SARS-CoV-2 Induced Herpes Virus Reactivations and Related Implications in Oncohematology: When Lymphocytopenia Sets in and Immunosurveillance Drops Out

The severe acute respiratory syndrome, coronavirus 2 (SARS-CoV-2), is a positive-sense single-stranded ribonucleic acid (RNA) virus contagious in humans and responsible for the ongoing coronavirus disease 2019 (COVID-19) [...].

Prognostic Relevance of Multi-Antigenic Myeloma-Specific T-Cell Assay in Patients with Monoclonal Gammopathies

Multiple Myeloma (MM) typically originates from underlying precursor conditions, known as Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Multiple Myeloma (SMM). Validated risk factors, related to the main features of the clonal plasma cells, are employed in the current prognostic models to assess long-term probabilities of progression to MM. In addition, new prognostic immunologic parameters, measuring protective MM-specific T-cell responses, could help to identify patients with shorter time-to-progression. In this report, we described a novel Multi-antigenic Myeloma-specific (MaMs) T-cell assay, based on ELISpot technology, providing simultaneous evaluation of T-cell responses towards ten different MM-associated antigens. When performed during long-term follow-up (mean 28 months) of 33 patients with either MGUS or SMM, such deca-antigenic myeloma-specific immunoassay allowed to significantly distinguish between stable vs. progressive disease (p < 0.001), independently from the Mayo Clinic risk category. Here, we report the first clinical experience showing that a wide (multi-antigen), standardized (irrespective to patients' HLA), MM-specific T-cell assay may routinely be applied, as a promising prognostic tool, during the follow-up of MGUS/SMM patients. Larger studies are needed to improve the antigenic panel and further explore the prognostic value of MaMs test in the risk assessment of patients with monoclonal gammopathies.

The dynamic functions of IRF4 in B cell malignancies

The trajectory of B cell development goes through subsequent steps governed by complex genetic programs, strictly regulated by multiple transcription factors. Interferon regulatory factor 4 (IRF4) regulates key points from pre-B cell development and receptor editing to germinal center formation, class-switch recombination and plasma cell differentiation. The pleiotropic ability of IRF4 is mediated by its “kinetic control”, allowing different IRF4 expression levels to activate distinct genetic programs due to modulation of IRF4 DNA-binding affinity. IRF4 is implicated in B cell malignancies, acting both as tumor suppressor and as tumor oncogene in different types of precursors and mature B cell neoplasia. Here, we summarize the complexity of IRF4 functions related to different DNA-binding affinity, multiple IRF4-specific target DNA motif, and interactions with transcriptional partners. Moreover, we describe the unique role of IRF4 in acute leukemias and B cell mature neoplasia, focusing on pathogenetic implications and possible therapeutic strategies in multiple myeloma and chronic lymphocytic leukemia.

Case Report: Free-Floating Intracoronary Thrombus: Who Is the Convict?

In young patients, especially with no traditional coronary risk factors, hypercoagulable states may always be considered as an alternative cause of acute coronary syndromes. The concomitant thrombotic and bleeding risk associated with myeloproliferative disorders complicates the decision-making, particularly regarding long-term dual antiplatelet therapy. The chosen therapy may need to be frequently revisited, depending on the patient's bleeding complications. We reported the case of a 49-year-old woman with acute myocardial infarction with no traditional risk factors for coronary artery disease where a myeloproliferative neoplasm was diagnosed.

Notch2 Increases the Resistance to Venetoclax-Induced Apoptosis in Chronic Lymphocytic Leukemia B Cells by Inducing Mcl-1

Chronic lymphocytic leukemia (CLL) has experienced a clinical revolution—thanks to the discovery of crucial pathogenic mechanisms. CLL is still an incurable disease due to intrinsic or acquired resistance of the leukemic clone. Venetoclax is a Bcl-2 inhibitor with a marked activity in CLL, but emerging patterns of resistance are being described. We hypothesize that intrinsic features of CLL cells may contribute to drive mechanisms of resistance to venetoclax. We analyzed the expression of Interferon Regulatory Factor 4 (IRF4), Notch2, and Mcl-1 in a cohort of CLL patients. We evaluated CLL cell viability after genetic and pharmaceutical modulation of Notch2 expression in patients harboring trisomy 12. We tested venetoclax in trisomy 12 CLL cells either silenced or not for Notch2 expression or in combination with an inhibitor of Mcl-1, AMG-176. Trisomy 12 CLL cells were characterized by low expression of IRF4 associated with high levels of Notch2 and Mcl-1. Notch2 and Mcl-1 expression determined protection of CLL cells from spontaneous and drug-induced apoptosis. Considering the involvement of Mcl-1 in venetoclax resistance, our data demonstrated a contribution of high levels of Notch2 and Mcl-1 in a reduced response to venetoclax in CLL cells carrying trisomy 12. Furthermore, reduction of Mcl-1 expression by silencing Notch2 or by treatment with AMG-176 was able to restore the response of CLL cells to venetoclax. The expression of Notch2 identifies a subset of CLL patients, mainly harboring trisomy 12, characterized by high levels of Mcl-1. This biological mechanism may compromise an effective response to venetoclax.

Monocyte Distribution Width (MDW) as novel inflammatory marker with prognostic significance in COVID-19 patients

Monocyte Distribution Width (MDW), a new cytometric parameter correlating with cytomorphologic changes occurring upon massive monocyte activation, has recently emerged as promising early biomarker of sepsis. Similar to sepsis, monocyte/macrophage subsets are considered key mediators of the life-threatening hyper-inflammatory disorder characterizing severe COVID-19. In this study, we longitudinally analyzed MDW values in a cohort of 87 COVID-19 patients consecutively admitted to our hospital, showing significant correlations between MDW and common inflammatory markers, namely CRP (p < 0.001), fibrinogen (p < 0.001) and ferritin (p < 0.01). Moreover, high MDW values resulted to be prognostically associated with fatal outcome in COVID-19 patients (AUC = 0.76, 95% CI: 0.66-0.87, sensitivity 0.75, specificity 0.70, MDW threshold 26.4; RR = 4.91, 95% CI: 1.73-13.96; OR = 7.14, 95% CI: 2.06-24.71). This pilot study shows that MDW can be useful in the monitoring of COVID-19 patients, as this innovative hematologic biomarker is: (1) easy to obtain, (2) directly related to the activation state of a fundamental inflammatory cell subset (i.e. monocytes, pivotal in both cytokine storm and sepsis immunopathogenesis), (3) well correlated with clinical severity of COVID-19-associated inflammatory disorder, and, in turn, (4) endowed with relevant prognostic significance. Additional studies are needed to define further the clinical impact of MDW testing in the management of COVID-19 patients.

Inflammatory Microenvironment and Specific T Cells in Myeloproliferative Neoplasms: Immunopathogenesis and Novel Immunotherapies

The Philadelphia-negative myeloproliferative neoplasms (MPNs) are malignancies of the hematopoietic stem cell (HSC) arising as a consequence of clonal proliferation driven by somatically acquired driver mutations in discrete genes (JAK2, CALR, MPL). In recent years, along with the advances in molecular characterization, the role of immune dysregulation has been achieving increasing relevance in the pathogenesis and evolution of MPNs. In particular, a growing number of studies have shown that MPNs are often associated with detrimental cytokine milieu, expansion of the monocyte/macrophage compartment and myeloid-derived suppressor cells, as well as altered functions of T cells, dendritic cells and NK cells. Moreover, akin to solid tumors and other hematological malignancies, MPNs are able to evade T cell immune surveillance by engaging the PD-1/PD-L1 axis, whose pharmacological blockade with checkpoint inhibitors can successfully restore effective antitumor responses. A further interesting cue is provided by the recent discovery of the high immunogenic potential of JAK2V617F and CALR exon 9 mutations, that could be harnessed as intriguing targets for innovative adoptive immunotherapies. This review focuses on the recent insights in the immunological dysfunctions contributing to the pathogenesis of MPNs and outlines the potential impact of related immunotherapeutic approaches.

Inflammatory Microenvironment and Specific T Cells in Myeloproliferative Neoplasms: Immunopathogenesis and Novel Immunotherapies

The Philadelphia-negative myeloproliferative neoplasms (MPNs) are malignancies of the hematopoietic stem cell (HSC) arising as a consequence of clonal proliferation driven by somatically acquired driver mutations in discrete genes (JAK2, CALR, MPL). In recent years, along with the advances in molecular characterization, the role of immune dysregulation has been achieving increasing relevance in the pathogenesis and evolution of MPNs. In particular, a growing number of studies have shown that MPNs are often associated with detrimental cytokine milieu, expansion of the monocyte/macrophage compartment and myeloid-derived suppressor cells, as well as altered functions of T cells, dendritic cells and NK cells. Moreover, akin to solid tumors and other hematological malignancies, MPNs are able to evade T cell immune surveillance by engaging the PD-1/PD-L1 axis, whose pharmacological blockade with checkpoint inhibitors can successfully restore effective antitumor responses. A further interesting cue is provided by the recent discovery of the high immunogenic potential of JAK2V617F and CALR exon 9 mutations, that could be harnessed as intriguing targets for innovative adoptive immunotherapies. This review focuses on the recent insights in the immunological dysfunctions contributing to the pathogenesis of MPNs and outlines the potential impact of related immunotherapeutic approaches.

A proof of evidence supporting abnormal immunothrombosis in severe COVID-19: naked megakaryocyte nuclei increase in the bone marrow and lungs of critically ill patients

Coronavirus disease 2019 (COVID-19) is a global public health emergency with many clinical facets, and new knowledge about its pathogenetic mechanisms is deemed necessary; among these, there are certainly coagulation disorders. In the history of medicine, autopsies and tissue sampling have played a fundamental role in order to understand the pathogenesis of emerging diseases, including infectious ones; compared to the past, histopathology can be now expanded by innovative techniques and modern technologies. For the first time in worldwide literature, we provide a detailed postmortem and biopsy report on the marked increase, up to 1 order of magnitude, of naked megakaryocyte nuclei in the bone marrow and lungs from serious COVID-19 patients. Most likely related to high interleukin-6 serum levels stimulating megakaryocytopoiesis, this phenomenon concurs to explain well the pulmonary abnormal immunothrombosis in these critically ill patients, all without molecular or electron microscopy signs of megakaryocyte infection.

Macrodontia associated with growth-hormone therapy: a case report and review of the literature

BACKGROUND

Macrodontia is a rare dental anomaly, and isolated macrodontia is even more infrequent. The aim of this article is to report on a young male patient with macrodontia of the mandibular premolars.

CASE REPORT

We herein present a case report of a young male patient receiving pharmacological growth hormone therapy for 10 years, who was diagnosed with macrodontia of the mandibular premolars. The patient underwent surgical treatment at the School of Dentistry of the University of Buenos Aires and was followed-up for more than 3 years.

CONCLUSION

Macrodontia is a rare condition. Early diagnosis and treatment of this anomaly favors adequate formation of the dental arches. In the light of this case report, a review of paediatric patients who received growth hormone therapy during the tooth formation stage would seem relevant.

Characterization and dynamics of specific T cells against nucleophosmin-1 (NPM1)-mutated peptides in patients with NPM1-mutated acute myeloid leukemia

Nucleophosmin(NPM1)-mutated protein, a leukemia-specific antigen, represents an ideal target for AML immunotherapy. We investigated the dynamics of NPM1-mutated-specific T cells on PB and BM samples, collected from 31 adult NPM1-mutated AML patients throughout the disease course, and stimulated with mixtures of 18 short and long peptides (9-18mers), deriving from the complete C-terminal of the NPM1-mutated protein. Two 9-mer peptides, namely LAVEEVSLR and AVEEVSLRK (13.9-14.9), were identified as the most immunogenic epitopes. IFNγ-producing NPM1-mutated-specific T cells were observed by ELISPOT assay after stimulation with peptides 13.9-14.9 in 43/85 (50.6%) PB and 34/80 (42.5%) BM samples. An inverse correlation between MRD kinetics and anti-leukemic specific T cells was observed. Cytokine Secretion Assays allowed to predominantly and respectively identify Effector Memory and Central Memory T cells among IFNγ-producing and IL2-producing T cells. Moreover, NPM1-mutated-specific CTLs against primary leukemic blasts or PHA-blasts pulsed with different peptide pools could be expanded ex vivo from NPM1-mutated AML patients or primed in healthy donors. We describe the spontaneous appearance and persistence of NPM1-mutated-specific T cells, which may contribute to the maintenance of long-lasting remissions. Future studies are warranted to investigate the potential role of both autologous and allogeneic adoptive immunotherapy in NPM1-mutated AML patients.

A typical atypical chronic myeloid leukemia

In the context of leukocytosis due to increased number of neutrophils and their precursors, with significant dysgranulopoiesis and no or minimal basophilia and no or minimal monocytosis, the typical feature of “clumped” chromatin, in irregularly coarse compacted nuclei, should lead to suspect the diagnosis of atypical chronic myeloid leukemia.

All-trans retinoic acid (ATRA) in non-promyelocytic acute myeloid leukemia (AML): results of combination of ATRA with low-dose Ara-C in three elderly patients with NPM1-mutated AML unfit for intensive chemotherapy and review of the literature

Based upon the clinical behavior of three patients, we suggest that the combination of low‐dose Ara‐C and all‐trans retinoic acid may potentially be effective in some elderly patients, unfit for intensive chemotherapy, affected with NPM1‐mutated acute myeloid leukemia without FLT3 mutations, warranting perspective clinical studies in these selected patients.

Mucorales-Specific T Cells in Patients with Hematologic Malignancies

Background

Invasive mucormycosis (IM) is an emerging life-threatening fungal infection. It is difficult to obtain a definite diagnosis and to initiate timely intervention. Mucorales-specific T cells occur during the course of IM and are involved in the clearance of the infection. We have evaluated the feasibility of detecting Mucorales-specific T cells in hematological patients at risk for IM, and have correlated the detection of such cells with the clinical conditions of the patients.

Methods and Findings

By using an enzyme linked immunospot assay, the presence of Mucorales-specific T cells in peripheral blood (PB) samples has been investigated at three time points during high-dose chemotherapy for hematologic malignancies. Mucorales-specific T cells producing interferon-γ, interleukin-10 and interleukin-4 were analysed in order to detect a correlation between the immune response and the clinical picture. Twenty-one (10.3%) of 204 patients, accounting for 32 (5.3%) of 598 PB samples, tested positive for Mucorales-specific T cells. Two groups could be identified. Group 1, including 15 patients without signs or symptoms of invasive fungal diseases (IFD), showed a predominance of Mucorales-specific T cells producing interferon-gamma. Group 2 included 6 patients with a clinical picture consistent with invasive fungal disease (IFD): 2 cases of proven IM and 4 cases of possible IFD. The proven patients had significantly higher number of Mucorales-specific T cells producing interleukin-10 and interleukin-4 and higher rates of positive samples by using derived diagnostic cut-offs when compared with the 15 patients without IFD.

Conclusions

Mucorales-specific T cells can be detected and monitored in patients with hematologic malignancies at risk for IM. Mucorales-specific T cells polarized to the production of T helper type 2 cytokines are associated with proven IM and may be evaluated as a surrogate diagnostic marker for IM.

Chronic and recurrent benign lymphadenopathy without constitutional symptoms associated with human herpesvirus-6B reactivation

Chronic/recurrent behaviour may be encountered in some distinct atypical or malignant lymphoproliferations, while recurrences are not generally observed in reactive/benign lymphadenopathies. We retrospectively analysed a consecutive series of 486 human immunodeficiency virus-negative adults, who underwent lymphadenectomy. Neoplastic and benign/reactive histopathological pictures were documented in 299 (61·5%) and 187 (38·5%) cases, respectively. Of note, seven of the 111 (6·3%) patients with benign lymphadenopathy without well-defined aetiology, showed chronic/recurrent behaviour, without constitutional symptoms. Enlarged lymph nodes were round in shape and hypoechoic, mimicking lymphoma. Reactive follicular hyperplasia and paracortical expansion were observed. Human herpesvirus (HHV)-6B positive staining in follicular dendritic cells (FDCs) was documented in all seven patients. Serological, molecular and immunological examinations suggested HHV-6B reactivation. Among the remaining 104 cases with reactive lymphoid hyperplasia in the absence of well-known aetiology and without recurrences, positivity for HHV-6B on FDCs was found in three cases, whereas in seven further patients, a scanty positivity was documented in rare, scattered cells in inter-follicular regions. Immunohistochemistry for HHV-6A and HHV-6B was invariably negative on 134 lymph nodes, with either benign pictures with known aetiology or malignant lymphoproliferative disorders, tested as further controls. Future studies are warranted to investigate a potential association between HHV-6B reactivation and chronic/recurrent benign lymphadenopathy.

Adapting EVIAVE methodology as a planning and decision-making tool in Venezuela

Landfills in Venezuela have serious problems regarding their location, design and operation. In fact, basic waste disposal is one of the main weaknesses of the municipal waste management in this country. The Venezuelan Ministry of Environment and Renewable Resources has studied and identified the negative impacts of operating landfills, but no program has been implemented to determine the cause-effect relation of these impacts or to design strategies to counteract with the serious environmental and health risks generated. This paper describes how EVIAVE methodology can be successfully used for landfill diagnosis, and shows how this type of landfill diagnosis was applied in Venezuela. For our research study, we carried out both a quantitative and qualitative evaluation of the environmental problems generated by 22 landfills in Venezuela. Our study was based on the following environmental indexes: Landfill Environment, Environmental Risk, Environmental Value, and Probability of Contamination. For the purposes of our study, it was first necessary to adapt EVIAVE to the legal system and social context in Venezuela. The results obtained confirmed the applicability of this methodology to Venezuelan landfills. EVIAVE was found to be an effective planning tool that provided crucial information for the development of action plans, which would improve landfill operation, and help make decisions pertaining to their closure, sealing and eventual recovery.

[Some behavioral characteristics of physicians desired by ambulatory patients. A pilot survey]

AIMS

We must pay attention to character formation of Medical Doctors because it could build a good or bad relationship with colleagues and patients: it is not a merely "humanistic" goal but a necessary component of professional excellence. The first endpoint of this study is to identify how to improve the quality of the outpatient visit.

MATERIALS AND METHODS

We tested a user-friendly questionnaire, distributed to 100 patients.

RESULTS AND CONCLUSIONS

The most important behavioral characteristics desired by patients from physicians are: 1. to have the physician's attention without feeling hurried (such as without the physician answering a phone call during the office visit); 2. to have continuity of care even in the ambulatory setting; 3. to find a relationship of empathy, participation and sharing; 4. to have a peaceful relationship of collaboration with the nurses and other health care personnel; 5. to find the physician appropriately groomed and dressed; 6. to receive the full diagnosis with clarity and at the most appropriate moment of communication.

Use of histopathological indicators on chub (Leuciscus cephalus) and brown trout (Salmo trutta fario) in evaluating river environments

A multidisciplinary study was conducted on water from two rivers in the Abruzzo region of Italy. The study highlighted the importance of histopathological investigations in the evaluation of the environmental impact on fish. Brown trout (Salmo trutta fario) from the Aterno river and chub (Leuciscus cephalus) from the Vomano river were sampled in winter and then again in spring. Histopathological investigations of gills, kidneys and livers revealed inflammatory and degenerative lesions, early warning signals of environmental stress. Lesions were evaluated semi-quantitatively and findings were ranked. The histopathological features were compared with results obtained from the analysis of water samples and macroinvertebrates collected in the two rivers (extended biotic index). All results confirmed alterations of the environment.

Vaccination trials of sea bass (Dicentrarchus labrax) against pasteurellosis using oral, intraperitoneal and immersion methods

Photobacterium damsela subsp. piscicida (Phdp) is the aetiological agent of fish pasteurellosis, causing heavy losses in intensive mariculture plants. The present work compares the protective efficacy of five different vaccine formulation: oral, intraperitoneal, immersion, bivalent immersion (Vibrio anguillarum) and immersion associated with immunostimulants. Each of these vaccine formulations containing whole cells of Phdp formalin inactivated (FKC), was administered to 100 sea bass weighing approximately 2 g; 100 non-vaccinated sea bass were used as controls. Protection against pasteurellosis was tested for 40 days after vaccination by intraperitoneal challenge: each fish was inoculated with Phdp cells at a concentration of 2.75 x 10(4) cfu/ml. Mortality was recorded over the following 14 days, vaccine protection was evaluated using a relative percentage survival (RPS) index. The intraperitoneal formulation gave excellent protection (RPS 82.4%). The most effective immersion form was that followed by simple immersion (RPS 23.1%) followed by the group vaccinated with bivalent vaccine (RPS 18.7%). Protection conferred orally (RPS 28.6%) is of interest for practical purposes.

[Predisposing factors for development of cardial adenocarcinoma]

After a careful revision of the various papers and on the basis of their personal experience, the persons responsible for this project analyse the factors that, today, influence the development of an adenocarcinoma in the region of the gastro-esophageal junction. They also study therapeutic strategies on the basis of new findings in anatomic-physiological matters of this region. From this analysis, specialists notice an increase in adenocarcinomas which affect the gastric region of the cardia, in comparison with carcinomas which affects the gastric region in toto. By considering Barrett, Hayward, Riedel and Ruol's studies, they maintain that the fundamental factor which causes the development of cardial adenocarcinoma is the gastroesophageal reflux. This reflux acts as a chronic irritative stimulus on the esophageal wall and therefore it provokes an increase in mucous secretion and the formation of metaplasia. This metaplasia is initially mucosecreting, acid-secreting and in the end it becomes intestinal. This also leads to the appearance of absorbent calciform cells; the absorption of toxic or mutagenic substance for the cell itself, will be the next step for the development of an adenocarcinoma. Nowadays the therapy of intestinal metaplasia provides for different therapeutic levels: from the endoscopic monitoring (which is used for the most serious cases of dysplasia), to the PPI medical treatment(today in disuse), to the surgical laparoscopic treatment with non-refluxing plasty (Nissen, Toupet). This last treatment is today associated with endoscopic esophageal mucosectomy in order to achieve a better effectiveness. This happens through the use of various methodologies, for example the multipolar electrocoagulation.

Lymph node dissection in surgical treatment of esophageal neoplasms

BACKGROUND

Until now therapy of carcinoma of the esophagus has presented an aura of pessimism, resulting in an attitude among physicians that cure was impossible. Presently the overall 5-year survival is between 38.3% and 55% thanks to new radical surgical techniques. The aim of this work is to evaluate lymph node dissection in treatment of esophageal carcinoma by analyzing morbidity, mortality, survival and quality of life.

METHODS

From 1975 to 1995, 170 patients with carcinoma of the esophagus and cardia underwent operation, of whom 165 underwent 2-field lymphadenectomy and four 3-field lymphadenectomy; one patient was submitted to self-transplanting jejunal loop to neck. One hundred and twenty-two patients had standard resection and 47 en bloc resection.

RESULTS

Lymph node involvement is often found in patients with superficial carcinoma and it greatly influences outcome after esophagectomy. In 2-field lymphadenectomy morbidity and mortality are more frequent in en bloc resections; global 3-year survival was better in patients with early lesions. Three-field lymphadenectomy was performed in only few cases, not sufficient to express a definitive opinion.

CONCLUSIONS

On the basis of our experience, we conclude that the better survival is particularly dependent on early diagnosis, histological type of neoplasia and following surgical treatment, especially on the type of resection with 2 or 3-field lymphadenectomy.

[Lung surgery in the elderly]

Lung surgery in the elderly, once considered a major risk, to be avoided if possible has become more popular in recent years as a result of many factors. First: lung cancer incidence has increased significantly in every age group but mostly in the elderly. Second: diagnosis at an early stage of the disease is higher in patients over 70 due to more frequent medical control in old subjects. Third: we now have more and more humans over 80 and a life expectancy increasing over the years. Fourth: preoperative, operative and postoperative medical supports are now safer and more reliable than previously. Operability criteria in the elderly are substantially the same as in younger group of patients for lung cancer. There are no reasons to refuse surgery in a subject over 80 because he is old. Lobectomy is the procedure of choice for lung cancer even in the elderly. Pneumonectomy must be avoided preferring a less radical procedure (wedge resection) so avoiding the risk of a postoperative respiratory failure that is often fatal for a patient with in border line functional respiratory tests, as often happens in the elderly. Thoracoscopic atypical resections must be considered in patients when a wedge resection is indicated preoperatively and almost always metastatic pulmonary lesion.

Surgical treatment of differentiated microcarcinomas of the thyroid

Thyroid microcarcinomas (TMC) are histologically malignant diseases, despite their limited dimensions and non-aggressive behaviour; frequent multifocality of the disease and local recurrence is really possible after conservative resection. Modern therapeutic approaches to thyroid microcarcinoma include both radical surgical treatment, influenced by the frequent locoregional diffusion of TMC, consisting of a total thyroidectomy with an eventual central and/or functional unilateral lymphadenectomy, depending on the clinical evidence of lymh node metastases and conservative treatment based on more limited resections which take into account the slow clinical progression of this type of tumour. The aim of our work is to examine the therapeutic guidelines for surgical treatment of TMC which, in our experience, are closely dependent on clinical presentation type. From 1991 to 2000, more than 400 patients with thyroid disease were referred to the Department of Surgical Science and Applied Medical Technologies "F. Durante". Threehundred-seventythree patients received surgical treatment: in 311 patients a benign disease was diagnosed, while in 62 neoplasia was present. In total we observed 30 TMC, consisting of 28 papillary and 2 follicular microcarcinomas. On the basis of clinical presentation we divided patients in three groups: A--patients with a clinically suspicious neoplastic lesion before surgical treatment; B--patients in whom histological diagnosis of cancer was "incidental" after an operation performed for benign disease; C--patients in whom a neck lymph node metastases were clinically found before diagnosis of an "occult" papillary carcinoma in the thyroid gland. 27 total thyroidectomies and 3 conservative resections, that required successive total exeresis, were performed. In 5 cases a central neck lymph node dissection was carried out and in 5 + 1 cases functional modified lateral neck dissections was deemed necessary. Our data suggest that an evaluation of tumor's malignancy cannot be carried out on the basis of its dimensions alone. Indeed, biological aggressivity, whether local or at a distance, is a prerogative of both large and small tumours. Therefore a microcarcinoma must be considered a full-blown form of thyroid cancer and as such must be treated. Total thyroidectomy may be followed by identification of possible local metastases. "Whole body" scintigraphy allows to identify and treat with radioiodine therapy, possible recurrent lesions. Therefore in conclusion, total resection is not only a useful, but also a necessary treatment for the correct diagnostic and therapeutic follow-up of these patients.

[Simultaneous bilateral pneumothorax. Case report]

A case report of a 44 year-old white man admitted to the surgical unit for a bilateral simultaneous pneumothorax is presented. The pneumothorax occurred on day one after a surgical operation for discal hernia; in the past the patient already presented a right spontaneous pneumothorax at 32 years of age and a left pneumothorax at 37 years of age, both treated with a pleural drainage. A thoracic drain was bilaterally positioned with a good result only in the right side. The persistence of the left pneumothorax induced the authors to perform a postero-lateral thoracotomy bullae excision and pleurectomy with a good postoperative course. After a few months a new right pneumothorax occurred and the patient was treated with a right postero-lateral thoracotomy, bullae resection and pleurectomy. On the basis of the case reported, the authors consider the different opportunities in the treatment of spontaneous pneumothorax in relation to the present knowledges and technologies. Surgical procedure is to be preferred in case of persistence of pneumothorax despite a pleural drain and in case of pneumothorax in high risk subjects. Even if thoracoscopy seems to give better results regarding postoperative pain, it is not always possible with such a method to perform a careful pleurectomy neither to obtain it in all cases (above all in secondary pneumothorax). Every case must then be carefully studied to choose the best treatment at present available.

[Duodeno-gastric reflux in gallbladder stones and after laparotomic cholecystectomy]

BACKGROUND

Duodeno gastric reflux (DGR) is still a not well-defined condition, even though it has been the subject of different studies for many years.

METHODS

The authors examine its relation with gallstones before and after the surgical removal of the gallbladder. After examining various study techniques, they present their experience of DRG. In this work the methodology used in a group of 40 patients suffering from gallstones and operated by laparotomic cholecystectomy is presented. All patients have been subjected to a clinical questionnaire in order to evaluate their symptoms, before and after cholecystectomy, and at the same time they have been subjected to an endoscopic exam. It s not easy to comment the RESULTS.

RESULTS

Actually, of 32 patients (80%) showing DGR symptoms before surgical treatment, 20 showed their persistence, worsening, or the appearance of new symptoms after cholecystectomy, while 12 were completely asymptomatic. Of 8 patients with no symptoms before cholecystectomy, 3 developed a typical DGR symptomatology while 5 were asymptomatic.

CONCLUSIONS

So 57% of patients were DGR symptomatic after surgical treatment. The compromised function of cholecystitis with calculi, antrum-pyloric-duodenal motility, continuous bile flux in the duodenum, surgical trauma all interact in determining DGR.

[Gastroduodenal reflux after laparotomic or laparoscopic cholecystectomy]

BACKGROUND

The authors analyse gastroduodenal reflux (GDR) in the light of the progress made over the past ten years. The good results achieved using mini-invasive techniques in cholecystectomy prompted the authors to compare laparotomic and laparoscopic cholecystectomy in order to evaluate the influence of both techniques in determining GDR and clinical symptoms.

METHODS

Symptoms were evaluated before and after surgery in 30 patients operated using a laparotomic technique and in 30 patients operated using a laparoscopic technique. Two groups of 10 patients, operated respectively using laparotomic and laparoscopic techniques, were studied both clinically and endoscopically before and after surgery.

RESULTS

The analysis of the results shows a lower incidence of GDR and typical symptoms of GDR in patients undergoing laparoscopic surgery. The rationale underlying the lower incidence of GDR and its symptoms in these patients compared to the more conventional group is not completely clear.

CONCLUSIONS

These results may be influenced by reduced surgical trauma and the careful selection of case or the laparoscopic technique, hence the exclusion of cases complicated by severe cholecystitis.

[Current diagnosis of gastroesophageal reflux disease: learning experience]

The authors report their study on gastro-esophageal reflux disease, a pathology that has become increasingly common over the past years reflecting both a real increase and the use of new and more sophisticated and reliable diagnostic methods and tests. It can be included in the group of pathologies absorbing the largest proportion of financial resources, even exceeding biliary lithiasic disease according to American studies. The authors start by analysing the symptoms of gastroesophageal reflux disease, drawing a distinction between typical (heartburn, epigastric pain and postprandial regurgitation) and atypical symptoms (laryngotracheal symptoms, bronchopulmonary symptoms and esophageal motor incoordination). They outline the diagnostic iter and tests most widely used today to achieve a correct diagnosis. Lastly, they report their experience of 160 patients attending their esophageal diagnostic unit since January 1999 who underwent a number of different instrumental tests, the results of which are compared. Three different aspects are compared: the presence of symptoms, 24-hour pH-metry and endoscopic tests. All these are necessary for a correct diagnosis of gastroesophageal reflux disease and to evaluate the possibility and efficacy of surgery. They emphasise the diagnostic importance of 24-hour pH-measurement as the only test that can directly reveal gastroesophageal reflux. Positive pH results represent a discriminating element in deciding whether the patient should undergo surgery.

[Spontaneous retroperitoneal hematoma: a case report]

The A.A. present a case report of retroperitoneal spontaneous hematoma and put in evidence the difficulties in making an etiopathogenetic diagnosis of spontaneous renal cyst rupture. The patient was a 72 years old man admitted to the hospital in emergency for a painful ipogastric syntomatology and biliary vomit. The ecography showed a distanced gallbladder and the endoscopy evidenced a duodenal stenosis with compression of the gastric posterior wall, so that we were initially directed towards a pancreatic tumor even if the modest increase of the serum bilirubinemy and mostly the fact that direct component was almost normal, gave us strong doubts. The spiral TC gave finally the diagnosis of retroperitoneal hematoma and the presence of a bilateral polycystic kidney with several subcapsular cyst, let us suggest, as well as the anamnestic report of a physical stress, a renal origin of the bleeding. A wild literature review did not evidence other similar cases, but the ecclusion of other possible causes of retroperitoneal hematoma, suggested this conclusion.

[Secondary costal myxoid chondrosarcoma. Presentation of a clinical case]

A type of malignant neoplasm of not frequent observation is reported and the difficulties concerning the distinction from the benign counterpart are underlined, for which a detailed instrumental study is made necessary, integrated with pre and, above all, postoperative histologic analysis. A white male patient of 83, affected by plurirecidivant chondromyxoma of the rib, was admitted for local recurrence. The lesion objectively appeared not dissimilar from the preceding ones, as an ovalar mass fixed on the underlying plains. Radiologic and ultrasonographic examinations seemed to confirm the admission diagnosis; at the end the patient underwent a new intervention. Histologic examination of the lesion yielded a diagnosis of chondromyxosarcoma. The clinical case is made even more interesting by the finding, through the TC technique, preoperatively performed, of a metastatic repetition on the opposite side. The authors examine the problem of the early recognition of a malignant neoplasm developing, in a patient with a clinical history of recidival chondromyxoma. Physical examination and laboratory analysis are not useful in the assessment of the occurring transformation. At molecular level chondromyxosarcoma is characterized by several genomic rearrangements and mutations. Though primitive chondromyxosarcoma often involves the ribs, chondromyxoma's transformation into its malignant counterpart is not a common event. The development of distant metastasis characterizes long term cases. Given the lack of encouraging results about chemo and radio-therapy efficacy in influencing the natural course of the disease, a systematic approach will be made necessary in patient management.

[Ileal occlusion caused by enterolith migrated from Meckel's diverticulum]

The authors present a case report of an intestinal obstruction due to a relatively big coprolite migrated from a large Meckel's diverticulum to the distal Ileum. The patients apparently healthy and a vegetarian, complained on admission of the absence of emission of faeces and gas since four days before with noticeable abdominal distension. In the physical examination he presented intestinal meteorism, a hard abdomen, painful on deep palpation in the median quadrants, especially in the epigastric and mesogastric ones. The abdominal X-RAY in the standing position confirms: an occlusive state with numerous liquid levels in the Ileum. Because of a worsening of the symptomatology and the appearance of generalized comprimission, two days later an exploratory laparotomy was performed. The intervention showed the presence of a Meckel's diverticulum with approximately 10 cm in length, with an ample neck, the distal Ileum for approximately 15 cm in dilation returned rapidly to a normal calibre, after a pastous endoluminal formation borne in the Meckel's diverticulum (Meckel resection presented actually a large niche at the fundus level with a eroded wall) and migrated in the distal Ileum where it could cause the obstruction. In the present case it is probably useful to perform a preoperative CT scan in order to get a precise etiology and perform an ascending Colonscopy, so avoiding a surgical procedure. According to the authors a CT scan is indicated in all cases of intestinal occlusion of unknown case, in order to have a more precise definition of the physiopathology of the occlusion.