Longer Leukocytes Telomere Length Predicts a Significant Survival Advantage in the Elderly TRELONG Cohort, with Short Physical Performance Battery Score and Years of Education as Main Determinants for Telomere Elongation

Leukocyte telomere length (LTL) represents a key integrating component of the cumulative effects of environmental, lifestyle, and genetic factors. A question, however, remains on whether LTL can be considered predictive for a longer and healthier life. Within the elderly prospective TRELONG cohort (n = 612), we aimed to investigate LTL as a predictor of longevity and identify the main determinants of LTL among many different factors (physiological and lifestyle characteristics, physical performance and frailty measures, chronic diseases, biochemical measurements and apolipoprotein E genotyping). We found an ever-increasing relationship between LTL quartiles and survival. Hazard ratio analysis showed that for each unit increase in LTL and Short Physical Performance Battery (SPPB) scores, the mortality risk was reduced by 22.41% and 8.78%, respectively. Conversely, male gender, Charlson Comorbidity Index, and age threatened survival, with mortality risk growing by 74.99%, 16.57% and 8.5%, respectively. Determinants of LTL elongation were SPPB scores (OR = 1.1542; p = 0.0066) and years of education (OR = 1.0958; p = 0.0065), while male gender (OR = 0.4388; p =  0.0143) and increased Disease Count Index (OR = 0.6912; p  =  0.0066) were determinants of LTL attrition. Longer LTL predicts a significant survival advantage in elderly people. By identifying determinants of LTL elongation, we provided additional knowledge that could offer a potential translation into prevention strategies.

C9orf72, age at onset, and ancestry help discriminate behavioral from language variants in FTLD cohorts

Objective

We sought to characterize C9orf72 expansions in relation to genetic ancestry and age at onset (AAO) and to use these measures to discriminate the behavioral from the language variant syndrome in a large pan-European cohort of frontotemporal lobar degeneration (FTLD) cases.

Methods

We evaluated expansions frequency in the entire cohort (n = 1,396; behavioral variant frontotemporal dementia [bvFTD] [n = 800], primary progressive aphasia [PPA] [n = 495], and FTLD–motor neuron disease [MND] [n = 101]). We then focused on the bvFTD and PPA cases and tested for association between expansion status, syndromes, genetic ancestry, and AAO applying statistical tests comprising Fisher exact tests, analysis of variance with Tukey post hoc tests, and logistic and nonlinear mixed-effects model regressions.

Results

We found C9orf72 pathogenic expansions in 4% of all cases (56/1,396). Expansion carriers differently distributed across syndromes: 12/101 FTLD-MND (11.9%), 40/800 bvFTD (5%), and 4/495 PPA (0.8%). While addressing population substructure through principal components analysis (PCA), we defined 2 patients groups with Central/Northern (n = 873) and Southern European (n = 523) ancestry. The proportion of expansion carriers was significantly higher in bvFTD compared to PPA (5% vs 0.8% [p = 2.17 × 10⁻⁵; odds ratio (OR) 6.4; confidence interval (CI) 2.31–24.99]), as well as in individuals with Central/Northern European compared to Southern European ancestry (4.4% vs 1.8% [p = 1.1 × 10⁻²; OR 2.5; CI 1.17–5.99]). Pathogenic expansions and Central/Northern European ancestry independently and inversely correlated with AAO. Our prediction model (based on expansions status, genetic ancestry, and AAO) predicted a diagnosis of bvFTD with 64% accuracy.

Conclusions

Our results indicate correlation between pathogenic C9orf72 expansions, AAO, PCA-based Central/Northern European ancestry, and a diagnosis of bvFTD, implying complex genetic risk architectures differently underpinning the behavioral and language variant syndromes.

The SIRT1 promoter polymorphic site rs12778366 increases IL-6 related human mortality in the prospective study "Treviso Longeva (TRELONG)"

Studies on sirtuins (SIRT), a family of proteins with deacetylase activity, have provided convergent evidence of the key role of these enzymes in aging-linked physiological functions. The link between SIRT1 and longevity has emerged in model organism but few data are available in humans, in particular relying on longitudinal studies. Here, we assessed whether a genetic variant within SIRT1 gene promoter (rs12778366) was associated to human longevity. We analyzed 586 genomic DNA (gDNA) collected in the study "Treviso Longeva" (TRELONG), including elderly over 70 years of age from the municipality of Treviso, a town in the Northeast of Italy, with a 11-year follow-up. We genotyped SIRT1 rs12778366 by real-time polymerase chain reaction (RT-PCR) allelic discrimination assay. A cross-sectional analysis performed by comparing people over and under 85 years of age did not evidence association between rs12778366 and longevity. When we performed a longitudinal analysis considering mortality as dependent variable, we did not observe an association of rs12778366 with longevity in the whole population (corrected P-value = 0.33). However, when we stratified the TRELONG subjects according to circulating level of interleukin-6 (IL-6), a predictor of disability and mortality, we found that rs12778366 (TC+CC) carriers were at increased risk of mortality in comparison to the TT reference group (corrected P-value = 0.03, HR 1.47). Our data do not support a major role of rs12778366 in human longevity, but the stratified analysis on IL-6 suggests that this variant may be involved in the detrimental effect of high circulating IL-6 in the elderly.

Modulation of human longevity by SIRT3 single nucleotide polymorphisms in the prospective study "Treviso Longeva (TRELONG)"

Human sirtuins are seven proteins with deacetylase activity that are emerging as key modulators of basic physiological functions. Some evidence links SIRT3 to longevity in mammals. This study aimed to investigate whether variants within SIRT3 gene were associated to human longevity. We analyzed 549 genomic DNA collected during the prospective study "Treviso Longeva," including elderly over 70 years of age from the municipality of Treviso, a small city in the northeast of Italy. We genotyped SIRT3 rs3825075, rs4980329, and rs11555236 single nucleotide polymorphisms (SNPs) by real-time polymerase chain reaction allelic discrimination assay. A cross-sectional analysis performed by comparing people over and under 85 years of age did not evidence association among the SIRT3 SNPs and longevity. However, when we performed a longitudinal analysis considering mortality as a dependent variable, we observed an association of SIRT3 rs11555236 and rs4980329 with longevity in the whole population (p values corrected for potential confounders = 0.04 and 0.03, respectively). After stratification according to gender, the same SNPs were associated to female longevity only (p values corrected for potential confounders = 0.03 and 0.02, respectively). Finally, as rs11555236 was reported to be in linkage disequilibrium with a putative functional enhancer within the SIRT3 gene, we assessed whether rs11555236 genotypes correlated with a different level of SIRT3 protein in peripheral blood mononuclear cells. We found an increased level of SIRT3 in subjects homozygous for the (T) allele. We suggest that SIRT3 genetic variability might be relevant for the modulation of human longevity in the Italian population.

Body mass index, lifestyles, physical performance and cognitive decline: the "Treviso Longeva (TRELONG)" study

OBJECTIVES

The relative contributions of risk factors, as body mass index (BMI), depression, chronic diseases, smoking, and lifestyles (as physical and performance activity, social contacts and reading habit) to cognitive decline in the elderly are unclear. We explored these variables in relation to 7-year cognitive decline in long-lived Italian elderly.

DESIGN

Secondary data analysis of a longitudinal study of a representative, age-stratified, population sample.

SETTING

The TREVISO LONGEVA (TRELONG) Study, in Treviso, Italy.

PARTICIPANTS

120 men and 189 women, age 77 years and older (mean age 80.2 ± 6.9 years) survivors after seven years of follow up.

MEASUREMENTS

Cognitive decline measured as difference between Mini-Mental State Examination (MMSE) score in 2003 and in 2010; Body mass index (BMI), handgrip, Short Physical Performance Battery (SPPB) score, social contacts, reading habit, sight, hearing, schooling, mediterranean diet and multiple clinical and survey data recorded at baseline in 2003.

RESULTS

In separate univariate analyses, age, SPPB score < 5, depressive symptoms (GDS) and more comorbidities (CCI) were associated with greater cognitive decline. Otherwise higher BMI, higher handgrip, reading habit, non-deteriorated sight and hearing, and schooling were protective. In a final multivariate model, age and higher BMI were associated with greater cognitive decline while reading habits was protective. SPPB score < 5 tends, though weakly, to be associated with greater cognitive decline. These associations remained with multivariate adjustment for gender, schooling, Charlson co-morbidity index (CCI) and baseline MMSE.

CONCLUSION

Age and higher baseline BMI, independent of gender, and other confounding factors, are risk factors for cognitive decline. Reading habit plays a protective role seven years later among northern Italian adults aged 70 years or older. Low physical performance tends, though weakly, to be associated with greater cognitive decline.

THE TREVISO DEMENTIA (TREDEM) STUDY: A BIOMEDICAL, NEURORADIOLOGICAL, NEUROPSYChOLOGICAL AND SOCIAL INVESTIGATION OF DEMENTIA IN NORTH-EASTERN ITALY

The incidence of dementia increases exponentially with age but knowledge of real disease-modifying interventions is still limited. Objectives: To describe the study design and methods of a large prospective cohort study aimed at exploring the complex underlying relationships existing among cognition, frailty, and health-related events in older persons with cognitive impairment. Design: Prospective cohort study of a representative population of outpatients attending the Treviso Cognitive Impairment Center between 2000 and 2010. Setting: The TREVISO DEMENTIA (TREDEM) Study conducted in Treviso, Italy. Participants: 490 men and 874 women, mean age 79.1 ± 7.8 years (range 40.2–100 years). Measurements: Physiological data, biochemical parameters, clinical conditions, neuroradiological parameters (e.g., brain atrophy and cerebral vascular lesions identified by computerized tomography scans), neuropsychological assessment, and physical function markers were measured at baseline. Patients were followed-up to 10 years. Results: The final sample included in the study was predominantly composed of women and characterized by an initial physical function impairment and increased vascular risk profile. Cognitive function of the sample population showed moderate cognitive impairment (Mini Mental State Examination 20.2 ± 6.3; Clinical Dementia Rating 1.2 ± 0.7), and a prevalence of vascular dementia of 26.9%. Cortical, subcortical and hippocampus atrophy were all significantly correlated with age and cognitive function. Conclusion: Results obtained from the preliminary analyses conducted in the TREDEM study suggest that the database will support the accomplishment of important goals in understanding the nature of cognitive frailty and neurodegenerative diseases.

Insulin-like growth factor 1 receptor polymorphism rs2229765 and circulating interleukin-6 level affect male longevity in a population-based prospective study (Treviso Longeva--TRELONG)

Insulin-like growth factor 1 (IGF-1) signaling modulation has been associated with increased lifespan in model organisms, while high levels of circulating interleukin-6 (IL-6) are a marker of disability and mortality. In the prospective, population-based "Treviso Longeva"--TRELONG Study from Italy (n = 668, age range 70-105.5 years at baseline, followed for seven years) we investigated the effects of survival on the IGF-1 receptor (IGF-1R) gene polymorphism rs2229765, the IL-6 gene promoter polymorphism rs1800795, and plasma concentrations of IGF-1 and IL-6, alone or in combination. We found a sex-dependent effect for the IGF-1R rs2229765 polymorphism, as male carriers of the homozygous A/A genotype survived longer, while the IL-6 rs1800795 genotype did not influence overall or sex-specific longevity. Higher IL-6 levels were more detrimental for survival among males than females, while IGF-1 had no dose-response effect. These findings sustain the hypothesis that sex-specific longevity relies on detectable differences in genetic and biochemical parameters between males and females.

Effect of conditioning horses every third day at v10 on measures of fitness

This study examined the effect of exercising horses five times per fortnight with two bouts of 5 min duration at their v(10) with 2 days between consecutive exercise sessions. Five Anglo-Arabian horses were treadmill-conditioned for 6 weeks. A standardized exercise test (SET) was performed at the beginning of the conditioning period (CP) to determine the blood lactate-running speed (BLRS) and the heart rate-running speed (HRRS) relationship and the SET was repeated every 2 weeks. After each SET, the BLRS relation was used to calculate the horse's speed (v = velocity), which produced a blood lactate concentration (LA) of 10 mmol/l (v(10) ) and 4 mmol/l (v(4) ). From the HRRS was calculated the speed at which the horses had a heart rate of 180 b/min (v(180) ). Each horse was then conditioned for the next 2 weeks five times at its individual v(10) for two 5-min bouts. Exercise speed was individually adapted to the new v(10) every 2 weeks. In addition, horses were submitted to another SET prescription to determine the peak oxygen consumption (VO(2 peak) ) before, after 3 weeks and at the end of CP. The v(4) of horses increased during the CP (p < 0.05). v(180) did not change (p > 0.05). VO(2 peak) increased in the first 3 weeks of CP (p < 0.05) and levelled off afterwards (p > 0.05). The conclusion drawn was that exercising horses five times per fortnight at their v(10) for two 5-min bouts with 2 days between consecutive exercise sessions improved v(4) and VO(2 peak) but not v(180).

Total hip arthroplasty offset measurement: is C T scan the most accurate option?

BACKGROUND

Femoral offset is difficult to precisely evaluate with conventional X-ray techniques. Femoral offset characterizes the balance between body weight and the resistance provided by the abductor muscles. Total hip arthroplasties should respect this balance.

HYPOTHESIS

Computed tomodensitometry (CT-scan) is more accurate than conventional X-ray to evaluate femoral offset.

MATERIALS AND METHODS

Sixty-one patients who received unilateral total hip arthroplasties were prospectively included in the study. Femoral offset was measured by three-dimensional CT-scan reconstruction using the "Hip Plan" (Symbios) software. Offset was also determined with conventional X-ray and results were compared. This software can be used to measure leg length by frontal telemetry. It was developed for preoperative-planning of cementless femoral stem implants with modular necks of various lengths and angles. All pre- and postoperative measurements were made according to the same protocol.

RESULTS

Femoral offset values in this study were very similar to anatomical values found in the literature. They were significantly higher than values obtained by conventional X-ray by an average of 8%. Implantation of hip replacements resulted in a significant increase in offset (1.88+/-4.71 mm) with a slight variation in leg length. Pre- and postoperative leg length increased slightly in the operated leg by an average of 1.66+/-5.63 mm. Seventeen percent of these femurs had high offset associated with small or average sized proximal medullary canals. This preoperative planning software made it possible to identify these difficulties and to adapt implant components using modular long 8 degrees varus necks to restore high offset. In most of these cases, only small femoral stems could be implanted because of the small size of the intramedullary femoral canal. These individual differences were identified with 3D CT-scan reconstruction and included in the preoperative planning. Moreover, leg length could also be evaluated with this method and included in the preplanning.

DISCUSSION

Compared to conventional X-ray, measurements obtained with this preoperative planning method using 3D CT-scan reconstruction are easy to obtain and not dependent upon test conditions because the frame is placed on the femoral axis. Measurements are not influenced by position inconsistencies or if the hip is fixed in external rotation. The significant number of cases with above average offset confirms the importance of obtaining these measurements and the necessity of adapting the strategy in these cases by using lateralized stems, or, as in our series, modular necks to adjust femoral offset and neck angle.

LEVEL OF EVIDENCE

Level III diagnostic prospective study.

Effect of neoadjuvant combined modality therapy with weekly docetaxel (D) and cisplatin (P), 5-fluorouracil (5-FU) continuous infusion (c.i.), and concurrent radiotherapy (RT) on pathological response rate in esophageal cancers (EC): A phase II study

4548

Background: The achievement of pathological complete response (pCR) seems essential to improve survival in EC. In a phase I study (Pasini et al, Ann Oncol 2005) we demonstrated the feasibility of a novel protocol of neoadjuvant chemoradiation. Based on these promising results, we have performed a phase II study. The primary end point was the pathological response rate, the secondary end points were survival and toxicity. Methods: 74 pts with stage II-III EC (37 adenocarcinomas) were enrolled; median age was 59 yrs (42–73). Treatment consisted of D 35 mg/m2 and P 25 mg/m2 d 1,8,15,29,36,43,50,57 plus 5-FU 180 mg/m2 c.i. d 1–21 and 150 mg/m2 c.i. d 29–64; concurrent RT (50 Gy) started on d 29. Surgery was performed 6 to 8 weeks after completion of RT. Results: 65/74 pts (88%) completed the planned chemo-radiation, while 9 required dose modification of chemotherapy. Median follow-up of living pts was 40 mo (18–75). Pathological findings: pT0 pN0 (pCR): 35 (47%); pTrm pN0:11 (15%)[residual microfoci]; Others: 28 (38%). The overall median survival was 50 mo; median survival times of Others, pTrm, and pCR subsets were 17, 42 months and not reached, respectively (p<0.001). The 3 years survival rates were 81%, 63.5% and 26% for pCR, pTrm and Othes subsets, respectively. During chemoradiation, grade 3–4 hematological toxicity occurred in 10 pts (13.5%); grade 3–4 non-hematological toxicities occurred in 22 pts (30%), mostly in the last 2 weeks. There were 3 toxic deaths (4%): one pulmonary embolism and 2 postoperative deaths. 67 pts underwent surgery, while 7 did not (4 progression, 3 refusal). Conclusions: High pCR rate (47%) and 3-yr survival rate of 81% were achieved. This weekly schedule allowed concomitant chemoradiation at cumulative doses impossible with three weeks protocols. Given the not negligible toxicity, this protocol requires management in dedicated institutions.

[Table: see text]

No significant financial relationships to disclose.

Accuracy of reconstruction of the hip using computerised three-dimensional pre-operative planning and a cementless modular neck

Pre-operative computerised three-dimensional planning was carried out in 223 patients undergoing total hip replacement with a cementless acetabular component and a cementless modular-neck femoral stem. Components were chosen which best restored leg length and femoral offset. The post-operative restoration of the anatomy was assessed by CT and compared with the pre-operative plan.

The component implanted was the same as that planned in 86% of the hips for the acetabular implant, 94% for the stem, and 93% for the neck-shaft angle. The rotational centre of the hip was restored with a mean accuracy of 0.73 mm (sd 3.5) craniocaudally and 1.2 mm (sd 2) laterally. Limb length was restored with a mean accuracy of 0.3 mm (sd 3.3) and femoral offset with a mean accuracy of 0.8 mm (sd 3.1).

This method appears to offer high accuracy in hip reconstruction as the difficulties likely to be encountered when restoring the anatomy can be anticipated and solved pre-operatively by optimising the selection of implants. Modularity of the femoral neck helped to restore the femoral offset and limb length.

Neoadjuvant combined modality therapy with weekly docetaxel (D) and cisplatin (P), 5-fluorouracil (5FU) continuous infusion (c.i.) and concurrent radiotherapy (RT) provides high pathological response rate in esophageal cancers (EC): A phase II study

4057

Background: The achievement of pathological complete response (pCR) is deemed essential to improve survival in EC. In a phase I study (Pasini et al, Ann Oncol 16; 1123, 2005) we demonstrated the feasibility of a novel protocol of neoadjuvant chemoradiation based on weekly D and P, c.i. of 5-FU and concurrent RT. Based on the promising results of the study, we then performed a phase II study aimed at evaluating pathological response rate and toxicity. Methods: 50 pts with stage II-III EC (26 adenocarcinomas) were enrolled (Simon test: P0=0.2, P1=0.6, alpha 0.05 beta 0.1; 54 pts); median age was 59 yrs (42–73). Treatment consisted of D 35 mg/m2 and P 25 mg/m2 d 1,8,15,29,36,43,50,57 plus 5-FU 180 mg/m2 c.i. d 1–21 and 150 mg/m2 c.i. d 29–64; concurrent RT (50 Gy) started on d 29. Surgery was performed 6 to 8 weeks after completion of RT. Results: 49/50 pts (98%) completed the planned chemo-radiation. Median follow-up is 22 mo (7–39). During chemo-radiation, grade 3–4 hematological toxicity occurred in 9 pts (18%)(4 pts grade 4) requiring GCSF support and postponement of CT of one week in 4. One HCV+ pt discontinued CT and continued with RT alone. In the last 2 weeks 12 pts (24%) experienced grade 3 non-hematological toxicities (asthenia, esophagitis, nausea) without need of treatment discontinuation. There was a fatal pulmonary embolism in a non neutropenic pt after completion of the therapy. 45 pts underwent surgery, while 5 did not (2 refusal). Pathological findings: pT0 pN0 (pCR): 25 (50%); pTrm pN0: 6 (12%)[residual microfoci]; pT2 pN0: 1 (2%); pT0–4 pN+: 9 (18% ); R+:4 ( 8%). Response rate was similar between adeno and squamous cell carcinoma. With a median follow-up of 24 mo, only 2 of 25 pCRs (8%) died (1 relapse, 1 postoperative death). Conclusions: i) a substantial pCR rate (50%) was achieved; ii) the weekly schedule allowed concomitant chemo-radiation at cumulative doses otherwise impossible with standard three weeks protocols; iii) because of the acceptable, but not negligible toxicity, this protocol requires to be managed in dedicated institutions.

No significant financial relationships to disclose.

High pathological response rate in locally advanced esophageal cancer after neoadjuvant combined modality therapy: dose finding of a weekly chemotherapy schedule with protracted venous infusion of 5-fluorouracil and dose escalation of cisplatin, docetaxel and concurrent radiotherapy

BACKGROUND

This phase I study was aimed at defining the toxicity profile and pathological response rate of a neoadjuvant schedule including weekly docetaxel and cisplatin, protracted venous infusion (PVI) of 5-FU and concomitant radiotherapy (RT) in locally advanced esophageal cancer.

PATIENTS AND METHODS

The schedule consisted of a first phase of chemotherapy alone and a second phase of concurrent chemoradiation. Initial doses were: docetaxel and cisplatin 20 mg/m2 on days 1, 8, 15, 29, 36 and 43 plus 5-FU 150 mg/m2 PVI on days 1-21 and 29-49; RT (40 Gy) started on day 29. In the following steps the doses were escalated up to docetaxel 35 mg/m2 and cisplatin 25 mg/m2 on days 1, 8, 15, 29, 36, 43, 50 and 57 plus 5-FU 180 mg/m2 PVI on days 1-21 and 150 mg/m2 PVI on days 29-63 concurrently with RT 50 Gy.

RESULTS

Forty-seven patients were enrolled and 46 completed the planned treatment. During the concomitant phase, grade 3-4 hematological toxicities occurred in three patients (6.5%) (or 3/174 cycles) and non-hematological toxicities in six patients (13%) (or 7/179 cycles). A pathological downstaging was obtained in 59.6% of the cases (28/47): complete remission (pCR) in 14 patients, near pCR (residual microfoci on the primary pN0) in eight patients, pT2 pN0 in three patients and partial response on the primary with positive lymph nodes in three patients. Six (13%) and 13 (28%) patients were considered stable and non-responders, respectively. In the last dose level, eight pCR and four near-pCR were obtained out of 15 patients. The maximum tolerable dose was not formally defined because dose escalation was stopped at the last dose level.

CONCLUSION

This schedule represents a feasible treatment and the high pathological response rate is extremely encouraging; the doses found in the last dose-level are the basis for an ongoing phase II study at our institution.

Survellaince Program for Prostate Carcinoma: Preliminary Results on 585 Blood Donors

Population screening for prostatic carcinoma (CP) is a struggled subject, and we don't know the real utility of it. Nowadays the Authors suggest only survey on little groups. In this study the male population of blood donors of our hospital between 45 and 65 years underwent a complete valutation for CP.

From this study we hope to obtain the following results: a) early diagnosis of CP (eradicable); b) eliminate keeper of neoplastic pathology from blood donations (theoretic risk of transmission of neoplastic cells in immunodepressed patients); c) studying the practicability, if we achieve a high percentage of ahdesions at this program, our model could be exportable.

Pattern of recurrence after surgery in adenocarcinoma of the gastro-oesophageal junction

AIMS

This study reports mode, timing and predictive factors of recurrence after curative surgery for cardia cancer.

METHODS

A prospective study in a series of 92 curatively (R0) resected patients from 1988 to 2002.

RESULTS

The 5-year recurrence rate was 71%. Lymph node involvement was the only predictor of recurrence. No patients with more than 6 metastatic nodes were free from relapse 2 years after surgery. Locoregional, peritoneal and haematogenous relapses showed a similar median recurrence time (12, 10 and 12 months, respectively), 80% occurred within 24 months.

CONCLUSIONS

Few patients can be cured by surgery, lymph nodal involvement is the only predictor of recurrence.

Persistent excess mortality from lung cancer in patients with stage I non-small-cell lung cancer, disease-free after 5 years

Among patients with non-small-cell lung cancer (NSCLC), those with pathological stage I have the best expectation of survival; however, survival is reduced to less than 50% in the long term. At present, it is unclear when patients can be reasonably defined as cured, and if they experience a higher incidence of malignant/nonmalignant diseases and a lower expectation of survival than the general population. A total of 134 stage I NSCLC patients, who had undergone resection at the Thoracic Surgery Unit of the General Hospital of Verona (north-eastern Italy) from October 1987 to December 1993, were still disease-free at 5 years. These subjects were further followed up, and morbidity and mortality rates were compared with those recorded in the general population of the same geographical area. The standardised incidence ratios (SIRs) for all malignancies and for lung cancer were higher than expected (2.39, 95% CI=1.6-3.5, P<0.001; 10.1, 95% CI=6.2-15.6, P<0.0001, respectively). The standardised mortality ratio (SMR) was also significantly increased (1.73, 95% CI=1.1-2.6, P=0.013). The excess mortality could be entirely explained by an increase in mortality from lung cancer (5.7, 95% CI=2.8-10.1, P<0.0001). This study shows that patients, resected for pathological stage I NSCLC and tumour-free after 5 years, have a higher incidence of new lung cancer compared with the general population, which in turn determines an excess in all-cause mortality in the following years.

Independent prognostic value of fascin immunoreactivity in stage I nonsmall cell lung cancer

Fascin-1, the most expressed form of fascin in vertebrate tissues, is an actin-bundling protein that induces cell membrane protrusions and increases motility of normal and transformed epithelial cells. Very few data are available on the role of this protein in nonsmall cell lung cancer (NSCLC). Two hundred and twenty patients with stage I NSCLC and long-term follow-up were evaluated immunocytochemically for fascin expression. Overall, variable fascin immunoreactivity was detected in 98% of 116 squamous cell carcinomas, in 78% of 96 adenocarcinomas, in 83% of six large cell carcinomas, and in the two adenosquamous carcinomas under study. Neoplastic emboli were commonly decorated by the antifascin antibody (P<0.001), also when the surrounding invasive carcinoma was unreactive. Fascin immunoreactivity correlated with high tumour grade (P=0.017) and, in adenocarcinomas, with high Ki-67 labelling index (P=0.021). Adenocarcinomas with a prevalent bronchiolo-alveolar in situ component were less commonly immunoreactive for fascin than invasive tumours (P=0.005). Contralateral thoracic or distant metastases were associated significantly with diffuse (>60% immunoreactive tumour cells) fascin expression in adenocarcinomas (P=0.043), and marginally with strong fascin immunostaining in squamous cell carcinomas (P=0.13). No associations were noted with any other clinicopathological variables tested. Patients with tumours showing diffuse (>60% immunoreactive neoplastic cells) and/or strong immunoreactivity for fascin had a shorter survival (P=0.006 for adenocarcinomas and P=0.026 for squamous cell carcinomas), even after multivariate analysis (P=0.014 and 0.050, respectively). The current study documents for the first time that fascin is upregulated in invasive and more aggressive NSCLC, being an independent prognostic predictor of unfavourable clinical course of the disease. Targetting the fascin pathway could be a novel therapeutic strategy of NSCLC.

High-dose chemotherapy in small-cell lung cancer

Small cell lung cancer (SCLC) is highly sensitive both to radiotherapy and chemotherapy. Given its high chemo sensitivity, even two decades ago, SCLC was one of the first malignancies deemed suitable for maximising the dose and dose intensity with the support of autologous bone marrow (ABMT). On the whole, results were disappointing and the procedure was practically abandoned. Nowadays some interest is again emerging due to improvements in supportive care, such as the availability of hematopoietic growth factors and the peripheral blood progenitor cells (PBPC). Data of 505 patients included in 26 studies were reviewed. About two thirds of these patients had LD (limited disease). Late intensification protocols were used in 311 patients who, however, represented only the 30% of the population initially given conventional chemotherapy. Of the patients not achieving complete remission (CR) after induction, high-dose induced a CR in 39% of the cases. The use of early intensification was reported in 8 studies including 194 patients. The CR rate was 51.5%. Overall, the probability of achieving the CR was 2-3 times higher in LD than in ED (extensive disease). Relapses occurred at the site of the primary in more than half of the cases, showing that the course of the disease was not modified by the use of high-dose chemotherapy. Toxic deaths occurred in 7% of the treated patients, without difference in the two treatment methods. Though the schedules were too variable to draw firm conclusions, the ICE (ifosfamide, carboplatin, etoposide) and the CBP (cyclophosphamide, cisplatin, carmustine) regimens apparently provided better results, with a 2-year survival rate of 30-50% in the LD subset. An european multicenter randomized trial is ongoing. At the present time high-dose chemotherapy is still to be considered experimental treatment, since major problems such as the selection of the patients, doses and timing of chemotherapy and radiotherapy remain unsolved.

The presence of bone marrow cytokeratin-immunoreactive cells does not predict outcome in gastric cancer patients

The independent prognostic significance of isolated tumour cells in bone marrow is still a matter of debate. This study evaluated the possible association of bone marrow micrometastases with tumour progression and prognosis in patients affected by gastric cancer. Bone marrow aspirates from both iliac crests were obtained from 114 consecutive patients operated on for gastric cancer. The specimens were stained with monoclonal antibody CAM 5.2 which reacts predominantly with cytokeratin filaments 8 and 19. Among 114 cases analysed, 33 cases (29%) had cytokeratine-positive cells in the bone marrow. There was no significant relationship between the presence of bone marrow micrometastases and site, depth of tumour invasion, lymph node metastases, presence of metastases. Patients with cytokeratine-positive cells had a trend towards a diffuse type histology (P=0.06). Among the 88 curatively resected patients, median survivals were 40 months and 36 months for cytokeratine-negative and cytokeratine-positive subsets respectively (P=0.9). Recurrence of the disease was observed in 39 cases (44.3%); 11 of 24 (45.8%) in the cytokeratine-positive subset and 28 of 64 (43.7%) in the cytokeratine-negative subset. In conclusion in our experience the presence of cytokeratine-positive cells in the bone marrow of curatively resected gastric cancer patients did not affect outcome and its independent prognostic significance remains to be proven before its official acceptance in the TNM classification.

Primary cultures of human hypertrophic prostate tissue in WAJC 404 medium: a study of cell morphology and kinetics

222 biopsy fragments of human hypertrophic prostate tissue were cultured in WAJC 404 serum-free medium for three weeks. Growth halos were examined after 7, 14 and 21 days of culture by optical and scanning electron microscopy. Colonies formed of two concentric areas showed in the inner halo elementary pseudo-lobular morphological units similar to the prostate structure. The cell morphological patterns of the halo turned out to be four in number. Every cell pattern was defined morphologically, morphometrically and phenotypically. Results indicate that all morphological differences must be attributed to the various phases of cell life, as all cell types were positive to cytokeratin. The nonconstant display of PSAP and PSA showed a moderate tendency to cell differentiation in WAJC 404 medium. Cell kinetics were also studied and revealed a decrease in proliferation after 14 days of culture. Primary cultures from biopsy fragments of human hypertrophic prostate tissue may be used as an experimental model up to the 14th day of culture.

Experimental vermeersiekte (Geigeria ornativa O. Hoffm. poisoning) in sheep. I: An evaluation of diagnostic aids and an assessment of the preventive effect of ethoxyquin

Dried milled Geigeria ornativa, which had been stored at room temperature for 4 years, was fed in rations to sheep. The usefulness of contrast radiography of the oesophagus, biopsies of oesophageal and skeletal muscles, electrocardiography, and clinical pathological parameters for diagnosing vermeersiekte were evaluated. Ethoxyquin was evaluated as a preventive agent. All the sheep developed signs of vermeersiekte but regurgitation was observed in only one animal. Contrast radiography and the examination of tissue biopsies were of diagnostic value in 8 out of 13 and 6 out of 6 sheep respectively. Electrocardiography did not aid in antemortal diagnosis of the condition and selected chemical parameters were non-specific. The inclusion of ethoxyquin in the diet of experimental animals (n = 3) prior to and during feeding of G. ornativa did not prevent the development of vermeersiekte. This study confirmed that dried stored G. ornativa retains its toxicity and that regurgitation is not a consistent clinical sign in sheep with vermeersiekte. The diagnostic value of contrast radiography of the oesophagus and examination of oesophageal and muscle biopsies is reported for the first time.

Electron Microscopy of Superficial Vesical Neoplasms: Preliminary Reports

The aim of this work was to study with scanning electron microscopy (SEM) the morphologic patterns of the lesions caused by superficial bladder cell carcinoma and to evaluate the possibility of using this method as prognostic index. Our observations showed three different kinds of morphologic patterns (wrinkled cell, dismorphic cells and cells with microvilli) of the neoplastic urothelium correlated with the evolution of the neoplastic disease. Results show that recurrence and invasiveness are more marked in the dismorphic cell kind, whereas the wrinkled cell kind represent a lower risk. SEM could be used as a parameter for biologically characterising superficial bladder cancer, as it is completely independent of neoplastic grading.

[I.V. ketorolac in the therapy of postoperative pain]

Forty-one patients suffering from postoperative pain were admitted to an open, noncomparative trial. A dose of 10 mg of Kerotolac was administered i.v. to patients complaining severe pain. The analgesic efficacy of the drug was evaluated at 5, 15, 30 minutes and at 1, 1.5, 2, 3, 4, 6 hours after injection; the patients were asked to score their pain relief on the VRS comparing the pre-injection evaluation to each post-injection period. A significant decrease of pain intensity (less than p 0.01) was observed at 45 minutes after injection. No side effects were observed. These results suggest that Ketorolac can be successfully used in the treatment of postoperative pain.

Immunocytochemical detection of estrogen receptors by staining with monoclonal antibodies on cytologic specimens of human breast cancer

A study was undertaken to test the possibility of determining the estrogen receptor (ER) content in human breast cancers by staining with commercial specific monoclonal antibodies (MAbs) on cytologic specimens (touch imprints and fine needle aspirates). The aspirates were suspended in a cell culture medium and cytocentrifuged onto slides to preserve their morphologic characteristics and to allow a proper immunocytochemical staining for ERs. MAb staining for ER was also performed on the respective surgical samples. The staining of cytologic samples for ER showed 100% specificity and 95% sensitivity in comparison to the staining of the histologic samples. Moreover, comparison of the percentage of stained cells in the cytologic specimens to the ER content in the respective surgical specimens, as assayed by the dextran-coated charcoal method, showed the MAb staining of cytologic samples to have 94% specificity and 100% sensitivity. These results support the reliability of MAb staining for ERs in cytologic samples and suggest that it could be the assay of choice in particular clinical settings in the evaluation of primary and recurrent breast cancers.

[New prospects offered by echography in the diagnosis of carcinoma of the gallbladder]

Experience in diagnosing several cases of primary carcinoma of the cholecyst echographically in reported. The most important ultrasonic characteristics in relation to staging of the lesion are reviewed. It is seen that echographic features always correlate with surgical findings, confirming the diagnostic accuracy of the method which permits morphofunctional as well as structural evaluation. At this time echography seems to be the most rational tool for efficient diagnosis, a step forward in ensuring timely surgery and the improvement of long term prospects for the condition.

[Adrenal hemorrhage in the newborn. Diagnostic problems and presentation of a case]

Adrenal haemorrhage is not an exceptional event in the newborn. The probable predisposing factors are difficult delivery, fetal hypoxia, trombocytopenia and coagulation defects. The recommended therapeutical approach is conservative, even if some Authors prefer surgical evacuation of the haematoma. This report was prompted by our recent experience of a case of unilateral adrenal haemorrhage in a newborn. The methods useful in the diagnosis are thoroughly evaluated and discussed with special emphasis on echography which holds an important position in the early diagnosis of this condition.

[Scope and limitations of the surgical treatment of diabetes]

A brief account is given of the current knowledge, experiments, and clinical findings concerning the surgical management of diabetes. The aim of all treatments, from conventional pancreas transplant to the sophisticated transplantation of islets and foetal pancreas, and a subject with its own special features, namely intestinal by-pass, is to relieve the patient from insulin management, which, while it increases his survival, does not defend him from possibly fatal vascular complications. Though far from providing a final solution, each of the topics dealt with provides an example of the way research and clinical practice continue to offer reasons for the experimentation of new therapeutic techniques.

[Correlation between hyperamylasemia and acute pancreatitis]

It is often difficult to differentiate acute pancreatitis (A.P.) from some other acute abdominal diseases, when there is an elevated serum amylase. In contrast, the renal clearance of amylase, expressed as a percentage of creatinine clearance, can separate patients with A.P. from patients with acute colecistitis, common duct stone without pancreatitis, hyperamylasemia after biliary surgery, acute peptic ulcer and acute salivary diseases.

[Early diagnosis of breast tumors:/is echography conclusive?]

The use of ultrasonic scanning in examination of the breast is discussed. It is felt that this method is the best that science can offer at present for this purpose, its superiority lying in its diagnostic dependability (90-95% exact diagnoses), low detectability limits (lesions of 5 mm can be diagnosed), suitability for the examination of breast of every age and size, complete freedom from risk, and systematic repeatibility.

[Ultrasonically-guided percutaneous nephrostomy]

Ultrasonically-guided percutaneous nephrostomy using Seldinger's technique is the most accurate and reliable procedure for pelvic catheterisation in obstruction-induced hydronephrosis. The procedure is straightforward and independent of renal function. Post-renal uraemia may thus be measured and corrected; hydropyonephrosis drained prior to surgical operation of choice. Injection of contrast media may identify an anatomo-pathological situation which cannot be defined with i.v. or retrograde pyelography.

[Biliodigestive anastomoses]

Experience with biliodigestive anastomosis in biliary surgery is reported. About 40 operations, subdivided into hepatojejunostomy, choledochojejunostomy, choledochoduodenostomy, hepaticojejunostomy, cholecystoejunostomy, etc. were performed in the period between 1970 and 1978. Indications for these operations are reported and the techniques adopted described. Complications and results are reviewed for each. A choledochoplasty operation using the serosa of an ansa in Roux fashion and transhepatic drainage is reported.

[Echography in renal tumors]

Echography is highly important today for the identification and differentiation of renal diseases. It also enable target biopsy of identified lesions to be carried out, thus making for precise histological diagnosis. Indications and results of echography in the diagnosis of 97 cases of suspect masses of renal origin consisting of cysts, hydropyonephrosis, tumours, multicystic and polycystic kidneys are considered. Overall diagnostic accuracy was 92.7%. The features pointing to differential diagnosis of individual lesions and the method of examination, based on the use A and B Scan with grey scale are described. It is concluded that, with their high diagnostic accuracy and non-invasivity, scanning techniques represent an indespensable tool for the diagnosis of renal masses.