Autophagic-Related Proteins in Brain Gliomas: Role, Mechanisms, and Targeting Agents

The present review focuses on the phenomenon of autophagy, a catabolic cellular process, which allows for the recycling of damaged organelles, macromolecules, and misfolded proteins. The different steps able to activate autophagy start with the formation of the autophagosome, mainly controlled by the action of several autophagy-related proteins. It is remarkable that autophagy may exert a double role as a tumour promoter and a tumour suppressor. Herein, we analyse the molecular mechanisms as well as the regulatory pathways of autophagy, mainly addressing their involvement in human astrocytic neoplasms. Moreover, the relationships between autophagy, the tumour immune microenvironment, and glioma stem cells are discussed. Finally, an excursus concerning autophagy-targeting agents is included in the present review in order to obtain additional information for the better treatment and management of therapy-resistant patients.

FRESHER: Challenges and opportunities for building Health/Healthy futures

Background

FRESHER (2016-2018) Foresight and modelling for European health policy and regulation - is a H2020 project that aimed at representing alternative health Scenarios to test future policies for tacking Non-Communicable Diseases (NCDs). The key added-value consists in the combination of qualitative foresight and quantitative forecast approaches: a micro-simulation model, specifically developed by the project, computed the health outcomes of the four FRESHER Scenarios.

Methods

The Scenarios building activities involved overall more than four-hundred experts and stakeholders, with different backgrounds within and beyond health fields, throughout all the steps of the process, in two surveys and nine workshops. The horizon scanning phase led to identify a wide range of societal trends that impact health and NCDs. Considering a long-term horizon at 2050, eight trends were then selected and ranked according to their importance and uncertainty.

Results

In the Scenario Building phase, the combination of different evolutions of the selected trends resulted in four alternative futures: a Business as Usual Scenario, “The rich get healthier”, two response Scenarios, “We will Health you” and “Healthy together”, and a worst case Scenario “Desolation Health”. The scenarios imagine different futures and depict how health would subsequently change in such worlds.

Conclusions

Given the increasing need to put health at the centre of all policies, it is necessary to make more evident the relationship between societal trends and their impact on health, specifically for NCDs. The translation of trends, and their evolutions, into changes of risk factors is a viable option to assess the impact of public health policy. FRESHER aimed to trigger a dialogue across different scientific and policy communities outside the health sector in order to define innovative strategies and identify disruptive innovations.

Immunoexpression of p62/SQSTM1/Sequestosome‑1 in human primary and recurrent IDH1/2 wild‑type glioblastoma: A pilot study

p62/SQSTM1/Sequestosome-1 is an autophagic protein that serves a crucial role in cellular metabolism, proliferation and malignant growth. Notably, autophagy may influence the development and resistance to therapy of numerous types of human cancer. In the present pilot study, the immunohistochemical pattern of p62 was analyzed in a cohort of patients with isocitrate dehydrogenase (IDH)1/2 wild-type glioblastoma (GBM), in primary and recurrent samples, in order to verify the concordance or discordance between the primary and recurrent tumors. In addition, the association between p62, and patient outcome and O⁶-methylguanine-DNA methyltransferase (MGMT) status was assessed. The results revealed p62 immunoexpression in the nucleus and cytoplasm of neoplastic elements in 45% of primary and 55% of recurrent cases of GBM. A discordant p62 immunoreactivity was detected in 35% of cases, with a variation either with positive or negative conversion of p62 status. Statistically, p62 expression and MGMT status exhibited a significant prognostic value by univariate analysis, whereas only MGMT promoter methylation status emerged as an independent prognostic factor by multivariate analysis. Finally, the most favorable prognosis was documented when the same GBM case was positively concordant for both p62 expression and MGMT methylated status. Since little data are available regarding the association between p62 expression and MGMT in GBM, further investigations may be required to determine if new targeted therapies may be addressed against autophagy-related proteins, such as p62.

Predictors of long-term mortality in left-sided infective endocarditis: an historical cohort study in 414 patients

INTRODUCTION

Very limited data are available on the long-term outcome of infective endocarditis (IE) and its determinants. The aim of this study was to identify the predictors of long-term mortality in patients affected by left sided IE (LSIE).

METHODS

This was an historical retrospective observational study on prospectively collected data from patients with LSIE hospitalized in our Unit (January 2000-December 2017). Multiple variables relevant to history, physical examination, laboratory tests, echocardiography, comorbidities, complications and outcome were analysed by Cox regression to identify predictors of long-term mortality.

RESULTS

414 patients were included, and followed up for a median of 39 months [IQR 11-74]. Median age was 59 years [range 3-89], and most patients were male. Over 50% showed at least one comorbidity. Hyperglycaemia, increased creatinine and an indication for surgery predicted in-hospital mortality, while a prior myocardial infarction, chronic kidney disease (CKD) on hemodialysis and a larger vegetation were independent predictors of 1-year mortality. At multivariate analysis, peripheral arterial disease (p= 0.017), hyperglycemia on admission (p=0.013) and a higher BMI (p=0.009) were independent predictors of long-term mortality in 1-year survivors. At multivariable Cox proportional hazard regression, peripheral arterial disease (p=0.002), hyperglycemia (p=0.041) and CKD on hemodialysis (p=0.025) confirmed to be independently associated with an increased risk of long-term mortality in the overall 414 patient cohort.

CONCLUSIONS

Cardiovascular and metabolic risk signals, specifically peripheral arterial disease and hyperglicemia, affect long-term mortality of LSIE. An active and long-term follow up seems warranted in IE survivors showing these conditions at outset.

Autophagy-related prognostic signature in HER2 positive gastric carcinomas

BACKGROUND

The immunohistochemical analysis of autophagy-related proteins (ATGs) has been recently applied in human pathology to study differentiation and cancer progression. The aim of the present study is to analyze a cohort of gastric carcinomas (GC) by five ATG antisera (Beclin-1, LC3A/B, p62, ULK-1 and AMBRA-1), also evaluating their possible relationship with clinicopathological parameters, HER2 status and final outcome of patients.

METHODS

A cohort of 123 GCs has been studied by ATG antisera utilizing Masuda's criteria that define positive cases in which at least two out of five protein expressions were documented.

RESULTS

The immunohistochemical signature for autophagy (A-IHC) was 49.59% as a whole. The percentage of A-IHC ranged from 31% for poorly cohesive carcinomas to 56% for adenocarcinomas. The performance of each ATG immunomarker documented high values for sensitivity, specificity and efficiency for LC3A/B, Beclin-1 and p62. In univariate analysis of GC, grade, stage, Ki67 expression, HER2 status as well as A-IHC appeared as emerged as relevant parameters with a high p-value (p < 0.001). Finally, in multivariate analysis, HER2 status, stage and A-IHC emerged as independent prognostic variables. In the comparison of survival curves, GC cases immunoreactive for A-IHC exhibited a shorter survival with a worse outcome.

CONCLUSIONS

We have hypothesized that A-IHC could represent an additional morphological tool to provide prognostic elements in order to identify patients affected by aggressive with shorter survival and worse outcome.

Microsatellite and RAS/RAF Mutational Status as Prognostic Factors in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) leads to prolonged survival for selected patients with colorectal (CRC) peritoneal metastases (PM). This study aimed to analyze the prognostic role of micro-satellite (MS) status and RAS/RAF mutations for patients treated with CRS.

METHODS

Data were collected from 13 Italian centers with PM expertise within a collaborative group of the Italian Society of Surgical Oncology. Clinical and pathologic variables and KRAS/NRAS/BRAF mutational and MS status were correlated with overall survival (OS) and disease-free survival (DFS).

RESULTS

The study enrolled 437 patients treated with CRS-HIPEC. The median OS was 42.3 months [95% confidence interval (CI), 33.4-51.2 months], and the median DFS was 13.6 months (95% CI, 12.3-14.9 months). The local (peritoneal) DFS was 20.5 months (95% CI, 16.4-24.6 months). In addition to the known clinical factors, KRAS mutations (p = 0.005), BRAF mutations (p = 0.01), and MS status (p = 0.04) were related to survival. The KRAS- and BRAF-mutated patients had a shorter survival than the wild-type (WT) patients (5-year OS, 29.4% and 26.8% vs 51.5%, respectively). The patients with micro-satellite instability (MSI) had a longer survival than the patients with micro-satellite stability (MSS) (5-year OS, 58.3% vs 36.7%). The MSI/WT patients had the best prognosis. The MSS/WT and MSI/mutated patients had similar survivals, whereas the MSS/mutated patients showed the worst prognosis (5-year OS, 70.6%, 48.1%, 23.4%; p = 0.0001). In the multivariable analysis, OS was related to the Peritoneal Cancer Index [hazard ratio (HR), 1.05 per point], completeness of cytoreduction (CC) score (HR, 2.8), N status (HR, 1.6), signet-ring (HR, 2.4), MSI/WT (HR, 0.5), and MSS/WT-MSI/mutation (HR, 0.4). Similar results were obtained for DFS.

CONCLUSION

For patients affected by CRC-PM who are eligible for CRS, clinical and pathologic criteria need to be integrated with molecular features (KRAS/BRAF mutation). Micro-satellite status should be strongly considered because MSI confers a survival advantage over MSS, even for mutated patients.

The molecular profiling of solid tumors by liquid biopsy: a position paper of the AIOM-SIAPEC-IAP-SIBioC-SIC-SIF Italian Scientific Societies

The term liquid biopsy (LB) refers to the use of various biological fluids as a surrogate for neoplastic tissue to achieve information for diagnostic, prognostic and predictive purposes. In the current clinical practice, LB is used for the identification of driver mutations in circulating tumor DNA derived from both tumor tissue and circulating neoplastic cells. As suggested by a growing body of evidence, however, there are several clinical settings where biological samples other than tissue could be used in the routine practice to identify potentially predictive biomarkers of either response or resistance to targeted treatments. New applications are emerging as useful clinical tools, and other blood derivatives, such as circulating tumor cells, circulating tumor RNA, microRNAs, platelets, extracellular vesicles, as well as other biofluids such as urine and cerebrospinal fluid, may be adopted in the near future. Despite the evident advantages compared with tissue biopsy, LB still presents some limitations due to both biological and technological issues. In this context, the absence of harmonized procedures corresponds to an unmet clinical need, ultimately affecting the rapid implementation of LB in clinical practice. In this position paper, based on experts’ opinions, the AIOM–SIAPEC-IAP–SIBIOC–SIF Italian Scientific Societies critically discuss the most relevant technical issues of LB, the current and emerging evidences, with the aim to optimizing the applications of LB in the clinical setting.

•

In the current clinical practice LB is used for the identification of driver mutations in circulating tumor DNA (ctDNA).

•

New applications in tumors other than non-small-cell lung cancer (NSCLC) are emerging as useful clinical tools.

•

Other blood derivatives, together with other biofluids, are an active field of research and may be adopted in the near future.

•

Despite the evident advantages, liquid biopsy still presents limitations due to both biological and technological issues.

•

Standardization of the procedures needs to be addressed to ensure widespread implementation in clinical practice.

BRAFV600E mutation is associated with increased prevalence of contralateral lymph-node metastases in low and low-to-intermediate risk papillary thyroid cancer

OBJECTIVE

Papillary thyroid cancer (PTC) is the most common endocrine malignancy. Despite good prognosis being generally associated with PTC, persistent/recurrent disease can be observed in a not negligible number of patients. Accurate postoperative management can lead to a significant improvement of risk stratification/staging of PTC patients identifying those at higher risk of a more aggressive clinical course. Molecular tests were introduced at the beginning of the 2000s to improve PTC risk stratification.

METHODS

We reviewed the records of 354/1185 patients affected by low or low-to-intermediate risk unilateral-PTC. In these patients, BRAFV600E mutation was looked for and 131-radioiodine therapy was performed 3 months after thyroid surgery. A radioiodine post-therapeutic imaging was obtained in all patients.

RESULTS

BRAFV600E mutation was found in 170/354 PTC patients (female = 126). Forty-two out of 170 BRAFV600E mutation +ve patients (female = 27) had ipsilateral (n = 24) or contralateral (n = 18) loco-regional metastases at post-therapeutic imaging. Significant differences in terms of 2015 American Thyroid Association risk stratification, Hashimoto thyroiditis prevalence, tumor size, multifocality, disease staging and aggressive variant were observed between BRAFV600E mutation +ve and BRAFV600E mutation -ve patients (P ≤ 0.001;P = 0.001; P ≤ 0.001; P = 0.026; P ≤ 0.001; P ≤ 0.001). Interestingly, the prevalence of contralateral lymph-node metastases was significantly higher in BRAFV600E mutation +ve than BRAFV600E mutation -ve patients (18/42 vs. 2/22, respectively; P = 0.013).

CONCLUSION

This study suggests that BRAFV600E mutation represents a significant risk factor for developing contralateral lymph-node metastases and confirms that BRAFV600E mutation is associated with more aggressive PTC features and a higher prevalence of metastatic disease also in low or low-to-intermediate-risk PTC patients.

Choroidal involvement in Rosai-Dorfman disease successfully treated with cobimetinib

Rosai- Dorfman disease (RDD) is a rare systemic pseudo-lymphomatous disorder with unknown etiology. No guidelines exist regarding its management and treatment when the disease is progressing. Choroidal involvement in RDD has rarely been reported and has often been misdiagnosed. We describe a case of a 64-year-old male diagnosed with RDD by means of choroidal biopsy, successfully treated with a MEK inhibitor, namely Cobimetinib, and its follow-up over 5 years, with good final anatomical and functional results. This is the first reported case of RDD diagnosed with an intraocular biopsy performed on a non-enucleated globe, thus preserving the integrity and function of the eye. This case emphasizes the need for a choroidal biopsy when the diagnosis is not straightforward and the starting of targeted therapy to retain a good visual function.

ReportFlow: an application for EEG visualization and reporting using cloud platform

Background

The cloud is a promising resource for data sharing and computing. It can optimize several legacy processes involving different units of a company or more companies. Recently, cloud technology applications are spreading out in the healthcare setting as well, allowing to cut down costs for physical infrastructures and staff movements. In a public environment the main challenge is to guarantee the patients’ data protection. We describe a cloud-based system, named ReportFlow, developed with the aim to improve the process of reporting and delivering electroencephalograms.

Methods

We illustrate the functioning of this application through a use-case scenario occurring in an Italian hospital, and describe the corresponding key encryption and key management used for data security guarantee. We used the X² test or the unpaired Student t test to perform pre-post comparisons of some indexes, in order to evaluate significant changes after the application of ReportFlow.

Results

The results obtained through the use of ReportFlow show a reduction of the time for exam reporting (t = 19.94; p < 0.001) and for its delivering (t = 14.95; p < 0.001), as well as an increase of the number of neurophysiologic examinations performed (about 20%), guaranteeing data integrity and security. Moreover, 68% of exam reports were delivered completely digitally.

Conclusions

The application resulted to be an optimal solution to optimize the legacy process adopted in this scenario. The comparative pre-post analysis showed promising preliminary results of performance. Future directions will be the creation and release of certificates automatically.

Multidisciplinary model for hospital-territory integrated management of patient with bone fragility: primary and secondary prevention of fractures according to severity and complexity

The aim of this study was to promote the construction of a real network and a shared diagnostic and therapeutic management model between hospitals and out-of-hospital healthcare services to capture as many patients with bone fragility as possible. Starting from the analysis of the clinical competences present in the province of Pavia, the bone specialists (BSs) organized some educational events involving both general practitioners (GPs) and hospital specialists. The Fracture Liaison Service (FLS) model, the revision of Note 79, the national plan for chronicity and the health reform of the Lombardy Regional Authority supported the structure of our model, in which the roles of clinicians are well defined and based on the complexity and severity of patients. In our method the GP has a central role as clinical manager, facilitating patient management and communication between the specialists and the BS. In January 2019, the Therapeutic Care Diagnostic Path (PDTA) shared between 2 bone specialists (BSs), 9 GPs, as reference treaters, and a multidisciplinary group of 25 specialists of the Province of Pavia was defined. The strategic directions of the two largest public hospitals in Pavia have supported the PDTA, which was validated by the quality departments of the hospitals themselves. Finally, sixty GPs belonging to the network have joined the PDTA. This model is the first example of integrated management between hospitals and out-of-hospital healthcare services for the primary and secondary prevention of fragility fractures (FF), where the GPs play a pivotal role as managers and supervisors to ensure proper care to chronic patients according to their levels of severity.

Clinical validation of REALQUALITY RQ-HPV Screen according to the international guidelines for human papillomavirus DNA test requirements for cervical screening

Background

According to international guidelines, HPV DNA tests represent a valid alternative to Pap Test for primary cervical cancer screening, provided that they guarantee balanced clinical sensitivity and specificity for cervical intraepithelial neoplasia grade 2 or more severe lesions. The aim of this study was to assess whether REALQUALITY RQ-HPV Screen, a new assay based on real time PCR that targets the E6-E7 region of 14 high-risk human papillomaviruses, meets the criteria for primary cervical cancer screening.

Methods

As required by guidelines, a non-inferiority test was conducted to compare the clinical performance of the test under evaluation with that of a clinically validated reference test (Hybrid Capture 2, HC2). The reproducibility of the device was assessed as well. The clinical samples used to test the hypothesis of non-inferiority and to asses reproducibility comprised 910 and 536 cervical specimens respectively. All specimens were originating from a population-based screening cohort.

Results

The study demonstrates that both the clinical sensitivity and specificity of REALQUALITY RQ-HPV Screen are non-inferior to those of HC2. In addition, an adequate intra- and inter-laboratory reproducibility has been reached by the test.

Conclusions

REALQUALITY RQ-HPV Screen fulfils all the requirements of the international guidelines and can be considered clinically validated for primary cervical cancer screening purposes.

An Unusual Presentation of Secondary Involvement of B-Cell Chronic Lymphocytic Leukemia. A Case Report

Extramammary tumors rarely metastasize to the breast. The commonest tumors to metastasize in breast tissue are lymphoproliferative diseases, melanoma, lung cancer and gynecological malignancies.

Primary breast lymphoma has been reported in the literature with a maximum percentage of about 0.5% of all breast malignancies, while secondary localizations of lymphomas in the breast are less well studied in the literature than primary ones. The authors report a rare case of a secondary localization of B-cell chronic lymphocytic leukemia to the breast in which the diagnosis was obtained by histopathology and immunohistochemistry and further confirmed by molecular data.

This occurrence must be considered in the differential diagnosis of a breast lump so that the primary hematological disease can be adequately treated and the correct type of breast surgery performed.

Optic Disc Drusen in Tilted Disc

Purpose

To investigate if a congenital anomaly of the head of the optic nerve like such as tilted disc can be a risk factor for the development of optic disc drusen.

Methods

The study was performed retrospectively on the files of 47 patients with optic disc drusen. The diagnosis was confirmed by fluorescein angiography and B-scan ultrasonography. The authors examined the fundus photographs and the fluorescein angiographies of these patients looking for the presence of tilted discs.

Results

Two of the 47 patients with optic nerve drusen had tilted discs as well, about twice the expected rate. Both cases presented a parapapillary hemorrhage.

Conclusions

The concomitant presence of tilted disc and optic disc drusen can have a cause-effect relationship. The axonal crowding in a scleral canal of reduced size, as seen in tilted disc, can compress the nerve fibers against the stiff lamina cribrosa, producing a chronic optic neuropathy leading to drusen.

Indocyanine Green Angiography in Congenital Hypertrophy of the Retinal Pigment Epithelium

PURPOSE

To report a case of congenital hypertrophy of the retinal pigment epithelium followed up for 7 years showing features not previously reported.

METHODS

A complete fundus examination including fluorescein angiography was performed at first examination and at follow-up.

RESULTS

The area of congenital hypertrophy of the retinal pigment epithelium presented morphologic changes, showing enlargement of the lesion on one side associated with partial regression on another side. In addition, the indocyanine green angiography findings revealed that this test was more useful than fluorescein angiography to delineate the real boundaries of the lesion and disclosed hypofluorescent areas inside the main lesion that were not appreciated at ophthalmoscopy or fluorescein angiography.

CONCLUSIONS

Indocyanine green angiography is an useful test to understand the findings and evolution of congenital hypertrophy of the retinal pigment epithelium.

Less frequently mutated genes in colorectal cancer: evidences from next-generation sequencing of 653 routine cases

AIMS

The incidence of RAS/RAF/PI3KA and TP53 gene mutations in colorectal cancer (CRC) is well established. Less information, however, is available on other components of the CRC genomic landscape, which are potential CRC prognostic/predictive markers.

METHODS

Following a previous validation study, ion-semiconductor next-generation sequencing (NGS) was employed to process 653 routine CRC samples by a multiplex PCR targeting 91 hotspot regions in 22 CRC significant genes.

RESULTS

A total of 796 somatic mutations in 499 (76.4%) tumours were detected. Besides RAS/RAF/PI3KA and TP53, other 12 genes showed at least one mutation including FBXW7 (6%), PTEN (2.8%), SMAD4 (2.1%), EGFR (1.2%), CTNNB1 (1.1%), AKT1 (0.9%), STK11 (0.8%), ERBB2 (0.6%), ERBB4 (0.6%), ALK (0.2%), MAP2K1 (0.2%) and NOTCH1 (0.2%).

CONCLUSIONS

In a routine diagnostic setting, NGS had the potential to generate robust and comprehensive genetic information also including less frequently mutated genes potentially relevant for prognostic assessments or for actionable treatments.

HGF/c-met system targeting PI3K/AKT and STAT3/phosphorylated-STAT3 pathways in pituitary adenomas: an immunohistochemical characterization in view of targeted therapies

The ligand/receptor hepatocyte growth factor (HGF)/c-met signaling system promotes cellular growth and angiogenesis through PI3K/phosphor-Akt and STAT3/phosphor-STAT3 downstream effectors. In this study, we have evaluated the expression of molecules of the HGF/c-met pathway in pituitary adenomas (PA). The expression of HGF, c-met, PI3K (p85αsubunit) pAkt, STAT3, and pSTAT3 was analyzed by immunohistochemistry in an archival series of 30 PA (12 non-functioning and 18 functioning; 25 macroadenomas and 5 microadenomas). PAs expressed all six proteins in tumor epithelial cells. The proportion of c-met(+ve) cells was greater than HGF(+ve) cells (49 ± 19 vs 34 ± 17 %, P < 0.01), the pAkt(+ve) cells greater than PI3K(+ve) cells (39 ± 16.0 vs 1.3 ± 0.5 %, P < 0.001), and the STAT3(+ve) cells greater than active pSTAT3(+ve) cells (14 ± 8 vs 7 ± 6 %, P < 0.01). Furthermore, endothelial Akt immunostaining was detected on the vascular surface area of 17 PAs, in macroadenomas more frequently than in microadenomas (82 vs 18 %). The percentage of immunostained endothelial cells was greater in macro than in microadenomas (19 ± 7 and 7 ± 3 %; P < 0.05). In conclusion, HGF and c-met are widely expressed in PA, and correlate with pAkt expression. These data, together with the finding of pAkt immunostaining on microvascular areas related to tumor size, suggest a major role of the pAKT signaling in tumor growth and angiogenesis. There might be practical implications for the targeted therapy of PA.

HER2 status in advanced gastric carcinoma: A retrospective multicentric analysis from Sicily

According to the ToGA trial, HER2 has been shown to be predictive for the success of treatment with trastuzumab in advanced gastric cancer (AGC). A number of studies have analyzed HER-2/neu overexpression in gastric carcinoma and identified the rate of HER2 positivity to be markedly varied. To date, the prevalence of HER2 overexpression in Sicilian people with AGC is unknown. Therefore, in the present study, a retrospective immunohistochemical analysis of HER2 was performed in a cohort of 304 AGC samples that were obtained from the archives of 10 Sicilian anatomopathological diagnostic units in order to verify the positive rate of HER2-positive cases. Furthermore, the characteristics of histotype, grade, stage and Ki-67 expression were also analyzed. HER2 overexpression was encountered in 17.43% of all the gastric adenocarcinomas, which was consistent with the results that have been reported elsewhere in the literature. A progressive increase in HER2 overexpression was observed, from the poorly cohesive histotype to the tubular adenocarcinomas and gastric hepatoid adenocarcinomas. HER2 overexpression was significantly associated with a high grade, advanced stage and high Ki-67 labeling index. Further investigations performed jointly by pathologists and oncologists within the geographical area of the present study should confirm that the association of trastuzumab with chemotherapy results in an improvement of survival in patients with AGC.

Immunoexpression of lactoferrin in bone metastases and corresponding primary carcinomas

Although the immunohistochemical presence of lactoferrin (LF) in pathological neoplastic bone and cartilage samples has previously been studied, no data concerning the distribution of LF in bone metastases of cancers that have originated from different organs are available at present. Consequently, using a monoclonal antibody, we have investigated the immunohistochemical LF pattern in 50 formalin-fixed and paraffin-embedded samples of human bone metastases and their corresponding primary carcinoma tumours (breast, 8; prostate, 4; kidney, 4; lung, 3; colon-rectum, 2 and uterus, 4). Quantification of LF immunoreactivity was performed using an intensity distribution (ID) score. LF immuno staining with a variable ID score was encountered in 11/25 (44%) metastatic lesions. In particular, the LF immunoreactivity was identified with a percentage ranging from 50 to 75% of bone metastases due to prostatic, renal, uterine and colorectal carcinomas; the positivity decreased in breast carcinomas (37.5%) and was completely absent in lung cancers. No differences in the LF-ID score were observed between primary and metastatic neoplastic localisations. Additionally, no correlations were identified between LF immunoexpression and the other parameters tested, including the age and gender of patients. Regardless of the mechanism of action of LF in human malignant tumours, we identified LF immunohistochemical reproducibility at primary and metastatic sites. Therefore, we hypothesise that the presence of LF in native neoplastic carcinomatous clones is maintained in secondary bone metastatic deposits.

HER2 status in unusual histological variants of gastric adenocarcinomas

AIM

To investigate HER2 status in a cohort of 109 gastric adenocarcinomas also including unusual variants, such as 14 hepatoid (HAS) and 9 mitochondrion-rich (MRC), characterised by an opposing clinical behaviour.

METHODS AND RESULTS

Using HercepTest (DAKO) and FISH test (pharmDx DAKO), HER2 overexpression/amplification was encountered in 23 of 109 (21.10%) of all gastric adenocarcinomas. A progressive increase in HER2 overexpression was observed moving from the poorly cohesive histotype to MRC, tubular adenocarcinomas and HAS. A statistically significant difference was found between poorly cohesive carcinomas and the others; a similar significant difference was encountered between HAS and all other variants of adenocarcinoma. HER2 overexpression was significantly associated with high grade, advanced stage, high Ki-67 labelling index value and death from gastric cancer. Multivariate analysis identified HER2 overexpression as an independent unfavourable prognostic variable for adenocarcinomas as a whole and also for the HAS variant.

CONCLUSIONS

Trastuzumab has been confirmed as an additional useful therapeutic standard option for patients with HER2-positive advanced gastric cancers, and also in aggressive variants of adenocarcinomas such as HAS.

Hematopoietic progenitor cells (HPCs) in node-negative invasive breast carcinomas: Immunohistochemical analysis and clinico-pathological correlations

Using immunohistochemistry, we investigated 603 negative lymph nodes from 51 patients affected by invasive breast cancer (BC) to recognize bone marrow-derived hematopoietic progenitor cells (HPCs). HPC aggregates, revealed by CD34, CD133, VEGFR1, and CD117 antisera, were determined by an intensity-distribution score (ID). Cases with an ID-score >3 at least for one marker were considered to strongly express HPCs. Twenty-five of 51 (49%) high expressor patients were identified by CD34 antiserum, while 24/51 (47.1%), 17/51 (33.3%), and 15/51 (29.4%) were identified by CD117, CD133, and VEGFR1, respectively. No significant relationships were found between HPCs status and histotype, tumor grade, stage, and hormone receptors, as determined at the moment of the first diagnosis. A significant correlation was recorded for Ki-67 values, as well as for death from invasive BC. No statistical significance was achieved regarding HER2 status, although a tendency toward a statistically significant P value was obtained. A significant relationship (P<0.001) was found between high expressors of HPC and progression of disease, documented by the development of distant metastases. An equivalent P value was ascertained for osseous localizations, with a lesser value in other metastatic sites. Regarding the appearance of distant metastases, the greatest efficiency value was obtained by CD133 (85.7%). Overall survival (OS) and distant metastases-free survival (DMFS) revealed a high statistical significance for HPC expression, Ki-67 values, and HER2 status. By multivariate analysis, HPC expression and Ki-67 values emerged as the higher independent prognostic variables in the analysis of DMFS and OS, respectively.

Prognostic impact of CD133 immunoexpression in node-negative invasive breast carcinomas

BACKGROUND

Hematopoietic progenitor cells (HPCs) are able to prepare the site for incoming neoplastic cells. Among different markers of HPCs, which one should be considered the most efficient was investigated.

PATIENTS AND METHODS

Five hundred and seventy-nine non-metastatic lymph nodes from 49 patients affected by invasive breast cancer were submitted to an immunohistochemical comparative analysis of hematopoietic (CD34), endothelial (CD133), mesenchymal (CD117) progenitors and vascular endothelial growth factor receptor 1 (VEGFR1, also known as Flt1). The cases with an intensity-distribution score >3 were considered as high HPC expressors. Survival univariate and multivariate analyses were performed.

RESULTS

Fifteen out of the 49 patients were recorded as HPC high expressors based on the immunohistochemical VEGFR1 staining. A highly significant relationship was found between high HPC immunoexpression and the development of distant metastasis as well as the occurrence of bone localization (p<0.001). By univariate analysis, CD133 showed a highly significant value regarding metastatic localizations in the bone; by multivariate analysis, CD133 emerged as the only independent prognostic variable.

CONCLUSION

CD133 expression shows a potential predictive role, thus representing a helpful tool for the management of breast cancer.

Detection and genotyping of human papillomavirus in gynaecologic outpatients of Messina, eastern Sicily, Italy

In order to determine the prevalence of human papillomavirus (HPV) infection in sexually active female population in Messina, we tested cervical scrapes of women referred to university clinics for routine gynaecologic care. Between March and December 2008, a total of 680 cervical samples of 598 patients (573 Italian from province of Messina and 25 resident aliens) were examined consecutively from laboratory of molecular biology at the Department of Human Pathology. For each sample, cervical cells were collected by centrifugation and DNA was extracted (QIAamp DNA mini kit, Qiagen), followed by a PCR-based HPV DNA assay and reverse dot blot genotyping (HPV-HS Bio plus HPV-strip, AB Analytica or HPV-type, AB Analytica). The overall rate of HPV DNA detection in Italian patients (mean age 34 years; range 15-69) was 70.5% (404/573), with 163 cases of multiple infections (40.3%). In 335 patients (82.9%) a high-risk HPV infection was detected. In this group the coexistence of a low-risk HPV infection was documented in 97 cases while 65 patients exhibited only a low-risk HPV infection. HPV-16 was the most prevalent (33.4%), followed by HPV-6 (28.0%), HPV-31 (24.3%), HPV-58 (11.4%), HPV-66 (11.1%), HPV-53 (6.4%), HPV-18 (6.2%), HPV-56 (5.4%), HPV-33 (5.2%) while the other genotypes identified (HPV-11, -40, -42, -43, -44, -54, -61, -70, -81, -26, -35, -39, -45, -51, -52, -59, -68, -73, -82) were below 5%. HPV prevalence (any type) was 78.7% at age < or =24 years, 73.4% at 25-34 years and 67.1% at 35-44 years and 58.1% at age > or =45 years. A significant association (chi2=12.718; P=0.006) between HPV DNA detection and the younger age was encountered. Since available data on the prevalence and distribution of HPV infection in Italy are somewhat discordant, this study represents a helpful contribution to the knowledge on the circulation of precise genotypes in east Sicily in order to improve new HPV vaccines.

Immunohistochemical localization and functional characterization of somatostatin receptor subtypes in a corticotropin releasing hormone-secreting adrenal phaeochromocytoma: review of the literature and report of a case

Somastostatin receptors are frequently expressed in phaeochromocytoma but data on somatostatin receptor subtyping are scanty and the functional response to the somatostatin analogue octretide is still debated.We report an unusual case of pheochromocytoma, causing ectopic Cushing’s syndrome due to CRH production by the tumour cells, in a 50-yr-old woman. Abdominal computed tomography revealed an inhomogeneous, 9-cm mass in the right adrenal gland, and [¹¹¹In-DTPA⁰] octreotide scintigraphy showed an abnormal uptake of the radiotracer in the right perirenal region, corresponding to the adrenal mass. The patient underwent laparoscopic surgery and formalin-fixed and paraffin-embedded samples were studied. The tumour was extensively characterized by immunohistochemistry and somatostatin receptor (SSTRs) subtypes expression was analyzed. Histological and immunohistochemical examination of the surgical specimens displayed a typical pheochromocytoma, which was found to be immunoreative to S-100, chromogranin A and neurofilaments. Immunostaining for SSTR subtypes showed a positive reaction for SSTR₁, SSTR_2A, SSTR_2B, antisera on tumour cells. The intense and diffuse immunostaining for corticotropin releasing hormone (CRH) antiserum indicated that Cushing’s disease was dependent on CRH overproduction by the pheochromocytoma, in which no immunostaining for adrenocorticotropic hormone was found. Our report confirms the heterogeneity of the pattern of SSTR expression in pheochromocytomas, and provide further evidence for functional SSTR subtype SSTR_2a in a subgroup of pheochromocytomas, suggesting that these tumours may represent potential target for octreotide treatment.

Immunohistochemical localization and functional characterization of somatostatin receptor subtypes in a corticotropin releasing hormone- secreting adrenal phaeochromocytoma: review of the literature and report of a case

Somastostatin receptors are frequently expressed in phaeochromocytoma but data on somatostatin receptor subtyping are scanty and the functional response to the somatostatin analogue octretide is still debated.We report an unusual case of pheochro-mocytoma,causing ectopic Cushing's syndrome due to CRH production by the tumour cells, in a 50-yr-old woman. Abdominal computed tomography revealed an inhomogeneous,9-cm mass in the right adrenal gland,and [111In-DTPA0] octreotide scintigraphy showed an abnormal uptake of the radiotracer in the right perirenal region,corresponding to the adrenal mass.The patient underwent laparoscopic surgery and formalin-fixed and paraffin embedded samples were studied. The tumour was extensively characterized by immunohistochemistry and somatostatin receptor (SSTRs) subtypes expression was analyzed.Histological and immunohistochemical examination of the surgical specimens displayed a typical pheochromocytoma,which was found to be immunoreative to S-100, chromogranin A and neurofilaments. Immunostaining for SSTR subtypes showed a positive reaction for SSTR1, SSTR2A, SSTR2B, antisera on tumour cells. The intense and diffuse immunostaining for corticotropin releasing hormone (CRH) antiserum indicated that Cushing's disease was dependent on CRH overproduction by the pheochromocytoma,in which no immunostaining for adrenocorticotropic hormone was found. Our report confirms the heterogeneity of the pattern of SSTR expression in pheochromocytomas,and provide further evidence for functional SSTR subtype SSTR2a in a subgroup of pheochromocytomas,suggesting that these tumours may represent potential target for octreotide treatment.

Actinic keratosis associated with squamous and basal cell carcinomas: an evaluation of neoplastic progression by a standardized AgNOR analysis

In an attempt to investigate the neoplastic progression in different stages of actinic keratosis (AK), a standardized AgNOR analysis was performed in 94 cases of AK, 35 of which were associated with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC), and in 31 cases of SCC and 22 cases of BCC. The cases were subdivided into low- and high-AgNOR-expressing (AgNOR status) AK by using the mean area of AgNORs per cell (NORA) value (3.996 micro(2)) as the cut-off. In AK samples, a progressive increase of the mean NORA value from Stage I to Stage IV was encountered. In addition, a significantly higher mean NORA value was found in the AK cases associated with SCC, in comparison to those without SCC; by contrast, no significant differences in the mean NORA value were noted between AK cases with or without BCC. A highly significant association between a high AgNOR quantity and the coexistence of SCC was encountered in AK; no association was appreciable between the AgNOR quantity and the co-occurrence of BCC. Moreover, when the co-existence of SCC in AK was considered as the reference point, the AK cases associated with SCC mostly (95.5%) presented a high AgNOR quantity (high sensitivity), but only 57.6% of cases without SCC displayed a low AgNOR quantity (low specificity). Additionally, our data document that the standardised AgNOR analysis represents a strong negative predictor for the association between SCC and AK. Indeed, a low AgNOR quantity mostly is associated with AK cases without SCC.

Immunoexpression of lactoferrin in human sporadic renal cell carcinomas

By immunohistochemistry, lactoferrin (Lf) expression was retrospectively investigated in 40 formalin-fixed paraffin-embedded kidney samples, obtained at surgery from an equal number of patients. Histologically, 28 cases were clear cell carcinomas (CCC), 7 papillary carcinomas (PC) and 5 chromophobe carcinomas (CC). Ten specimens of unaffected renal parenchyma were utilized as tissue control. On 4-microm thick sections, the Lf immunoreactivity was revealed either by a rabbit polyclonal or mouse monoclonal anti-human Lf antisera; the quantification of Lf immunoreactivity was performed using an intensity-distribution (ID) score. A positive immunoreaction by both anti-Lf antibodies was found in 62.5% (25/40) of RCC, mainly evident and diffuse by monoclonal antiserum. The immunoreactivity was observed in the cytoplasmic boundary of neoplastic cells in CCC and PC, while in CC Lf showed a diffuse granular cytoplasmic localization. Moreover, significant differences in Lf ID score were found among CCC and non-CCC variants (P<0.00001), the former showed a lower score; no relationships between immunohistochemical data and the sex or age of patients, grade of RCC, stage of the disease or degree of terminal anemia were encountered. Normal unaffected tubular structures were positive for Lf; glomeruli were unstained. The reduced Lf immunoexpression in some CCC may be because of the down-regulation of Lf gene due to the frequent deletion of 3p regions reported in this RCC variant.

Variations in Central Corneal Thickness During the Menstrual Cycle in Women

PURPOSE

We report changes in the central corneal thickness during various phases of the menstrual cycle.

METHODS

We recruited 16 healthy women of reproductive age and measured the central corneal thickness at 3 points in their menstrual cycle, beginning on days 1 to 3 and again at ovulation and at the end of the cycle (days 27-32). Ovulation was determined with a test that determines the peak of luteinizing hormone in the urine.

RESULTS

We found that the central cornea was thinnest at the beginning of the cycle (mean = 536 microm). Corneal thickness increased at ovulation (mean = 549 microm) and at the end of the cycle (mean = 559 microm). The difference in corneal thickness was statistically significant at ovulation (P = 0.003) and the end of cycle (P = 0.001) compared with values at the beginning of the cycle.

CONCLUSION

The central corneal thickness changes during the menstrual cycle; the cornea is thinnest at the beginning of the cycle and thickest at the end. These changes could be secondary to hormonal influences; estrogen receptors can be found in human corneas, suggesting that estrogen may have a role in corneal physiology.

Changes in colour discrimination during the menstrual cycle

A group of normal women of reproductive age were recruited to investigate colour discrimination during the various phases of the menstrual cycle. Colour vision was tested with the Farnsworth-Munsell 100-hue arrangement test, and the test was administered at 3 time points: the beginning of the cycle, ovulation, and the end of the cycle. We found that colour discrimination was better at ovulation than at the other 2 time points. It is possible that psychological as well as hormonal factors could contribute to improved colour vision performance at ovulation.

Optical coherence tomographic findings in bietti's crystalline tapetoretinal dystrophy

PURPOSE

To report the optical coherence tomography (OCT) findings of Bietti crystalline tapetoretinal dystrophy.

DESIGN

Observational case report.

METHODS

A subject with Bietti crystalline tapetoretinal dystrophy was evaluated with ophthalmoscopy, fluorescein angiography, and OCT (Stratus).

RESULTS

OCT showed thinning and hyporeflectivity of the outer nuclear layer in the macula due to photoreceptor degeneration. The retinal areas showing atrophy of the retinal pigment epithelium displayed greater penetration of the optical beam into the choroid and visualization of residual choroidal vessels. The hyperreflective band normally seen under the neurosensory retina was extremely wide when atrophy of the entire retinal pigment epithelium/choriocapillaris complex was found. Above this band, and within the neurosensory retina, some hyperreflective dot-like lesions were seen that could be related to crystals.

CONCLUSIONS

In cases of Bietti crystalline tapetoretinal dystrophy, OCT shows changes secondary to fundus atrophy and more specific changes that can be related to the presence of crystals, thereby making OCT particularly useful for demonstrating macular atrophic abnormalities.

Caveolin-1 in meningiomas: expression and clinico-pathological correlations

Caveolin-1 (Cav-1) protein has been documented in several neoplasms with a controversial role in cell proliferation, tumour development and progression. The aim of the present study was to investigate the Cav-1 immunohistochemical expression in human meningiomas. Sixty-two cases, classified as 11 meningothelial (17%), 12 transitional (19%), 5 fibrous (8%), 3 microcystic (5%), 3 secretory (5%), 1 clear cell (2%), 1 chordoid (2%) and 26 (42%) atypical meningiomas, were selected from our pathological files. Clinico-pathological data, including Ki-67 values and survival data were also available. Ten leptomeningeal samples were utilized as normal tissue control. For each case, a polyclonal antibody against Cav-1 was applied and an intensity distribution (ID) score was determined. The Cav-1 immunoexpression was found in 95% of meningiomas with a variable ID score, while only minimal, not uniform, reactivity was noted in non-neoplastic meninges. Of note, higher Cav-1 ID score was significantly correlated with tumour site, Simpson's grade, histological type, higher histologic grade, Ki-67 labelling index > or = 4% and clinical course. Kaplan-Meier curves demonstrated a significantly worse survival in patients with higher Cav-1 ID score, Ki-67 > or = 4% and 2-3 Simpson grade. Multivariate analysis indicated that only Ki-67 was an independent prognostic factor. Increased immunoexpression of the Cav-1 seems to be associated with the biological aggressiveness of meningiomas, reflecting a worse prognosis.

Platelet-rich plasma treatment and hemostasis in patients with hemorrhagic risk

AIM

Our research aimed to evaluate the risk of haemorrhage following oral surgical operations, in patients who were undergoing an anticoagulant therapy, and to test the usefulness of the autologous platelet gel in order to control haemostasis.

METHODS

A total of 208 patients (84 males/124 females) undergoing an anticoagulant therapy and submitted to oral surgery, were divided at random into 4 groups (A, B, C, D) consisting of 52 patients each, using as criterion of differentiation the kind of treatment we adopted in order to get haemostasis. The patients belonging to the first 3 groups (A, B, C), underwent a surgical operation without discontinuing the dicumarol therapy. In order to get haemostasis, we used: platelet-rich plasma (PRP) and suture, in group A; PRP, haemostatic sponges and suture, in group B; haemostatic sponges, suture and compression by means of gauzes soaked in tranexamic acid in group C. Group D, instead, consisted of patients who underwent a surgical operation, before which the dicumarol therapy had been suspended and replaced by heparincalcium.

RESULTS

Patients belonging to the groups A and B showed a very good haemostasis like the patients of group D (control group). As the coumarin therapy didn't need to be discontinued some days before the surgical operation, so the days of hospital stay were reduced and there wasn't the risk of thromboembolism. As to group C (19 males), 6 patients (i.e. 11.5%) showed a good haemostasis, both at once and in the long term, so that they could be discharged on day 2 after surgery.

CONCLUSIONS

The results obtained during our research, highly encourage using PRP regularly when carrying out surgical treatments on patients who are undergoing a coumarin therapy.

Optical coherence tomography of chorioretinal and choroidal folds

PURPOSE

To report the optical coherence tomography (OCT) findings in cases of chorioretinal and choroidal folds.

METHODS

Eight subjects with folds of the fundus of the eye were examined with fundus photography, fluorescein angiography, B-scan ultrasonography and Stratus OCT.

RESULTS

Two types patterns were found on OCT. Five cases showed undulating retinal as well as retinal pigment epithelial lines of normal thickness; these were defined as chorioretinal folds. The posterior vitreous surface often adhered to the crests of the folds only. Three cases exhibited a wavy appearance of the retinal pigment epithelium and a flat retinal surface; these were classified as choroidal folds.

CONCLUSIONS

Scanning by OCT can differentiate chorioretinal folds from choroidal folds and reveal the relationships between the folds and the posterior vitreous surface.

Lactoferrin immunoexpression in endometrial carcinomas: relationships with sex steroid hormone receptors (ER and PR), proliferation indices (Ki-67 and AgNOR) and survival

We have investigated Lf immunoexpression as well as its biological meaning in 71 formalin-fixed, paraffin-embedded surgical samples of endometrial carcinomas (EC); 64 EC were endometrioid type, whereas 7 were non-endometrioid carcinomas. Immunohistochemistry was performed by primary antibodies against Lactoferrin (Lf), estrogen receptor (ER), progesterone receptor (PR) and Ki-67 antigen. Quantification of Lf immunoreactivity was performed using an intensity-distribution (ID) score. Moreover, the AgNOR technique according to guidelines of the Committee on AgNOR Quantification was used to assess the proliferation rate (NORA). A variable expression of Lf was revealed in 43 cases (61%) of EC. Endometrioid type carcinoma showed a significant higher Lf ID-score than non-endometrioid type; in contrast, no relationships were demonstrated between Lf immunoexpression and histologic grade, stage, clinical course as well as proliferative activity of EC. Moreover, a significantly higher Lf ID-score was encountered in ER-positive carcinomas. Survival analysis in EC indicated the architectural, nuclear and combined histologic grades as well as the stage, PR, Ki-67 and NORA as significant parameters. The utilization of Lf as a prognostic marker, able to identify patients at different risk of death, or alternatively, its clinical application as therapeutic agent, must be considered with great caution.

Quantity of AgNORs in gastric endocrine carcinoid tumours as a potential prognostic tool

In order to assess if the quantity of silver-stained nucleolar organizer region (AgNOR) proteins represents a prognostic tool in gastric carcinoids, a standardised AgNOR analysis was performed on 24 samples collected from the pathology archives of the Universities of Messina and Parma; the samples were taken at surgery from 11 males and 13 females (mean age 55 yrs, age range 28-77 yrs); 13 cases were defined as Type I, 1 case as Type II and 10 cases as Type III; 16 cases showed a diameter <1 cm, 8 >1 cm. Only 6 tumours were deeply invasive, breaking through the muscularis propria or the subserosa. The proliferative status of carcinoids performed by Ki67 protein antibodies was available in 20/24 cases. The quantification of AgNORs was performed according to the guidelines of the Committee on AgNOR Quantification and the mean area (microm2) of AgNORs per nucleus (NORA) was determined by means of image analyser and specific software programs. The relationship between NORA values and Ki67 data was investigated by Spearman correlation test. The mean NORA value of all 24 gastric carcinoids was 1.279 microm2 (SD 0.404); values ranged from 0.734 to 2.142 microm2. A significantly higher (p < 0.001) mean NORA value (1.736 microm2; SD 0.283) was found in tumours larger than 1 cm, in comparison to the smaller neoplasms (1.051 microm2; SD 0.214); moreover, cases showing deep wall invasion exhibited a mean NORA value of 1.765 microm2 (SD 0.276), significantly higher (p < 0.001) than those with superficial growth (1.118 microm2; SD 0.296). Finally, a similar highly significant difference was seen between type III carcinoids (1.615 microm2; SD 0.375) and type I-II (1.040 microm2; SD 0.208). A linear relationship between Ki67 and corresponding NORA values was obtained by the Spearman correlation test (p = 0.001). No other significant correlations were found between mean NORA values and other clinico-pathological parameters. The AgNOR method seems to be an additional tool potentially able to predict the prognosis of this kind of endocrine tumour, facilitating the identification of fast-growing tumours and being able to directly correlate with the size, deep invasion of gastric wall and tumour type, generally considered as the best prognostic indicators.

A case-control study on risk factors for nuclear, cortical and posterior subcapsular cataract: The Casteldaccia Eye Study

PURPOSE

To investigate risk factors for nuclear, cortical and posterior subcapsular age-related cataract.

METHODS

A case-control study was carried out on subjects aged 40 years and older, living in Casteldaccia, Sicily. Twenty-seven potential risk factors were investigated. Nuclear, cortical and posterior subcapsular opacities of the lens were classified according to the Lens Opacities Classification System II. Subjects with advanced lens opacities represented the cases, while an identical number of subjects without or with early cataract, matched for sex and age, were recruited as controls from within the same population.

RESULTS

Univariate analysis showed that myopia and iris atrophy were significantly associated with nuclear cataract. Iris atrophy, use of corticosteroids, pseudoexfoliation syndrome and familial occurrence of cataract were positively correlated with cortical cataract. Myopia, iris atrophy, use of corticosteroids and familial occurrence of cataract presented an association with posterior subcapsular cataract. After multivariate analysis, the variables that remained significantly associated were myopia and iris atrophy for nuclear cataract; iris atrophy, pseudoexfoliation syndrome and familial occurrence of cataract for cortical cataract; and myopia, iris atrophy and familial occurrence of cataract for posterior subcapsular cataract.

CONCLUSION

In addition to well known risk factors such as myopia or use of corticosteroids, the Casteldaccia case-control study shows that iris atrophy represents a previously unrecognized risk factor for each of the three types of cataract.