Prognostic value of specific KRAS mutations in patients with colorectal peritoneal metastases

BACKGROUND

There is little evidence on KRAS mutational profiles in colorectal cancer (CRC) peritoneal metastases (PM). This study aims to determine the prevalence of specific KRAS mutations and their prognostic value in a homogeneous cohort of patients with isolated CRC PM treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

MATERIALS AND METHODS

Data were collected from 13 Italian centers, gathered in a collaborative group of the Italian Society of Surgical Oncology. KRAS mutation subtypes have been correlated with clinical and pathological characteristics and survival [overall survival (OS), local (peritoneal) disease-free survival (LDFS) and disease-free survival (DFS)].

RESULTS

KRAS mutations occurred in 172 patients (47.5%) out of the 362 analyzed. Two different prognostic groups of KRAS mutation subtypes were identified: KRASMUT1 (G12R, G13A, G13C, G13V, Q61H, K117N, A146V), median OS > 120 months and KRASMUT2 (G12A, G12C, G12D, G12S, G12V, G13D, A59E, A59V, A146T), OS: 31.2 months. KRASMUT2 mutations mainly occurred in the P-loop region (P < 0.001) with decreased guanosine triphosphate (GTP) hydrolysis activity (P < 0.001) and were more frequently related to size (P < 0.001) and polarity change (P < 0.001) of the substituted amino acid (AA). When KRASMUT1 and KRASMUT2 were combined with other known prognostic factors (peritoneal cancer index, completeness of cytoreduction score, grading, signet ring cell, N status) in multivariate analysis, KRASMUT1 showed a similar survival rate to KRASWT patients, whereas KRASMUT2 was independently associated with poorer prognosis (hazard ratios: OS 2.1, P < 0.001; DFS 1.9, P < 0.001; LDFS 2.5, P < 0.0001).

CONCLUSIONS

In patients with CRC PM, different KRAS mutation subgroups can be determined according to specific codon substitution, with some mutations (KRASMUT1) that could have a similar prognosis to wild-type patients. These findings should be further investigated in larger series.

In Vivo Confocal Microscopy Characterization of Candida parapsilosis Keratitis

ABSTRACT

The present clinical case concerns two patients with mycotic keratitis because of Candida parapsilosis in which corneal confocal microscopy presented a characteristic feature of this pathogen. Both described patients used a therapeutic contact lens and administered a therapy with steroid eye drops which are well known predisposing factors for the onset of corneal mycoses. This report can be useful for correctly identifying the pathologic condition and quickly directing the therapy.

The effect of transport on some metabolic parameters and meat quality in pigs

Two groups of 40 castrated male pigs were selected at random in an abattoir from pigs arriving from two farms, situated 650 km (group A) and 180 km (group B) from the plant, respectively. The animals were kept in lairage overnight and slaughtered the following morning. At slaughter, samples of blood were collected to determine serum levels of some enzymes [lactic dehydrogenase (LDH), glutamic oxaloacetic transaminase (GOT) and glutamic phosphatase transaminase (GPT)]. Measurements of pH were then taken on the Longissimus thoracis at the level of the last rib 45 min, 3 h and 24 h post mortem. After overnight chilling of the sides at +2°C, a portion of the Longissimus thoracis was removed for colour and drip measurements. Results show that distance travelled affects pH values at 45 min and 24 h, group A presenting higher values than group B (P < 0·001). Drip loss did not differ significantly between the two groups, while group A showed lower values of L (∗) and higher a (∗) values than group B (P < 0·05 and P < 0·01, respectively), with no differences in the mean values of b (∗). In group A, a higher value of LDH was observed (P < 0·001) than in group B. GOT and GPT showed no significant difference between the two groups. It is concluded that, although some significant effects of treatment were recorded on some quality traits, the magnitude of the differences are not considered of much practical significance.

Secondary cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent epithelial ovarian cancer: a multi-institutional study

OBJECTIVE

To assess the efficacy and morbidity and mortality of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in recurrent epithelial ovarian cancer (EOC).

DESIGN

A retrospective study conducted using information extracted from a multi-institutional prospective database on peritoneal surface malignancies (PSMs). Setting Four Italian centres specializing in locoregional treatment of PSM.

POPULATION

Patients with recurrent EOC.

METHODS

Fifty-six patients underwent 57 combined procedures. CRS was performed using peritonectomy procedures and HIPEC using the closed-abdomen technique with cisplatin and doxorubicin or cisplatin and mitomycin-C.

MAIN OUTCOME MEASURES

Overall survival (OS), progression-free survival (PFS), morbidity and mortality rates.

RESULTS

The median age of the patients was 55.2 years (range 30-75 years). The median peritoneal cancer index was 15.2 (range 4-30). Forty-seven patients had microscopic residual disease (completeness of cytoreduction, CC-0), seven had residual disease ≤2.5 mm (CC-1) and one had residual disease >2.5 mm (CC>2). Major complications occurred in 15 patients (26.3%), and procedure-related mortality occurred in three patients (5.3%). The median follow-up time was 23.1 months. The median OS and PFS were 25.7 (95% CI 20.3-31.0) and 10.8 (95% CI 5.4-16.2) months, respectively. The 5-year OS and PFS were 23% and 7%, respectively. Independent prognostic factors affecting OS according to the multivariate analysis were Eastern Cooperative Oncology Group performance status, preoperative serum albumin, and completeness of cytoreduction.

CONCLUSIONS

Patients with recurrent EOC treated with CRS and HIPEC showed promising results in terms of outcome. The combined treatment strategy could benefit subsets of patients wider than that defined for conventional secondary debulking surgery without HIPEC. These data warrant further evaluation in randomised clinical trials.

[Intestinal perforation by ingested foreign bodies in the digestive tract: an insidious pathology always of interest. Our experience]

The authors want to present five cases (from May 1999 to May 2009) of acute abdomen from perforation of the foreign body introduced with food. They highlight how the accidental ingestion is very common but the perforation is rare. The preoperative diagnosis, in these cases, is always very difficult and the radiological examinations are not always able to resolve the diagnostic doubt with other acute intestinal diseases that are responsible of perforation. Then, the surgery procedure is, necessarily, the only possible diagnostic and therapeutic means. The mortality and the morbidity remain still high first of all for the delay in the diagnosis and the advanced age of patients.

Massive bleeding from a Dieulafoy's lesion of the duodenum successfully treated with "adjuvant" transarterial embolization and endoscopic laser coagulation

Dieulafoy's lesions, very rare in the duodenum, are considered uncommon causes of gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial lesions. We report a case of Dieulafoy's lesion of the duodenum, in which a first diagnostic approach by using endoscopy and angiography was not successful; then, due to a high operative risk, we performed an "adjuvant" embolization of the gastroduodenal artery with the aim of reduce the flow through the artery, allowing the endoscopic localization of the site of bleeding and subsequent effective treatment. To our knowledge, this is the first case reported in the literature, in which, without aetiological diagnosis, an "adjuvant" embolization of the gastroduodenal artery was performed with the aim of reduce the blood flow in the duodenal wall, permitting an easier endoscopic diagnosis of Dieulafoy's duodenal lesion and successful treatment with laser coagulation.

Quintuple primitive malignant neoplasms. A case report

The authors describe the case of a patient who developed during 31 months, five malignant tumours, three synchronous and two metachronous. The primitive origin and the long interval of time between the occurrence of each tumour, allow to set them in the group of Multiple Primitive Malignant Neoplasm. The authors, reviewing the classifications and the pathogenesis of these tumours, underline the importance of the follow-up in oncology patients and emphasize the role of nosographic setting in order to plan the most suitable therapeutic approach.

CD81 expression on CD19+ peripheral blood lymphocytes is associated with chronic HCV disease and increased risk for HCV infection: a putative role for inflammatory cytokines

The level of CD81 cell surface expression, a cellular co-receptor for hepatitis C virus (HCV), is critical for productive HCV infection of host cells. In addition, the cross-linking of HCV-E2 protein to CD81 can alter the function of T and B lymphocytes as well as that of NK cells by interfering with the activation signalling pathway. The down-regulation of CD81 expression on peripheral blood lymphocytes (PBL) has been associated to effective therapy of HCV infection. The aim of the present study is to quantitatively assess the levels of CD81 expression in PBL from HCV-infected patients compared to subjects at high risk for HCV infection such as HIV-infected individuals or patients with Porphyria Cutanea Tarda (PCT). The expression of CD81 was quantified by flow-cytometry using Phycoerythrin-labelled standard beads. Determination of CD81 was performed on CD3+ and CD19+ lymphocytes from 34 healthy controls, 51 patients with HCV infection and different clinical outcomes [these included HCV-RNA-negative subjects (8), patients with chronic active hepatitis (16), recipients of liver transplantation under immunosuppressive therapy (12), a subgroup with concomitant HIV infection (9) or concomitant PCT (6)]. In addition, 60 HIV-infected subjects and 4 patients with PCT were studied. The putative role of inflammatory cytokines in modulating CD81 was explored in vitro by assessing the effect of IL-6 or IFN-gamma on cultured human hepatocytes. A significant increase of the CD81 expression was found on CD19+ lymphocytes in association with either HIV or HCV infection, as compared to the control group. Immunosuppressive therapy with FK506, subsequent to liver transplantation, restored CD81 expression at normal levels. Data gathered in vitro using the WRL 68 hepatocytic cell line confirmed that inflammatory cytokines can up-regulate CD81 expression in liver cell inclusion. Our data suggest that CD81 up-regulation can increase the risk of HCV infection, particularly in HIV-infected subjects. In addition, the results strongly suggest that the cytokines released by activated lymphocytes at sites of inflammation may play a part in up-regulating CD81 expression.

Association between porphyria cutanea tarda and beta-thalassemia major

The paper describes the first two cases of porphyria cutanea tarda associated with beta-thalassemia major. The clinical course of two female patients affected by beta-thalassemia major was complicated by the onset of porphyria cutanea tarda. Both patients were also suffering from hepatitis C virus infection, iron overload and anemia. We discuss about the role performed by some of these conditions in triggering overt porphyria cutanea tarda. An improvement of the clinical and biochemical picture of porphyria cutanea tarda in both patients was obtained with chloroquine therapy given that their chronic anemia did not permit phlebotomy.

Four novel mutations of the coproporphyrinogen III oxidase gene

Here we report the characterization of four novel mutations and a previously described one of the coproporphyrinogen III oxidase (CPO) gene in five Italian patients affected by Hereditary Coproporphyria (HCP). Three of the novel genetic variants are missense mutations (p.Gly242Cys; p.Leu398Pro; p.Ser245Phe) and one is a frameshift mutation (p.Gly188TrpfsX45).

Evaluation of quality of life of patients submitted to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinosis of gastrointestinal and ovarian origin and identification of factors influencing outcome

BACKGROUND

The prognosis of patients with peritoneal tumors has been improved by the association of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, though still with an unclear impact on patients' quality of life. The purpose of our study was to evaluate the quality of life in 18 cases submitted to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and particularly to identify the factors that influence it.

PATIENTS AND METHODS

Quality of life was evaluated using the functional assessment of cancer therapy; the results were correlated with 25 parameters.

RESULTS

The study demonstrated that the patients'quality of life was not modified by treatment with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy; the dose of mitomycin C, the site of the primary tumor, gastrointestinal, renal and neurological toxicity, adjuvant chemotherapy, the patients' age and leukopenia were factors that influenced the quality of life.

CONCLUSION

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy allows conservation of preoperative quality of life.

Excretion profile of boldenone and its metabolites after oral administration to veal calves

The residue profiles of boldenone (17beta-Bol), its epimer (17alpha-Bol) and the related compound androsta-1,4-diene-3,17-dione (ADD), were investigated by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in urine of male calves orally treated with boldenone, boldenone esters, and/or ADD. In all the experiments with the administered steroids residues of 17alpha-Bol decreased rapidly after end of treatment; detectable amounts of 17alpha-Bol were however noticed along the withdrawal observation period after end of treatment. Differently, residues of 17beta-Bol were detectable only shortly after administration. This in vivo research concerning oral treatments of cattle with boldenone related substances proves ADD to be a very active boldenone precursor in bovine animals.

[Multiple primitive lipoma of the transverse mesocolon: a rare disease]

The Authors describe a case of multiple lipomatosis of the mesocolon and, after a careful review of the literature, they examine particular findings and discuss diagnostic difficulties, anatomopathological features and treatment. Intraabdominal lipoma is very rare and presents difficulties in diagnosis, both for aspecific symptoms and for the unusual site which does not allow early identification. As it is a tumor which arises from primitive and totipotent mesenchymal cells, radical surgery is the only therapeutic option. The correct diagnosis depends on histological testing which can differentiate the lesion from other mesenchymal tumors.

Serum levels of interleukin 1beta, interleukin 8 and tumour necrosis factor alpha as markers of gastric cancer

Despite the efforts made, a serum marker reliable for the screening and follow-up of patients with gastric cancer has not yet been identified. The aim of this preliminary study was to test the role of pro-inflammatory cytokines interleukin 1beta, interleukin 8 and tumour necrosis factor alpha in patients with gastric cancer and in control groups. The statistical analysis of cytokines serum levels in the group with gastric cancer versus control groups has shown considerable differences (p < 0.001) in their mean rates. The results indicate that the cytokines interleukin 1beta, interleukin 8 and tumour necrosis factor alpha might perhaps act as diagnostic markers in patients with gastric cancer. Therefore, it is hypothesized that after more extended trials, their use in the screening and prognostic assessment of these patients could be a possibility.

[Endoscopic prosthetic treatment of the esophagojejunal leaks after total gastrectomy: clinical experience]

The Authors, on the basis of their experience on the use of self-expanding prostheses in abdominal surgery, report on the use of these prostheses in two patients who, having undergone a gastrectomy for cancer, developed a fistula of the esophago-jejunal anastomosis. Given recent data from literature, using a prosthesis for an anastomotic fistula may be a valid alternative to a second operation, which, apart from obvious difficulties, has a high mortality rate in patients in weakened general health conditions. In these cases, after the application of a stent, excellent results can be obtained and, after some days, the patients can begin a semi-liquid diet, then proceeding to a semi-solid diet, improving quality of life; in addition, within a reasonable time span, after the healing of the fistula, the prosthesis can easily be removed by endoscopy.

Hemorrhage from primitive rectal varices in patient with idiophatic thrombosis of portal vein: case report

INTRODUCTION

Rectal varices, primitive or secondary to hypertensive or thrombotic disorders of mesenteric-portal circle, represent an uncommon cause of lower digestive bleeding. The presence of rectal varices associated to idiopathic venous portal thrombosis represents a distinct nosologic entity, with important clinical and therapeutic problems related to it.

CASE REPORT

Patient of young age, with positive anamnesis for primitive rectal varices, admitted to our department for a serious recttorragy. The laboratory underlined moderate anaemia and the endoscopy documented the presence of multiple rectal varices, without evident signs of bleeding; the endoscopy documented the presence of two esophageal small varicose cords F1. The hepatobiliary sonography and the portography showed the massive thrombosis of the portal vein. The new serious episode of rectal bleeding induced us to subject the patient to a surgical operation of Hartmann recto-sigmoid resection.

CONCLUSION

Because of the slight number of reported cases of primitive rectal varices and because of the scattering of many dates it is difficult to draw an univocal diagnostic and therapeutic algorithm. Clinical framing and subsequent therapeutic approach rise often up from personal experience rather than well defined guidelines. The treatment is controversial, time by time many therapeutic options are reported either conservative or interventionist. The failure of conservative therapy and the recurrent episodes of bleeding give indication to surgical treatment, that is represented by Hartmann colonic resection and/or the porto-systemic shunts in the cases of portal hypertension; in our case we made colonic resection sec. because of lapsed performing status of the patient.

Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy

BACKGROUND

The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy.

PATIENTS

From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05.

RESULTS

Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001).

CONCLUSIONS

The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.

Combined antegrade and retrograde ureteral stenting: the rendezvous technique

Ureteral stenting is a routine procedure in endourology. To increase the success rate in difficult cases, it may be helpful to use the rendezvous technique, a combined antegrade and retrograde approach. We performed 16 urological rendezvous in 11 patients with ureteral strictures or urologic lesions. The combined approach was successful in all patients, without morbidity or mortality. In our experience the rendezvous technique increased the success rate of antegrade ureteral stenting from 78.6 to 88.09% (p > 0.05). This procedure is a valid option in case of failure of conventional ureteral stenting.

Presence and metabolism of the anabolic steroid boldenone in various animal species: a review

The review summarizes current knowledge on the possible illegal use of the anabolic steroid boldenone. The presence of' boldenone and metabolites in different animal species and the possibility of the occurrence of endogenous boldenone and metabolites is assessed, as are the methods of analysis used for detection. Different laboratories in the European Union have examined the occurrence of boldenone and its metabolites. The results were discussed at different meetings of a European Commission DG-SANCO Working Party) and summarized in an expert report. The situation of the different laboratories at this time is also covered herein. The overall conclusion of the Working Party was that there was a necessity for further research to distinguish between naturally occurring and illegally used boldenone forms. The confirmation of the presence of boldenone metabolites (free and conjugated forms) in certain matrices of animals is proposed as a marker for the illegal treatment with boldenone.

Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report

The case described here is of a 73-year-old male patient who developed a colocutaneous fistula following necrotizing pancreatitis, diagnosed by imaging and treated endoscopically by the application of an endoclip. Pancreatic and gastrointestinal fistulas, common complications of surgery for necrotizing pancreatitis, frequently require surgical treatment. Colonic perforations are the most difficult to treat surgically on account of the risk of peritonitis. A technique, namely, endoscopic clips application, has recently been developed to close anastomotic leakages and perforations of the oesophagus, stomach and colon. In the patient described here, endoscopic repair was technically easy and the good result was confirmed within a few days. In order to repair colonic fistulas following pancreatitis, application of endoclips could, in our opinion, provide a useful therapeutic option, feasible in selected patients.

Pneumaturia in a patient with ectopic vas deferens opening in the bladder and agenesis of the ipsilateral seminal vesicle. Case report

Ectopia of the vas deferens (EVD) combined with agenesis of the seminal vesicle, is a rare congenital abnormality. We describe a case of EVD with agenesis of the ipsilateral seminal vesicle, presenting with pneumaturia and frequent urinary tract infection.

Endocrine effects in the hazard assessment of drugs used in animal production

Criteria of toxicological assessment are currently reviewed to ensure an adequate protection to susceptible groups, such as infants and children; in particular, concern arises about altered endocrine homeostasis in the developing organism, eliciting possible persistent effects such as reproductive disturbances and increased risk of tumours in target organs. Such items are obviously relevant also for veterinary drugs, whose main safety issue is potential lifetime exposure to residues. Two groups of chemicals, nitroimidazoles and imidazole antifungals, are reviewed as examples of the relevance of endocrine toxicity to the hazard assessment of compounds used in animal production. Nitroimidazoles are metabolized into genotoxic intermediates; in rodents they induce testicular toxicity and carcinogenicity. In particular, mammary neoplasms, mostly fibroadenomas, are consistently induced in rats as the most important effect in chronic studies; this may hint to possible endocrine-related mechanisms. Accordingly, evidences on other chemicals (e.g., triazines) show mammary tumorigenicity in rodents associated to hormonal alterations. In fact, nitroimidazoles affect synthesis of both pituitary and steroid hormones in vitro and rise progesterone and FSH levels in rats; also, limited clinical data in humans indicate endocrine-related effects. Overall, nitroimidazoles appear to affect the endocrine balance; however, the actual importance of such alterations, especially in regards to rat mammary tumours, has yet to be clarified. Imidazole antimycotics are broad-spectrum inhibitors of steroid synthesis; accordingly, diverse reproductive and developmental alterations are observed, depending on age and sex of animals exposed. Effects include pregnancy loss, delayed pup growth as well as reduced weight of androgen-dependent tissue; however, it is still difficult to identify the most susceptible biological phase. Overall the potential for inducing endocrine-related alterations should be carefully evaluated also for drugs used in animal production. A screening battery should produce a distinct fingerprint for each major endocrine activity, thus targeting longer-term tests (such as the two-generation study) on the most relevant endpoints. Moreover, the validation of molecular approaches would contribute to a biologically-based evaluation, by providing insights on such items as early effects and species-specificity.

The vesical granuloma: rare and late complication of laparoscopic cholecystectomy

The spillage of gallstones into the peritoneal cavity from iatrogenic perforation of the gallbladder that occurs during laparoscopic cholecystectomy can result in late and serious complications. We report a case of vesical granuloma with symptoms of dysuria, pollakiuria, and vesical tenesmus that occurred 23 months after a laparoscopic cholecystectomy. Preoperative diagnostic evaluation showed a 3-cm vesical neoformation. A partial cystectomy was performed; macroscopic and histologic examination documented a central nidus of fragmented gallstones and a picture of chronic granulomatous inflammation. Although complications related to unretrieved gallstones that spill into the peritoneal cavity during laparoscopic cholecystectomy are rare, they are being reported with increasing frequency. Therefore, it is important to use tools and techniques that prevent lacerations of the gallbladder and involve retrieval of spilled gallstones.

Three-dimensional optic nerve head algorithm for the detection of glaucomatous damage

PURPOSE

To determine whether a three-dimensional optic disc algorithm could be useful in differentiating optic nerve heads (ONH) with a normal visual field from those with an abnormal visual field also when using a simultaneous stereoscopic computerised ONH analyser.

METHODS

One eye was randomly chosen from 45 normals and 55 patients with glaucoma (mean deviation -7.7 +/- 9.0 dB, corrected pattern standard deviation 3.1 +/- 2.3 dB). All the subjects were examined with the Humphrey Perimeter (program 30-2) and with the Topcon Image-net X Rev-3.51 b. Using the topographic map of the system, the algorithm of the third moment or cup shape measure was applied to the numbers (the number of points ranged from 623 to 1,883 depending on the size of the disc area) that identify the heights of all the points of the optic disc surface. Findings were analysed by means of the Mann-Whitney U test and receiver operator characteristic curves.

RESULTS

The sensitivity and specificity of this three-dimensional ONH algorithm applied to Topcon Image-net was 90.6% and 85.1% respectively. No difference was found between the groups for age, disc area and number of the analysed points.

CONCLUSIONS

The algorithm of cup shape measure or third moment is a useful parameter to separate eyes with normal from those with abnormal visual field also when using a simultaneous stereoscopic system such as Image-net.

[Combined diagnosis in breast carcinoma: preoperative role of mammoscintigraphy with Tc99m-sestamibi. Our Experience]

The Authors, taking recent literature on tumoral pathology breast studies in to consideration, studied a group of patients with a node or a suspect adenous zone by clinical and instrumental examination with mammoscintigraphy. 22 patients were selected by clinical examination, mammography and ultrasonography. A mammoscintigraphy (Tc 99m Sestamibi) was performed before the surgical operation. The histologic examination revealed 14 cases of breast cancer; 12 of these (86%) resulted positive after scintigraphy, while 2 were false negative. In this study, the scintigraphic exam and its diagnostic accuracy were analyzed, both in relation to anatomical structure of the mammary gland (thick breast, fibrocystic mastopathy, postsurgical scars, etc.) and also in relation to characteristics of the suspected node, the nature of which was not possible to determine from other exams carried out. In conclusion, after comparison between our experience and those reported in literature, we conclude that because of its high specificity and sensibility the mammoscintigraphy exam assumes an important comparative index in obtaining elements for an additional evaluation when other instrumental examinations are dubious.

[Myogenic stromal tumors of the stomach: personal experience]

Myogenic gastric tumours are a rare pathology and present difficulties in terms of nosographic classification, which in most cases can be overcome thanks to improvements in imaging and immunohistochemical techniques. Over the period 1995-1999 we observed 5 patients with aspecific dyspeptic symptoms and occasional epigastric pain, suffering from non-epithelial gastric tumours, associated, in one case, with a carcinoma of the stomach. Histological examination of endoscopic biopsies was inconclusive for a definite histopathological diagnosis, while intraoperative biopsies showed the myogenic origin and the absence of morphostructural abnormalities. In the light of these data, we performed three wedge resections, one distal gastric resection and, in the patient with advanced gastric cancer, a D3 total gastrectomy. Histological examination, immunohistochemistry and cytofluorometry enabled us to diagnose stromal tumours with a low risk of malignancy in all cases. At follow-up after 9-54 months all patients are still alive and free of disease. Though the preoperative diagnosis of stromal tumours is possible with endosonography and CT, only histology, immunohistochemistry and cytofluorometry enable us to define the condition nosographically and establish a prognosis with sufficient accuracy to allow correct surgical treatment. A prolonged follow-up is always necessary to identify eventual relapses and/or metastases, which are particularly frequent in the borderline group or in cases with a high risk of malignancy.

[The Allgrove syndrome]

Allgrove syndrome, rare autosomal recessive pathology, characterized by adrenocortical insufficiency, achalasia and alacrimia, rises usually in pediatric age, while its observation in adults is very rare. A clinical case appeared in an adult, observed by the Authors, is the reason to evaluate the etiopathogenetic mechanisms of this syndrome, with particular attention about potential role of genetic abnormalities and about others factors, again not well known.

Molecular fingerprinting of strains of Yersinia ruckeri serovar O1 and Photobacterium damsela subsp. piscicida isolated in Italy

We studied the ribotypes, patterns of pulsed-field gel electrophoresis (PFGE) and interspersed repeated sequences (IRS)-PCR of 30 strains of Yersinia ruckeri O1 and 20 strains of Photobacterium damsela subsp. piscicida isolated from apparently unrelated epizootic outbreaks occurring on Italian fish farms between 1993 and 1999. All of the Y. ruckeri O1 strains had similar profiles, as demonstrated by all three typing methods, thus confirming the clonal structure of this species. The strains of P. damsela subsp. piscicida showed similar profiles when tested with ribotyping and PFGE; however, two slightly different profiles were distinguished by IRS-PCR using the primer ERIC2. The two profiles appeared to be related to the geographic origin of the strains, since each of them was specific to isolates from a certain area (i.e. northern or southern Italy). This result suggests that PCR fingerprinting may be a valuable tool in typing fish bacterial pathogens, which often present a great degree of genetic homogeneity.

Echographic study of extraocular muscle thickness in children and adults

BACKGROUND

Echobiometric evaluation of extraocular muscles in normal subjects has been performed previously, but only in adults. We determined extraocular muscle thickness in normal subjects in three age groups.

METHODS

Extraocular muscle thickness was studied in 75 normal subjects divided into three age groups (5-10, 11-15 and 28-37 years) using a Biovision B-scan-S instrument in standardized A-mode (frequency, 10 MHz; biometry resolution, 0.15 mm; depth, 40-60 mm; points on X axis, 512; levels on Y axis, 256). All measurements were performed by the same operator and repeated five times. The reproducibility of the technique was determined using the coefficient of variation. The one-way ANOVA test was used to compare the three groups, and the two-tailed unpaired t-test was used to compare subjects aged 5-10 years and those aged 11-15 years, and subjects aged 11-15 years with those aged 28-37 years.

RESULTS

The technique showed good reproducibility. In subjects 5-10 years old, the coefficient of variation was 8%; in subjects 11-15 years and 28-37 years old, it was 5%. Increased muscle thickness was observed with age (p < 0.001). A statistically significant difference between the medial and inferior recti muscles in subjects 11-15 years and 28-37 years old was found (p < 0.001).

CONCLUSIONS

The increased thickness of all recti muscles may be influenced by growth (primarily during puberty), and the variations in thickness of the extraocular muscles may be attributable to near-vision stimulus of the inferior and medial recti muscles.

Molecular analysis of the hydroxymethylbilane synthase (HMBS) gene in Italian patients with acute intermittent porphyria: report of four novel mutations

Acute intermittent porphyria (AIP) is an autosomal disorder caused by molecular abnormalities in the hydroxymethylbilane synthase (HMBS) gene coding for the third enzyme in the heme biosynthetic pathway. So far, more than 160 different mutations responsible for AIP have been identified in this gene. We have now identified seven mutations in eight unrelated Italian patients with AIP: two splicing defects (IVS7+2T-->C, 612G-->T), three small deletions (308-309delTG, 730-731delCT, 182delA) and two missense mutations (134C-->A, 541C-->T). The splicing defects were responsible for activation of splicing cryptic sites respectively within intron 7 (15 bp insertion) and exon 10 (9 bp deletion). The small deletions resulted in frameshifts leading to the formation of premature stop codons. The 134C-->A and 541C-->T mutations caused the formation of stop codons likely to be responsible for drastic disruption of the HMBS structure (Ser45Ter, Gln181Ter). This is the first molecular study in AIP patients of Italian origin leading to the identification of four new mutations and three molecular defects that have already been described.

Clinical and pharmacological profile in a clenbuterol epidemic poisoning of contaminated beef meat in Italy

Long-acting beta adrenergic agonists, such as clenbuterol accumulate in the liver, but not meat of treated farm animals, and result in epidemic poisonings in consumers. We describe an outbreak of poisoning in 15 people, following the consumption of meat. Clinical symptoms (distal tremors, palpitations, headache, tachipnoea-dyspnoea, and also moderate hyperglycaemia, hypokalemia and leucocytosis) were seen in nine hospitalised patients, starting about 0.5-3 h after poisoning, and disappearing within 3-5 days later. Clenbuterol was found in the urine of all the symptomatic patients, at higher levels than pharmacokinetic computing (mean level 28 ng/ml, 36 h after ingestion), based on the levels found in the meat (1140-1480 ng/g edible tissue). Thus, epidemic poisoning can be produced following the consumption of contaminated meat. The need for a better definition of pharmaco- and toxico-kinetics, not only for drugs ingested as parent drug, but also when ingested as residues with animal tissues, is recommended.

Decrease of vancomycin-resistant enterococci in poultry meat after avoparcin ban

In Italy, 18 months after the ban of avoparcin, the percentage of poultry meat samples containing vanA gene-positive vancomycin-resistant enterococci fell from 14.6% to 8%.

Optic disc surface smoothness and visual field indices

BACKGROUND

In order to ascertain whether the optic disc surface smoothness (ODSS) could be used to predict the amount of visual field damage in glaucomatous eyes, the correlations between ODSS and visual field indices were evaluated.

METHODS

One eye was randomly chosen from each of 40 normals and 50 patients with glaucoma. The morphology of the optic disc surface was analyzed using the Topcon IMAGEnet X Rev-3.51b. In order to define the level of "smoothness" of the optic disc surface, the differences of the relative position of each surface point was studied by measuring the standard deviation (SD) from the average height of the points (number of points ranged from 623 to 1883 depending on the size of the disc area) that identify the optic disc surface. All the subjects were also examined with the Humphrey perimeter (Program 30-2) and the results were analyzed by Mann-Whitney U-test and Spearman rank correlation coefficient.

RESULTS

The difference in ODSS between the glaucomatous and the normal eyes was statistically significant. No significant correlation was found between age and ODSS. A significant correlation was found between ODSS and mean deviation (MD) and between ODSS and corrected pattern standard deviation (CPSD). In the glaucoma group there were significant correlations between ODSS and the perimetric indices MD and CPSD; no correlations were found in the normal group.

CONCLUSION

The ability of ODSS to reflect the level of visual field change in glaucomatous eyes appears to be rather limited, even if statistically significant. This fact does not limit the clinical usefulness of ODSS as a diagnostic parameter in consequence of its strong correlations with the other morphometric parameters and its high sensitivity and specificity in separating normal from glaucomatous eyes.

Hepatitis C virus in patients with porphyria cutanea tarda: relationship to HCV-genotypes

Porphyria cutanea tarda (PCT) is a rare metabolic disorder characterized by an abnormal porphyrin metabolism and typical cutaneous lesions. Recently a strong association between PCT and hepatitis C virus (HCV) has been proposed. Studies in south Europe have shown high prevalence (53 to 91%) of HCV markers in patients with PCT. We studied HCV genotypes in 72 subjects: 40 with PCT and 32 patients with chronic liver disease. A high rate of HCV-RNA positive PCT patients (84%) was observed, reflecting an active HCV replication, the genotypes study showed a prevalence of genotype 1b in PCT patients (61.2%). These findings implicate HCV in the aetiology of PCT-associated liver disease suggesting that hepatitis C serological and virological testing could be indicated in all patients with PCT.

[Magnetic resonance pyelography: clinical use of ultrafast breath-hold sequences in obstructive uropathy. Personal experience]

INTRODUCTION

We investigated the diagnostic yield of MR pyelography (MRP) performed with two ultrafast breath-hold sequences in obstructive uropathy patients.

MATERIAL AND METHODS

Thirty-four patients with US demonstration of urinary tract dilation were examined with MRP at 1.5 T and with a standard body coil. HASTE sequences (TE 66, ETL 128, FA 180 degrees, 1 NEX, MA 240 x 256, slice thickness 4 mm, TA 13 s) were always performed and 26/34 patients were also examined with single-shot TSE sequences (TE 1100, ETL 240, FA 150 degrees, 1 NEX, slice thickness 7 cm, MA 240 x 256, FS, TA 7 s); 20/34 patients were given 500 mL superparamagnetic contrast agent (Lumirem). MRP findings were interpreted independently by two radiologists and analyzed for image quality, the presence/absence of dilation, the obstruction grade (mild, moderate, severe), site (intrarenal; ureteropelvic junction; proximal, mid-, distal ureter; indeterminate) and cause (intrinsic obstruction from a stone or other conditions; stenosis; indeterminate cause). The sensitivity, specificity, positive and negative predictive values for the detection of urinary tract dilation were calculated for each reviewer and interobserver agreement was calculated with the k analysis relative to the presence, grade, site and cause of urinary tract dilation.

RESULTS

MRP examinations were considered technically adequate in all cases by both observers. As for the presence of urinary tract dilation, the values were 100% for the first observer and 97%, 100%, 100%, and 95%, respectively, for the second observer. Interobserver agreement was .98 for dilation presence (excellent), .80 for dilation degree (excellent), .62 for dilation site (good) and finally .69 for dilation cause (good).

DISCUSSION AND CONCLUSIONS

MRP performed with the ultrafast breath-hold technique provides very good results in diagnosing urinary tract dilation, as well as the obstruction grade, site and cause, with results equal or even superior to those of non-breath-hold sequences. Ultrafast MRP lasts only 10 minutes, meaning it occupies the magnet shortly and costs less: it can be thus considered a routine alternative to conventional diagnostic imaging, especially ivp, in the evaluation of obstructive uropathy.

RA/DA cumulative curve analysis of local and diffuse neuroretinal rim area damage in glaucoma patients

AIM

To evaluate the validity of cumulative rim/disc area (RA/DA) curve analysis as a clinical tool for the identification of glaucoma induced optic disc pathology.

METHODS

71 normal and 83 glaucomatous eyes were evaluated from a series of 154 subjects recruited for this study. For each eye, the cumulative distribution of RA/DA was calculated from 36 equally spaced rim sectors of each optic disc obtained by the automatic evaluation of simultaneous videographics (Image-net X Rev.3/51b). To increase the sensitivity of this analysis in early glaucoma and in normal eyes, these cumulative curves were subsequently divided into two equal segments and the slopes of their respective regression lines compared.

RESULTS

The median RA/DA value obtained from the 36 sectors was significantly different in glaucomatous eyes compared with normals (p < 0.001). Nevertheless, the curves (5th-95th percentile of the cumulative curves distribution) of early glaucomatous eyes fell within the normal range. When the cumulative curve of these marginal cases was then divided into two equal segments, the comparison of the slopes of the regression lines showed a significant difference (p < 0.05) in 100% of early glaucomatous eyes. Furthermore, normal eyes were shown to be true negatives in 93% of the cases in which no significant difference between the two slopes was observed.

CONCLUSION

Analysis of the RA/DA cumulative curve from 36 sectors of the optic disc was a valid method for the identification of glaucomatous disc pathology; however, a further calculation of the slopes of the two RA/DA regression lines was needed to identify early glaucomatous damage.