoplasms at our institution between 2007 and 2016. Among the 309 patients, the median age was 67 years and 56% were men. The most common presenting symptoms were abdominal pain (37%) and jaundice (29%). Concordance between radiographic diagnosis and final pathology was 89%. The mean lesion size was 34.9 mm on computed tomography and 31.5 mm on EUS. There were 197 patients (64%) with localized disease, of whom 115 (58%) had resectable lesions, 61 (31%) had borderline resectable, and 21 (11%) had unresectable lesions (mean CA 19-9 levels 1705 U/mL, 2490 U/mL, and 479 U/mL, respectively). A median of 3 FNA passes were performed to establish a pathologic diagnosis. Two patients (1%) had postprocedural adverse events. Median overall survival was 47 months in those who underwent surgery after EUS and 12 months in those who did not (P<0.001). A multidisciplinary approach is employed for management of suspected pancreatic neoplasm at our tertiary cancer center. A combination of cross-sectional imaging and EUS-FNA serves as a highly effective duo in establishing a tissue diagnosis and staging with a low adverse event rate. Counterintuitively, CA 19-9 is not necessarily higher with resectable lesions than with unresectable lesions, indicating the limitation of CA 19-9 as a pancreatic tumor marker.

Carcinoembryonic Antigen–Related Cell Adhesion Molecule Type 5 Receptor–Targeted Fluorescent Intraoperative Molecular Imaging Tracer for Lung Cancer

Localization of subcentimeter ground glass opacities during minimally invasive thoracoscopic lung cancer resections is a significant challenge in thoracic oncology. Intraoperative molecular imaging has emerged as a potential solution, but the availability of suitable fluorescence agents is a limiting factor. To evaluate the suitability of SGM-101, a carcinoembryonic antigen-related cell adhesion molecule type 5 (CEACAM5) receptor-targeted near-infrared fluorochrome, for molecular imaging-guided lung cancer resections, because glycoprotein is expressed in more than 80% of adenocarcinomas. For this nonrandomized, proof-of-principal, phase 1 controlled trial, patients were divided into 2 groups between August 1, 2020, and January 31, 2022. Patients with known CEACAM5-positive gastrointestinal tumors suggestive of lung metastasis were selected as proof-of-principle positive controls. The investigative group included patients with lung nodules suggestive of primary lung malignant neoplasms. Patients 18 years or older without significant comorbidities that precluded surgical exploration with suspicious pulmonary nodules requiring surgical biopsy were included in the study. SGM-101 (10 mg) was infused up to 5 days before index operation, and pulmonary nodules were imaged using a near-infrared camera system with a dedicated thoracoscope. SGM-101 localization to pulmonary nodules and its correlation with CEACAM5 glycoprotein expression by the tumor as quantified by tumor and normal pulmonary parenchymal fluorescence. Ten patients (5 per group; 5 male and 5 female; median [IQR] age, 66 [58-69] years) with 14 total lesions (median [range] lesion size, 0.91 [0.90-2.00] cm) were enrolled in the study. In the control group of 4 patients (1 patient did not undergo surgical resection because of abnormal preoperative cardiac clearance findings that were not deemed related to SGM-101 infusion), the mean (SD) lesion size was 1.33 (0.48) cm, 2 patients had elevated serum CEA markers, and 2 patients had normal serum CEA levels. Of the 4 patients who underwent surgical intervention, those with 2+ and 3+ tissue CEACAM5 expression had excellent tumor fluorescence, with a mean (SD) tumor to background ratio of 3.11 (0.45). In the patient cohort, the mean (SD) lesion size was 0.68 (0.22) cm, and no elevations in serum CEA levels were found. Lack of SGM-101 fluorescence was associated with benign lesions and with lack of CEACAM5 staining. This in-human proof-of-principle nonrandomized controlled trial demonstrated SGM-101 localization to CEACAM5-positive tumors with the detection of real-time near-infrared fluorescence in situ, ex vivo, and by immunofluorescence microscopy. These findings suggest that SGM-101 is a safe, receptor-specific, and feasible intraoperative molecular imaging fluorochrome that should be further evaluated in randomized clinical trials. ClinicalTrials.gov identifier: NCT04315467.

Submucosal Necrotic Nodule of the Colon: An Enigmatic Entity Potentially Related to Anisakis Infection.

Discrete submucosal necrotic nodules may rarely manifest as colon polyps. To characterize the clinical and pathologic features of this lesion, which has been under-studied in the literature. We conducted an international search to compile a series. For each potential case, photomicrographs were centrally reviewed to confirm the diagnosis. We gathered clinical and pathologic information on each confirmed case. The final cohort included 25 patients, with 23 having 1 lesion and 2 having several (31 lesions total). Mean patient age was 62 years; 13 patients (52%) were male. Symptoms were nonspecific, although 4 patients (16%) had blood in stool; 14 patients were asymptomatic. Patient history and medications appeared noncontributory. Most cases were located in the right colon (n = 18; 58%). Mean lesion size was 0.4 cm (range, 0.1-1.7 cm). Histology typically showed a centrally necrotic nodule with peripheral fibrosis, chronic inflammation, and sometimes palisading granulomatous inflammation. Percent necrosis ranged from 5% to 95% (average, 70%), and percent fibrosis ranged from 3% to 70% (average, 25%). In 3 cases, degenerated parasitic structures consistent with Anisakis could be seen on hematoxylin-eosin and trichrome special stain. No patient experienced disease recurrence. Submucosal necrotic nodules can present as colon polyps. Most cases are unifocal, and patients do well on follow-up. At least some examples appear to be caused by Anisakis, implicating patient diet. Patients are often asymptomatic, and many cases show no histologic evidence of the causative agent.

Comparison of Endoscopic Ultrasound-Guided Fine-Needle Aspiration with Fine-Needle Biopsy for Solid Gastrointestinal Lesions: A Randomized Crossover Single-Center study

Abstract Background/Aims The purpose of this study was to compare the results of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) and fine-needle biopsy (FNB) performed at the same site in a single session in the same patient. Methods Consecutive patients with solid gastrointestinal lesions referred for EUS evaluation underwent EUS-FNA and FNB using 22G needles with three and two passes, respectively, in the same session. Patients were randomized to one group having EUS-FNA first followed by EUS-FNB, while other group had EUS-FNB first followed by EUS-FNA. Results Total 50 patients (31 male) of mean age 56.58 ± 14.2 years and mean lesion size of 2.6 (±2) cm were included. The Kappa agreement for final diagnosis for FNA and FNB was 0.841 and 0.61, respectively. The sensitivity and specificity of FNA versus FNB were 85.19 versus 62.96% and 100 versus 100%, respectively, in comparison with final diagnosis. Conclusion Both EUS-FNA and FNB are equally safe when compared between the two techniques simultaneously in same lesion. EUS-FNA is better than FNB in terms of sensitivity, diagnostic accuracy, and tissue yield for solid GI lesion. However, the specificity and positive predictive value were equally good for both the modalities.

High-resolution diffusion-weighted imaging compared with conventional diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging with regard to image quality and assessment of breast cancer morphology

To evaluate the image quality and tumor morphology depiction ability of high resolution (HR) diffusion- weighted imaging (f-DWI) in comparison to conventional DWI (c-DWI) and dynamic contrast- enhanced magnetic resonance imaging (DCE-MRI) in the primary breast cancer setting. The f-DWI, c-DWI, and DCE-MRIs of 160 malignant breast masses were evaluated retrospectively by two independent radiologists. Data on image quality [sharpness, distortion, and perceived signalto- noise ratio (SNR)], apparent diffusion coefficient (ADC) value, lesion size, and tumor morphology (shape, margin, and internal pattern) obtained on f-DWI, c-DWI, and DCE-MRI were compared. Consistency between the readers and imaging methods for morphological parameters was analyzed. The ADC values measured on f-DWI were significantly lower than those measured on c-DWI for both readers (P < 0.001 for each), whereas mean lesion size was significantly larger in c-DWI than in f-DWI and DCE-MRI for both readers (P < 0.001 for each). Higher consistency values were obtained for f-DWI compared with c-DWI when correlated with DCE-MRI for each morphological parameter. The least distorted images were obtained using DCE-MRI compared with c-DWI and f-DWI for both readers, whereas the highest distortion scores were obtained using c-DWI. Sharpness and perceived SNR scores were rated as significantly higher for f-DWI and DCE-MRI images compared with c-DWI by both readers (P < 0.001 for all). The concordance between c-DWI and DCE-MRI was fair to slight (κ = 0.15 to 0.41), whereas concordance between f-DWI and DCE-MRI was significantly better (κ = 0.68 to 0.87) for each reader and for all morphological parameters (P < 0.001). The highest concordance between the readers was achieved in margin assessment (κ = 0.87 to 0.89) regardless of the MRI method, followed by shape and internal pattern parameters (κ = 0.63 to 0.79). The results demonstrated that f-DWI produces higher-quality images than c-DWI, enabling the morphological features to be identified in similar detail to that offered by HR DCE-MRI. Accordingly, f-DWI, as a method that highly correlates with DCE in determining the morphological characteristics of breast cancers, seems to have potential in the evaluation of breast tumors in patients for whom the use of contrast media is contraindicated.

Comparing the performance of three modalities of breast cancer screening within a combined programme targeting at-risk women in Indonesia: An implementation study

ABSTRACT Although mammography is the gold standard for breast cancer screening, the World Health Organization recommends clinical breast examination (CBE) as the preferred early detection method in countries with limited resources. However, its effectiveness as a ‘stand-alone’ screening modality compared with other techniques remains unclear. Therefore, we evaluated a risk-based opportunistic breast cancer screening programme using three modalities. Between June and December 2018, we conducted a cross-sectional study in Yogyakarta, Indonesia, of women aged >40 years with at least one risk factor for breast cancer. Subjects underwent CBE, mammography, and ultrasonography. We calculated the proportion of breast lesions detected through each modality and compared their mass size. A total of 503 eligible subjects were screened. Five cases of potential malignant lesions were detected; pathological tests conducted for 4 of them confirmed breast cancer diagnoses. A combined assessment of mammography and ultrasonography examinations revealed 343 breast lesions (68.2%), whereas CBE screening detected only 76 breast lesions (15.1%). The mean lesion sizes detected by mammography or ultrasonography, but not through CBE, were significantly smaller (p-values of 0.037 and 0.007 for mammography and ultrasonography, respectively). In conclusion, mammography and ultrasonography produced higher detection rates for benign and malignant breast lesions compared with CBE.

Outcome of nonfunctioning pancreatic neuroendocrine tumors after initial surveillance or surgical resection: a single-center observational study.

Current guidelines consider observation a reasonable strategy for G1 or G2 nonfunctional pancreatic neuroendocrine tumors (nf pNETs) ≤2 cm. We aimed to characterize their natural behavior and confront the data with the outcomes of patients undergoing upfront surgery. Data from patients with histologically confirmed nf pNETs ≤2 cm, managed at a single tertiary referral center between 2002 and 2020, were retrospectively reviewed. Thirty-nine patients (mean age 62.1 years, 56% male) with 43 lesions (mean size 12.7±3.9 mm; 32 grade 1 [G1] and 7 grade 2 lesions [G2]) were managed by careful surveillance. Progression was observed in 15 lesions (35%; mean follow up 47 months). Six patients (18%) underwent secondary surgery because of an increase in tumor size or dilation of the main pancreatic duct; 3 of them had lymph node metastasis in the resected specimen. Surgery was followed by pancreatic fistula in 2/6 patients, 1 of whom died. Fourteen patients (mean age 59 years, 64.3% female, mean size of lesions 11.4±3.1 mm) underwent pancreatic surgery immediately after diagnosis. The surgery-associated complication rate was 57.1% (8/14). Of the 14 patients, 13 remained recurrence free (mean follow up 67 months). Recurrent metastatic disease was observed 3 years after pancreaticoduodenectomy (R0, 15 mm G2 lesion, 0 N+/8 N) in 1 patient. The behavior of small nf pNETs is difficult to predict, as there is evidence for malignant behavior in a subgroup of patients, even after surgical treatment. Optimal management remains challenging, as pancreatic surgery is associated with significant morbidity.

Outcomes of Endoscopic Resection for Colorectal Polyps With High-Grade Dysplasia or Intramucosal Cancer

Background and AimsLittle is known about the outcomes of endoscopic resection (ER) for patients with colorectal adenomas (CRAs) with high-grade dysplasia (HGD) or intramucosal cancer (IMCA). This study aimed to estimate the rate of local/malignant recurrence, identify the predictive factors for local recurrence (LR), and evaluate the treatment outcomes of recurrence after ER for HGD/IMCA. MethodsA retrospective review was performed to identify patients who underwent ER for HGD/IMCA in 2 academic medical centers. Risk factors for LR were determined by Cox regression analysis. ResultsOverall, 188 lesions with HGD/IMCA were included; 61 lesions were removed by en-bloc ER (e-ER), whereas 127 lesions were removed in a piecemeal ER (p-ER). The mean lesion size was 20.3 mm. Of the 125 patients who underwent follow-up, local adenoma recurrence occurred in 31 (23%), and malignant recurrence occurred in 2 (1.6%) patients at a median follow-up of 16 months. HGD/IMCA ≥ 4 cm removed by p-ER have the greatest hazard ratio (HR = 21.5; 95% CI 2.5-180.5; P = 0.005) for LR, compared with the HGD/IMCA < 4 cm removed by e-ER. Surgery was performed in 3.2% of patients after a complete ER, all after p-ER. Of all patients who had LR, 22.6% (7/31 patients) had recurrent adenomas despite repeat ER attempts after a mean of 1.9 ± 0.79 procedures from the index ER. ConclusionOur study demonstrates a high rate of LR (23%) after ER of CRAs with HGD/IMCA with a rate of malignant recurrence of 1.6%, especially after p-ER. Thus, e-ER should be preferred for these lesions whenever technically feasible.

Performance of artificial intelligence in the characterization of colorectal lesions.

Image-enhanced endoscopy (IEE) has been used in the differentiation between neoplastic and non-neoplastic colorectal lesions through microvasculature analysis. This study aimed to evaluate the computer-aided diagnosis (CADx) mode of the CAD EYE system for the optical diagnosis of colorectal lesions and compare it with the performance of an expert, in addition to evaluating the computer-aided detection (CADe) mode in terms of polyp detection rate (PDR) and adenoma detection rate (ADR). A prospective study was conducted to evaluate the performance of CAD EYE using blue light imaging (BLI), dichotomizing lesions into hyperplastic and neoplastic, and of an expert based on the Japan Narrow-Band Imaging Expert Team (JNET) classification for the characterization of lesions. After white light imaging (WLI) diagnosis, magnification was used on all lesions, which were removed and examined histologically. Diagnostic criteria were evaluated, and PDR and ADR were calculated. A total of 110 lesions (80 (72.7%) dysplastic lesions and 30 (27.3%) nondysplastic lesions) were evaluated in 52 patients, with a mean lesion size of 4.3 mm. Artificial intelligence (AI) analysis showed 81.8% accuracy, 76.3% sensitivity, 96.7% specificity, 98.5% positive predictive value (PPV), and 60.4% negative predictive value (NPV). The kappa value was 0.61, and the area under the receiver operating characteristic curve (AUC) was 0.87. Expert analysis showed 93.6% accuracy, 92.5% sensitivity, 96.7% specificity, 98.7% PPV, and 82.9% NPV. The kappa value was 0.85, and the AUC was 0.95. Overall, PDR was 67.6% and ADR was 45.9%. The CADx mode showed good accuracy in characterizing colorectal lesions, but the expert assessment was superior in almost all diagnostic criteria. PDR and ADR were high.

The Utility of 68Ga-PSMA PET/CT in Decisions Regarding Administering Salvage Radiotherapy to Men with Prostate Cancer

Numerous papers have described 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT)'s sensitivity in identifying prostate cancer (PCa) recurrence. This study aimed to characterize the role of 68Ga-PSMA PET/CT in deciding to re-irradiate pelvic structures. 68Ga-PSMA PET/CT scans performed at Sheba Medical Center over seven years in 113 men were reviewed. All had undergone radiation to the prostate (70, 61.9%) or post-radical prostatectomy radiation to the prostate fossa (PF) (43, 48.1%), and had local or oligometastatic PCa recurrence and received salvage radiotherapy (SRT) based on PET/CT findings. Mean age was 70.7 years. The mean grade group was 2.9; the mean prostate-specific antigen was 9.0. The 68Ga-PSMA PET/CT positive findings included: 37 (32.7%) in the prostate, 23 (20.4%) in seminal vesicles, 7 (6.2%) in the PF, and 3 (2.7%) in the seminal vesicle fossa. The mean standardized uptake value was 10.6 ± 10.2 (range: 1.4-61.6); the mean lesion size was 1.8 ± 3.5 mm (range: 0.5-5.1). SRT was directed toward the prostate and seminal vesicles in 48 (42.5%), PF in 18 (15.9%), and intrapelvic lymph node and bone in 47 (41.6%). Toxicities were mostly mild to moderate. 68Ga-PSMA PET/CT-identified relapse with targeted SRT was well-tolerated and may result in less onerous treatments.

Benign tumors of the superficial lobe of the parotid gland.

The study retrospectively reviewed all parotidectomies for benign parotid tumors of the superficial lobe performed in the Department of ENT, Municipal Emergency Clinical Hospital, Timişoara, Romania, between January 2014 and December 2018. The following patient data were collected: age; sex; follow-up duration; extension of the resection; use of FN monitoring and lesion features, including position, pathology, and size. Preoperative investigation protocol included a computed tomography (CT) scan to assess the size and location of the tumor helping the treatment planning. The same surgical team performed both standard SP and ECD for the treatment of these tumors. All cases were confirmed as benign parotid tumors. Recurrences of any kind and tumors involving the deep lobe of the gland were excluded from the study. All patients underwent a macroscopically complete resection of the tumor. The main outcome was the postoperative complications in the two groups. Data regarding these complications were recorded on follow-up visits at one, six, 12 and 24 months. Ninety-five patients with benign parotid tumors were operated by the same surgical team at the Department of ENT, Municipal Emergency Clinical Hospital, Timişoara, between January 2014 and December 2018 but only 89 (38 men and 51 women) met the follow-up criteria and were included in the study. Sixteen (18%) patients underwent ECD, and 73 (82%) patients underwent SP as a primary intervention. The mean lesion size for ECD group was 2.0±0.9 cm and 4.2±1.7 cm in the SP group, and it was statistically significant (p<0.05). As expected, the most common type of tumor was PA but the distribution between the groups was different: in the SP group, PA represents 83% (61∕73) of cases but only 44% (7∕16) of cases in the ECD group. Median follow-up time was comparable in the two groups - 33±8 months for the ECD group and 39±11 months for the SP group. There were also differences between the two groups regarding the postoperative complication rate. There were significantly more transient and permanent FN paralysis, transient and permanent great auricular nerve (GAN) dysfunctions and Frey's syndrome (FS) in the SP group. A comparison between ECD and SP as surgical procedures for the treatment of benign tumors of the parotid seems inappropriate as their indications do not overlap. ECD showed similar effectiveness and fewer side effects than SP and can be considered the treatment of choice for small, superficial and/or marginal tumors located in the lateral lobe of the parotid gland.

Evaluation of a Novel Multi-Epitope Peptide Vaccine Candidate from LACK, LeIF, GP63, SMT Antigens of Leishmania major in BALB/c Mice.

Leishmaniasis is one of the major health problems in most countries of the world. Millions of people around the world are at risk for the disease. Given the prevalence of this parasite in Iran and developing countries and the emergence of resistance in some cases to existing drugs, developing an effective vaccine against leishmaniasis is necessary. This research aims to design a multi-epitope vaccine derived from LACK, LeIF, GP63, and SMT antigens of Leishmania major based on the combination of bioinformatics methods. The synthesized construct with 16.86 KDa was cloned and sub-cloned in pEGFP- N1 and pLEXSY-neo2, respectively. They were then transfected in promastigotes of L. tarentolae. After confirmation of expression, immunization was carried out in 8 groups of BALB/c mice (9 mice per group) three times at two-week intervals. Cellular immune responses were assessed before and after the challenge by L. major. Furthermore, at 3rd week post-infection, the survival rate, mean lesion size, and parasite burden were assessed. All vaccinated mice demonstrated partial immunity to higher IFN-γ levels than the control groups (P<0.05). Immunized mice with cytosolic complex (G1) indicated the highest levels of IFN-ɤ and ratio of IFN ɤ/ IL-4, the lowest levels of IL-4 and IL-10 compared to control and the other groups (P≤0.05), and produced a partial Th1 immune response. Mean lesion size and parasite burden of G1 and G5 reduced significantly compared to the other and control groups post-challenge (P<0.05). The outputs of our result could be a hopeful sign in the achievement of practical approaches as multi-epitope vaccines against Leishmania major.

Intraoperative Appearance of Endosalpingiosis: A Single-Center Experience of Laparoscopic Findings and Systematic Review of Literature.

Background: Endosalpingiosis is assumed to be the second most common benign peritoneal pathology after endometriosis in women. Although recent studies indicate a significant association with gynecologic malignancies, many underlying principles remain unclear. This work aimed to systematically describe the intraoperative appearance of endosalpingiosis. Methods: Data and intraoperative videos of patients with histologically verified endosalpingiosis were retrospectively reviewed. The main outcome measures were macroscopic phenotype and anatomical distribution. Additionally, a systematic review searching PubMed (Medline) and Embase was conducted. Results: In the study population (n = 77, mean age 40.2 years (SD 16.4)), the mean size of lesions was 3.6 mm and the main visual pattern was vesicular (62%). The most frequent localization was the sacrouterine ligaments (24.7%). In the systematic review population (n = 1174 (210 included studies overall), mean age 45.7 years (SD 14.4)), there were 99 patients in 90 different studies with adequate data to assess the appearance of the lesions. The mean size of the lesions was 48.5 mm, mainly with a cystic visual pattern (49.5%). The majority of the lesions affected the ovaries (23.2%), fallopian tubes (20.4%), or lymph nodes (18.5%). Comparing this study to the literature population, the main differences concerned the size (p < 0.001) and main visual patterns (p < 0.001) of lesions. Conclusions: The usual intraoperative findings of endosalpingiosis appeared less impressive than described in the literature. In our study population, lesions of a few millimeters in size with a vesicular appearance were mostly seen, most frequently in the sacrouterine ligament area. Intraoperative recognition by the gynecologic surgeon and histologic diagnosis should play an important role in further understanding this entity, scientifically and clinically.

Closure of Mucosal Defects Using Endoscopic Suturing Following Endoscopic Submucosal Dissection: A Single-Center Experience

Background and AimsEndoscopic submucosal dissection (ESD) is a therapeutic technique for en-bloc resection of both large (>20 mm) and smaller, complex gastrointestinal neoplasms. ESD has a higher success rate of en-bloc resection and a lower rate of local recurrence compared with endoscopic mucosal resection. Removal of lesions via ESD can leave large mucosal defects, raising unique challenges leading to adverse events. We aimed to determine clinical outcomes, including delayed bleeding, perforation, and hospitalization, in patients undergoing endoscopic suturing after ESD. MethodsThis was a single-center retrospective study of a prospectively collected database of consecutive adult patients who underwent ESD with mucosal defect closure using endoscopic suturing. Primary outcomes were adverse events, specifically delayed bleeding or perforation. Secondary outcomes included need for hospitalization and suturing complications. ResultsFifty-five patients (mean age: 67 years) were included, with a mean lesion size of 27.4 ± 15 mm. Defect closure occurred in the esophagus (6), gastroesophageal junction (2), stomach (30), cecum (2), sigmoid colon (2), and rectum (13). A mean of 1.8 ± 1.0 sutures were required for defect closure. The hospital admission rates was 14% (8/55), with an average length of stay 2 days (range 1-3 days). Intraprocedural perforation occurred in 2 patients, and both were successfully treated with endoscopic suturing. There was one case of delayed bleeding and no cases of delayed perforation or suturing complications. ConclusionThe use of endoscopic suturing following ESD is a safe and clinically reliable method to close mucosal defects. This approach is associated with minimal adverse events and need for hospitalization. Larger studies are needed to further validate these findings.