Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology

Cutaneous squamous cell carcinoma (CSCC) accounts for ∼20%-25% of all skin tumors. Its precise incidence is often challenging to determine due to limited statistics and its incorporation with mucosal forms. While most cases have a favorable prognosis, challenges arise in patients presenting with locally advanced or metastatic forms, mainly appearing in immunocompromised patients, solid organ transplantation recipients, or those facing social difficulties. Traditionally, chemotherapy and targeted therapy were the mainstays for advanced cases, but recent approvals of immunotherapeutic agents like cemiplimab and pembrolizumab have revolutionized treatment options. These guidelines, developed by the Italian Association of Medical Oncologists (AIOM) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, aim to guide clinicians in diagnosing, treating, and monitoring patients with CSCC, covering key aspects from primitive tumors to advanced stages, selected by a panel of experts selected by AIOM and other national scientific societies. The incorporation of these guidelines into clinical practice is expected to enhance patient care and address the evolving landscape of CSCC management.

Guidelines for the diagnosis and treatment of basal cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology

Basal cell carcinoma (BCC) is the most common form of cancer, with a high impact on the public health burden and social costs. Despite the overall prognosis for patients with BCC being excellent, if lesions are allowed to progress, or in a small subset of cases harboring an intrinsically aggressive biological behavior, it can result in local spread and significant morbidity, and conventional treatments (surgery and radiotherapy) may be challenging. When a BCC is not amenable to either surgery or radiotherapy with a reasonable curative intent, or when metastatic spread occurs, systemic treatments with Hedgehog inhibitors are available. These guidelines were developed, applying the GRADE approach, on behalf of the Italian Association of Medical Oncologists (AIOM) to assist clinicians in treating patients with BCC. They contain recommendations with regard to the diagnosis, treatment and follow-up, from primitive tumors to those locally advanced or metastatic, addressing the aspects of BCC management considered as priorities by a panel of experts selected by AIOM and other national scientific societies. The use of these guidelines in everyday clinical practice should improve patient care.

Capillary pruning couples tissue perfusion and oxygenation with cardiomyocyte maturation in the postnatal mouse heart

Introduction: Removal of poorly perfused capillaries by pruning contributes to remodeling the microvasculature to optimize oxygen and nutrient delivery. Blood flow drives this process by promoting the intravascular migration of endothelial cells in developing networks, such as in the yolk sac, zebrafish brain or postnatal mouse retina. Methods: In this study, we have implemented innovative tools to recognize capillary pruning in the complex 3D coronary microvasculature of the postnatal mouse heart. We have also experimentally tested the impact of decreasing pruning on the structure and function of this network by altering blood flow with two different vasodilators: losartan and prazosin. Results: Although both drugs reduced capillary pruning, a combination of experiments based on ex vivo imaging, proteomics, electron microscopy and in vivo functional approaches showed that losartan treatment resulted in an inefficient coronary network, reduced myocardial oxygenation and metabolic changes that delayed the arrest of cardiomyocyte proliferation, in contrast to the effects of prazosin, probably due to its concomitant promotion of capillary expansion. Discussion: Our work demonstrates that capillary pruning contributes to proper maturation and function of the heart and that manipulation of blood flow may be a novel strategy to refine the microvasculature and improve tissue perfusion after damage.

Macrophages promote endothelial-to-mesenchymal transition via MT1-MMP/TGFβ1 after myocardial infarction

Macrophages (Mφs) produce factors that participate in cardiac repair and remodeling after myocardial infarction (MI); however, how these factors crosstalk with other cell types mediating repair is not fully understood. Here we demonstrated that cardiac Mφs increased the expression of Mmp14 (MT1-MMP) 7 days post-MI. We selectively inactivated the Mmp14 gene in Mφs using a genetic strategy (Mmp14^f/f:Lyz2-Cre). This conditional KO (MAC-Mmp14 KO) resulted in attenuated post-MI cardiac dysfunction, reduced fibrosis, and preserved cardiac capillary network. Mechanistically, we showed that MT1-MMP activates latent TGFβ1 in Mφs, leading to paracrine SMAD2-mediated signaling in endothelial cells (ECs) and endothelial-to-mesenchymal transition (EndMT). Post-MI MAC-Mmp14 KO hearts contained fewer cells undergoing EndMT than their wild-type counterparts, and Mmp14-deficient Mφs showed a reduced ability to induce EndMT in co-cultures with ECs. Our results indicate the contribution of EndMT to cardiac fibrosis and adverse remodeling post-MI and identify Mφ MT1-MMP as a key regulator of this process.

Endothelial MT1-MMP targeting limits intussusceptive angiogenesis and colitis via TSP1/nitric oxide axis

Pathological angiogenesis contributes to cancer progression and chronic inflammatory diseases. In inflammatory bowel disease, the microvasculature expands by intussusceptive angiogenesis (IA), a poorly characterized mechanism involving increased blood flow and splitting of pre-existing capillaries. In this report, mice lacking the protease MT1-MMP in endothelial cells (MT1iΔEC ) presented limited IA in the capillary plexus of the colon mucosa assessed by 3D imaging during 1% DSS-induced colitis. This resulted in better tissue perfusion, preserved intestinal morphology, and milder disease activity index. Combined in vivo intravital microscopy and lentiviral rescue experiments with in vitro cell culture demonstrated that MT1-MMP activity in endothelial cells is required for vasodilation and IA, as well as for nitric oxide production via binding of the C-terminal fragment of MT1-MMP substrate thrombospondin-1 (TSP1) to CD47/αvβ3 integrin. Moreover, TSP1 levels were significantly higher in serum from IBD patients and in vivo administration of an anti-MT1-MMP inhibitory antibody or a nonamer peptide spanning the αvβ3 integrin binding site in TSP1 reduced IA during mouse colitis. Our results identify MT1-MMP as a new actor in inflammatory IA and a promising therapeutic target for inflammatory bowel disease.

PKM2 regulates endothelial cell junction dynamics and angiogenesis via ATP production

Angiogenesis, the formation of new blood vessels from pre-existing ones, occurs in pathophysiological contexts such as wound healing, cancer, and chronic inflammatory disease. During sprouting angiogenesis, endothelial tip and stalk cells coordinately remodel their cell-cell junctions to allow collective migration and extension of the sprout while maintaining barrier integrity. All these processes require energy, and the predominant ATP generation route in endothelial cells is glycolysis. However, it remains unclear how ATP reaches the plasma membrane and intercellular junctions. In this study, we demonstrate that the glycolytic enzyme pyruvate kinase 2 (PKM2) is required for sprouting angiogenesis in vitro and in vivo through the regulation of endothelial cell-junction dynamics and collective migration. We show that PKM2-silencing decreases ATP required for proper VE-cadherin internalization/traffic at endothelial cell-cell junctions. Our study provides fresh insight into the role of ATP subcellular compartmentalization in endothelial cells during angiogenesis. Since manipulation of EC glycolysis constitutes a potential therapeutic intervention route, particularly in tumors and chronic inflammatory disease, these findings may help to refine the targeting of endothelial glycolytic activity in disease.

Effects of locally applied Insulin-like Growth Factor-I on osseointegration

BACKGROUND

The aim of this study was to assess the effect of local application of IGF-I on osseointegration of dental implants placed in osteoporotic bones.

MATERIAL AND METHODS

16 rabbits were randomly distributed into two groups: eight animals were ovariectomized and fed a low-calcium diet for six weeks, in order to induce experimental osteoporosis, and the others were sham-operated and fed a standard diet. A titanium implant was inserted into the tibiae in both groups. In half of the rabbits, 4 μg of IGF-I was applied into the ostectomy, prior to the implant insertion. A total of 32 implants were placed. Animals were sacrificed two weeks after surgery and decalcified samples were processed for Bone-To-Implant Contact (BIC) and Bone Area Density (BAD) measurements. Analysis of variance (ANOVA) was used for statistical evaluation. P<0.05 was considered to be significant.

RESULTS

Ovariectomy induced statistically significant lower BAD values (p=0.008) and a tendency towards lower BIC values when compared osteoporotic and healthy groups. The administration of 4 μg of IGF-I did not produce statistically significant differences neither on BIC nor on BAD values, neither in the osteoporotic animals nor in healthy.

CONCLUSIONS

Within the limitations of this experimental study, local administration of 4 μg of IGF-I was not able to induce any changes in the osseointegration process two weeks after surgery, neither in healthy rabbits nor in the osteoporotic group.

Effects of long-term administration of Lactobacillus reuteri DSM-17938 on circulating levels of 5-HT and BDNF in adults with functional constipation

Accumulated evidence shows that some probiotic strains ameliorate functional constipation (FC) via the modulation of specific gastrointestinal peptide pathways. The aims of this study were to investigate: (1) the effects of long-term administration of Lactobacillus reuteri (LR) DSM 17938 on the serum levels of serotonin (5-HT) and brain-derived neurotrophic factor (BDNF); (2) the possible link between 5-HT, BDNF, and specific constipation-related symptoms; (3) whether genetic variability at the 5-HTT gene-linked polymorphic region (5-HTTLPR) and BDNF Val66Met loci could be associated with serum 5-HT and BDNF variations. LR DSM 17938 was administered to 56 FC patients for 105 days in a randomised, double-blind manner. The fasting blood samples were collected during the randomisation visit (V₁), at day 15 (induction period, V₂), day 60 (intermediate evaluation, V₃), and day 105 (V₄) and the Constipaq questionnaire (the sum of Constipation Scoring System (CSS) and patient assessment constipation quality of life (PAC-QoL)) was administered. A group of healthy subjects was enrolled as controls (HC). At V1, the mean serum 5-HT level in the whole patient group was significantly higher (P=0.027) than in HC subjects, while serum BDNF did not. At the end of probiotic administration (V4), 5-HT and BDNF levels were significantly lower than the initial values (V1) (P=0.008 and P=0.015, respectively). 5-HT and BDNF serum concentration were significantly associated (r=0.355; P=0.007). Neither 5-HT nor BDNF serum levels correlated with the CSS item scores and with the PAC-QoL. Lastly, the regression analysis demonstrated that the presence of the S allele of the 5-HTTLPR accounted for the reduction in the 5-HT concentration at V4. In conclusion, the long-term administration of LR DSM 17938 demonstrated that such a probiotic strain could improve FC by affecting 5-HT and BDNF serum concentrations.

Malignant Rhabdoid Tumor of the Vulva: A Case Report and Review of the Literature

Malignant rhabdoid tumor (MRT) is an uncommon aggressive neoplasm which usually occurs in the kidney of children, but it has also been found in extrarenal sites. MRT arising in the vulva is extremely rare. Only four cases of MRT of the vulva have been reported in the English literature. We herein present another case. The diagnosis and management of vulva MRT are reviewed.

Nipple Discharge as a Sign of Preneoplastic Lesion and Occult Carcinoma of the Breast: Clinical and Galactographic Study in 103 Consecutive Patients

A clinical and galactographic investigation was carried out on 103 patients with hematic, serous-hematic, and serous nipple discharge. The age of the patients ranged from 18 to 72 years. A single papilloma was found in 20 cases, diffuse papillomatosis in 2 cases, atypical ductal hyperplasia in 8 cases, and ductal carcinoma in 4 cases (3 of these were infiltrating and 1 was noninfiltrating associated with a diffuse papillomatosis). Mammography gave no indications of carcinoma in any of the 4 cases. In the remaining 49 patients, pictures of ductal hyperplasia, periductal mastitis or sclerosis, sclerosing adenosis, or ductal ectasia were observed. The various types of lesions were often associated. Lacunae, stenosis, or occlusion of the ducts, evidenced by galactography, correlated well with the histologic findings of proliferative lesions of the ductal epithelium. Nevertheless, in practice, it should be the type of discharge that indicates surgery rather than galactographic or cytologic data, which appeared to have little diagnostic value. The frequency with which preneoplastic (or limit) lesions, and also nonsuspect carcinomas were found in patients with a significant nipple discharge confirm the importance of this symptom for a secondary prevention or early diagnosis of mammary neoplastic lesions originating from galactophorous ducts. Finally, complete resection of the galactophorous ducts must be considered as the best treatment in all patients with a suspicious nipple discharge that requires surgery.

Sentinel Node Biopsy and Selective Dissection for Melanoma Nodal Metastases

Background

Early detection of nodal metastases still represents an important goal in the management of melanoma patients. A sentinel node is defined as the first colored node in the regional lymphatic basin following injection of blue dye in the site of the primary melanoma. Sentinel node biopsy may represent a feasible technique for early identification of occult disease. A therapeutic dissection is then performed only in patients with proven nodal disease, thus introducing the concept of selective dissection.

Methods

At the National Cancer Institute of Milan from February 1994 to October 1996, 74 patients with a melanoma of the trunk or limbs and without clinically detectable node metastases were submitted to sentinel node biopsy and eventual selective dissection.

Results

The sentinel node was identified in 67 patients (90%). Nodal metastases were detected in 11 patients (16%); 5 of these were identified by an intraoperative frozen section examination. In all but one case, only the sentinel node was affected at radical dissection. Incidence of positive sentinel nodes was correlated with depth of infiltration of the primary lesion. Mapped nodal basin failures were observed in 3 patients with negative sentinel node biopsy. All patients but one, presenting distant metastases, are alive at this writing and free of disease with a follow-up ranging from 2 to 34 months.

Conclusions

Our study adds to accumulating evidence supporting the efficacy of sentinel node biopsy in detecting occult localizations and the potential of the technique to better select the group of patients that may benefit from nodal dissection.

Prognostic Factors in Operable Breast Cancer

A series of 743 consecutive cases of operable breast cancer, admitted and treated at the Istituto Nazionale Tumori of Milan from 1969 to 1970, was analized by a multivariate statistical method to evaluate a) the variables of the host and the primary tumor associated with the frequency of nodal metastases, b) the variables that significantly affect survival, and c) the identification of homogeneous risk groups. As regards the frequency of regional node metastases, they were more frequently observed in young than in old patients with large tumors (P values 10–5 and 3×10–5, respectively). Tumors that originated in the axillary tail, upper, outer and central quadrants were significantly associated with a higher rate of node metastases (P = 0.002). Each of these variables maintained its significant value when adjusted by the other two. Survival was affected at a statistically significant level by the age of the patients (P = 2×10–4), the pathologic diameter of the primary tumor (P < 10–6), and the number of metastatic regional nodes (P < 10 –6). The number of involved nodes appears to be the most relevant factor in the assessment of prognosis of patients with positive nodes, Age of the patients, size of the primary tumor, and number of involved nodes maintain their own statistical significance when each is adjusted by the remaining two. The site of origin of the primary tumor, even if associated with the frequency of regional node metastases, did not affect survival. Three groups with a significantly different risk of death were identified in patients with negative lymph nodes and three groups in patients with positive nodes. It is concluded that age, size of the primary, and number of involved lymph nodes are important pieces of information that clinicians should have at hand following radical surgery, not only to make a prognosis, but also to identify groups of patients with high risk of death on which the role of adjuvant treatment should be evaluated.

Malignant Melanoma of the Penis. A Report of Four Cases

Malignant melanoma (MM) of the penis is a rare neoplasia. We report 4 cases by a retrospective survey of all cases of MM observed at the Istituto Nazionale Tumori of Milano from 1967 to 1988. The problem of the therapeutic approach is still unsolved. Therefore, any case is useful for a better knowledge of the natural history of this disease.

Adenocarcinoma of the Large Intestine in Young Adults

Twenty-eight cases of adenocarcinoma of the large intestine in patients under 30 years of age, admitted to the National Cancer Institute of Milan from 1955 to 1975, are reported. Fourteen patients underwent radical surgery: of these, 8 are alive, and the survival times range from 8 months to 17 years. The 14 patients who received palliative therapy only all died within 15 months. The degree of infiltration of the intestinal wall seemed to be the most significant prognostic factor. The worse prognosis for the neoplasia in young adults with respect to older people, already reported in the literature and confirmed by our data, seems to be correlated, more than with the histologic type or biologic behavior of the tumor, with the diagnostic delay, which results in more advanced forms, with respect to those seen in older patients, being observed at clinical examination.

Sebaceous Carcinoma Arising from the Eyelid and from Extra-Ocular Sites

Sebaceous carcinoma is slow growing, locally aggressive and capable of metastatic spread. The natural history of sebaceous carcinoma arising from the eyelid is well known, but less than 100 cases arising from other cutaneous sites have been reported. Five cases of sebaceous carcinoma, 3 of which originated from the eyelid and 2 from extraocular sites are here reported. The patients (3 men and 2 women; median age, 69 years) were treated at the Istituto Nazionale Tumori of Milan between 1974 and 1984. Pathologic features, complete follow-up and natural history are reported.

Nuclear Morphology in False Negative and Negative Rectal Biopsies

An atypical nuclear structure consisting of a cribriform and condensed chromatin pattern with hyperchromasia, a small nucleolus and a moderately increased nuclear-cytoplasmic ratio was observed in the epithelial cells of the crypts and in the stromal and muscular cells of 51 out of 70 oncologically negative biopsies of the rectal mucosa. The subsequent retrieval of all clinical and histologic data revealed that the 51 cases included 39 of adenocarcinoma of the large intestine either present (15 cases) at a variable distance from the false negative biopsy or removed previously (24 cases), 7 of extraintestinal malignant tumor (parotid gland, urinary bladder, endometrium, breast, stomach, metastatic, anus) and 5 with benign conditions of the large intestine. Of the remaining 19 cases whose biopsies did not reveal the atypical nuclear structure 16 had benign lesions of the large intestine and nowhere evidence of malignancy, two had an adenocarcinoma of the large bowel (one present and one removed previously) and one a carcinoma of the anus. In the rectal biopsies examined the atypical nuclear structure was detected in 93.9 % of the cases with a malignant tumor either present or removed previously and in 19 % of the cases with benign conditions. The morphologic evidence indicated that the atypical nuclear structure was compatible with a possible disturbance of the mitotic cycle since the findings were restricted to the generative compartment of rectal epithelium. The results are discussed in connection with their possible practical use as a diagnostic aid in the evaluation and interpretation of false negative and negative rectal biopsies as well as with their possible significance in the biology of tumor-bearing hosts.

A Case of Adenocarcinoma of the Upper Third of the Esophagus Arising on Ectopic Gastric Tissue

A case of adenocarcinoma of the upper third of the esophagus, arising from ectopic mucosa of gastric type, is described. The possible origins, from ectopic islets of gastric mucosa, tracheobronchial rests or esophageal glands, are discussed. The precence of ectopic gastric mucosa on the surface of the esophagus adjacent to the tumor suggests that this esophageal adenocarcinoma arose from ectopic gastric mucosa.

Immunohistochemical Reactivity of the Antimelanoma Monoclonal Antibody Mel-1

The immunohistochemical reactivity of the monoclonal antimelanoma antibody MEL-1 was evaluated on frozen sections of 9 malignant melanomas, 5 nevi, 1 squamous cell carcinoma, 1 basal cell carcinoma, 2 benign dermal fibrous histiocytomas, 1 infiltrating ductal and 2 infiltrating lobular carcinomas of the breast, 1 primary squamous cell carcinoma and 1 adenocarcinoma of the lung, 1 lung metastasis of gastric adenocarcinoma, 1 adenocarcinoma of the large bowel, 1 lymph node, 1 case of malignant histiocytosis and one of lymph nodal immunoblastic lymphoma, and 1 biopsy of oral cavity mucosa. In primary and metastatic malignant melanoma, junctional nevi, and the upper half of compound and dermal nevi, the staining was intense. Also, benign dermal fibrous histiocytoma and the case of lymph nodal malignant histiocytosis showed an intense reactivity, whereas the immunostaining positivity of the squamous cell carcinoma of the skin, the lung adenocarcinoma, the squamous cutaneous and mucosal epithelium, and the sweat and sebaceous glands was slight. In ductal and lobular infiltrating carcinoma of the breast only focal areas or isolated tumor cells were positive. The lack of reactivity of deep dermal melanocytes of compound and dermal nevi may be correlated with a different antigenic phenotype of the melanocytes. After discussion of the technical problems, the application of MEL-1 was suggested, for diagnostic purpose, to identify lymph nodal metastases in cases of primary self regressed malignant melanoma and to detect lymph nodal metastatic microfoci of malignant melanoma.

Surgery for Malignant Mesenchymal Tumors of the Breast: A Series of 31 Cases

Thirty-one cases of malignant mesenchymal tumors of the breast were analyzed with the purpose of identifying the most suitable type of surgery to be recommended. All the cases considered underwent pathologic review. Even young women were affected, and menopausal status did not seem to influence the development of mesenchymal tumors. Mammography was of little use for diagnosis. All cases underwent surgery and 26 had an adequate follow-up. In 8 cases a relapse occurred with a mean free interval of 6 months. Total mastectomy was sufficient to provide local control, whereas axillary dissection turned out to be not worthwhile. Postoperative radiotherapy did not improve distant results. Relapses mainly consisted of lung metastases. Fifteen patients were alive, free of disease, at a time ranging from 9 months to 13 years after surgery.

Topography and Clinical Characteristics of Malignant Tumors of the Urachus

Nine patients with urachal tumors have been reevaluated. There were 5 men and 4 women, whose ages ranged from 6 to 72 years. Surgery was performed in 4 cases, radiotherapy was used in 2 cases, and the remaining 3 cases were judged to be beyond therapeutic help. Three years after treatment, also all cases subjected to therapy were dead. The diagnostic delay, the inadequacy of treatment, and therefore the absolutely unfavorable prognosis of these tumors are discussed.

A Case of Pancreatoduodenectomy as Resolutive Treatment for a Solitary Metastasis of Breast Cancer

A 49-year-old woman was hospitalized for obstructive jaundice 4 years after extended mastectomy for lobular infiltrating carcinoma. After routine investigations that detected a malignant lesion of the pancreas head, the patient underwent pancreatoduodenectomy. The surgical specimen revealed unexpected breast carcinoma metastatic to the pancreas and duodenum wall. The woman is alive and free of disease at 10 years from the mastectomy and 6 years from the pancreatoduodenectomy. This experience confirms the validity of a surgical radical treatment for metastatic lesions in selected cases.

Convoluted Cell Lymphoblastic Lymphoma

The recent identification among non-Hodgkin's malignant lymphomas of a high-grade malignancy entity of possible thymic origin and defined as lymphoblastic convoluted-cell lymphoma allowed the morphologic and radiological diagnosis of nine cases of this disease. Males outnumbered females (6/9) and the age ranged from 6 to 54 years. The histologic diagnosis relied upon the characteristic non cohesive cellularity as well as upon the peculiar cribriform nuclear structure, the convoluted appearance of the nuclei, the anisokaryosis, the paucity of the cytoplasm and the minimal size of the nucleoli. The anatomical distribution of the disease was ascertained in the lymph nodes, spleen, liver and several other extranodal sites. Bone marrow invasion was observed in seven cases and presence of lymphoma cells in the peripheral blood in six. A thymic mediastinal mass was present radiologically in seven cases and lymphography was positive in five. Follow-up data revealed death of four patients within 10 months and survival of two up to 17 months. The cellular morphology of the malignant lymphoma seems to be sufficiently diagnostic. This entity deserves an autonomous position within the classifications of malignant lymphomas as it appears in the functional one proposed by Lukes and Collins (21) as well as in the Kiel classification (13).

Deciphering microvascular changes after myocardial infarction through 3D fully automated image analysis

The microvasculature continuously adapts in response to pathophysiological conditions to meet tissue demands. Quantitative assessment of the dynamic changes in the coronary microvasculature is therefore crucial in enhancing our knowledge regarding the impact of cardiovascular diseases in tissue perfusion and in developing efficient angiotherapies. Using confocal microscopy and thick tissue sections, we developed a 3D fully automated pipeline that allows to precisely reconstruct the microvasculature and to extract parameters that quantify all its major features, its relation to smooth muscle actin positive cells and capillary diffusion regions. The novel pipeline was applied in the analysis of the coronary microvasculature from healthy tissue and tissue at various stages after myocardial infarction (MI) in the pig model, whose coronary vasculature closely resembles that of human tissue. We unravelled alterations in the microvasculature, particularly structural changes and angioadaptation in the aftermath of MI. In addition, we evaluated the extracted knowledge's potential for the prediction of pathophysiological conditions in tissue, using different classification schemes. The high accuracy achieved in this respect, demonstrates the ability of our approach not only to quantify and identify pathology-related changes of microvascular beds, but also to predict complex and dynamic microvascular patterns.

3D Image Analysis of the Microvasculature in Healthy and Diseased Tissues

The vasculature ensures optimal delivery of nutrients and oxygen throughout the body. The ability to respond to changing tissue demands requires constant reshaping of the vascular network through modulation of its density, diameter, or patterning. These processes are especially prominent after tissue damage or in tumors. The matrix metalloproteinase (MMP) family of endopeptidases are key contributors to vascular remodeling, able to cleave all extracellular matrix components and also soluble factors and membrane receptors. Observations recorded over several decades have established that the vasculature changes in pathological contexts, and this has formed the basis for developing angiotherapies as a novel approach to treating disease. For example, inhibition of angiogenesis or normalization of the vasculature has been proposed as treatment for cancer and chronic inflammatory diseases. In contrast, boosting angiogenesis may be helpful in ischemic conditions such as myocardial infarction and in regenerative medicine. Classical histological methods for the analysis of tissue vasculature have relied on thin sections that do not capture the complex 3D structure of the vascular network. Given the importance of understanding disease-associated vascular changes for the development of rational angiotherapeutic interventions, we present a protocol for thick section-based 3D image analysis of vasculature structure and function.

New sepsis criteria: do they replace or complement what is known in the approach to the infectious patient?

There have recently been profound changes in both the definitions of sepsis and septic shock and the diagnostic criteria established for daily clinical practice. In addition, a new screening tool known as qSOFA has been introduced to identify patients at risk of a poor short-term outcome. This score has been accompanied by some controversy due to presenting a lower sensitivity than the systemic inflammatory response criteria previously used to identify such patients. In this article, we shall summarise and analyse the most important recently published studies in relation to these new criteria.

Melanocytic nevi and non-neoplastic hyperpigmentations

This is the first of three chapters that will be progressively published on Pathologica as updating activity of the Italian Study Group of Dermatopathology (GISD), Italian Society of Pathology and Cytology (SIAPeC IAP). The first chapter concerns non-neoplastic hyperpigmented skin lesions and nevi, the second will address the topics of dysplastic nevus, borderline and low malignant potential melanocytic proliferations and the third melanoma in its variants and differential diagnoses with a supplement on the immunohistochemistry and molecular support to diagnostic and prognostic definition of nevi and melanomas. Although we believe that great advances were made in the application of ancillary genetic, immunohistochemical and molecular techniques, for the diagnosis and biological characterization of melanocytic tumors the morphology still remains the gold standard. These chapters are not intended as substitutes or even claim to be compared to the numerous and valuable texts that are also recently published, but they want to present, concisely and quickly available, all of those traits that we believe essential to the histopathological evaluation of a melanocytic lesion. No morphological parameter is exclusive and individually sufficient to make the correct diagnosis of nevus or melanoma but to reach a final conclusive and appropriate interpretation a set of morphological characters must be evaluated and compared. I was lucky enough to be able to examine several thousand cases and to draw lessons from each of these increasing my diagnostic experience. I had a great lesson by my teacher and good friend Prof. Martin C. Mihm Jr of Boston, dermato-pathologist with undisputed international reputation, who, with great passion, patience and friendship, transferred me much of his experience and knowledge and for which I always thank him. Special thanks I would like to address Dr. Agostino Crupi, dermatologist, skin-oncologist and brilliant dermatoscopist who taught me how the diagnosis of melanocytic lesions starts from the clinic examination and the mutual comparison between dermatologist and pathologist is a great richness of knowledge for both. Finally thank to my collaborators Barbara Rubino, Barbara Bruni and Antonella Festa for the large number of material collected in these years at the Pathology Service of the IRCCS Policlinico San Donato and a particular thank to Marco Turina who collaborated in the drafting of this text.

Pivotal role for skin transendothelial radio-resistant anti-inflammatory macrophages in tissue repair

Heterogeneity and functional specialization among skin-resident macrophages are incompletely understood. In this study, we describe a novel subset of murine dermal perivascular macrophages that extend protrusions across the endothelial junctions in steady-state and capture blood-borne macromolecules. Unlike other skin-resident macrophages that are reconstituted by bone marrow-derived progenitors after a genotoxic insult, these cells are replenished by an extramedullary radio-resistant and UV-sensitive Bmi1⁺ progenitor. Furthermore, they possess a distinctive anti-inflammatory transcriptional profile, which cannot be polarized under inflammatory conditions, and are involved in repair and remodeling functions for which other skin-resident macrophages appear dispensable. Based on all their properties, we define these macrophages as Skin Transendothelial Radio-resistant Anti-inflammatory Macrophages (STREAM) and postulate that their preservation is important for skin homeostasis.

DOI:http://dx.doi.org/10.7554/eLife.15251.001

The skin forms an essential barrier that defends our body from external damage. For this reason, it is important to understand the complex mechanisms involved in healing wounds and maintaining healthy skin. This could allow us to find effective treatments for skin diseases such as atopic dermatitis and psoriasis.

Immune cells called macrophages can protect the body in different ways depending on the signals they receive. Their protective roles include killing microbes that may cause disease, and helping to repair damaged tissues. Barreiro et al. have now investigated the roles of the macrophages in the skin by means of a number of complementary techniques, including a method called intravital microscopy that can image cells in a living organism.

The experiments revealed that a division of labor exists among the macrophages that reside in the skin of mice. Some macrophages help to trigger inflammatory responses in the skin. These immune cells disappear after being exposed to ionizing radiation (such as that used to treat cancer) but can be replaced via a bone marrow transplant. Other macrophages that help to repair tissues can survive being exposed to ionizing radiation but cannot resist high levels of ultraviolet light. Both types of macrophages perform unique and essential roles, and both types are necessary for maintaining healthy skin.

Barreiro et al. also discovered that the skin macrophages that help to repair tissues have the ability to move into blood vessels and take up substances from the blood. A question for future investigation is whether the macrophages perform this scavenging process to trigger a protective immune response in the nearby skin.

DOI:http://dx.doi.org/10.7554/eLife.15251.002

Analysis of metallic traces from the biodegradation of endomedullary AZ31 alloy temporary implants in rat organs after long implantation times

AZ31 alloy has been tested as a biodegradable material in the form of endomedullary implants in female Wistar rat femurs. In order to evaluate the accumulation of potentially toxic elements from the biodegradation of the implant, magnesium (Mg), aluminium (Al), zinc (Zn), manganese (Mn) and fluorine (F) levels have been measured in different organs such as kidneys, liver, lungs, spleen and brain. Several factors that may influence accumulation have been taken into account: how long the implant has been in place, whether or not the bone is fractured, and the presence of an MgF2 protective coating on the implant. The main conclusions and the clinical relevance of the study have been that AZ31 endomedullary implants have a degradation rate of about 60% after 13 months, which is fully compatible with fracture consolidation. Neither bone fracture nor an MgF2 coating seems to influence the accumulation of trace elements in the studied organs. Aluminium is the only alloying element in this study that requires special attention. The increase in Al recovered from the sampled organs represents 3.95% of the amount contained in the AZ31 implant. Al accumulates in a statistically significant way in all the organs except the brain. All of this suggests that in long-term tests AZ31 may be a suitable material for osteosynthesis.

Fracture bone healing and biodegradation of AZ31 implant in rats

The ideal temporary implant should offer enough mechanical support to allow healing of the fracture and then biodegrade and be resorbed by metabolic mechanisms without causing any toxic effect. The aim of this research has been to simultaneously study in situ bone healing and the biodegradation of AZ31 Mg alloy as an osteosynthesis material. The in vivo study was carried out in AZ31 implants with and without Mg-fluoride coating inserted in un-fractured and fractured femurs of Wistar rats for long experimentation time, from 1 to 13 months, by means of computed tomography, histological and histomorphometric analysis. Tomography analysis showed the bone healing and biodegradation of AZ31 implants. The fracture is healed in 100% of the animals, and AZ31 maintains its mechanical integrity throughout the healing process. Biodegradation was monitored, quantifying the evolution of gas over time by 3D composition of tomography images. In all the studied groups, gas pockets disappear with time as a result of the diffusion process through soft tissues. Histomorphometric studies reveal that after 13 months the 46.32% of AZ31 alloy has been resorbed. The resorption of the coated and uncoated AZ31 implants inserted in fractured femurs after 1, 9 and 13 months does not have statistically significant differences. There is a balance between the biodegradation of AZ31 and bone healing which allows the use of AZ31 to be proposed as an osteosynthesis material.

Modelling human eye under blast loading

Primary blast injury (PBI) is the general term that refers to injuries resulting from the mere interaction of a blast wave with the body. Although few instances of primary ocular blast injury, without a concomitant secondary blast injury from debris, are documented, some experimental studies demonstrate its occurrence. In order to investigate PBI to the eye, a finite element model of the human eye using simple constitutive models was developed. The material parameters were calibrated by a multi-objective optimisation performed on available eye impact test data. The behaviour of the human eye and the dynamics of mechanisms occurring under PBI loading conditions were modelled. For the generation of the blast waves, different combinations of explosive (trinitrotoluene) mass charge and distance from the eye were analysed. An interpretation of the resulting pressure, based on the propagation and reflection of the waves inside the eye bulb and orbit, is proposed. The peculiar geometry of the bony orbit (similar to a frustum cone) can induce a resonance cavity effect and generate a pressure standing wave potentially hurtful for eye tissues.

Metabolic effects of a diet with inulin-enriched pasta in healthy young volunteers

Different lines of evidence suggest that higher intake of fiber may somehow protect against metabolic syndrome. The prebiotic inulin has widely been studied in relation to its putative beneficial effects on lipid and glucose metabolism. Therefore, adding inulin to diet may be a suitable strategy to prevent metabolic syndrome. Aim of the present study was to evaluate the effects of the daily consumption of inulin-enriched pasta on lipid and glucose metabolism as well as on gastrointestinal motility in young healthy subjects. Methods. Twenty-two healthy young male volunteers entered a randomized double blind cross-over study consisting of a 2-weeks a run-in period, two 5-weeks study periods (11% inulin-enriched or control pasta), and an 8-weeks wash-out period in between. Serum lipid and glucose concentrations were evaluated by routine biochemical analyses. Gastric emptying time and electrical activity were non-invasively evaluated by ultrasound and electrogastrography. Data were analyzed by Friedman Repeated Measures ANOVA test. Results. Significant differences among baseline and the treatment group were found for HDL-cholesterol (p=0.004), total cholesterol/HDL-cholesterol ratio (p=0.006), triglycerides (p=0.04), fasting glucose level (p=0.044), fructosamine (p=0.0478), HbA1c (p=0.04), and homeostatic model assessment (HOMA-IR) (p=0.045). The gastric emptying, expressed as final emptying time, was found significantly delayed in the group that assumed inulin-enriched pasta (p=0.008). Conclusions. Inulin-enriched pasta improved lipidic and glicidic metabolism as well as the insulin resistance in healthy young subjects. In addition, it delayed the gastric emptying time which may represent the physiological counterpart of its metabolic effects.

Atypical esophageal vascular lesions observed in liver cirrhosis

Chronic liver disease is known to be associated with several vascular alterations including portal hypertension and hepato-pulmonary insufficiency. We report a case of esophageal vascular lesions resembling spider naevi in a patient with nonalcoholic cirrhosis who underwent an upper gastrointestinal (GI) endoscopy. We observed the presence of multiple white round elevations, 5-6 mm in size, with radiating thin-walled vessels, in the middle and distal esophagus. The histological examination documented the presence of multiple dilated blood vessels in the mucosal layer of the esophagus, with striking thickening of the endothelium wall. There was no evidence of esophagogastric varices, but only of a moderate congestive antral gastropathy. To our knowledge, these endoscopic esophageal findings have not yet been described in cirrhosis.

A fluorescence in situ hybridization (FISH) procedure to assist in differentiating benign from malignant melanocytic lesions

OBJECTIVE

Misdiagnosis of melanocytic lesions can result in unnecessary psychological distress to patients, under- or overtreatment, inaccurate prognosis and improper follow-up and family member surveillance. It is well recognized that, despite many attempts to 1) put forth a set of histologic criteria that can accurately and reproducibly be used to diagnose melanocytic lesions, and 2) identify reliable markers of malignancy as an adjunct to routine histopathology, misdiagnoses still occur in a significant number of cases.

METHOD

A multi-color FISH probe mixture has been devised to assist pathologists in differential diagnosis of difficult melanocytic lesions. The mixture includes a centromeric probe for chromosome 6 and unique sequence probes for three other chromosomal regions that have most frequently shown amplifications or deletions in melanoma. We have carried out a preliminary evaluation of this new probe set in 25 cases of benign and malignant pigmented lesions.

RESULTS

The tool reliably identified all nevi and ordinary melanomas, and only failed to identify a pigmented epithelioid melanocytoma and two malignant lesions that, by morphology and behavior, have distinct features from common invasive melanomas, i.e., a desmoplastic melanoma and a nevoid melanoma. Considering this, 100% specificity and 75% sensitivity was achieved.

CONCLUSION

The FISH tool used in this study was able to separate accurately benign nevi from ordinary melanoma. Failure to identify uncommon melanocytic lesions adds to its advantage and calls for further studies to unveil the molecular profile of these rare entities.

Greenhouse evaluation of struvite and sludges from municipal wastewater treatment works as phosphorus sources for plants

Sewage sludge obtained by a conventional aerobic activated sludge process (CSS), P-rich sewage sludge from an enhanced biological P removal process (PRS), and struvite (MgNH 4PO 4 x 6H 2O) recovered from an anaerobic digester supernatant using a low-grade MgO byproduct from the calcination of natural magnesite as a Mg source (STR) were evaluated as P sources for plant growth. For this purpose, a greenhouse pot experiment was conducted using a P-deficient loamy sand soil and perennial ryegrass ( Lolium perenne L.) as the test crop. The P sources were applied at rates equivalent to 0, 9, 17, 26, 34, and 44 mg/kg P. Single superphosphate (SUP) was used as reference for comparison with the other P sources. The results obtained indicated that STR was as effective as SUP in increasing the dry matter yield and supplying P to ryegrass. Compared to SUP and STR, PRS and especially CSS exhibited less agronomic effectiveness as P sources, which may be attributed, at least partially, to greater soil P fixation because of the larger amount of Fe incorporated with these materials.

Phenotypic expression of familial amyloid polyneuropathy in Brazil

Familial amyloid polyneuropathy (FAP) is an inherited amyloidosis mainly associated with transthyretin Val30Met variant. Clinical heterogeneity has been reported in different populations with FAP and Va130Met variant. In order to characterize FAP expression in Brazilians and to compare its features to those reported in other cohorts, 44 Brazilian patients (27 females, median age 36 [23-53] years) with FAP and the Val30Met variant were investigated. Approximately 40% of their family members, with the exception, of parents and siblings, had FAP. Most of the patients had symptoms of peripheral neuropathy at onset. Median age at onset was 32 [20-44] years. Earlier onset was observed in males (27 [20-43] years in males vs. 33 [20-44] years in females, P = 0.02) and in patients whose parents had FAP (31 [20-44] years vs. 40 [37-43] years in patients, respectively with and without affected parents, P = 0.03). Phenotypic expression of FAP in Brazil is similar to the one reported in Portugal, characterized by high disease penetrance, early onset, particularly in males and in subjects with affected parents, and major symptoms of peripheral neuropathy. These data highlight the influence of common genetic factors, shared by both groups of patients, in disease expression.