Use of catheter-based cholangioscopy in the diagnosis of indeterminate stenosis: a multicenter experience

BACKGROUND

Direct bile ducts visualization through cholangioscopy has gained popularity due to its better diagnostic accuracy than a standard ERCP in indeterminate biliary stricture.

METHODS

We aimed to review our catheter-based cholangioscopy interventions in patients with indeterminate biliary stenosis, using the SpyGlass Direct Visualization System (SDVS) and summarize our experience in terms of procedures and results. We collected 25 consecutive patients with indeterminate biliary stricture over 3 years.

RESULTS

The overall procedural success in our cohort amounted to 96% (24/25). If we focus on the diagnostic procedures, the ability to merely visualize the region of interest/lesion and perform biopsy of the lesion was possible in 96% (24/25) In our cohort localization in the common bile duct (P=0.03; 95% CI: 0.27-0.96) was found as positive determining factor for diagnosis. Sensitivity, specificity and accuracy for visual diagnosis by SDVS in our cohort were 100, 83.3 and 96%, respectively. The use of biopsy or obtaining a histological diagnosis to assist in identifying patients with malignant stenosis, to exclude malignancy and to correctly classify diagnosed patients resulted in a sensitivity of 100%, a specificity of 73% with an overall accuracy of 94.4%. Only a mild adverse event (cholangitis, treated conservatively) occurred.

CONCLUSIONS

Today, the SDVS should be considered essential in diagnosing indeterminate biliary strictures, since the procedure is associated with high procedural success in terms of diagnostic accuracy, alters clinical outcome in over 80% of considered insolvable cases, with an acceptable safety profile.

Primary thromboprophylaxis in not surgically treated intra-luminal gastrointestinal cancer (ILGC) treated with first-line chemotherapy: A single institution preliminary safety report

Occurrence of venous thromboembolism in cancer patients (patients) undergoing chemotherapy is a remarkable concern for the oncologist. In addition, careful attention has to be paid to the possible major bleeding when patients carrying gastrointestinal cancer need antithrombotic therapies. To date some Cancer Associated Thrombosis (CAT) risk scores as Khorana and PROTECHT score have been developed to identify the cancer population at high-risk for venous thromboembolism (VTE). Consensus guidelines recommend to consider also low molecular weight heparin (LMWH) for primary thromboprophylaxis in high-risk patients. This is a report on a retrospective case series of 15 intra-luminal not surgically treated gastrointestinal cancer patients deemed high risk for VTE. The patients had a Khorana or PROTECHT score of 2 points or more (at least ≥ 2 points). They were undergoing first line chemotherapy in the absence of endoscopic signs of cancer spontaneous bleeding. A prophylactic dose of LMWH was administered just before starting the chemotherapy session and until 48 hours after its completion. The authors mainly aimed to report occurrence of clinically perceptible gastrointestinal bleeding events. Fifteen patients were administered LMWH - median age: 59 (range: 42-79); gender: male 12 (80%); tumor type: stomach - 13 patients (86%); gastro-esophageal junction: 2 patients (14%). Duration of heparin treatment: the total treatment duration was 228 days; mean 15.2 days (range: 5-45); nadroparin: mean 14.7 days (range: 5-45); enoxaparin: mean 10.1 days (range: 5-20); parnaparin: a total of 5 days. None of the patients experienced perceptible gastrointestinal bleeding. Short-term LMWH thromboprophylaxis appeared to be safe for this series of patients.

BCR::ABL1 levels at first month after TKI discontinuation predict subsequent maintenance of treatment-free remission: A study from the "GRUPPO TRIVENETO LMC"

We analyzed BCR::ABL1 expression at stop and in the first month after discontinuation in 168 chronic myeloid leukemia patients who stopped imatinib or 2nd generation tyrosine kinase inhibitors (2G-TKIs) while in sustained deep molecular response. Patients were divided among those who maintained response (group 1, n = 123) and those who lost major molecular response (group 2, n = 45). Mean BCR::ABL1 RNA levels 1 month after discontinuation were higher in group 2 than in group 1 (p = 0.0005) and the difference was more evident 2 months after stop (p < 0.0001). The same trend was found both for imatinib and 2G-TKIs. A receiver operating characteristic (ROC) analysis to determine a threshold value of BCR::ABL1 at 1 month after discontinuation identified a cut-off value of 0.0051%, with 92.2% specificity, 31.7% sensitivity and a likelihood ratio of 4.087.

Digital single‑operator cholangioscopy in treating difficult biliary stones: results from a multicenter experience

BACKGROUND

In clinical practice, standard endoscopic treatment of biliary stones fails in up to 10% of patients, and more invasive procedures such as percutaneous trans-hepatic interventions or surgery might become necessary. The aim of this multi-center retrospective study, based on prospectively-collected data, was to evaluate both the efficacy and the safety of Digital-Single Operator Cholangioscopy (D-SOC) to treat difficult biliary stones, in cases with a previous failure of conventional endoscopic methods.

METHODS

Only patients with a previous failure of endoscopic standard treatment and a DSOC- based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone clearance rate per procedure and per patient. Out of 1258 ERCP performed at our (three?) centers, 31 cholangioscopies in 21 patients were solely performed for the treatment of difficult biliary stones using EHL or LL.

RESULTS

A complete biliary stone removal was achieved in 67.7% (21/31) of all procedures including initial and repeated examinations, while in 35.4% (11/31) of all procedures an incomplete removal was accomplished of which 36.3% had a partial stone removal. In 22 procedures EHL was adopted as techniques to fragment and remove biliary stones, while in 9 procedures LL was used. In both the techniques, the complete stone removal rate and the incomplete stone removal rate were similar (75% vs 77.7%, p>.05). Furthermore, the success rate of digital DSOC to treat difficult biliary stones was assessed per patient: overall, 100% of patients with difficult biliary stones were successfully treated using D-SOC. Only one patient experienced mild cholangitis classified ad mild adverse event following ASGE (American Society of Gastrointestinal Endoscopy) lexicon.

CONCLUSIONS

In conclusion, our data indicate that digital D-SOC assisted biliary stone treatment is highly efficient for the treatment of difficult biliary stones even in such patients in whom previous conventional endoscopic methods to treat biliary stones have failed. Therefore, D-SOC might be considered the new standard of care for these patients, being both, effective and safe.

Histology of the spleen in immune thrombocytopenia: clinical-pathological characterization and prognostic implications

OBJECTIVE

Immune thrombocytopenia (ITP) is an acquired disorder, characterized by immune-mediated platelet destruction. The spleen plays a key pathogenic role in ITP and splenectomy is a valuable second-line therapy for this disease. Little is known on ITP spleen histology and response to splenectomy is unpredictable. This study aims to characterize ITP spleen histology and assess possible predictors of splenectomy outcome.

METHODS

A series of 23 ITP spleens were retrospectively assessed for the following histological parameters: density of lymphoid follicles (LFs), marginal zones (MZs), T helper and cytotoxic T cells; presence of reactive germinal centers (GCs); width of perivascular T cell sheaths; and red pulp features. Clinical and histological data were matched with postsplenectomy platelet counts to assess their prognostic relevance.

RESULTS

Three histological patterns were documented: a hyperplastic white pulp pattern, a non-activated white pulp pattern (lacking GCs), and a white pulp-depleted pattern. Poor surgical responses were associated with presplenectomy high-dose steroid administration, autoimmune comorbidities and low T follicular helper cell density. The combination of such parameters stratified patients into different splenectomy response groups. The removal of accessory spleens was also associated with better outcome.

CONCLUSION

ITP spleens are histologically heterogeneous and clinical-pathological parameters may help predict the splenectomy outcome.

Second primary malignancy in myelofibrosis patients treated with ruxolitinib

Ruxolitinib (RUX), the first JAK1/JAK2 inhibitor approved for myelofibrosis (MF) therapy, has recently been associated with the occurrence of second primary malignancies (SPMs), mainly lymphomas and non-melanoma skin cancers (NMSCs). We analyzed the incidence, risk factors and outcome of SPMs in 700 MF patients treated with RUX in a real-world context. Median follow-up from starting RUX was 2·9 years. Overall, 80 (11·4%) patients developed 87 SPMs after RUX start. NMSCs were the most common SPMs (50·6% of the cases). Multivariate analysis demonstrated that male sex [hazard ratio (HR): 2·37, 95% confidence interval (95%CI): 1·22-4·60, P = 0·01] and thrombocytosis> 400 × 10⁹ /l at RUX start (HR:1·98, 95%CI: 1·10-4·60, P = 0·02) were associated with increased risk for SPMs. Risk factors for NMSC alone were male sex (HR: 3·14, 95%CI: 1·24-7·92, P = 0·02) and duration of hydroxycarbamide and RUX therapy > 5 years (HR: 3·20, 95%CI: 1·17-8·75, P = 0·02 and HR: 2·93, 95%CI: 1·39-6·17, P = 0·005 respectively). In SPMs excluding NMSCs, male sex (HR: 2·41, 95%CI: 1·11-5·25, P = 0·03), platelet > 400 × 10⁹ /l (HR: 3·30, 95%CI: 1·67-6·50, P = 0·001) and previous arterial thromboses (HR: 3·47, 95%CI: 1·48-8·14, P = 0·004) were shown to be associated with higher risk of SPMs. While it is reassuring that no aggressive lymphoma was documented, active skin surveillance is recommended in all patients and particularly after prolonged hydroxycaramide therapy; oncological screening should be triggered by thrombocytosis and arterial thrombosis, particularly in males.

Pressing Issues in COVID-19: Probable Cause to Seize SARS-CoV-2 for Its Preferential Involvement of Posterior Circulation Manifesting as Severe Posterior Reversible Encephalopathy Syndrome and Posterior Strokes

Since December 2019, a novel Severe Acute Respiratory Syndrome coronavirus 2 from China has rapidly spread worldwide. Although respiratory involvement is the mainstay of coronavirus disease 2019 (COVID-19), systemic involvement has recently drawn more attention. In particular, a number of recent articles have shed light on the nervous system as one of the possible targets. At our institution, we observed 15 patients with acute brain vascular manifestations; most interesting, we had a higher prevalence of the posterior circulation acute impairment. In our series, 7 patients had acute posterior cerebral injury: 1, hemorrhagic posterior reversible encephalopathy syndrome; 5, posterior circulation ischemic stroke; and 1, parieto-occipital hemorrhagic stroke. On the basis of our evidence and previous basic science reports, we believe a common etiopathogenetic thread may connect ischemic/hemorrhagic events of the posterior circulation and posterior reversible encephalopathy syndrome in the setting of COVID-19.

Safety and efficacy of switching from branded to generic imatinib in chronic phase chronic myeloid leukemia patients treated in Italy

The use of generic drugs after patent expiration of their originators is a relative novelty in the treatment of chronic cancer patients in Western countries. In this observational study we analyzed a cohort of 294 Italian chronic phase chronic myeloid leukemia patients treated frontline with branded imatinib (Glivec®) for at least 6 months and then uniformly switched to generic imatinib upon requirement of health authorities in early 2017. Median age at diagnosis was 57 years (range 19-87). Sokal risk was low/intermediate/high in 55%, 32% and 8% of cases, respectively. Median duration of branded imatinib treatment was 7.4 years (range 0.5-16.7). At a median follow-up of 7.5 months after switch to generic imatinib, 17% of patients reported new or worsening side effects, but grade 3-4 non-hematological adverse events were rare. Six patients switched back to branded imatinib, with improvement in the side effect profile, and 4 pts moved to bosutinib or nilotinib for resistance/intolerance. The majority of patients were in major (26%) or deep molecular response (66%) at the time of switch. Molecular responses remained stable, improved or worsened in 61%, 25% and 14% of patients, respectively. We conclude that switch to generic imatinib for patients who have been receiving branded imatinib appears to be effective and safe. Molecular responses may continue to improve over time. Some patients experienced new or worsened side effects but less than 5% of the whole cohort needed to switch back to branded imatinib or move to other treatments. Savings were around 3 million Euros.

Frequency and clonality of peripheral γδ T cells in psoriasis patients receiving anti-tumour necrosis factor-α therapy

Hepatosplenic γδ T cell lymphoma (HSTCL) has been observed in patients with Crohn's disease (CD) who received anti-tumour necrosis factor (TNF)-α agents and thiopurines, but only one case was reported in a psoriasis patient worldwide. This difference could be due to differences in either the nature of the inflammatory diseases or in the use of immunomodulators. We investigated the impact of anti-TNF-α agents on the level and repertoire of γδ T cells in peripheral blood from psoriasis patients. Forty-five men and 10 women who were treated with anti-TNF-α agents for psoriasis were monitored for a median 11 months for the level and clonality of γδ T cells via flow cytometry and polymerase chain reaction (PCR) analysis of T cell receptor gamma (TCR-γ) gene rearrangements. Seventeen men had a repeated analysis within 48 h of the infliximab infusion to reveal a possible expansion of γδ T cells, as observed previously in CD patients. Ten psoriasis patients who were never exposed to biologicals and 20 healthy individuals served as controls. In the majority of psoriasis patients, the level and clonal pattern of γδ T cells was remarkably stable during infliximab treatment. A single male patient repeatedly experienced a significant increase in the level of γδ T cells after infliximab infusions. A monoclonal γδ T cell repertoire in a polyclonal background tended to be more frequent in anti-TNF-α-treated patients than naive patients, suggesting that anti-TNF-α therapy may promote the clonal selection of γδ T cells in psoriasis patients.

Self-expandable metal stents for malignant colonic obstruction: data from a retrospective regional SIED-AIGO study

BACKGROUND

Self-expandable metal stents are a non-surgical option for the treatment of symptomatic malignant colorectal obstruction as palliative treatment or as a bridge to surgery.

AIMS

To report data from a regional study on self-expandable metal stent (SEMS) placement for malignant colorectal obstruction.

METHODS

Two hundred and four patients (male 54.9%, mean age of 69.5 ± 14.2) were retrospectively evaluated and data on technical and clinical success, and complications, were analyzed.

RESULTS

Technical and clinical success rates were 99% and 94.6% respectively, with 36.7% treated on an emergency basis and 63.3% electively. Palliative treatment was administered to 70.1%, and as a bridge to surgery for 29.9%. Complications were 17 neoplastic ingrowths, 10 stent migrations, and 4 perforations. Palliative treatment was associated with a higher risk of stent ingrowth (p=0.003), and chemotherapy with a lower risk of stent ingrowth (p=0.009).

CONCLUSION

This regional study, although it has certain limitations, confirms the positive role of self-expandable metal stents in the treatment of symptomatic malignant colorectal obstruction, and that chemotherapy decreases the risk of ingrowth.

The GMOS cyber(e)-infrastructure: advanced services for supporting science and policy

The need for coordinated, systematized and catalogued databases on mercury in the environment is of paramount importance as improved information can help the assessment of the effectiveness of measures established to phase out and ban mercury. Long-term monitoring sites have been established in a number of regions and countries for the measurement of mercury in ambient air and wet deposition. Long term measurements of mercury concentration in biota also produced a huge amount of information, but such initiatives are far from being within a global, systematic and interoperable approach. To address these weaknesses the on-going Global Mercury Observation System (GMOS) project ( www.gmos.eu ) established a coordinated global observation system for mercury as well it retrieved historical data ( www.gmos.eu/sdi ). To manage such large amount of information a technological infrastructure was planned. This high-performance back-end resource associated with sophisticated client applications enables data storage, computing services, telecommunications networks and all services necessary to support the activity. This paper reports the architecture definition of the GMOS Cyber(e)-Infrastructure and the services developed to support science and policy, including the United Nation Environmental Program. It finally describes new possibilities in data analysis and data management through client applications.

Impact of chemotherapy regimen and rituximab in adult Burkitt lymphoma: a retrospective population-based study from the Nordic Lymphoma Group

BACKGROUND

Standard treatment of adult Burkitt lymphoma is not defined due to the lack of randomised trials. In this situation, population-based data may represent a useful contribution in order to identify an optimal treatment strategy.

PATIENTS AND METHODS

The aims of this study were to investigate the outcome for adult HIV-negative BL with different chemotherapy regimens, and to assess possible improvement within the time frame of the study. The study population was identified through the Swedish and Danish lymphoma registries 2000-2009.

RESULTS

A total of 258 patients were identified. Since 2000, overall survival (OS) improved significantly only for younger patients (<65 years). Intensive regimens such as the Berlin-Frankfurt-Münster, hyper-fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (hyper-CVAD) and cyclophosphamide, vincristine, doxorubicin, methotrexate, ifosfamide, etoposide, and cytarabine (CODOX-M/IVAC) were associated with a favourable 2-year OS of 82%, 83%, and 69%, respectively. The low-intensive CHOP/CHOEP regimens achieved a 2-year OS of 38.8%, confirming their inadequacy for the treatment of BL. In a multivariate analysis, rituximab was not significantly associated with improved OS.

CONCLUSIONS

In this population-based retrospective series of adult BL, intensive chemotherapy regimens were associated with favourable outcome. The impact of the addition of rituximab remains uncertain and warrants further investigation.

Spectroscopic ellipsometry study of liquid crystal and polymeric thin films in visible and near infrared

In this work, we propose spectroscopic ellipsometry as a suitable method for measuring optical properties in soft materials, polymers and liquid crystals, specially selected for use in photonics applications. We show the results of our measurements on some multilayered samples, in the range from visible to the near-IR region, of interest for telecom applications. We point out potentialities and limits of the technique and compare the obtained results with another experimental method, the m-lines spectroscopy, and/or with existing data in the literature. The results about the optical parameters for the analysed materials (the nematic liquid crystal 5CB, one commercial and one lab made optical polymer, and an Indium Tin Oxide film) are useful and interesting by themselves. In fact, as a paradigmatic example, we briefly discuss how an incomplete knowledge of this kind of data can lead to a wrong design of a Bragg grating device. However, more than in the provided data, we put the interest of the present analysis in the warnings about spectroscopic ellipsometry utilization and eventually the necessity of getting complementary information.

A case of pheochromocytoma with renal artery stenosis and post-surgical watery diarrhea

A 35-year-old woman was admitted to our hospital with the following complaints, headache, sweating, anxiety, dizziness, nausea, vomiting and severe hypertension. The technical images (abdominal CT, scintigraphic octreotide scan and renal arteriography) revealed the presence of a left adrenal pheochromocytoma and stenosis of the renal artery. Ten days following adrenalectomy, watery diarrhea appeared. The long-acting somatostatin analogue octreotide (LAR, 30 mg/month, i.m.), was started, and after 2 weeks diarrhea decreased and gradually disappeared. In conclusion, we were confronted with an unusual case of pheochromocytoma associated with renal artery stenosis and the appearance of watery diarrhea some days after surgical treatment. Treatment with octreotide brought about the remission of diarrhea in this patient.

Scurvy mimicking systemic vasculitis

An 91 years old woman was hospitalized because of lethargy, shortness of breath and diffuse subcutaneous hemorrhage of legs. Clinical features were consistent with the diagnosis of vasculitis with systemic involvement. However dermatologic characteristics of the legs, in association with malnutrition, suggested vitamin C deficiency which was confirmed by laboratory test. Ascorbic acid supplement dramatically improved her clinical symptoms. This case remarks how scurvy may mimmick a systemic vasculitis.

[Endoscopic treatment of a gastric phytobezoar using electrohydraulic lithotripsy: a case report]

The Authors report a case of spontaneous large gastric phytobezoar in an unoperated stomach and describe this pathology especially with regards to pathogenesis, diagnosis and endoscopic treatment.

Primary central nervous system lymphomas in immunocompetent individuals: histology, Epstein-Barr virus genome, Ki-67 proliferation index, p53 and bcl-2 gene expression

Epstein-Barr virus (EBV) has been detected in the large majority of HIV-related primary central nervous system lymphomas (PCNSL) suggesting a pathogenetic role of the virus. Unlike HIV-related PCNSL, conflicting data exist with regard to the presence of EBV in non immunodeficiency-related (sporadic) PCNSL. For this reason, a population based material of 41 sporadic PCNSL was analysed for the presence of EBV genome (EBER, BHLF) using RNA in situ hybridisation (RISH). Furthermore, the expression of the gene products of the bcl-2 oncogene and the p53 tumor suppressor gene and the tumor growth fraction reactive with the monoclonal antibody Ki-67 have been evaluated. All cases but two were EBV genome negative. In the two positive cases less than 5% of tumor cells showed EBER positivity. In contrast, more than 75% of cells morphologically belonging to the tumor-cell population stained positively for EBER in two cases of HIV related PCNSL. Immunostaining for the bcl-2 oncoprotein was positive in 28 (72%) of 39 cases examined. In most cases more than 75% of tumor cells showed cytoplasmic expression. Of 37 cases investigated for p53 expression, 21 (57%) stained positively. However, in the large majority of positive cases less than 10% of the neoplastic cells stained. The percentage of Ki-67 positive cells ranged between 10% and 80% with a mean of 50%. The expression of the p53 and bcl-2 oncoproteins and the growth fraction did not have any prognostic impact. We conclude that the EBV genome is rarely detected in sporadic PCNSL, indicating that a pathogenetic role of EBV is unlikely. Like extracerebral B-cell lymphomas a large fraction of PCNSL expresses the p53 and bcl-2 oncoproteins, a feature, however, which does not seem to have prognostic implications.

[Neuroleptic malignant syndrome: a neurologic pathology of great interest for the internist]

Two cases of neuroleptic malignant syndrome are reported. Although affecting chiefly psychiatric patients, this rare, polymorphic disease should be well-known to internists, general practitioners, and emergency staff because of its high risk of fatality. Our patients, who presented without some of the main symptoms, fell in the category of incomplete variants of the syndrome, the most difficult to recognize. In both patients, computerized tomography carried out at the outset of symptoms, evidenced signs of cerebral edema, a datum never before reported. The symptomatic polymorphism, pathogenesis, differential diagnosis, and therapy of this disease are illustrated and discussed.

[Beta blockers and heart failure]

This above paper presents a critical revision of a controversial matter: the use of the beta blockers in congestive heart failure. The authors explain the appearances pathophysiological and the potentialities therapeutic also promote an increase of the attentive follow up for a better acquaintance of the use of these drugs in the along period of it.

[Stenosing esophagitis caused by Trichosporon beigelii: presentation of a rare case]

The Authors describe a rare case of esophageal stenosis complicated by gastroesophageal reflux due to Trichosporon beigelii in the absence of a pathologic predisposition or immunodeficiency. The diagnosis was drawn by embedding membrane fragments obtained endoscopically in Sabouraud and blood-Agar cultures. The patient was treated with antimicotics, immunostimulants, inhibitors of the gastric protonic pump, prokinetics and later underwent endoscopic dilatation combined with Savary-Guillard and pneumatic dilatators of growing diameter, until complete "restitutio ad integrum" of the esophageal lumen.

Drug-induced cholestasis. Clinical contribution

We described two cases of drug-induced hepatitis: in both cases we recognised a pathogenesis based on hypersensivity mechanism. The first case, determined by naproxen, presented a serious cholestatic jaundice and histologic pattern due to ductular cholestasis without any inflammatory reaction. The second case, by a-metildopa, was characterized by spread necrosis of liver cells and peri-portal flogistic infiltrated. This chapter of modern epatology is becoming more and more important, because of both the opportunity of studyng physiopathologica mechanism and the increasing morbidity. The peculiarity of these cases was due not only to the morbidity, but also to the seriousnes of clinical symptoms which involved problems of early differential diagnosis and of attentive follow-up.

[Silent myocardial ischemia. Physiopathologic, clinical, and therapeutic considerations and review of the literature]

The need for a modern methodological approach based on recent acquisitions concerning pathophysiology, diagnostics, and therapy of silent ischemic heart disease, as well as the need to establish criteria for prognostic evaluation have prompted the authors to reexamine the subject in light of their own experience and of the current literature.

Clinicopathological features, survival and prognostic factors of primary central nervous system lymphomas: trends in incidence of primary central nervous system lymphomas and primary malignant brain tumors in a well-defined geographical area. Population-based data from the Danish Lymphoma Registry, LYFO, and the Danish Cancer Registry

It has been claimed that Primary Central Nervous System Lymphomas (PCNSL), a rare neoplasm accounting for only a small fraction of malignant brain tumors and extranodal non-Hodgkin lymphomas (NHL), occur with increasing frequency in immunologically normal as well as in immunocompromised individuals. In an attempt to characterize the clinicopathological features, outcome and prognostic factors of PCNSL we here report our experience in a large unselected series of patients from a well-defined region. In addition, we present data on trends in incidence of PCNSL and primary malignant brain tumors in a well-defined geographical area. In a Danish population-based NHL registry (LYFO) representing a population of 2.7 million all new cases of NHL were registered during the approximate 11-year period from 1st January 1983 to 31st May 1994. Incidence data of primary malignant tumors of the brain and central nervous system in western Denmark for the period 1971-1990 have been obtained from the Danish Cancer Registry. During the approximate 11-year period 3124 new cases of NHL were registered. Of these, 1152 (37%) were extranodal and 48 were non-AIDS related PCNSL accounting for 4.2% of extranodal NHL and 1.5% of all NHL, respectively. The average annual incidence rate of non-AIDS related PCNSL during the period was 1.56 cases per million population (age range: 15-85 yrs, median: 62 yrs, M/F ratio: 1). In a 23-year period there was no trend towards an increasing incidence of non-AIDS related PCNSL in a well-defined population. PCNSL accounted for 1.7% of all primary malignant brain tumors. Incidence of primary malignant brain tumors was stable, except for age ranges over 70 years. However, diagnostic artifacts might be responsible for this apparent increase. Histologically, 85% were high grade. Using the Kiel classification centroblastic diffuse (60%) and immunoblastic lymphoma (13%) were the most common subtypes. Forty-three patients had B-cell lymphoma and no T-cell lymphoma was detected. Forty-seven cases were diagnosed pre mortem. Treatment included surgical resection (26 patients), whole brain irradiation (WBRT) (43 patients) and chemotherapy (28 patients). Median survival for those receiving either WBRT or WBRT and chemotherapy was 8 months and 20 months, respectively (p = 0.78). Overall survival was 53%, 38% and 26% at 1, 2 and 5 years. Cox-regression analysis identified only one factor having independent impact on survival in PCNSL: performances score > or = 2 (p < 0.001, RR = 5.8).

A retrospective analysis of treatment outcome in 106 cases of localized gastric non-Hodgkin lymphomas. Danish Lymphoma Study Group, LYFO

197 cases of gastric lymphoma were reported to a population-based Danish registry of non-Hodgkin's lymphomas. 106 of these cases were localized, representing stages IE and II1E, and were analyzed retrospectively, using Cox regression analysis. 67 had surgical resection, 51 chemotherapy, and 55 radiotherapy, or combinations thereof. No type of treatment showed any superiority as regards survival (p = 0.13). Overall 5-year survival was 67%. The pretherapeutic presence of fever or S-LDH-elevation had a far more significant influence on survival than histology or any of the treatments or treatment combinations. Surgical resection was associated with a significantly higher risk of late complications than radiotherapy, suggesting that radiotherapy may be preferable to surgery as the primary treatment in localized gastric lymphoma. It could not be determined from the available data whether the addition of chemotherapy to the primary treatment provides any survival benefit.

Autoimmune phenomena in non-Hodgkin's lymphoma

In order to obtain valid data on the pattern, frequency and prognostic significance of autoimmune derangements in non-Hodgkin's lymphoma (NHL) we studied 626 consecutive adult NHL patients participating in a population-based lymphoma registry. A total of 86 patients, corresponding to 13.7%, showed autoimmune phenomena (AP). Of these, 7.8% exhibited clinical autoimmune phenomena (CAP), and 5.9% showed immunohaematological phenomena (IHP). The distribution of histological subgroups of NHL in the AP and non-AP patients was similar. The same holds true for the CAP and IHP patients. A slight, non-significant overrepresentation of NHL, T-cell phenotype was found in patients with AP. CAP preceded the diagnosis of NHL in most patients, whereas IHP was associated with active lymphoma disease. AP as a whole did not predict for time to complete response, time to relapse or for survival. The finding that IHP patients relapsed earlier than CAP patients was not reflected in a significant difference in survival.

[Sarcoidosis with pulmonary abscess caused by emerging microorganisms]

The association sarcoidosis-lung abscess due to emerging microorganisms-mycetoma has prompted the authors to report the above clinical case which is interesting in view of the rarity of the disease and of its infective complications. The authors also review the literature on the subject.

[Rhinocerebral mucormycosis in type 2 diabetes mellitus. Description of a clinical case with favorable outcome]

The case is reported of a 70-year-old man with decompensated non-acidotic type-2 diabetes mellitus and with rhinocerebral mucormycosis, manifested by inflammatory infiltration of the left nasal, paranasal, maxillary, and orbital bone structures with left ophthalmoplegia. The patient was cured after amphotericin B treatment (total dose 2.7 g) and 30 sessions of hyperbaric oxygen (2.8 atmospheres). Cure was confirmed by follow-up over more than 2 years. It is concluded that rhinocerebral mucormycosis must be treated, in addition to control of predisposing factors, and especially by restoring endocrine-metabolic balance, by adequate surgical revision, with specific high-dose amphotericin B treatment and adjunctive hyperbaric oxygen. Further studies are desirable in order to define the advantages of these therapeutic measures.

Incidence, presenting features and prognosis of low-grade B-cell non-Hodgkin's lymphomas. Population-based data from a Danish lymphoma registry

During the period January 1983 to January 1988 1597 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) were included in a Western Danish population-based NHL registry. Of these, 31% (N = 496) were low-grade NHL (LG-NHL) consisting of (Kiel): 9% lymphocytic (LY), 27% lymphoplasmacytic/-cytoid (IC), 53% follicular centroblastic/-centrocytic (CB/CCf) and 11% unclassifiable low-grade. LG-NHL (age range: 26-94 yrs, median: 64 yrs; M/F ratio: 0.8) had an age-standardised incidence rate (IR) of 2.7/10(5)/yr. Age-specific IR's showed an age-related exponential rise in all subtypes except for CB/CCf. Compared with the intermediate (IG)- and high-grade (HG) group, LG-NHL had more female cases (M/F ratio: 0.79 vs. 1.2; p = 0.0002), a higher frequency of stage III-IV disease (66% vs. 53%; p < 0.00005) and of bone marrow involvement (39% vs. 19%; p < 0.00005). A later revision of all IC cases (N = 132) distinguished 79 non-polymorphic (ICnp) from 25 polymorphic (ICp) cases; 28 cases were differently classified. In 34 LG-NHL patients histologic transformation was verified: CB/CCf to CB diffuse (22 pts) and LY to immunoblastic or CB type (6 pts). The 7-yr survival for LG-NHL was 63% (IG: 48%, HG: 38%; p < 0.00005). A Cox-regression analysis identified the following adverse prognostic factors for survival in LG-NHL: age > 50 with a relative risk (RR) of 3.2, hepatic involvement (RR = 2.1), elevated s-LDH (RR = 1.9), B-symptoms (RR = 1.8) and IC histology (ICnp+ICp) (RR = 1.7).(ABSTRACT TRUNCATED AT 250 WORDS)

[Scrofula in an elderly woman. A clinical case]

The case is described of an elderly woman with scrofula. The peculiarity of this case consisted in the comparative rarity of primary tubercular lymphadenopathy (a pathology that in the past used to be common in poor socioeconomic conditions) even considering the present renewed diffusion of tuberculosis; especially as this elderly patient had no previous history of tubercular infection.

[Micropolyarteritis. The modern nosographic picture and a discussion of a clinical case]

Having observed a patient presenting micropolyarteritis with necrotic skin lesions, hypertension and renal injury, the authors had the opportunity to define more closely a disease that only recently has been recognized as a separate nosological entity within the vast and as yet not fully understood field of arterial disorders. In addition, recent literature on the subject is critically reviewed.

The role of occupational exposure and immunodeficiency in B-cell malignancies. Working Group on the Epidemiology of Hematolymphopoietic Malignancies in Italy

Excesses of non-Hodgkin's lymphoma have been observed among farmers exposed to phenoxyacetic acid herbicides and, less persuasively, among workers exposed to insecticides. Exposure to organic solvents (particularly chlorinated hydrocarbons) has also been associated with an increased risk of NHL. TCDD (which is a contaminant of phenoxy herbicides), DDT, and chlorinated solvents have all been reported to induce impairment or suppression of cell-mediated immunity. We hypothesize that NHL is caused by common viruses, such as the Epstein-Barr virus, that induce proliferation and immortalization of B-cells, followed by T-cell impairment entailing cell-mediated immunodeficiency. The increased risk of NHL with HIV infection and heart or kidney transplantation, in which immunodeficiency also occurs, is consistent with this hypothesis.

[Cardiothyrosis. Presentation of a clinical case]

The observation of a severe from of cardiotoxicosis in a patient with Plummer's toxic thyroid adenoma has prompted the authors to make some considerations on the pathophysiology and clinical pattern of a type of pathology that is infrequent but clinically highly interesting.

Nutritional repletion in malnourished patients with emphysema

We examined the effect of nutritional supplementation for 13 wk on anthropometric, pulmonary function, and immunological status in malnourished ambulant patients with pulmonary emphysema (EP). The study was placebo controlled, randomized and double blind. Twenty-eight patients were included. Thirteen patients in the fed group were provided with a nutritional formula providing 20% protein, 30% fat, and 50% carbohydrate, 1 Kcal/ml, 400 ml/day. The control group was provided with a reference product of the same consistency and taste containing 0.1 Kcal/ml, 400 ml/day for 13 wk. The fed group had a mean weight gain of 1.5 kg during the study period, the control group increased concomitantly 0.16 kg, the difference being significant (p less than 0.01). Sum of four skinfolds increased 2.7 mm in the fed group, and decreased 0.9 mm in the control group the difference being significant (p less than 0.01). No difference were observed regarding pulmonary function or immunological status. We also found a high habitual energy intake in our study group (204% Basal Energy Expenditure). We conclude that nutritional supplementation produce weight gain in malnourished patients with EP, but it does not change other indices of well-being.

Establishment and characterization of a cloned giant cell line from a patient with Hodgkin's disease

The phenotypic characteristics of a cloned giant cell line, SU/RH-HD-1, established from the spleen of a patient with Hodgkin's disease were studied. The cells grew slowly, adhered to the culture vessel surface, and had an elongated, irregular shape. After trypsinization, they became spherical and measured 30-100 micron in diameter. Although most cells were mononuclear, binucleated and multinucleated cells could be identified in expanded cultures. The cells phagocytized latex and ink particles and were nonspecific esterase-positive, but they did not secrete lysozyme. They were Epstein-Barr nuclear antigen-negative, and their culture fluid supernatants were devoid of reverse transcriptase activity. Electron microscopy revealed cells with a pronounced smooth endoplasmic reticulum, free ribosomes, some filaments, and mitochondria. Many 0.5- to 1.0-micron invaginations (pits) were seen along the cell membrane. Nucleoli were enlarged and prominent in the very heterochromatic nuclei. The SU/RH-HD-1 cells had 10- to 100-micron-long pseudopodia that were sometimes forked or branching, as well as multiple stress fibers. Electron microscopic appearance was suggestive of that of macrophages. This interpretation of the results was substantiated by monoclonal antibody studies, which revealed that the cells express antigenic determinants distinctive for cells of the monocyte-macrophage lineage and by functional studies demonstrating that the cells are capable of specific antigen presentation to immune T-cells. The SU/RH-HD-1 cells were aneuploid and could be cloned, first in liquid culture by limiting dilution and later in semisolid medium. It was likely that the SU/RH-HD-1 cells were derived from the neoplastic giant cell population in Hodgkin's disease and that they originated from cells of the mononuclear phagocyte-reticulum cell lineage.

Leucovorin Protection on Pluripotent Hemopoietic Stem Cells in Mice Treated with High-Dose Methotrexate

Haematologic effects of delayed 16 h administration of leucovorin (LV) following high-dose methotrexate (HDMTX) were analyzed in C57B1×C3HF1 mice. Results show that 16 h administration of LV significantly reduces the toxic effects of HDMTX on hemopoietic progenitors and bone marrow cells. At 12 days after HDMTX administration, the bone marrow level of CFUs was significantly higher in HDMTX-LV treated mice than in HDMTX treated animals. In comparison with previous data obtained when LV was injected 2 h after HDMTX, the delay in administration of LV does not appear to reduce the protective effect of the vitamin.

Activity of 4'-epi-doxorubicin on normal hematopoietic precursor cells in mice

The effects of 4'epi-doxorubicin (4'-epi-DX) on survival of in situ murine bone marrow hematopoietic precursor cells (HPC) were studied. The drug was given to (C57BL X C3H)F1 mice in increasing single doses, in repeated administration (three time in 5 days), or for a long period (twice a week for 10 weeks). Survival of colony-forming units (CFUs, spleen; CFUc, culture; and CFUe, erythroid) was assayed by in vivo and in vitro methods; dose survival curves were exponential. It appears that single doses of 4'epi-DX have a greater impact on murine HPC than single doses of the parent compound. Following repeated administrations, pluripotential stem cells recover better after the derivative than after its parent drug. During prolonged treatment, the bone marrow content of committed progenitors is depleted to a lesser extent in the animals treated with 4;-epi-DX than in those receiving DX. It is, however, possible that, following the same prolonged treatment, this difference is minimal. The conclusion, these experimental data seem to indicate that 4'-epi-DX has lower toxicity in murine HPC than DX and that this is evident mainly after repeated administrations for a short period of time.

Hematopoietic precursor cells in mice treated with 4-demethoxydaunorubicin and doxorubicin

The hematologic toxicity of 4-demethoxydaunorubicin (4-dmDNR), a new anthracycline more potent and less cardiotoxic than doxorubicin (Dx), was studied. Dose-survival curves of bone marrow hematopoietic precursor cells (HPC) in situ were determined with the use of (C57BL X C3H)F1 mice and with assays of colony-forming units--spleen, culture, and erythroid--by in vivo and in vitro methods. Time response of HPC was followed in mice treated at days 0, 2, and 5 with 0.75 mg 4-dmDNR/kg of 4.5 mg Dx/kg and in mice receiving 2.23 mg 4-dmDNR/kg or 3.96 mg Dx/kg twice a week for 4 weeks. The dose-survival curves of HPC for 4-dmDNR were exponential. Slight differences in sensitivity among assayed populations were seen. Although the doses of 4-dmDNR required to reduce the survival of HPC to 37% were similar or lower than those of Dx, following intermittent treatment with doses of 4-dmDNR with the same optimal antitumor activity as with Dx, 4-dmDNR seemed to have a lesser effect on hematopoietic progenitors and a greater effect on peripheral blood cells than did Dx. However, during prolonged administration 4-dmDNR appeared to be toxic at every hematopoietic level.

Evaluation of Doxorubin Toxicity on Normal Hemopoietic Stem Cells

The effect of administration of Doxorubicin (Dx) on the bone marrow CFUs, CFUe and CFUe has been evaluated in mice following injection of scalar single doses of the drug or during its repeated (3 times in 5 days) or prolonged (5 or 10 weeks) administration. In the first experiment the dose survival curves were exponential and the sensitivity of the 3 types of hemopoietic progenitors assayed was almost similar. During repeated or prolonged administration of Doxorubicin the CFUs appeared to be less affected by the drug than the committed progenitors.

[Behaviour of bone marrow and splenic hemopoietic stem cells following administration of anthracyclines]

The effect of Adriamycin and 4-Eip-Adriamycin was studied on CFUs, CFUc, CFUe of murine bone marrow and spleen. Differences among the bone marrow stem cells and the spleen stem cells have been observed. It seems possible to explain some of these differences admitting a process of redistribution from the bone marrow to the spleen.