Ketogenic diet for epilepsy and obesity: Is it the same?

The term "ketogenic diet" (KD) is used for a wide variety of diets with diverse indications ranging from obesity to neurological diseases, as if it was the same diet. This terminology is confusing for patients and the medical and scientific community. The term "ketogenic" diet implies a dietary regimen characterized by increased levels of circulating ketone bodies that should be measured in blood (beta-hydroxybutyrate), urine (acetoacetate) or breath (acetone) to verify the "ketogenic metabolic condition". Our viewpoint highlights that KDs used for epilepsy and obesity are not the same; the protocols aimed at weight loss characterized by low-fat, low-CHO and moderate/high protein content are not ketogenic by themselves but may become mildly ketogenic when high calorie restriction is applied. In contrast, there are standardized protocols for neurological diseases treatment for which ketosis has been established to be part of the mechanism of action. Therefore, in our opinion, the term ketogenic dietary therapy (KDT) should be reserved to the protocols considered for epilepsy and other neurological diseases, as suggested by the International Study Group in 2018. We propose to adjust the abbreviations in VLCHKD for Very Low CarboHydrate Ketogenic Diet and VLEKD for Very Low Energy Ketogenic Diet, to clarify the differences in dietary composition. We recommend that investigators describe the researchers describing efficacy or side effects of KDs, to clearly specify the dietary protocol used with its unique acronym and level of ketosis, when ketosis is considered as a component of the diet's mechanism of action.

PARENTERAL NUTRITION IN A GLUT1DS PATIENT FOLLOWING CLASSIC KETOGENIC DIET: IDEAL VERSUS REAL-WORLD MANAGEMENT IN AN ACUTE SURGICAL SETTING

BACKGROUND

GLUT1 deficiency syndrome is a rare neurometabolic disorder, whose current gold standard treatment is represented by ketogenic dietary treatments (KDTs). KDTs are generally administered per os; however, in an immediate gastro-enteric post-surgical setting, short-term parenteral (PN) administration might be required.

CASE REPORT

a 14-year-old boy diagnosed with GLUT1DS and in chronic treatment for many years with KDTs underwent urgent laparoscopic appendectomy. Subsequently, after one day of fasting, PN-KDT was started as the boy was unable to tolerate enteral nutrition postoperatively. On the sixth day, enteral nutrition was progressively reintroduced. Since ad hoc PN-KDTs products were unavailable, the patient received infusion of OLIMEL N4 (Baxter). Outcome was characterized by prompt recovery and no exacerbation of neurological symptoms was observed.

CONCLUSION

we described the first pediatric patient with GLUT1DS in chronic treatment with KDT efficiently treated with exclusive PN for five days. We presented our real word management and the ideal recommendations for PN-KDT in acute surgical setting. This article is protected by copyright. All rights reserved.

Comparing different approaches in robotic-assisted surgery for unicompartmental knee arthroplasty: outcomes at a short-term follow-up of MAKO versus NAVIO system

The popularity of unicompartmental knee arthroplasty (UKA) continues to grow among orthopaedic surgeons and robotic surgery may be helpful in obtaining a precise placement of the prosthetic components, thanks to the meticulous intra-operative computer study for simulating the prosthetic positioning. This may lead to longer implant survivorship as well as a reduction in intermediate and long-term prosthetic complications, despite the initial greater costs than those of manual UKA. In this preliminary study, from January 2017 and October 2017, 18 patients underwent UKA with MAKO robotic system assistance and 10 patients received UKA with NAVIO robotic system assistance. The two groups were homogeneous by age, BMI, degree of osteoarthritis involvement, and postoperative program. Patients were followed both clinically (Numeric Rating Scale NRS and Knee Injury Osteoarthritis Outcome Scores KOOS) and radiographically. At the end term follow up (2 years), no significant difference was observed for NRS and KOOS as well as for clinical parameters as an active range of motion. A significant discrepancy was detected regarding the duration of the surgery and time of using the robotic system, that appeared to be longer in the NAVIO group than that of MAKO group, likely due to the specific technical aspects that characterize these two different robotic systems. The main finding of this study is that favorable clinical and radiographical results may be obtained using a robotic approach (MAKO or NAVIO) for UKA positioning at a short follow up. Due to the lack of significant clinical differences observed between the two groups of patients at end term follow up, the "concept" of a robotic approach, more than a specific patented system, may be considered the key element for improving UKA technique and it is likely that in the near future the choice of a single specific robotic system will still be a "surgeon's preference". The results of the study add scientific evidence regarding the effective improvement of UKA results using different robotic approaches. They also show possible economic sustainability of this therapeutic strategy related to the optimal patients' performance obtained at short term follow up, suggesting that the robotic assistance may really become a key element for better long-term survivorship of unicompartmental knee arthroplasty.

Lobular Breast Cancer: How Useful is Breast Magnetic Resonance Imaging?

Rationale and objectives

To review magnetic resonance imaging (MRI) findings in lobular breast carcinoma, the in situ or infiltrating subtype, with special attention to the dynamic curves with the aim to evaluate possible differences with ductal carcinoma.

Methods

In 2 years, 27 patients with lobular and one with tubular carcinoma underwent MRI at the Istituto Nazionale Tumori of Milan.

Results

All lobular carcinomas demonstrated early or late enhancement (100% sensitivity), without significant differences in morphology compared with ductal carcinoma, but frequently with a different shape of the dynamic curves.

Conclusions

Due to its infiltrative growth associated to only limited connective tissue reaction, lobular carcinoma often encounters difficulties in mammographic diagnosis. In contrast, MRI can be very helpful in evaluating the true extension of the disease, especially when breast conservation is considered. Due to a more consistent fibrotic stroma, these lesions sometimes show a delayed enhancement, which suggests that more than one set of subtracted images should be evaluated during MRI analysis.

Clinical presentation and pathogenesis of cold-induced autoinflammatory disease in a family with recurrence of an NLRP12 mutation

Objective

NLRP12 mutations have been described in patients affected with peculiar autoinflammatory symptoms. This study was undertaken to characterize NLRP12 mutations in patients with autoinflammatory syndromes, particularly a novel missense mutation, p.D294E, affecting a protein sequence crucial for ATP binding, which was identified in a Caucasian family with familial cold-induced autoinflammatory syndrome in some family members.

Methods

Fifty patients were tested for NLRP12 mutations. A Caucasian family with the p.D294E missense mutation of NLRP12 in some family members was clinically characterized. In vitro analysis of the effects of the mutation on NF-κB activity was performed in HEK 293 cells after cotransfection of the cells with a luciferase NF-κB–responsive element and mutant or wild-type (WT) NLRP12 expression plasmids. NF-κB activity was also evaluated 24 hours after stimulation with tumor necrosis factor α in monocytes from individual family members carrying the mutation. Furthermore, secretion of interleukin-1β (IL-1β), production of reactive oxygen species (ROS), and activation of antioxidant systems in patient and healthy donor monocytes, under resting conditions and after stimulation with pathogen-associated molecular patterns (PAMPs), were also assessed.

Results

In the family assessed, the p.D294E mutation segregated in association with a particular sensitivity to cold exposure (especially arthralgias and myalgia), but not always with an inflammatory phenotype (e.g., urticarial rash or fever). In vitro, the mutant protein maintained the same inhibitory activity as that shown by WT NLRP12. Consistently, NLRP12-mutated monocytes showed neither increased levels of p65-induced NF-κB activity nor higher secretion of IL-1β. However, the kinetics of PAMP-induced IL-1β secretion were significantly accelerated, and high production of ROS and up-regulation of antioxidant systems were demonstrated.

Conclusion

Even with a variable range of associated manifestations, the extreme sensitivity to cold represents the main clinical hallmark in an individual carrying the p.D294E mutation of the NLRP12 gene. Although regulation of NF-κB activity is not affected in patients, redox alterations and accelerated secretion of IL-1β are associated with this mild autoinflammatory phenotype.

Ultraviolet electroluminescence from randomly assembled n-SnO(2) nanowiresp-GaN:Mg heterojunction

Electroluminescence characteristics of a heterojunction light-emitting diode, which was fabricated by depositing a layer of randomly assembled n-SnO(2) nanowires on p-GaN:Mg/sapphire substrate via vapor transport method, were investigated at room temperature. Peak wavelength emission at around 388 nm was observed for the diode under forward bias. This is mainly related to the radiative recombination of weakly bounded excitons at the shallow-trapped states of SnO(2) nanowires, Under reverse bias, near bandedge emission from the p-GaN:Mg/sapphire leads to the observation of emission peak at around 370 nm.

4 Hands/4 Ports Laparoscopic Radical Prostatectomy

Introduction

Radical laparoscopic prostatectomy is a challenging procedure, which requires a steep learning curve and involves normally three operators. Consequently this is an expensive procedure due both to the time spent for surgery in the operating theatre and the number of operators involved. But time consumption and consequently money costs can be reduced thanks to the learning curve enhancement and, moreover, by reducing the number of operators involved. This work is based on the idea of performing laparoscopic prostatectomy with two operators only.

Material and Methods

Our cases are 124 radical laparoscopic prostatectomies, performed from January 2004 until April 2009; of these, 13 non-consecutive, were carried out with 2 operators and 4 ports. The first attempt - not totally successful due to time spent in the operating theatre and to some operational difficulty - was carried out as 60th procedure (learning curve was not complete). Once the method was applied as 103rd procedure, it could then be constantly implemented.

Results

We demonstrate that this option is feasible once the team performing the laparoscopic radical prostatectomy has acquired a good level in the learning curve. The outcomes are very interesting with regard to time consumption (205’ minutes: one minute more than the 3 operators/5 ports procedure) and early oncological and functional results.

Expression profiles of phases 1 and 2 metabolizing enzymes in human skin and the reconstructed skin models Episkin and full thickness model from Episkin

BACKGROUND

Episkin and full thickness model from Episkin (FTM) are human skin models obtained from in vitro growth of keratinocytes into the five typical layers of the epidermis. FTM is a full thickness reconstructed skin model that also contains fibroblasts seeded in a collagen matrix.

OBJECTIVES

To assess whether enzymes involved in chemical detoxification are expressed in Episkin and FTM and how their levels compare with the human epidermis, dermis and total skin.

METHODS

Quantification of the mRNA expression levels of phases 1 and 2 metabolizing enzymes in cultured Episkin and FTM and human epidermis, dermis and total skin using Realtime PCR.

RESULTS

The data show that the expression profiles of 61 phases 1 and 2 metabolizing enzymes in Episkin, FTM and epidermis are generally similar, with some exceptions. Cytochrome P450-dependent enzymes and flavin monooxygenases are expressed at low levels, while phase 2 metabolizing enzymes are expressed at much higher levels, especially, glutathione-S-transferase P1 (GSTP1) catechol-O-methyl transferase (COMT), steroid sulfotransferase (SULT2B1b), and N-acetyl transferase (NAT5). The present study also identifies the presence of many enzymes involved in cholesterol, arachidonic acid, leukotriene, prostaglandin, eicosatrienoic acids, and vitamin D3 metabolisms.

CONCLUSION

The present data strongly suggest that Episkin and FTM represent reliable and valuable in vitro human skin models for studying the function of phases 1 and 2 metabolizing enzymes in xenobiotic metabolisms. They could be used to replace invasive methods or laboratory animals for skin experiments.

Steroid metabolism and profile of steroidogenic gene expression in Episkin: high similarity with human epidermis

The skin is a well-recognized site of steroid formation and metabolism. Episkin is a cultured human epidermis. In this report, we investigate whether Episkin possesses a steroidogenic machinery able to metabolize adrenal steroid precursors into active steroids. Episkin was incubated with [14C]-dehydroepiandrosterone (DHEA) and 4-androstenedione (4-dione) and their metabolites were analyzed by liquid chromatography/mass spectrometry (LC/MS/MS). The results show that the major product of DHEA metabolism in Episkin is DHEA sulfate (DHEAS) (88% of the metabolites) while the other metabolites are 7alpha-OH-DHEA (8.2%), 4-dione (1.3%), 5-androstenediol (1.3%), dihydrotestosterone (DHT) (1.4%) and androsterone (ADT) (2.3%). When 4-dione is used as substrate, much higher levels of C19-steroids are produced with ADT representing 77% of the metabolites. These data indicate that 5alpha-reductase, 17beta-hydroxysteroid dehydrogenase (17beta-HSD) and 3alpha-hydroxysteroid dehdyrogenase (3alpha-HSD) activities are present at moderate levels in Episkin, while 3beta-HSD activity is low and represents a rate-limiting step in the conversion of DHEA into C19-steroids. Using realtime PCR, we have measured the level of mRNAs encoding the steroidogenic enzymes in Episkin. A good agreement is found between the mRNAs expression in Episkin and the metabolic profile. High expression levels of steroid sulfotransferase SULT2B1B and type 3 3alpha-HSD (AKR1C2) correspond to the high levels of DHEA sulfate (DHEAS) and ADT formed from DHEA and 4-dione, respectively. 3beta-HSD is almost undetectable while the other enzymes such as type 1 5alpha-reductase, types 2, 4, 5, 7, 8, and 10 17beta-HSD and 20alpha-hydroxysteroid dehydrogenase (20alpha-HSD) (AKR1C1) are highly expressed. Except for UGT-glucuronosyl transferase, similar mRNA expression profiles between Episkin and human epidermis are observed.

Conservative surgery in breast cancer. Significance of resection margins

We approached the issue of surgical margins in the conservative treatment of breast cancer by examining the literature germane to four precise questions: At what distance from the macroscopic margin of the tumour should the resection margin be? To what extent do histologically clear resection margins indicate complete local control of the disease? To what extent do histologically involved margins indicate persistence of disease? and Does the local recurrence rate correlate with the status of the resection margin? We propose categorizing margin involvement into five groups (absent, focal, minimal, moderate and extensive involvement) according to strict histological criteria, and assigning increasingly aggressive subsequent treatments according to the extent of any margin involvement.

Transdifferentiation of corneal epithelium: evidence for a linkage between the segregation of epidermal stem cells and the induction of hair follicles during embryogenesis

Corneal epithelium transdifferentiation into a hair-bearing epidermis provides a particularly useful system for studying the possibility that transient amplifying (TA) cells are able to activate different genetic programs in response to a change in their fibroblast environment, as well as to follow the different steps of rebuilding an epidermis from induced stem cells. Corneal stem and TA cells are found in different locations - stem cells at the periphery, in the limbus, and TA cells more central. Moreover, the TA cells already express the differentiating corneal-type keratin pair K3/K12, whereas the limbal keratinocytes express the basal keratin pair K5/K14. In contrast, suprabasal epidermal keratinocytes express keratin pair K1-2/K10, and basal keratinocytes the keratin pair K5/K14. The results of tissue recombination experiments show that adult central corneal cells are able to respond to specific information originating from embryonic dermis. First, the cells located at the base of the corneal epithelium show a decrease in expression of K12 keratin, followed by an increase in K5 expression; they then proliferate and form hair follicles. The first K10 expressing cells appear at the junction of the new hair follicles and the covering corneal epithelium. Their expansion finally gives rise to epidermal strata, which displace the corneal suprabasal keratinocytes. Corneal TA cells can thus be reprogrammed to form epidermal cells, first by reverting to a basal epithelial-type, then to hair pegs and probably concomitantly to hair stem cells. This confirms the role of the hair as the main reservoir of epidermal stem cells and raises the question of the nature of the dermal messages which are both involved in hair induction and stem cell specification.

Altered maturation of peripheral blood dendritic cells in patients with breast cancer

Tumours have at least two mechanisms that can alter dendritic cell (DC) maturation and function. The first affects the ability of haematopoietic progenitors to differentiate into functional DCs; the second affects their differentiation from CD14+ monocytes, promoting an early but dysfunctional maturation. The aim of this study was to evaluate the in vivo relevance of these pathways in breast cancer patients. For this purpose, 53 patients with invasive breast cancer were compared to 68 healthy controls. To avoid isolation or culture procedures for enrichment of DCs, analyses were directly performed by flow cytometry on whole-blood samples. The expression of surface antigens and intracellular accumulation of regulatory cytokines upon LPS stimulation were evaluated. The number of DCs, and in particular of the myeloid subpopulation, was markedly reduced in cancer patients (P<0.001). Patient DCs were characterized by a more mature phenotype compared with controls (P=0.016), and had impaired production of IL-12 (P<0.001). These alterations were reverted by surgical resection of the tumour. To investigate the possible role of some tumour-related immunoactive soluble factors, we measured the plasmatic levels of vascular endothelial growth factor, IL-10 and spermine. A significant inverse correlation between spermine concentration and the percentage of DCs expressing IL-12 was found. Evidence was also obtained that in vitro exposure of monocyte-derived DCs to spermine promoted their activation and maturation, and impaired their function. Taken together, our results suggest that both the above-described mechanisms could concomitantly act in breast cancer to affect DC differentiation, and that spermine could be a mediator of dysfunctional maturation of DCs.

Long-term expansion of human functional epidermal precursor cells: promotion of extensive amplification by low TGF-beta1 concentrations

We have previously introduced the concept of high proliferative potential-quiescent (HPP-Q) cells to refer to primitive human hematopoietic progenitors, on which transforming growth factor-beta1 (TGF-beta1) exerts a pleiotropic effect. TGF-beta1 confers to these slow-dividing cells a mitogenic receptor(low) phenotype and maintains immature properties by preventing differentiation and apoptosis. However, the effect of TGF-beta1 on long-term expansion has not yet been clearly demonstrated. Here, we describe the characterization of a human skin keratinocyte subpopulation, highly enriched for primitive epidermal precursors, on the basis of high adhesion capacity (Adh+++) and low expression of the epidermal growth factor receptor (Adh+++EGF-Rlow). In our standard culture condition without feeder cells, the mean estimated output for cells from an unfractionated population of primary foreskin keratinocytes was 10(7)-10(8), increasing to 10(12)-10(13) in cultures initiated with selected Adh+++EGF-Rlow precursors. Characterization of these cells revealed a hitherto unknown property of TGF-beta1: its addition at a very low concentration (10 pg/ml) in long-term cultures induces a very significant additional increase of expansion. In this optimized system, outputs obtained in cultures initiated with Adh+++EGF-Rlow cells repeatedly reached 10(16)-10(17) ( approximately 60 population doublings, approximately 4 x 10(18) keratinocytes produced per clonogenic cell present in the initial population). At the molecular level, this effect is associated with an increase in Smad1, Smad2 and Smad3 phosphorylation and an increase in alpha6 and beta1 integrin expression. No such effect could be observed on mature keratinocytes with low adhesion capacity (Adh-/+). We finally demonstrated that the progeny of Adh+++EGF-Rlow precursors after long-term expansion is still capable of generating a pluristratified epidermis in a model for skin reconstruction. In conclusion, after further characterizing the phenotype of primitive epidermal precursors, we demonstrated a new function of TGF-beta1, which is to promote undifferentiated keratinocyte amplification.

Hair follicle stem cells

The workshop on Hair Follicle Stem Cells brought together investigators who have used a variety of approaches to try to understand the biology of follicular epithelial stem cells, and the role that these cells play in regulating the hair cycle. One of the main concepts to emerge from this workshop is that follicular epithelial stem cells are multipotent, capable of giving rise not only to all the cell types of the hair, but also to the epidermis and the sebaceous gland. Furthermore, such multipotent stem cells may represent the ultimate epidermal stem cell. Another example of epithelial stem cell and transit amplifying cell plasticity, was the demonstration that adult corneal epithelium, under the influence of embryonic skin dermis could form an epidermis as well as hair follicles. With regards to the location of follicular epithelial stem cells, immunohistochemical and ultrastructural data was presented, indicating that cells with stem cell attributes were localized to the prominent bulge region of developing human fetal hair follicles. Finally, a new notion was put forth concerning the roles that the bulge-located stem cells and the hair germ cells played with respect to the hair cycle.

Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-D-glucose-positron emission tomography: clinical evaluation and alternative management

BACKGROUND

Surgical removal of axillary lymph node and histologic examination for metastases are used to determine whether adjuvant treatment is necessary for patients with breast cancer. Axillary lymph node dissection (ALND) is a costly procedure associated with various side effects, and 80% or more of patients with tumors of 20 mm or less are lymph node negative and might avoid ALND. In this study, we evaluated whether an alternative, noninvasive method--i.e., positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG)-- could be used to determine axillary lymph node status in patients with breast cancer.

METHODS

One hundred sixty-seven consecutive patients with breast cancers of 50 mm or less (range = 5-50 mm; mean = 21 mm) scheduled for complete ALND were studied preoperatively with FDG-PET, and then PET and pathology results from ALND were compared. All statistical tests were two-sided.

RESULTS

The overall sensitivity, specificity, and accuracy of lymph node staging with PET were 94.4% (PET detected 68 of 72 patients with axillary involvement; 95% confidence interval [CI] = 86.0% to 98.2%), 86.3% (82 of 95 patients without axillary involvement; 95% CI = 77.8% to 91.9%), and 89.8% (150 of 167 patients with breast cancer; 95% CI = 84.2% to 93.6%), respectively. Positive- and negative-predictive values were 84.0% (68 patients with histologically positive lymph nodes of 81 patients with positive FDG-PET scan; 95% CI = 74.2% to 90.5%) and 95.3% (82 patients with histologically negative lymph nodes of 86 patients with negative FDG-PET scan; 95% CI = 88.2% to 98.5%), respectively. When PET results for axillary metastasis were analyzed by tumor size, the diagnostic accuracy was similar for all groups (86.0%-94.2%), with higher sensitivity for tumors of 21-50 mm (98.0%) and higher specificity for tumors of 10 mm or less (87.8%), and the range was 93.5%-97.3% for negative-predictive values and 54.5%-94.1% for positive-predictive values. Among the 72 patients with axillary involvement, PET detected three or fewer metastatic lymph nodes in 27 (37.5%) patients, about 80% of whom had no clinically palpable axillary lymph nodes.

CONCLUSIONS

Noninvasive FDG-PET appears to be an accurate technique to predict axillary status in patients with breast cancer and thus to identify patients who might avoid ALND. These results should be confirmed in large multicenter studies.

Adult corneal epithelium basal cells possess the capacity to activate epidermal, pilosebaceous and sweat gland genetic programs in response to embryonic dermal stimuli

Recent work has shown remarkable plasticity between neural and hematopoeitic, as well as between hematopoeitic and muscle stem cells, depending on environmental stimuli (Fuchs, E. and Segre, J. A. (2000) Cell 100, 143–155). Stem cells give rise to a proliferative transient amplifying population (TA), which is generally considered to be irreversibly committed. Corneal epithelium provides a particularly useful system for studying the ability of TA cells to activate different genetic programs in response to a change in their fibroblast environment. Indeed, corneal stem and TA cells occupy different localities - stem cells at the periphery, and TA cells more central (Lehrer, M. S., Sun, T. T. and Lavker, R. M. (1998) J. Cell Sci. 111, 2867–2875) - and thus can be discretely dissected from each other. It is well known that pluristratified epithelia of cornea and skin display distinct programs of differentiation: corneal keratinocytes express keratin pair K3/K12 and epidermal keratinocytes keratin pair K1-2/K10; moreover, the epidermis forms cutaneous appendages, which express their own set of keratins. In our experiments, central adult rabbit corneal epithelium was thus associated either with a mouse embryonic dorsal, upper-lip or plantar dermis before grafting onto nude mice. Complementary experiments were performed using adult mouse corneal epithelium from the Rosa 26 strain. The origin of the differentiated structures were identified in the first case by Hoechst staining and in the second by the detection of beta-galactosidase activity. The results show that adult central corneal cells are able to respond to specific information originating from embryonic dermis. They give rise first to a new basal stratum, which does not express anymore corneal-type keratins, then to pilosebaceous units, or sweat glands, depending of the dermis, and finally to upper layers expressing epidermal-type keratins. Our results provide the first evidence that a distinct TA cell population can be reprogrammed.

[Nephron-sparing treatment of kidney neoplasms in transplanted kidney. Our experience]

BACKGROUND

To evaluate survival rate, follow-up and renal function in patients treated with "nephron-sparing" approach due to cancer in a transplanted kidney.

METHODS

During the 18 years' activity of our Transplantation Centre 3 renal carcinomas in transplanted kidneys (0.24%) have been found. Diagnoses were made in one case during transplantation procedures and, in the remaining two, 1 month and 10 years after. All tumours were unifocal, small (10, 12 and 18 mm of diameter), capsulated and low stage (T1). The resection of the mass ("nephron-sparing" surgery) and of a layer (1 cm thick) of the tissue surrounding the tumour was performed. The histological exam showed in all cases low grade (G2) renal cell carcinoma and negative surgical margins.

RESULTS

138, 94 and 15 months after transplant all patients are alive, without disease recurrence and with good renal function. In all cases the doses of immune-suppressive therapy were reduced.

CONCLUSIONS

Renal cancer in transplanted kidneys is generally treated with nephrectomy. On the contrary, we decided to apply the same criteria which are accepted for the treatment of renal neoplasms in general and then to perform a "nephron-sparing" surgery when the tumour is small, capsulated and with negative surgical margins at the intraoperative histological exam. In personal experience good results from the oncologic and nephrologic point of view have been accomplished.

Impact of nodal status on indication for adjuvant treatment in clinically node negative breast cancer. Istituto Nazionale per lo Studio e las Cura dei Tumori

We addressed the problem of the need for axillary dissection in clinically node-negative breast cancer by determining how the information provided by the dissection suggests a different treatment to that indicated by primary tumour characteristics and age alone. We examined retrospectively 260 cases of clinically node negative early breast cancer all of whom underwent breast surgery, radiotherapy and axillary dissection. We assigned adjuvant therapy according to accepted guidelines with and without consideration of pathological node status and compared the difference. Fifty-six patients had involved axillary nodes. There was no change in adjuvant chemotherapy indication for the 44 cases over 65 years. The change in indication for the remaining 216 cases was 18.5% to 6%, depending on whether none or all of the intermediate risk patients were originally assigned chemotherapy (all were originally assigned tamoxifen). Since the trend is for most intermediate risk patients is to be assigned adjuvant chemotherapy, and since tamoxifen is anyway considered effective therapy for low and intermediate risk patients, we conclude that the information provided by axillary dissection is probably not necessary if guidelines recommending wide application of systemic adjuvant chemotherapy are applied. Satisfactory prognostic information can be obtained by consideration of primary tumour characteristics, while new prognostic markers are likely to further refine prognostic precision in the near future.

Breast cancer patients treated without axillary surgery: clinical implications and biologic analysis

OBJECTIVE

To evaluate the impact of breast carcinoma (T1-2N0) surgery without axillary dissection on axillary and distant relapses, and to evaluate the usefulness of a panel of pathobiologic parameters determined from the primary tumor, independent of axillary nodal status, in planning adjuvant treatment.

METHODS

In a prospective nonrandomized pilot study, 401 breast cancer patients who underwent breast surgery without axillary dissection were accrued from January 1986 to June 1994. At surgery, all patients were clinically node-negative and lacked evidence of distant metastases after clinical or radiologic examination. A precise 4-month clinical and radiologic follow-up was performed to detect axillary or distant metastases. Patients with clinical evidence of axillary nodal relapse were considered for surgery as salvage treatment. Biologic characteristics of primary carcinomas were investigated by immunohistochemistry, and four pathologic and biologic parameters (size, grading, laminin receptor, and c-erbB-2 receptor) were analyzed to determine a prognostic score.

RESULTS

The 5-year follow-up of these patients revealed a low rate of nodal relapses (6.7%), particularly for T1a and T1b patients (2% and 1.7%, respectively), whereas T1c and T2 patients showed a 10% and 18% relapse rate, respectively. Surgery was a safe and feasible salvage treatment without technical problems in all 19 cases of progressive disease at the axillary level. The low rate of distant metastases in T1a and T1b groups (<6%) increased to 15% in T1c and 34% in T2 patients. Analyzing the primary tumor with respect to the panel of pathologic and biologic parameters was predictive of metastatic spread and therefore can replace nodal status information for planning adjuvant treatment.

CONCLUSIONS

Middle-term follow-up shows that the rate of axillary relapse in this patient population is lower than expected, suggesting that only a minimal number of microembolic nodal metastases become clinically evident. Avoidance of axillary dissection has a negligible effect on the outcome of T1 patients, particularly in T1a and T1b tumors with no palpable nodes, because the rate of axillary node relapse is very low for both. In T1 breast carcinoma, postsurgical therapy should be considered on the basis of biologic characteristics rather than nodal involvement. The authors' prognostic score based on the primary tumor identified patients who required postsurgical treatment, providing a practical alternative to axillary status for deciding on adjuvant treatment. Conversely, in the T2 group, the high rate of salvage surgery for axillary relapses, which is expected in tumors larger than 2.5 cm or 3.0 cm, represents a limit for avoiding axillary dissection. Preoperative evaluation of axillary nodes for modification of surgical dissection in this subgroup would be more useful more than in T1 breast cancer because of the high risk. Complete dissection is feasible without technical problems if precise follow-up detects progressive axillary disease.

Using Impedance Spectroscopy to Assess the Viability of the Rapid Chloride Test for Determining Concrete Conductivity

The suitability of using the initial current from the rapid chloride test (ASTM C 1202) to determine specimen conductivity is tested using impedance spectroscopy with a frequency spectrum of 10 Hz to 1 MHz. The specimen conductivity has an analytical relationship to specimen diffusivity and so is a useful quantity in service life prediction. Measurements made on specimens of different lengths indicate that the total charge passed during the six hour conduction test carried out according to ASTM C 1202 is not a direct measure of specimen conductivity. Further, ohmic heating during the 6 hour test makes it nearly impossible to directly measure any specimen transport property from the results. The total charge passed during the 6 hour conduction test is, therefore, not a reliable quantity for service life prediction. Results indicate that the direct current (dc) measurement of resistance using a voltage of 60 V is sufficient to overwhelm polarization effects, thereby yielding an accurate estimate of the true specimen conductivity. Impedance spectroscopy measurements also indicate that corrosion may form on the brass electrodes, adding bias to a conductivity estimate based upon a dc measurement.

Induction of apoptosis through the PKC pathway in cultured dermal papilla fibroblasts

The dermal papilla (DP) consists of a discrete population of specialized fibroblasts that are important in the morphogenesis of the hair follicle in the embryo and in the control of the hair growth cycle in the adult. This mitotically quiescent and long-lived cell population expresses gene products that promote cell survival such as Bcl-2, and thus normally might be protected from apoptosis. We investigated whether cultured DP fibroblasts are able to undergo apoptosis by treatment with the protein kinase inhibitor staurosporine. Involvement of the PKC signaling pathway in DP fibroblast survival/death was investigated by inhibition (staurosporine and Bisindolylmaleimide (Bis) treatment) or activation (TPA; 12-O-tetradecanoylphorbol-13-acetate treatment) of PKC and characterization of DP-expressed PKC isoforms by RT-PCR. We determined that cultured DP fibroblasts undergo apoptosis, in a dose-related manner, when treated with staurosporine but not when treated with Bis, an inhibitor with narrow PKC isoform specificity. TPA confers partial and transient resistance to staurosporine-induced DP apoptosis. Staurosporine and Bis each induced G1 arrest, whereas TPA treatment of cultured DP resulted in increased entry into S-phase. The differential responses to individual inhibitors and activators of PKC may be related to the multiple PKC isoforms that DP fibroblasts express. Flow cytometric analysis indicates that the mechanism of staurosporine-induced apoptosis may be through decrease of Bcl-2 in treated DP cells or through modulation of cell cycle regulators. Correlation between sensitivity to induction of apoptosis and proliferation suggests that dermal papilla cells may normally be protected from apoptosis in vivo by their mitotically quiescent state.

Adult epidermal keratinocytes are endowed with pilosebaceous forming abilities

Pluristratified epithelia of adult vertebrate skin continuously regenerate from stem cells, and the question still arises as to whether those cells are committed to the production of only one cell lineage, or in contrast they conserve their embryonic pluripotentiality. In order to investigate the abilities of adult cultured as well as wound healing epidermis, heterospecific fibroblast-keratinocyte recombinations were performed, which allow unquestionable identification of the cells implicated in the structures that differentiate. Adult human cultured breast epidermal cells and full-thickness wound healing from human facial skin and foreskin were associated with either rabbit embryonic trichogenic dermis or cultured dermal papilla cells of adult rat, before grafting onto nude mice for two weeks to one month. In situ hybridization with a human specific sequence Alu probe labeled the human cells, whereas implanted rabbit or rat and host mouse cells were distinguished by the Hoechst staining of their nuclei. The results show that human adult cultured breast epidermal cells are able to form hair buds and to participate in hair follicle formation, while adult healing epidermis from a sparsely hairy skin as the human face or the dorsal skin of nude mouse, or even from a glabrous epidermis as the human foreskin, are able to differentiate pilosebaceous units. Although a follicular origin of the involved keratinocytes cannot be excluded in the three first cases, the formation of hair and sebaceous glands by foreskin keratinocytes of children 2 to 10 years-old establishes the cutaneous appendage ability of the interfollicular epidermal stem cells. The formation of interspecies mosaic follicles also highlights the fact that there must be a significant level of commonality in the interactive signaling molecules used by epithelial cells from different species.

A phase I-II trial of fixed-dose carboplatin and escalating paclitaxel in advanced ovarian cancer

We conducted a phase I-II study with escalating paclitaxel doses plus carboplatin at a fixed dose for previously untreated patients with advanced ovarian cancer in order to define the maximum tolerated dose. Eligible for the study were women with a histologically confirmed diagnosis of ovarian cancer stage III-IV according to the FIGO classification. In the first phase of the study, 6 patients were allocated escalating paclitaxel doses with fixed-dose carboplatin in order to establish the maximum tolerated dose. The starting dose of paclitaxel was 150 mg/m2 given after carboplatin (300 mg/m2) every 4 weeks for a total of six courses. The paclitaxel dose step was 25 mg/m2 up to 250 mg/m2. The study then progressed to a phase II trial using the maximum tolerated paclitaxel dosage reached during the escalating dose phase. A total of 27 patients entered phase I and 23 phase II. Neurotoxicity was observed in 47 patients (94%; 29 grade 1, 17 grade 2, 1 grade 3, according to the WHO classification). The intensity of neurotoxicity tended to be dose related: out of the 15 patients who received < or = 200 mg paclitaxel, a total of 14 grade 1, but no grade 2 or 3 neurotoxicities, were observed. The frequency of grade 1, 2 and 3 neurotoxicity was 15, 17 and 1, respectively, in the 35 women who received > or = 225 paclitaxel +300 mg carboplatin. There was no clear relationship between median WBC and platelet nadir and dose level. Among other toxicities, alopecia was observed in all 50 cases, hypersensitivity in two (4%) and myalgia in 41 (82%; 34 grade 1 and 7 grade 2). These frequencies tended to increase with the dose, but the relationship was not statistically significant. The overall response rate was 78% (39/50) with a complete response rate of 62% (31/50). In conclusion, this study suggests that carboplatin and paclitaxel can be administered safely to patients with advanced ovarian carcinoma. The maximum dose reached was 250 mg/m2 paclitaxel and 300 mg/m2 for carboplatin, but from a clinical point of view the maximum paclitaxel dose we would consider safe is 225 mg/m2.

Antiemetic efficacy of granisetron in patients with gynecological malignancies

The efficacy and tolerability of granisetron in the management of acute and delayed emesis was compared with that of a multiple antiemetic drug combination regimen, including metoclopramide, dexamethasone, lorazepam and orphenadrine. The trial was a randomized, cross-over study involving 111 patients with gynecological cancers undergoing chemotherapy with cisplatin. Granisetron was significantly more effective than the combination regimen during the first 24 h after chemotherapy; complete response, rates were 67 and 48%, respectively (p = 0.002). There was a significant reduction in the effectiveness of the combination during the second treatment cycle, compared with the first. In contrast, the efficacy of granisetron did not differ between the two cycles. The response rate during the 6 days after chemotherapy was 40.8% in both groups. At the end of the study, 55% of patients preferred granisetron and 23% preferred the combination (p < 0.001). Granisetron was well tolerated. The principal adverse event was headache, which was reported in 7% of patients. The results of this study confirm that granisetron is effective in the treatment of cisplatin-induced nausea and vomiting during the 24 h after chemotherapy.

Ureterolitholapaxy: Our experience

The authors report on their experience of treating ureteral stones in 1183 patients with ballistic and electrohydraulic endoscopic lithotripsy. Since the outcome was successful in 95% of cases with few complications (2%), this method is considered highly effective for treating stones in any part of the ureter, with the possibility of resolving renal colic in real-time. In the push-up cases (25% for sub-junctional ureteral lithiasis, 10% other sites) a second treatment was performed with ESWL after positioning a double J catheter.

[Renal agenesis and homolateral seminal vesicle cyst. Case report]

The authors present a case of renal agenesis and seminal vesicle cyst in a young man, diagnosed because of several micturion disorders partially cleared up with antibiotic therapy. We discuss about the diagnosis technique which includes Ultrasound Scanner, Computed Tomography, Magnetic Resonance and pelvic arteriography. Then we describe the surgical approach and finally we discuss about embryogenesis.

Survival of women with advanced ovarian cancer and complete pathologic response at second-look laparotomy

BACKGROUND

The purpose of the study was to analyze the determinants of long term survival in women with advanced ovarian cancer and negative second-look laparotomy.

METHODS

A series of 140 advanced (Stage III-IV) ovarian cancer patients (median age, 54 years; range, 22-74 years) with negative second-look laparotomy after primary surgery and chemotherapy is included in the analysis. At first diagnosis, all patients were treated with radical or debulking surgery. After primary surgery, the patients were treated with a chemotherapy regimen based on cisplatin or carboplatin alone or in combination with other drugs. All second-look laparotomies were performed 6-8 months after first surgery.

RESULTS

The overall survival rates were 76% at 3 years, 66% at 5 years, and 51% at 8 years. The corresponding rates for disease free survival were 57, 50, and 43%, respectively. Survival rates were better for women with a residual tumor 1 cm or less after primary surgery. The 5-year probability of survival was 78% in this group, compared with 55% in women with a residual tumor more than 1 cm (log rank test, P < 0.05). Survival rates for women with tumor Grade 3 tended to be worse than Grades 1-2, but the difference was only of borderline statistical significance. No relationship emerged between survival and age, histotype, and presence of ascites at diagnosis. Women with a residual tumor 1 cm or less and positive lymph nodes had a 66% 5-year probability of survival, compared with 85% for women with a residual tumor 1 cm or less and negative lymph nodes. This difference was significant (log rank test, P = 0.05). The 5-year survival probabilities were 47 and 58%, respectively, in women with a residual tumor more than 1 cm and positive or negative lymph nodes.

CONCLUSIONS

This analysis shows a favorable long term survival rate for women with advanced ovarian cancer and complete pathologic response after debulking surgery and postoperative chemotherapy. It further suggests that lymph nodal status is a prognostic factor for women with minimal residual tumor after surgery.