An Innovative Scoring System to Select the Optimal Surgery in Breast Cancer after Neoadjuvant Chemotherapy

INTRODUCTION

The selection of surgery post-neoadjuvant chemotherapy (NACT) is difficult and based on surgeons' expertise. The aim of this study was to create a post-NEoadjuvant Score System (pNESSy) to choose surgery, optimizing oncological and aesthetical outcomes.

METHODS

Patients (stage I-III) underwent surgery post-NACT (breast-conserving surgery (BCS), oncoplastic surgery (OPS), and conservative mastectomy (CMR) were included. Data selected were BRCA mutation, ptosis, breast volume, radiological response, MRI, and mammography pre- and post-NACT prediction of excised breast area. pNESSy was created using the association between these data and surgery. Area under the curve (AUC) was assessed. Patients were divided into groups according to correspondence (G1) or discrepancy (G2) between score and surgery; oncological and aesthetic outcomes were analyzed.

RESULTS

A total of 255 patients were included (118 BCS, 49 OPS, 88 CMR). pNESSy between 6.896-8.724 was predictive for BCS, 8.725-9.375 for OPS, and 9.376-14.245 for CMR; AUC was, respectively, 0.835, 0.766, and 0.825. G1 presented a lower incidence of involved margins (5-14.7%; p = 0.010), a better locoregional disease-free survival (98.8-88.9%; p < 0.001) and a better overall survival (96.1-86.5%; p = 0.017), and a better satisfaction with breasts (39.8-27.5%; p = 0.017) and physical wellbeing (93.5-73.6%; p = 0.001).

CONCLUSION

A score system based on clinical and radiological features was created to select the optimal surgery post-NACT and improve oncological and aesthetic outcomes.

Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience

Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. Results: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. Conclusions: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.

Mastectomy and immediate prepectoral versus submuscular breast reconstruction after neoadjuvant chemotherapy: Our early experience

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Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that allows to improve aesthetic results and patient quality of life. Traditionally, implants have been placed in a submuscolar (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of prosthesis is increasingly used in order to avoid morbidities related to manipulation of PMM. The aim of this study was to compare outcomes of SM vs PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our Istitution from January 2018 to December 2021. Conservative mastectomy was performed in 155 of the 400 patients that underwent NAC during the study period. Patients were divided in 2 groups based on the positioning of implants: 60 SM versus 95 PP. Results: The two cohorts were similar for age (mean age 45 and 42 years in the SM and PP group respectively) and follow‐up (32 and 21 months, respectively). Mean operative time was 55 minutes shorter in the PP group (298 and 243 minutes in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss occurred was observed in 1.6% of patients (1/60) in the SM group and 1,05% of patients (1/95) in PP group. No differences were observed among the two groups in local or regional recurrence. Conclusions: Our preliminary experience, that represents one of the largest series of PP-IPBR after NAC at a single Institution documented in the Literature, seems to confirm that PP - IPBR after NAC is a safe, reliable and effective alternative to traditional SM - IPBR with excellent aesthetic and oncological outcomes; it is easy to perfom, reduces operative time and minimizes complications related to manipolation of PPM. However this promising results need to be confirmed in prospective trials with longer follow-up.

GENERATOR Breast DataMart-The Novel Breast Cancer Data Discovery System for Research and Monitoring: Preliminary Results and Future Perspectives

Background: Artificial Intelligence (AI) is increasingly used for process management in daily life. In the medical field AI is becoming part of computerized systems to manage information and encourage the generation of evidence. Here we present the development of the application of AI to IT systems present in the hospital, for the creation of a DataMart for the management of clinical and research processes in the field of breast cancer. Materials and methods: A multidisciplinary team of radiation oncologists, epidemiologists, medical oncologists, breast surgeons, data scientists, and data management experts worked together to identify relevant data and sources located inside the hospital system. Combinations of open-source data science packages and industry solutions were used to design the target framework. To validate the DataMart directly on real-life cases, the working team defined tumoral pathology and clinical purposes of proof of concepts (PoCs). Results: Data were classified into “Not organized, not ‘ontologized’ data”, “Organized, not ‘ontologized’ data”, and “Organized and ‘ontologized’ data”. Archives of real-world data (RWD) identified were platform based on ontology, hospital data warehouse, PDF documents, and electronic reports. Data extraction was performed by direct connection with structured data or text-mining technology. Two PoCs were performed, by which waiting time interval for radiotherapy and performance index of breast unit were tested and resulted available. Conclusions: GENERATOR Breast DataMart was created for supporting breast cancer pathways of care. An AI-based process automatically extracts data from different sources and uses them for generating trend studies and clinical evidence. Further studies and more proof of concepts are needed to exploit all the potentials of this system.

In-situ gelling xyloglucan formulations as 3D artificial niche for adipose stem cell spheroids

Three-dimensional spheroidal cell aggregates of adipose stem cells (SASCs) are a distinct upstream population of stem cells present in adipose tissue, with enhanced regeneration properties in vivo. The preservation of the 3D structure of the cells, from extraction to administration, can be a promising strategy to ensure optimal conditions for cell viability and maintenance of stemness potential. With this aim, an artificial niche was created by incorporating the spheroids into an injectable, in-situ gelling solution of partially degalactosylated xyloglucan (dXG) and an ad hoc formulated culture medium for the preservation of stem cell spheroid features. The evolution of the mechanical properties and the morphological structure of this artificial niche was investigated by small amplitude rheological analysis and scanning electron microscopy, respectively. Comparatively, systems produced with the same polymer and the typical culture medium (DMEM) used for adipose stem cell (ASC) growth in adherent cell culture conditions were also characterised. Cell viability of both SASCs and ASCs incorporated inside the hydrogel or seeded on top of the hydrogel were investigated as well as the preservation of SASC stemness conditions when embedded in the hydrogel.

Diagnosis and Treatment of Bone Metastases in Breast Cancer: Radiotherapy, Local Approach and Systemic Therapy in a Guide for Clinicians

The standard care for metastatic breast cancer (MBC) is systemic therapies with imbrication of focal treatment for symptoms. Recently, thanks to implementation of radiological and metabolic exams and development of new target therapies, oligometastatic and oligoprogressive settings are even more common-paving the way to a paradigm change of focal treatments role. In fact, according to immunophenotype, radiotherapy can be considered with radical intent in these settings of patients. The aim of this literature review is to analyze available clinical data on prognosis of bone metastases from breast cancer and benefits of available treatments for developing a practical guide for clinicians.

Adult Onset Still's Disease and Radiotherapy treatment for breast cancer: Case report about management of this rare association and literature review

AIM

This manuscript focuses on the first experience in literature of a patient with a complicated Adult Onset Still's Disease-related heart failure who thereafter underwent adjuvant radiotherapy for left breast cancer.

BACKGROUND

AOSD is a rare autoimmune inflammation-related disease, in which life-threatening pulmonary and cardiac complications can occur. In literature, AOSD is often associated with cancer, as paraneoplastic syndrome, but there are few data about primary AOSD and management of oncological therapies.

MATERIALS AND METHODS

A patient who needed adjuvant breast cancer radiotherapy underwent tumour board evaluation to define feasibility of an RT in a patient with of a history of a heart life-threatening complication 2 years before AOSD. Results of the review were discussed by a multidisciplinary panel of experts that chose the type of surgery, radiotherapy and monitoring of patient.

RESULTS

Literature review confirmed association of AOSD with BC in some pts and uniqueness of this treatment management experience. Patient underwent RT according to schedule of 40.05/2.67 Gy/fx on residual left breast and 10/2 Gy/fx on tumour bed with the gating technique. The panel chose to keep immunosuppressive therapy with anakinra. No complications were observed at clinical, ECG and laboratory examinations. Maximum toxicity was G2 skin. At first follow up AOSD signs of flare were negative.

CONCLUSION

In conclusion, when oncological treatments, especially radiotherapy, are mandatory for AOSD pts, multidisciplinary management and tailored monitoring are necessary to avoid acute adverse effects and allow pts to complete therapies.

Oncotype DX Predictive Nomogram for Recurrence Score Output: The Novel System ADAPTED01 Based on Quantitative Immunochemistry Analysis

PURPOSE

Oncotype DX (ODX) predicts breast cancer recurrence risk, guiding the choice of adjuvant treatment. In many countries, access to the test is not always available. We used correlation between phenotypical tumor characteristics, quantitative classical immunohistochemistry (IHC), and recurrence score (RS) assessed by ODX to develop a decision supporting system for clinical use.

PATIENTS AND METHODS

Breast cancer patients who underwent ODX testing between 2014 and 2018 were retrospectively included in the study. The data selected for analysis were age, menopausal status, and pathologic and IHC features. IHC was performed with standardized quantitative methods. The data set was split into two subsets: 70% for the training set and 30% for the internal validation set. Statistically significant features were included in logistic models to predict RS ≤ 25 or ≤ 20. Another set was used for external validation to test reproducibility of prediction models.

RESULTS

The internal set included 407 patients. Mean (range) age was 53.7 (31-80) years, and 222 patients (54.55%) were > 50 years old. ODX results showed 67 patients (16.6%) had RS between 0 and 10, 272 patients between 11 and 25 (66.8%), and 68 patients > 26 (16.6%). Logistic regression analysis showed that RS score (for threshold ≤ 25) was significantly associated with estrogen receptor (P = .004), progesterone receptor (P < .0001), and Ki-67 (P < .0001). Generalized linear regression resulted in a model that had an area under the receiver operating characteristic curve (AUC) of 92.2 (sensitivity 84.2%, specificity 80.1%) and that was well calibrated. The external validation set (183 patients) analysis confirmed the model performance, with an AUC of 82.3 and a positive predictive value of 91%. A nomogram was generated for further prospective evaluation to predict RS ≤ 25.

CONCLUSION

RS was related to quantitative IHC in patients with RS ≤ 25, with a good performance of the statistical model in both internal and external validation. A nomogram for enhancing clinical approach in a cost-effective manner was developed. Prospective studies must test this application in clinical practice.

Shoulder girdle impairment in breast cancer survivors: the role of range of motion as predictive factor for dose distribution and clinical outcome

Background:

Pain and functional impairment of the ipsilateral shoulder girdle in patients who underwent surgery and radiotherapy for breast cancer (BC) is a late complication reported in the literature. We analyze a correlation with dosimetric parameters and propose an algorithm for sparing strategies.

Methods:

A total of 111 patients treated for BC were included in this observational analysis during follow-up protocol visits. Exclusion criteria were the presence of moderate or severe arthrosis history and/or rheumatologic diseases. All the patients had complete physical and multidimensional examinations during joint (physiatrist and radiotherapy oncology) follow-up visits. A scapula–humeral articulation (SHA) standardized contouring was performed retrospectively on Eclipse® treatment plans. A possible correlation between patients’ characteristics, radiotherapy, and dosimetry analysis and functional impairment was investigated at statistical analysis. Results of analysis were summarized into a proposal of algorithm for sparing SHA.

Results:

A total of 111 patients were selected during follow-up visits. Mean age of patients was 60 years (range 41–85 years). A total of 103 patients (93%) underwent conservative surgery, with 110 patients (99%) undergoing axilla surgery as well. Fifty-two patients (46.8%) presented a reduction of range of motion (ROM) abduction on the treated side at the observational analysis. Mean ROM abduction reduction was 13°06’ (range 0°–100°). Disability of the Arm, Shoulder and Hand questionnaire (DASH) score results were excellent in 79 patients (71.2%), discrete in 15 patients (13.5%), good in 15 patients (13.5%), and sufficient in 2 patients (1.8%). Median EQD2Dmaxat SHA was 18 Gy (range 0.22–51.9 Gy) and median EQD2mean dose at SHA was 2 Gy (range 0.04–24.32 Gy). Univariate analysis showed a linear correlation between DASH score and ROM of abduction of treated side (ρ=−0.7), ROM of abduction and ROM of flexion in ipsilateral arm (ρ=0.8), or ROM of abduction and ROM of flexion in contralateral arm (ρ=0.8). A statistically significant difference in ROM abduction between the 2 arms was found at χ2test ( P<0.05 at χ2confidence interval = 95%). Cox linear regression analysis showed ROM abduction on treated arm as a predictive factor of DASH score ( P<0.0001). Age ( P<0.05), DASH score ( P=0.006), and ROM abduction on treated arm ( P=0.005) were found as independent predictive factors of mean dose at multivariate analysis. A mean dose higher than 7 Gy and ROM abduction reduction more than 30° were related to DASH score level reduction.

Conclusions:

This hypothesis-generating study introduces an algorithm to be validated for management of sparing SHA and improving quality of survivorship. ROM evaluation after surgery, early physiotherapy, standard contouring, and planning adaptation represent possible indications to preserve shoulder impairment. Further prospective studies are needed to discriminate impairment of surgery and radiotherapy in order to personalized therapeutic plan programs.

New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient

The surgical management of breast cancer has undergone continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long, but constant, despite the controversies that appeared every time a new procedure came to light. Today, the aesthetic satisfaction of breast cancer patients coupled with the oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and cosmesis by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present work will highlight the new surgical treatment options increasingly efficacy and respectful of breast cancer patients.

Integrated breast cancer surgical treatment: novel aspects of minimally-invasive treatments

The surgical management of breast cancer has been undergoing continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long but constant, despite the controversies arising every time a new procedure came to light. Today, the esthetic satisfaction of breast cancer patients coupled with oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy still remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and esthetic outcome by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present special article will highlight the new surgical treatment options, which are more and more effective and respectful of breast cancer patients.

Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap

BACKGROUND

Achilles tendon ruptures are becoming more common. Complications after open or minimally invasive surgery are: recurrent rupture (2-8%), wound breakdown, deep infections, granuloma, and fistulas. The authors expose their experience with a personal technique.

MATERIALS

In 8 patients with acute rupture of Achilles tendon the surgery was performed at least 25 days after trauma. Clinical exam and MR demonstrated in all case a total lesion of tendon. After a posterolateral skin incision the tendon stumps were debrided and suture in end-to-end fashion. A tendon flap was harvested from the proximal part of the tendon, in order to protect and reinforce the suture itself. A plaster cast was applied for 3 weeks and the patients started the rehabilitation protocol.

RESULTS

After 4 months all patients returned to pre-injury daily activities. The mean follow up was 13 months (ranged between 6 and 24 months). No major complications occurred.

CONCLUSION

The posterolateral skin incision, not above the tendon, preserves the vascularity of the soft tissues, allows identifying and not accidentally injuring the sural nerve, and prevents the cutaneous scar is overlapped the tendon. In this way is favoured physiological tendon sliding. The preparation of the flap tendon does not weaken the overall strength of the tendon and protects the tendon suture. The tension on sutured stumps is less than being spread over a larger area. In our sample of 8 patients the absence of short-and long-term complications and the rapid functional recovery after surgery suggest that the technique used is safe and effective.

Update on the surgical management of breast cancer

The surgical management of breast cancer has undergone continuous and profound changes over the last three decades. For patients with early stage breast cancer, breast-conserving surgery followed by radiation therapy has been definitively validated as a safe alternative to radical mastectomy, with similar survival rates, better cosmetic outcomes and acceptable rates of local recurrence. Thanks to the improvements in diagnostic work-up, as well as the wider diffusion of screening programs and efforts in patient and physician education, tumors are more often detected at an early stage, furtherly facilitating the widespread use of breast conserving techniques. Breast-conserving surgery has been introduced also in the treatment of patients with locally advanced tumors after tumor downsizing with preoperative chemotherapy, with acceptable rates of ipsilateral breast tumor recurrence. When performing breast-conserving surgery all efforts should be made to ensure negative surgical margins in order minimize the risk of ipsilateral breast tumor recurrence as they are associated with worse distant-disease-free and breast cancer- specific survival rates. The recent introduction of "oncoplastic techniques", that may allow more extensive excisions of the breast without compromising the cosmetic results, has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy, but several controversies still remain about completion of axillary lymph node dissection in patients with a pathologic positivity in sentinel lymph node biopsy. The present work will highlight the benefits and unresolved issues of the different surgical treatment options in breast cancer and axillary treatment.

"Downward steps technique" with CO2 ultrapulsed laser for the treatment of rhinophyma: our protocol

BACKGROUND

The rhinophyma is an important soft-tissue hypertrophy of the nose. In literature a wide range of surgical approaches to rhinophyma has been described such as dermoabrasion, scalpel shave, cryosurgery, electrocautery, near total excision with skin grafting, and laser excision.

PATIENTS AND METHODS

The authors describe their experience with CO(2) ultrapulsed laser in 14 elderly male patients, using their personal approach, the Downward steps technique. With this technique they removed the pathological hypertrophic tissue using a progressive reduction of the laser power during the treatment. They obtained good results from morphological and aesthetic point of view, in a single laser session.

CONCLUSIONS

Major complications such as hypertrophic scars, infections, hyperpigmentation were not observed.

Treatment of stages IIIIV of the Dupuytrens Disease using a personal approach: percutaneous needle fasciotomy (PNF) and minimal invasive selective aponeurectomy

The authors present their experience in treating 23 fingers on 20 patients affected by Dupuytrens Disease in stages III and IV of the Tubiana classification with their personal technique that involves the percutaneous needle fasciotomy followed 40 days after by a selective open aponeurectomy on the previously treated cord, by making a small cutaneous incision. The treatment requires careful selection of the patients. In fact, patients suffering from the disease for more than 5 years and all the cases with a suspicion of joint rigidity are excluded from the study. The average follow up period was approximately 48 months. 18 out of the 20 patients had excellent functional recovery. Skin grafts or local flaps are not required after selective aponeurectomy with these surgical steps. The advantages of this technique include its simplicity, minimal discomfort to patients, rapid functional recovery, low recurrence rate and low cost.

Update on oncoplastic breast surgery

Oncoplastic surgery of the breast (OPS) has generated great excitement over the past years and has become an integrated component of the surgical treatment of breast cancer. Oncoplastic surgical procedures associate the best surgical oncologic principles to achieve wide tumor-free margins with the best principles of plastic surgery to optimize cosmetic outcomes. Thanks to oncoplastic techniques, the role of breast conserving surgery (BCS) has been extended to include a group of patients who would otherwise require mastectomy to achieve adequate tumor clearance. As OPS continues to gain acceptance and diffusion, an optimal and systematic approach to these techniques is becoming increasingly necessary. This article has the aim to review the essential principles and techniques associated with oncoplastic surgery, based on the data acquired through an extensive search of the PUBMED and MEDLINE database for articles published using the key words "breast cancer oncoplastic surgery". This review analyzes possible the advantages", classifications, indications, and the criteria for a proper selection of oncoplastic techniques to facilitate one's ability to master these procedures and make OPS a safe and an effective procedure.

Giant condylomata (Buschke-Löwenstein tumours): our case load in surgical treatment and review of the current therapies

BACKGROUND

Buschke-Löwenstein tumour (BLT) or giant condyloma is a verrucous infiltrating lesion, due to a sexually transmitted virus infection, human papilloma virus subtypes 6 and 11. Poor hygiene, promiscuity, chronic irritation and cellular immunocompromised states are often implicated in its genesis. Typical treatment of giant condyloma includes imiquimod cream, podophillin resin, cryotherapy, laser surgery, tangential shave excision with electrocautery.

OBJECTIVE

The authors report their case load in the treatment of giant condyloma and the review of the modern therapies.

METHODS AND MATERIALS

27 consecutive patients (18 men, nine women) underwent surgery for giant condylomata of perianal region and externa genitalia at the Department of Plastic Surgery of the University of Palermo, from October 2006 to December 2009. All the patients had been treated before with conservative therapies without significant results. We performed the radical excision with split-thickness skin graft in all the patients.

RESULTS

No significant complications have occurred in all the cases. The functional and aesthetic outcome were satisfying. No recurrence of disease were noticed in the follow-up.

CONCLUSION

the radical excision with split-thickness skin graft appears to be a successful option of treatment for Buschke-Löwenstein tumours. Compared to other methods it does not necessitate several stages of treatment, moreover it has the advantage of a lower risk of recurrence, it allows a complete histologic examination, the healing process is rapid, the improvement of quality of patients's life is significant.

Dupuytren's contracture as result of prolonged administration of phenobarbital

Dupuytren's disease is a fibroproliferative condition involving the superficial palmar fascia, leading to a progressive and irreversible flexion of the fingers. In literature, there are different opinions regarding the phenobarbital, a common antiepileptic drug, and its effective role in the genesis and development of Dupuytren's disease. In this retrospective investigation the association between phenobarbital and Dupuytren's contracture is discussed. Three patients in treatment with phenobarbital who had no others significant risk factors for Dupuytren's contracture were included in this study. The disease occurred after one to four years of drug therapy, at dosage of 100 mg/day. After surgery, Dupuytren's disease showed different evolutions in relation to dosage and type of antiepileptic drug used. Phenobarbital causes a dose and time-dipendent profibrotic effect. A clinical regression was observed when phenobarbital was substituted by carbamazepine, maintaining the same dosage (100 mg/day). This data confirms that not all the antiepileptic drugs are implicated in palmar fibrosis, and suggests that, according to the efficacy and adverse effects, the administration of benzodiazepine reduces the risk of Dupuytren's recurrence.

Immunohistochemical evaluation of inflammatory and proliferative markers in adjacent normal thyroid tissue in patients undergoing total thyroidectomy: results of a preliminary study

Background

Total thyroidectomy is the treatment of choice in the majority of thyroid malignancies, preventing the risk of reoperative surgery due to recurrences. In order to assess the usefulness of such an approach, expression levels of inflammatory and proliferative markers were evaluated immunohistochemically in non-lesional adjacent thyroid tissues from a group of patients who underwent total thyroidectomy for different thyroid diseases.

Methods

Nineteen consecutive patients treated by total thyroidectomy for different thyroid diseases entered the study. IL-6Rb gp130 component of the IL-6 cytokine family members receptor complexes, STAT3 cytokine signalling transduction and transcription activation factor, p53 as tumour suppressor and CK19 cytokeratin as proliferation marker were analyzed in non-lesional thyroid tissues.

Results

Gp 130 expression was detected in all tissue samples with a scattered distribution while STAT3 and p53 positivity was observed in 17 out of 19 patients with a prevailing cytoplasmic localization. Cytokeratin 19 positivity was found in patients with papillary carcinoma, in one case of follicular adenoma, 3 multinodular goiters and one Basedow disease.

Conclusion

Based on the results of this preliminary study, it may be concluded that the presence of a persisting cytokine-mediated activation associated with cytoplasmic localization of p53 is frequently observed in different thyroid diseases. Such a process seems to occur in the thyroid gland as a whole. Moreover, STAT3 activation as well as mutant p53 are risk factors for the development of neoplastic diseases. Total thyroidectomy may be supported as an adequate therapeutic approach for all the patients in whom overexpression of cytokine-dependent markers is detected.

The role of fine-needle aspiration performed with liquid-based cytology in the surgical management of thyroid lesions

BACKGROUND

The aim of this retrospective study was to assess the accuracy and usefulness of cytological classification of fine-needle aspirates in determining the appropriate surgical treatment for thyroid lesions studied with conventional smears (CS) and liquid-based cytology (LBC) in a split-sample method.

PATIENTS AND METHODS

A total of 353 patients were studied with both CS and LBC. The cytological diagnoses were classified according to the British Thyroid Association into 5 groups: Thy1, inadequate; Thy2, non-neoplastic or benign group including goiter, thyrocytic hyperplasia without nuclear atypia and thyroiditis; Thy3 or indeterminate/follicular proliferation, including follicular neoplasm not otherwise specified and oxyphilic follicular neoplasm; Thy4, suspicious for malignancy, including follicular lesion with nuclear pleomorphism; Thy5, diagnostic for malignancy including papillary carcinoma and medullary carcinoma. The efficacy of thyroid fine-needle aspiration processed by CS with LBC in a split-sample method was evaluated.

RESULTS

Overall 164 patients were included in the Thy2, 97 in the Thy3, 49 in the Thy4, and 43 in the malignant Thy5 group. The percentage of unnecessary thyroidectomies decreased from 58.5 to 42% in our series.

CONCLUSION

Our subclassification, according to the British Thyroid Association classification, attempts to reduce the number of Thy3 who undergo surgery. The comparison between the traditional management of thyroid lesions and our morphological categories with the use of CS and LBC together allows the number of unnecessary thyroidectomies to be reduced.

Conservative treatment of a rare case of multifocal adenoid cystic carcinoma of the breast: case report and literature review

BACKGROUND

Adenoid cystic carcinoma of the breast is a rare neoplasm accounting for 0.1% of all malignant breast tumors and presenting most commonly as a painful breast mass. Compared with the more common histological forms of breast cancer, it has a more favorable prognosis and lymph node involvement or distant metastases seldom occur.

CASE REPORT

A unique case of multifocal adenoid cystic carcinoma of the breast presenting as a painful and well-defined lump and treated with conservative surgery with adjuvant radiotherapy is reported.

CONCLUSIONS

There is no consensus on the optimal management of this disease. A breast-conserving approach may be recommended even if mastectomy has been traditionally the treatment of choice. Chemotherapy, radiation, and hormonal therapy have been infrequently used and so far have had no defined role in this kind of neoplasm. The authors found no other reports in the literature focusing on a conservative approach to multifocal adenoid cystic carcinoma.

Reconstruction of the face with skin-grafted muscle flaps: optimizing the aesthetic outcome

BACKGROUND

Cutaneous facial defects repaired with perforator or fasciocutaneous flaps do not always give optimal aesthetic results due to excess bulk and colour mismatch. The authors present their experience in reconstruction of cutaneous facial defects with skin-grafted free muscle flaps.

MATERIALS AND METHODS

From May 2004 to May 2006, 9 serratus anterior, 2 gracilis and 1 vastus lateralis skin-grafted free muscle flaps were used on 12 patients, after cancer excision in 11 cases and after hardware exposure in 1 case. Full thickness skin grafts were taken from the supraclavicular skin in 3 cases, from the groin in 1 case and from the muscle donor site in 8.

RESULTS

No major complications were observed. Results were excellent in terms of contour and colour match. In the elderly, FTSGs taken from the muscle harvesting incision seem to eventually make a good colour match with the facial skin. No relevant donor site morbidity was observed with the muscles used in this series.

CONCLUSIONS

In the search for good aesthetic results in facial skin reconstruction, skin-grafted muscle flaps permit optimal contour and colour match to be achieved with little donor site morbidity and a shorter operating time.

Conservative and radical oncoplastic approches in the surgical treatment of breast cancer

In the attempt to optimise the balance between the risk of local recurrence and the cosmetic outcomes in breast surgery, new surgical procedures, so-called oncoplastic techniques, have been introduced in recent years. The term oncoplastic surgery refers to surgery on the basis of oncological principles during which the techniques of plastic surgery are used, mostly for reconstructive and cosmetic reasons. The advantage of the oncoplastic surgery for breast cancer is the possibility of performing a wider excision of the tumour with a good cosmetic result. Oncoplastic surgery is a broad concept that can be used for several different combinations of oncological surgery and plastic surgery: excision of the tumour by reduction mammoplasty, tumour excision followed by remodelling mammoplasty, mastectomy with immediate reconstruction of the breast and partial mastectomy with reconstruction. Careful patient selection and preoperative planning are key components for the success of any oncoplastic operation for breast cancer. Accurate preoperative evaluation of the clinical and biological features of the tumour as well as of the morphological aspects of the breast allow the surgeon to make a decision if a conservative or radical approach is preferable and select the most effective oncoplastic surgical technique. In this review we summarise the indications, advantages and limitations of several oncoplastic procedures.

[Immediate and long-term results after laparoscopic primary ventral hernia repair]

OBJECTIVE

Umbilical and epigastric hernias are relatively frequent amounting to about 10% of all primary hernias. The aim of this study was to evaluate the efficacy and safety of laparoscopic primary ventral hernia repair.

MATERIAL AND METHODS

From January 2002 through July 2007 a total of 23 consecutive patients were treated by laparoscopy for primary ventral hernia. Main demographics, intraoperative and postoperative data were collected.

RESULTS

There were 14 males and 9 females with a mean age of 53.1 yrs (range 28-70 yrs). Mean body mass index was 25.2 kg/m2 (range 19.4 - 35.2). Fifteen patients had an umbilical hernia, 6 patients had an epigastric hernia and 2 a Spigelian hernia. Mean defect size was 8,4 cm2 (range 1.7 - 81.6). Mean mesh size was 115.9 cm2 (range 62.8-310.8). Mean operating time was 76.1 min (range 50-130). Mean hospital stay was 3,4 days (range 2-8). The median postoperative pain score (evaluated by a visual analog scale - VAS) was 2 at day 1, 4 at day 3 and 1 at day 7. Morbidity rate was 4.3%. After a mean follow-up of 28.5 months none recurrences were observed.

CONCLUSIONS

Our study confirmed the feasibility of laparoscopic repair in terms of postoperative morbidity and recurrence rate. Thus laparoscopic primary ventral hernia repair should be considered an effective alternative to open techniques.

Free style facial artery perforator flap for one stage reconstruction of the nasal ala

The nasolabial skin is the ideal donor site for nasal ala reconstruction. The classic techniques involve a two-stage procedure to reconstruct an aesthetically pleasing nasal ala. A one-stage technique for reconstruction of the nasal ala with a free style nasolabial perforator flap is presented in this article.

PATIENTS AND METHODS

The technique has been used in eight patients between November 2004 and June 2007. In most of the cases (seven out of eight) the whole alar subunit was reconstructed.

RESULTS

Besides a small distal 2mm necrosis in one flap--which healed without further treatment--all the flaps healed uneventfully with aesthetically pleasing results using the one-stage technique.

CONCLUSIONS

The free style perforator nasolabial island flap has become the method of choice in the authors' institution for nasal ala reconstruction, especially when the defect involves the whole subunit. It allows one-stage reconstruction with very similar tissue and a concealed scar in the natural groove.

[Laparoscopic repair of incisional and ventral hernia]

The application of laparoscopic principles to ventral or incisional hernia repair has recently been shown to be a safe and effective alternative to open procedures. In this study we analyzed our recent experience with laparoscopic incisional-ventral hernia repair. The outcomes of 75 consecutive patients (January 2002 to July 2006) who underwent laparoscopic repair for incisional-ventral hernia were reviewed. Patient's demographics, hernia parameters, and intraoperative and postoperative data were collected. Of the 75 patients, 44 were females and 31 males. Mean age was 59.1 yrs (range 29-80 yrs). Mean BMI was 25.9 (range 19.4-36.7). Twenty-one patients had primary ventral hernias while 54 patients had an incisional hernia. Fifty-three patients had a single defect and 22 patients multiple defects. In 45 cases the incisional hernia was a primary hernia; in 4 cases it was a first recurrence; in 2 cases a 2nd recurrence; and in 3 cases a 3rd recurrence. The mean defect size was 52,7 cm2 (range 4-432). Laparoscopic hernia repair was successfully performed in 71 cases (94.7%). The mean mesh size was 211 cm2 (range 63-694). Mean operating time was 101 min (range 50-220 min). The mean hospital stay was 4.7 days. The postoperative morbidity rate was 14%. After a mean follow-up of 24.6 months (range 7-56) the recurrence rate was 7% (5/71). Laparoscopic repair of incisional-ventral hernias seems to be safe and effective. Medium-term outcomes were promising with a relatively low rate of conversion to open surgery, a low complication rate and a low risk of recurrence.

Steatohepatitis is associated with diabetes and fibrosis in genotype 1b HCV-related chronic liver disease

Liver steatosis, diabetes mellitus and hepatitis C virus (HCV) genotype have been implicated in liver fibrosis in HCV-related chronic active hepatitis (CAH). The aim of this study was to evaluate whether steatosis and diabetes were associated with more severe liver fibrosis in patients with genotype 1b HCV-related CAH. One-hundred and eighty patients (98 men, 82 women; age range 17-68 years; median 51) infected with genotype 1b HCV underwent ultrasound examination and liver biopsy because of elevated levels of serum alanine transaminase. Based on liver histology, patients were divided into three steatosis classes: 1 (involving <33% of hepatocytes), 2 (34-66%) and 3 (>66%). Fibrosis was graded with the Ishak score (range: 0-6). Virological and epidemiologic characteristics, biochemical data, body mass index, and apparent duration of disease were recorded. Diabetes was identified according to American Diabetes Association criteria. The median fibrosis grade was 2 (23 patients had liver cirrhosis) in the three steatosis classes, with no significant differences between classes. At multivariate analysis, fibrosis was significantly related to age, alanine transaminase, diabetes, hepatitis B core antibody, steatohepatitis and grading. At binary logistic regression analysis, only diabetes and fibrosis stage were significantly associated with steatohepatitis. Steatosis was not an independent risk factor for liver disease severity in our CAH/genotype 1b HCV-infected patients. Steatohepatitis was associated as well as diabetes and affected the severity of liver fibrosis.

Unexpected ulnar nerve schwannoma. The reasonable risk of misdiagnosis

Peripheral nerve tumors are rare clinical entities that can present with mild symptoms and no neurological deficit. The authors describe one case of asymptomatic schwannoma of the ulnar nerve in a 64-year-old man. The mass was associated with mild and sporadic discomfort due to the mass size; the clinical neurological examination was not conclusive, with Tinel's sign negative; surgery confirmed the nervous origin of the tumor and the histopathologic exam confirmed the diagnosis of schwannoma. These tumors are difficult to diagnose clinically and have often been confused with other benign tumors such as lipomas, hemangiomas, synovial cysts, neurofibromas, etc. Clinical care is important to prevent, during the surgery, the unfortunate resection of the nerve; all too frequently this diagnosis is made intraoperatively or postoperatively with the potential to compromise the outcome of the treatment. An appropriate degree of awareness is necessary for the inclusion of peripheral nerve tumors as a differential diagnosis of an upper extremity mass.

Further application of the bilobed flap: the split bilobed flap for reconstruction of composite posterior auricular and mastoid defects

In this article a modified bilobed flap from mastoid and lateral neck skin for reconstruction of complex defects of the posteromedial surface of the auricle and mastoid skin, with the preservation of the retroauricular sulcus, is described. Reconstruction of the postero-medial auricular surface has almost never been a concern for reconstructive surgeons. It is in fact a shaded area with little aesthetic relevance and direct closure, skin grafting and even secondary healing are used for skin cancer defects repair. Also mastoid skin defects can be repaired with simple techniques such as skin grafts or transposition flaps from the remaining mastoid skin or from the neck. On the other hand, cancers involving the postero-medial auricular surface, the retroauricular sulcus and the mastoid skin require wide and deep resections that involve the posterior auricular muscles and reach the perichondral and periosteal surfaces. Direct closure with undermining, if feasible, will obliterate the retroauricular sulcus causing asymmetry with the contralateral ear and, if defects are cephalad will impair the possibility of wearing spectacles, thus leaving functional and aesthetic impairment. Transposition flaps from the remaining mastoid skin, due to the lack of skin laxity, are not feasible because the donor site cannot be closed. Two patients, both affected by basal cell carcinoma involving the posteromedial auricular surface and the mastoid skin have been treated with this flap. In both cases the use of the modified bilobed flap described in this article allowed preservation of the retroauricular sulcus and closure of the donor site. Scars were hidden along minimal tension lines and the possibility of wearing spectacles along with sensitivity all over the reconstructed area were maintained.

Dupuytren's contracture: an update of biomolecular aspects and therapeutic perspectives

The so-called fibrogenic cytokines, able to induce the growth of fibroblasts and their differentiation into myofibroblasts and to stimulate their production of extracellular matrix, are involved in the genesis of Dupuytren's contracture. Although many studies have been made of biomolecular aspects of palmar fibromatosis, practical applications from them are still far from imminent because of the real difficulty of blocking their action in vivo, even in a chronic, progressive lesion such as Dupuytren's disease. Consequently, surgical excision of the palmar fascia still remains the treatment of choice.

A less invasive, selective, functional neck dissection for papillary thyroid carcinoma

HYPOTHESIS

To describe an alternative lateral neck access in order to perform neck dissection in papillary thyroid carcinoma (PTC) with lymph node involvement.

DESIGN

Prospective (January 2000 to December 2003), 36-month study.

SETTING

Catholic University of Rome and University of "Tor Vergata", Rome, Italy.

PATIENTS AND METHODS

Twenty-four consecutive patients with PTC and cervical lymph node metastases were included. Functional neck dissection (FND), unilateral or bilateral, was performed acceding via a lateral dissection through a traditional Kocher incision, running along the superficial fascia of the neck and posteriorly to the sternocleidomastoideus muscle.

RESULTS

Mean age was 39.04+/-13.69 years. Twenty patients were women and four were men. Mean tumour size was 2.5+/-1 cm, while the greatest metastatic lymph node size was 4.5 cm. Minimally invasive, selective FND was performed in all patients associated to total thyroidectomy and central compartment lymph node clearance. Metastatic lymph nodes were found in 142 out of 340 of the lymph nodes dissected.

CONCLUSIONS

Minimally invasive neck dissection seems to carry a lower risk in terms of specific morbidity and allows a quicker recovery and a better aesthetic result. This access has to be considered as a less invasive procedure compared to the other surgical accesses for the radical or modified lateral neck dissection.

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy

CONCLUSION

Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology.

OBJECTIVES

A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications.

MATERIAL AND METHODS

A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation.

RESULTS

A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52-80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.

[Thermal ablation by radiofrequency of hepatic metastasis of colorectal cancer: short-term results]

Radiofrequency (RF) was used to ablate 42 colorectal liver metastases in 20 patients (10 males and 10 females) in a four years period. Median age was 62.2 years, 36 lesions (75%) had 3 cm diameter or less. An open surgical approach was adopted in 13 patients, whereas a percutaneous one in 14. On 27 surgical sessions, RFA was used in 49 procedures for a total of 81 needle applications. Morbidity was 6.0% (3 cases), one patient died on third po day for myocardial infarction. No differences in terms of complete ablation rate was observed in the two approach's groups. Overall survival was 65% with a median follow-up of 18.5 months.

[Legal contentions in thyroid surgery. Kind of preoperative information to the patients]

The question of patients information and the achievement of an informed consent to medical and/or surgical treatment by the patient still represents one of the main issue of the medical profession, having greater importance nowadays in respect to the past regarding the relationship doctor-patient and to the diagnostic-therapeutic approach to the patient. Written informed consent is a pre requisite for surgical intervention as it provides the forum for the patient to appreciate implications of the procedure and the doctor to explain details and effects of the surgery. Patients refusal is, nowadays, according to the latest orientation of the Italian Supreme Court, the major limitation to medical or surgical intervention. For these reason we have thought better to propose a written form of informed consent regarding the thyroid surgery, which implies, more than other surgery's act, the exposition of the patient to adverse iatrogenic risks and as a consequence it can expose the surgeon to criminal or civil liabilities.

Diagnostic Lobectomy for Unilateral Follicular Nodules of the Thyroid Gland

We describe our technique of diagnostic lobectomy (DL) and the rationale it is based on. We define DL as a minimally invasive procedure consisting of total lobectomy and isthmusectomy, with preservation of the omolateral recurrent laryngeal nerve and parathyroid glands, but without digital exploration of the contralateral lobe. The fact that re-entry into the previously explored field to complete thyroidectomy increases the risk of complications must be taken into consideration. The subjects were 63 consecutive patients who underwent surgery for unilobar follicular neoplasms of the thyroid gland between January 1997 and December 2002. There were 49 follicular adenomas and 14 carcinomas. In the 14 patients with thyroid cancer, total thyroidectomy was performed within 2 weeks after the first operation in a sterile environment with normal anatomical cleavage plains, avoiding any risk of injury to the laryngeal nerves and parathyroid glands. It is concluded that DL is a safe and suitable surgical procedure for patients with follicular-structured lesions of the thyroid gland.

An innervated retroauricular skin flap for total earlobule reconstruction

In this article, the authors describe a technique for total earlobule reconstruction in a patient who underwent earlobule excision for basal cell carcinoma. The reconstruction was by means of an innervated retroauricular skin flap, folded double. The flap presented preserved skin sensitivity over all the reconstructed area, which is compromised by those techniques using a cranially or medially based flap which lead to the reconstruction of an insensible earlobule. This is a very important aspect of this technique, especially for those who wear pendant earrings, since a non-sensitive lobule would be more vulnerable to traumas causing laceration. In addition, it allows a good aesthetic result without evident donor site scars. Further investigation is needed to decide if this method is suitable for other types of total earlobule loss (e.g. congenital, traumatic), or not.

Modified radical neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma

The purpose of this study was to describe an alternative lateral neck access to perform lymph nodes sampling and/or neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma with lymph nodes involvment. Twenty-four consecutive patients with papillary thyroid carcinoma were included. Lymph nodes sampling and modified radical neck dissection, unilateral or bilateral, were performed acceding via a lateral dissection through a traditional Kocher incision, running along the medial fascia of the neck, posteriorly to the sterno-cleido-mastoideus muscle (SCM). Mean age was 39.04 +/- 13.69 years. Twenty patients were women, and 4 were men. Mean tumor size was 2.5 +/- 1 cm.. Total thyroidectomy with lymph nodes dissection of the central compartment associated to modified radical neck dissection was performed in 17 patients: among these, nine patients had a preoperative diagnosis of the latero-cervical lymph nodes metastases, and eight had a perioperative diagnosis of metastases of the extensive sampling of the lower third of the jugular chain. Metastatic lymph nodes were found in 107 out of 615 lymph nodes dissected. The MNRD vets access for modified lateral neck dissection seems to carry a lower risk in terms of specific morbility and allows a quicker recovery and a better cosmetic result. This access has to be considered as a less invasive procedure compared to other surgical accesses for the radical modified lateral neck dissection.

The supra-auricular arterial network: anatomical bases for the use of superior pedicle retro-auricular skin flaps

The authors present an anatomical study on vascularization of the retro-auricular skin, focusing on the origin, distribution and anastomoses of the superior auricular artery. This artery is used as the pedicle of a retro-auricular flap to repair defects in the upper third of the auricle and in the temporal region. The study was carried out on 13 fresh cadavers, with a total of 25 auricles. The common carotid artery had previously been injected with dyed latex. The superior auricular artery was found in all specimens. It had constant course and caliber, mean axial length 2.4 cm, mean caliber 0.8 mm. This artery connected the superficial temporal artery, or its parietal branch, and the posterior auricular artery network. This branch proved a reliable vascular pedicle for the mobilization of retro-auricular flaps. The results of this study are presented together with preliminary clinical results obtained using an antero-superior retro-auricular flap, never previously described, to reconstruct the superior third of the auricle and the temporal region.

[External oblique muscle-cutaneous flap use of the in the reconstruction of large chest wall defects after mastectomy]

The use of an external oblique muscle-cutaneous flap in the reconstruction of large chest wall defects after mastectomy is described. The flap is drown as a V-Y advancement-rotation flap, laterally based, on the ipsilateral abdominal wall. The flap extends from the posterior axillary line to the linea alba, vascular supply is provided by the musculo-cutaneous perforating arteries of the intercostal vessels. Mobilization starts medially including the anterior rectus sheath, décollement continues between the external and the internal oblique muscles as far as the posterior axillary line. The abdominal wall, after flap mobilization, is reinforced by the plication of the internal oblique sheath. The flap was used in 13 patients with major anterior chest-wall defects after mastectomy. In one patient a marginal skin necrosis of about 2 cm was observed. The flap described differs from other external oblique flaps already described in several technical innovations that allow to obtain better functional and esthetic results.

Transcript profiling of human dendritic cells maturation-induced under defined culture conditions: comparison of the effects of tumour necrosis factor alpha, soluble CD40 ligand trimer and interferon gamma

Using cDNA arrays, we characterized patterns of gene expression in populations of human dendritic cells (DCs) produced for clinical use. Culture and maturation induction of myeloid adherent cells under serum-free conditions yielded DCs with phenotypes similar to those described in serum-based systems. Analysis of gene expression in DCs treated with tumour necrosis factor alpha, soluble CD40L trimer or interferon gamma, however, showed specific patterns for each factor examined. Our studies document the expression of several transcripts that have not hitherto been described in DCs and/or differentially regulated according to the differentiation state of the DCs, and suggest important functional differences among the DC populations examined. In addition, DC maturation directs changes in the levels of mRNA specific for transcriptional regulators that effect the production of cytokines (e.g. BCL-6, c-rel). Other changes observed, including alteration in the gene expression profile of adhesion molecules and chemokine receptors such as CD44H, CD 49B, Rantes R, CXCR5 and CD37, suggest differences in trafficking potential between the populations studied. This broad-based description of DC populations, produced under serum-free conditions, has enabled us to better define intermediate stages of DC maturation as well as the differentiation-inducing effects of cytokines on these cells.