Clinical and histological outcome predictors in renal limited pauci-immune crescentic glomerulonephritis: a single centre experience

Renal-limited vasculitis is a pauci-immune crescentic glomerulonephritis with no signs of systemic involvement, representing one of the most common causes of rapidly progressive glomerulonephritis. The study aims to examine clinical and histological features in twenty-four patients with RLV diagnosed by the Nephrology Department of Sapienza University of Rome, Italy, evaluating the role of these parameters in predicting renal survival. Patients details, clinical and histological features and outcomes were recorded at the time of renal biopsy and over a mean follow-up period of 36±6 months. In our study, serum creatinine at presentation was significantly higher in patients who had a poor outcome than in those who survived with independent renal function (6.3±2.47 mg/dl vs 2.84±2.01 mg/dl, P= 0.002). The presence of C3c was found in the area of glomerular fibrinoid necrosis and in small arteries and arterioles with fibrinoid necrosis in 17 patients (P= 0.018). In conclusion, serum creatinine at presentation and focal C3c depositions in areas of glomerular and arteriolar fibrinoid necrosis were the best determinants of poor renal outcome, maybe underlining the pathogenic role of alternative pathway activation of complement system but also demonstrating the focal distribution of necrotizing lesions.

Insulin-like growth factor-I (IGF-1), IGF-binding protein-3 (IGFBP-3) and mammographic features

INTRODUCTION

The IGF system has recently been shown to play an important role in the regulation of breast tumor cell proliferation. However, also breast density is currently considered as the strongest breast cancer risk factor. It is not yet clear whether these factors are interrelated and if and how they are influenced by menopausal status. The purpose of this study was to examine the possible effects of IGF-1 and IGFBP-3 and IGF-1/IGFBP-3 molar ratio on mammographic density stratified by menopausal status.

PATIENTS AND METHODS

A group of 341 Italian women were interviewed to collect the following data: family history of breast cancer, reproductive and menstrual factors, breast biopsies, previous administration of hormonal contraceptive therapy, hormone replacement therapy (HRT) in menopause and lifestyle information. A blood sample was drawn for determination of IGF-1, IGFBP-3 levels. IGF-1/ IGFBP-3 molar ratio was then calculated. On the basis of recent mammograms the women were divided into two groups: dense breast (DB) and non-dense breast (NDB). Student's t-test was employed to assess the association between breast density and plasma level of IGF-1, IGFBP-3 and molar ratio. To assess if this relationship was similar in subgroups of pre- and postmenopausal women, the study population was stratified by menopausal status and Student's t-test was performed. Finally, multivariate analysis was employed to evaluate if there were confounding factors that might influence the relationship between growth factors and breast density.

RESULTS

The analysis of the relationship between mammographic density and plasma level of IGF-1, IGFBP-3 and IGF-1/ IGFBP-3 molar ratio showed that IGF-1 levels and molar ratio varied in the two groups resulting in higher mean values in the DB group (IGF-1: 109.6 versus 96.6 ng/ml; p= 0.001 and molar ratio 29.4 versus 25.5 ng/ml; p= 0.001) whereas IGFBP-3 showed similar values in both groups (DB and NDB). Analysis of plasma level of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio compared to breast density after stratification of the study population by menopausal status (premenopausal and postmenopausal) showed that there was no association between the plasma of growth factors and breast density, neither in premenopausal nor in postmenopausal patients. Multivariate analysis showed that only nulliparity, premenopausal status and body mass index (BMI) are determinants of breast density.

CONCLUSIONS

Our study provides a strong evidence of a crude association between breast density and plasma levels of IGF-1 and molar ratio. On the basis of our results, it is reasonable to assume that the role of IGF-1 and molar ratio in the pathogenesis of breast cancer might be mediated through mammographic density. IGF-1 and molar ratio might thus increase the risk of cancer by increasing mammographic density.

Possible effects of insulin-like growth factor-I, IGF-binding protein-3 and IGF-1/IGFBP-3 molar ratio on mammographic density: a cross-sectional study

The purpose of this study was to examine the possible effects of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio on mammographic density and assess whether this relationship was similar in subgroups of pre- and postmenopausal women. A group of 341 Italian women of childbearing age or naturally postmenopausal who had performed mammographic examination at the section of radiology of our department a maximum three months prior to recruitment were enrolled. A blood sample was drawn for determination of IGF-1, IGFBP-3 levels and IGF-1/IGFBP-3 molar ratio was calculated. On the basis of recent mammograms the women were divided into two groups: dense breast (DB) and non-dense breast (NDB). To assess the association between mammographic density and IGF-1, IGFBP-3 and Molar ratio Student's t-test was employed before and after stratified by menopausal status. The analysis of the relationship between mammographic density and plasma levels of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio showed that IGF-1 levels and molar ratio varied in the two groups resulting in higher mean values in the DB group whereas IGFBP-3 showed similar values in both groups (DB and NDB). After stratification of the study population by menopausal status, no association was found. Our study provides strong evidence of a crude association between breast density, and plasma levels of IGF-1 and molar ratio. IGF-1 and molar ratio might increase mammographic density and thus the risk of developing breast cancer.

Acute renal failure in liver transplant recipients: role of pretransplantation renal function and 1-year follow-up

Chronic renal failure and acute renal failure (CRF and ARF) are common complications after orthotopic liver transplantation (OLT) that adversely affect patient survival. Many factors influence the development of ARF in the OLT setting. In a previous study we reported an association between ARF and the development of CRF at 1 month after OLT. The aims of our study were to evaluate the influence of ARF on short-, middle-, and long-term renal function after OLT and its influence on 1-year survival of patients and grafts. Fourty-four patients who underwent deceased donor OLT between August 2008 and August 2010 were evaluated pretransplantation, in the perioperative period, and at 1, 6, and 12 months posttransplantation. ARF was associated with CRF at 1 month post-OLT, whereas no association was observed at 6 and 12 months post-OLT. The development of CRF at 6 months post-OLT was associated with pre-OLT renal dysfunction and 1 month post-OLT CRF. Four patients died in the ARF group, whereas 3 patients died in the group without ARF. We confirmed ARF to be a predictive event for short-term renal dysfunction. The majority of patients recovered renal function after the first month. Although many pre-, peri-, and post-OLT factors may contribute to the development of posttransplantation CRF, pre-OLT CRF seemed to be the most important risk factor.

Model for end-stage liver disease score versus simplified acute physiology score criteria in acute renal failure after liver transplantation

Hepatic function and renal failure are closely related among patients with end-stage liver disease (ESLD) due to splanchnic hemodynamic mechanisms that characterize advanced decompensated cirrhosis. Acute renal failure (ARF) is a frequent complication that occurs immediately post-orthotopic liver transplantation (OLT). The Model for End-stage Liver Disease (MELD) score describes the survival of patients with ESLD awaiting OLT related to the severity of liver disease. The Simplified Acute Physiology Score (SAPS II) is a mortality prediction model that scores the severity of illness among intensive care unit patients. In a previous study we observed an association between ARF post-OLT and a higher MELD score, but it was not clear whether this association depends on the grade of ESLD or on the critical condition of liver transplant patients. The aim of this study was to evaluate the association of ARF with MELD score and/or SAPS II criteria among liver transplant patients. We analyzed 46 patients with ESLD who underwent deceased donor OLT. All patients were evaluated at baseline and in the first 7 days post-OLT. According to the RIFLE classification, the incidence of the worst grade of ARF post-OLT was 19.2%. These patients showed significantly higher MELD scores, while there was no association with systemic parameters related to the critical patient's condition or with the mortality score as evaluated by SAPS II criteria. We confirmed the association between renal failure and hepatic function among liver transplant patients. A more severe degree of hepatic dysfunction before OLT was associated with a greater incidence of ARF that can adversely affect patient survival.

Tacrolimus trough levels and level-to-dose ratio in stable renal transplant patients converted to a once-daily regimen

Numerous evidence has been reported to support a safe 1:1 conversion from the twice-daily tacrolimus (Tac-T) to the once-daily tacrolimus regimen (Tac-O), but frequently there is a reduction in drug trough levels, which has been estimated by some authors to be about 20%. The relationship between Tac-O dosage and trough levels after conversion is not clear. The tacrolimus trough levels-to-dose ratio has been applied to better define the wide variability in doses and blood levels of tacrolimus. The aim of this study was to evaluate tacrolimus trough levels, tacrolimus daily dosage, and tacrolimus level-to-dose ratio during 1 year pre-postconversion follow-up in 31 stable kidney transplant patients who had received Tac-T therapy for over 6 months with stable renal function. They were converted to the same dosage of Tac-O. Patients before and after conversion were their own controls. The trough levels of tacrolimus showed a slight albeit significant reduction after conversion, remaining in the therapeutic range. Nineteen percent underwent an adjustment in total daily dosage after conversion versus 39% before conversion with no significant difference. No significant differences were detected in the total daily dose administered either by tacrolimus level-to-dose ratio before or after conversion. Kidney transplant recipients under Tac-O therapy were safely maintained using the same therapeutic monitoring as when receiving Tac-T.

RIFLE criteria and hepatic function in the assessment of acute renal failure in liver transplantation

Renal dysfunction in cirrhotic patients is primary related to disturbances of circulatory function, triggered by portal hypertension with chronic intrarenal vasoconstriction and hypoperfusion. Pretransplant renal function is an important factor implicated in the development of acute renal failure (ARF) after liver transplantation (OLT), but other factors mostly related to liver function seem to influence the development of ARF. The Acute Dialysis Quality Initiative workgroup developed the RIFLE classification to define ARF. We sought to evaluate the incidence of ARF among patients undergoing OLT, to evaluate the association of ARF with pre-OLT renal and hepatic functions, and to evaluate the influence of ARF on chronic kidney disease (CKD) at 1 month post-OLT. Clinical, renal, hepatic function, and donor risk index data of 24 patients who underwent deceased donor OLT were collected before transplantation, in the perioperative period and in the first month post-OLT. ARF occurred in 37.5% of patients with 56% developing the R grade and 44% the I grade; no patient showed the F grade. An association was observed between ARF and a higher Model for End-Stage Liver Disease (MELD) score and between ARF and a reduced pre-OLT serum albumin. No association was noted between ARF and other pre-OLT parameters. In cirrhotic patients serum creatinine is a bias for renal function assessment and the Modification of Diet in Renal Disease formula overestimates GFR. Post-OLT CKD was present in 6.7% of patients without ARF and in 44.4% of patients with ARF. The R grade developed more frequently among patients with viral cirrhosis. The association of ARF with MELD and hypoalbuminemia may be the result of a close relationship between renal and hepatic functions among cirrhotic patients. Post-OLT CKD may be the result of unrecognized, preexisting CKD and/or the effects of not fully resolved acute damage to an injured kidney.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Prostate cancer detection rate of transrectal ultrasonography, digital rectal examination, and prostate-specific antigen: results of a five-year study of 6- versus 12-core transperineal prostate biopsy

AIM

The purpose of the present comparative work was the processing and assessment of data collected in a five-year period of urological practice with more than 1.500 transperineal, ultrasound-guided, prostatic biopsies performed. Our aim was to identify advantages and limitations of 6 and 12-core protocols, by extending the evaluation not only to cancer detection rate but also to the other histological findings.

METHODS

A total of 1.151 patients were included in the study. Two subgroups were identified: 836 patients who had undergone a 6-core biopsy from 2001 to 2004, and 315 patients who had undergone a 12-core biopsy from 2005 to 2006.

RESULTS

Cancer detection rate was 291/836 (34.8%) in group 1 (6-core biopsy), and 148/315 (47%) in group 2 (12-core biopsy) (P<0.0001). The total number of histological diagnoses other than cancer was 162/836 in group 1 (19.4%) and 103/315 (32.7%) in group 2 (P<0.0001).

CONCLUSION

In prostate biopsy, a higher number of cores seems to definitely improve its diagnostic value by dramatically decreasing the number of negative findings. The 12-core technique is particularly effective in case of prostate-specific antigen (PSA) values ranging between 4.1 and 10 ng/mL combined with a free-to-total PSA ratio below 16%, in case of negative digital rectal examination and when serum prostate-specific antigen levels are lower than 4 ng/mL. On the other hand, in the case of abnormal digital rectal examination, especially when combined with high prostate-specific antigen levels and/or changes detected at transrectal ultrasound, the 6-core technique can be considered a reasonable strategy.

Response to anti-tumour necrosis factor alpha blockade is associated with reduction of carotid intima-media thickness in patients with active rheumatoid arthritis

OBJECTIVES

To determine whether tumour necrosis factor (TNF)-alpha blockers may reduce carotid intima-media thickness (cIMT) in patients with active rheumatoid arthritis (RA) steadily responsive to such therapy.

METHODS

From 287 consecutive RA patients attending our out-patient clinic and diagnosed on the basis of the American College of Rheumatology (ACR) criteria, 49 without traditional cardiovascular risk factors and meeting the requirements for TNF-alpha blockers therapy were selected. Among them, 39 actually started TNF-alpha blockers, but only 30, who reached at least a response on the ACR 20% improvement criteria at 14 weeks, maintained during the whole year of treatment, were finally considered (group A). The remaining 10/49, homogeneous for age, sex, traditional cardiovascular risk factors, socioeconomic status, disease activity and duration, who did not consent to TNF-alpha-blocker administration, were used as controls (group B). Disease activity score in 44 joints (DAS44), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were evaluated before starting the study, and 3, 6, 12 months thereafter; cIMT was measured by ultrasound before and 12 months thereafter only.

RESULTS

Patients in group A showed a very significant cIMT reduction (P < 0.0001 and P < 0.0001, on the right and left side, respectively), preceded by an early and lasting significant decrease in DAS44, ESR and CRP. Moreover, a significant correlation was found between cIMT and DAS44 (r = 0.435, P < 0.05).

CONCLUSIONS

These results demonstrate that TNF-alpha blockade is associated with cIMT reduction in RA patients steadily responsive to therapy, probably by lowering inflammation.

Preconditioning effects of levosimendan in coronary artery bypass grafting—a pilot study

BACKGROUND

The calcium sensitizer levosimendan protects against myocardial ischaemia and reperfusion injury in animal models.

METHODS

The present pilot study investigated whether a short infusion before coronary artery bypass grafting (CABG) would protect the myocardium and improve postoperative haemodynamics. Twenty-four patients with stable angina undergoing elective CABG surgery were randomized to receive either placebo or levosimendan (24 microg kg(-1)) infused i.v. over a 10 min period just before placing the patient on cardiopulmonary bypass.

RESULTS

Perioperative haemodynamic variables, concentrations of cardiac troponin I over the 48 h postoperative period, and clinical outcomes were assessed. There were no adverse effects related to levosimendan. Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.05) and a higher cardiac index (P<0.05).

CONCLUSION

Patients receiving a short infusion of levosimendan before CABG showed evidence of less myocardial damage, suggestive of a preconditioning effect. Larger outcome studies are thus indicated to confirm benefit.

[Predictive variables of lymphatic metastasis in breast carcinoma with a diameter below 2 cm]

The axillary lymph node status of patients with newly diagnosed breast cancer remains the most important prognostic information available at the moment. However, only a minority of patients presents with such node metastases at diagnoses. We reviewed our database and studied 500 consecutive patients with early breast cancer, and found that age inferior to 50 years, high grade, diameter superior to 1 cm, elevated Ki-67, and expression of oncogene p-53 are all factors associated with lymph node metastases.

Changes in serum inhibin B during normal male puberty

OBJECTIVE

In adult men, inhibin B (InhB) regulates FSH secretion by a negative feedback. The aims of this study were to evaluate the changes of InhB during puberty in the male and the relationship between InhB and FSH, LH, testosterone and testicular volume.

DESIGN

Cross-sectional study.

METHODS

InhB was measured using a two-site ELISA in 100 healthy boys subdivided by their pubertal development according to Tanner into five groups of 20.

RESULTS

During puberty we observed an increase of InhB level (G1 = 84.3 pg/ml, G3 = 132.2 pg/ml, G5 = 206.1 pg/ml). In G1, InhB correlated positively with FSH (P = 0.0001), LH (P = 0.005), testosterone (P = 0.001) and testicular volume (P = 0.007); in G5, InhB correlated inversely with FSH (P = 0.001) and LH (P = 0.045) and directly with testicular volume (P = 0.013). The multivariate analysis demonstrated that: in G1, FSH is the most important, and testosterone the second most significant, stimulus for InhB increase; in G2 only FSH has a positive effect on InhB variation; in G3 only mean testicular volume fits the model (G1-G3: InhB dependent variable); considering the FSH dependent variable, in G4, InhB is the most important stimulus for FSH decrease and mean testicular volume is a secondary directly proportional variable; in G5, only InhB shows a significant inverse relationship with FSH.

CONCLUSIONS

During puberty there is a regular increase of InhB. In the first phases of gonadal maturation, InhB and FSH correlate positively, while in mid-late stages the relationship is inverse. We found that in mid-puberty (G3-G4), the serum concentration of InhB increases, as its inverse relationship with FSH is being established and hence spermatogenesis.

Early childhood caries. Oral health survey in kindergartens of the 19th district in Rome

AIM

The aim of this cross-sectional survey was to determine the prevalence of early childhood caries (ECC) in a pediatric sample randomly chosen in public kindergartens or the 19th district in Rome, according to the WHO guidelines and to access the dental and orthodontic status of the affected children.

METHODS

A total of 546 children aged 3-to 5-years were examined. Clinical examination had been executed from January 1999 to June 2000 by 4 calibrated operators; WHO clinical assessment form and anamnestic questionnaires for parents were performed.

RESULTS

Children affected by ECC with a dmft score of 6.3 were 8.2% and 93% were ''treatment need'' (TN); low levels of oral health was significantly related with father's low socioeconomical status, both occupational and educational: most of these families were from less industrialized countries; 40% of these kids used to suck sucking-bottles with honey: many others used to drink too much sweet things (milk and sugar, fruit juice etc.); the most frequent orthodontic features in the ECC group were: brachifacial (26.7%), convex profile (70%), 3rd class terminal plane (30%).

CONCLUSIONS

The results obtained point out that information, health education and health promotion are lacking throughout this part of roman population. Primary preventive dentistry programs should be therefore organized targeting parents, nursery schools and kindergartens' operators and pediatricians.

Detection of Melanoma Cells in Sentinel Lymph Nodes by Reverse Transcriptase-Polymerase Chain Reaction: Prognostic Significance

BACKGROUND

Recently reverse transcriptase-polymerase chain reaction (RT-PCR) has been proposed as a new sensitive method for the detection of submicroscopic melanoma nodal metastases. Sentinel lymph node (SLN) status is considered the most important prognostic factor for melanoma patients. Thus, in recent years, melanoma research has been focused on identifying new molecular markers of micrometastases.

METHODS

In this study, 129 SLNs were collected and analyzed by RT-PCR for tyrosinase and melanoma inhibitory activity (MIA) messenger RNA (mRNA) expression. RESULTS from PCR analysis were then compared with those obtained by hematoxylin and eosin and immunohistochemistry and related to progression of disease.

RESULTS

MIA gene expression was positive by RT-PCR in 27% of the tyrosinase-positive SLNs. When the correlation between tyrosinase and/or MIA mRNA expression and disease-free survival was evaluated by the Kaplan-Meier exact test, there was a statistically significant correlation between simultaneous tyrosinase and MIA gene expression in SLNs and progression of disease.

CONCLUSIONS

RT-PCR analysis for both MIA and tyrosinase mRNA may identify a subset of melanoma patients with a worse prognosis whom the routine methods, such as histology and immunohistochemistry, fail to identify because of the poor sensitivity of these methods.

Impact of lung volume reduction surgery versus rehabilitation on quality of life

This study aims at evaluating the effects of lung volume reduction versus respiratory rehabilitation on quality of life, assessed by three different questionnaires. Sixty emphysematous patients were randomised by computer to receive either surgery (n = 30) or rehabilitation (n = 30). Life quality was evaluated by the Nottingham Health Profile, the Short Form (SF)-36 item and the St George's questionnaires. As reported previously, dyspnoea index, forced expiratory volume in one second, residual volume, 6-min walk test and arterial oxygen tension improved after surgery more than after rehabilitation. Quality of life was significantly improved after surgery as follows Nottingham Health Profile physical mobility; SF-36 physical and social functioning, mental and general health, emotional role; St George's general, activity. At multivariate analysis 6- and 12-month changes after surgery of Short Form-36 physical functioning, general health, and St George's activity domains were significantly correlated with forced expiratory volume in one second, while Short Form-36 social functioning and Nottingham Health Profile isolation correlated with residual volume. Functional and especially symptomatic improvements persisted: dyspnoea index, residual volume, and Short Form-36 and St Georges's physical scores were still significant at 4 yrs. Surgery produces greater and longer effects than rehabilitation on quality of life by improving both physical and psychosocial domains. Symptomatic improvements persisted at 4 yrs.

Atherosclerotic ischemic renal disease

AIM

Atherosclerotic ischemic renal disease is a frequent cause of end-stage renal failure leading to dialysis among the elderly; its prevalence is inferred from autopsy or retrospective arteriographic studies. Screening investigation for ischemic nephropathy on large cohorts, based on non invasive diagnostic techniques, have not so far been published. This study has been conducted on 269 subjects over 50 with hypertension and/or chronic renal failure, unrelated to other known causes of renal disease.

METHODS

All 269 patients were studied either by color-flow duplex sonography (n=238) or by renal scintigraphy (n=224), and 199 of the 269 patients were evaluated using both of these techniques. Forty patients, found to have renal artery stenosis, were subjected to 3D-contrast enhancement magnetic resonance angiography (MRA) and/or digital selective angiography (DSA). An additional 23 cases, negative both to scintigraphy and to ultrasound study, underwent renal angiography (MRA and/or DSA).

RESULTS

Color-duplex sonography, carried out in 238 patients, revealed 49 cases of renal artery stenosis. MR or DSA was carried out in 35 of these 49 patients, and confirmed the diagnosis in 33. Color-duplex sonography was 91.7% sensitive and 90.9% specific, with positive predictive value of 94.2% and negative predictive value of 86.9%. Specificity and sensitivity of renal scintigraphy, carried out in 224 patients, was significantly lower. Patients with renal artery stenosis showed a higher degree of renal insufficiency compared to non stenotic patients while there were no differences in the extent of proteinuria between the two groups. Renal artery stenosis, based on color-duplex sonography studies, was present in 11% of patients in the age group 50-59, 18% in the 60-69 and 23% at age 70 and above.

CONCLUSION

A relatively large percentage of the elderly population with renal insufficiency and/or hypertension is affected by renal artery stenosis and is at risk of developing end-stage renal failure. Color-duplex ultrasonography is a valid routine method of investigation of population at risk for renal artery stenosis.

Expression and prognostic significance of LIVIN, SURVIVIN and other apoptosis-related genes in the progression of superficial bladder cancer

BACKGROUND

It has been suggested that progression of superficial bladder cancer may be regulated at the molecular level by a typical pattern of expression of genes involved in apoptosis. Recently LIVIN, belonging to the inhibitors of apoptosis (IAP) family, has been found to be expressed in most solid tumors, where its expression is suggested to have prognostic significance. No data are available concerning the significance of LIVIN in the progression of bladder tumors.

PATIENTS AND METHODS

In the present paper we used RT-PCR to investigate the expression of LIVIN isoforms alpha and beta, SURVIVIN, BCL-X and BCL-2/BAX expression ratio both in normal and tumoral bladder tissues, and correlated their expression with the emergence of early relapses in a follow-up of 4 years. This study shows that only the alpha isoform of LIVIN, which is not expressed in normal bladder tissue, is expressed in a proportion of tumors with a high risk of relapse.

RESULTS

LIVIN was found in 7/30 patients (23%), SURVIVIN in 9/30 (30%), BCL-2/BAX ratio >1 in 16/30 (53%), BCL-2/BAX expression ratio <1 in 14/30 (46.6%) and BCL-X, only in isoform BCL-X(L), in 11/30 (36.6%). When we evaluated the dependence between each gene expression and relapse free time of patients, we found that LIVIN, high BCL-2/BAX ratio and BCL-X(L), but not SURVIVIN, reached statistical significance in order to predict relapses.

CONCLUSIONS

Our findings suggest that LIVIN may be involved in the progression of superficial bladder cancer and used as a marker of early recurrence; while the expression of SURVIVIN cannot be used to identify patients with high risk of relapse.

Hysteroscopic findings in postmenopausal abnormal uterine bleeding: a comparison between HRT users and non-users

OBJECTIVES

The aim of our study was to investigate hysteroscopic findings in a sample of 410 menopausal women (hormonal replacement therapy, HRT users n = 219 and HRT non-users n = 191) and to evaluate the relationship between the presence of intrauterine disease, the use of HRT and the presence of AUB.

METHODS

Two hundred and nineteen women on HRT underwent standard office hysteroscopy by means of the Hamou hysteroscope (in 94 cases for abnormal uterine bleeding (AUB) and in 125 cases for periodic endometrium monitoring). One hundred and ninety-one women who had never received HRT were submitted to office hysteroscopy (154 for AUB and 37 for other reasons).

RESULTS

Intrauterine diseases are more frequent in patients who do not use HRT (P = 0.02). Endometrial polyps is a frequent disease present in 30% of the sample (23.7% of HRT users and 30.8% of HRT non-users). Myomas were present in 8.7% of all patients examined (6.8% of HRT users and 11% of HRT non-users). Irregular bleeding in menopause is often associated with endouterine abnormalities: in symptomatic patients the frequency of endouterine diseases was 41% while in asymptomatic patients was 28% (P = 0.003). In patients taking HRT (n = 219) endouterine disease is demonstrated in 37% with AUB and in 26% without AUB (P = 0.07).

CONCLUSION

Benign intrauterine diseases (endometrial polyps and submucous myomas) are more frequent in postmenopausal women who do not use HRT. In patients taking HRT irregular bleeding is associated with intrauterine diseases; however, the absence of AUB does not exclude the presence of endometrial polyps or myomas.

Transxiphoid bilateral palpation in video-assisted thoracoscopic lung metastasectomy

OBJECTIVE

To evaluate indications, limits, and merits of transxiphoid bilateral palpation during video-assisted thoracoscopy (VAT) lung metastasectomy.

DESIGN

Survey retrospective study with a minimum follow-up of 1 year.

SETTING

University hospital.

PATIENTS

From December 1995 to September 1999, 29 of 45 patients operated on for pulmonary metastasectomy were approached through a transxiphoid VAT. Primary sites were colon-rectum (n = 13), kidney (n = 4), limb osteosarcoma (n = 3), uterus (n = 2), larynx (n = 2), breast (n = 1), skin melanoma (n = 1), prostate gland (n = 1), back fibrosarcoma (n = 1), and ovary (n = 1). Bilateral palpation was performed in 23 patients, although only 10 had radiological evidence of bilateral disease.

RESULTS

No perioperative or 30-days postoperative mortality was recorded. Acute and chronic pain was similar to that of other VATs and significantly less than sternotomy. Mean +/- SD chest-drain time and hospital stay were 2.8 +/- 1.19 days and 4.3 +/- 1.78 days, respectively. Sixty-nine lesions, 60 of them metastatic, were resected by laser (n = 29) or stapler (n = 40). Bilateral exploration permitted the discovery of 15 radiologically undetected lesions, 11 of which were found to be malignant. Contralateral metastases were found in 5 patients predicted to have unilateral disease. Mean +/- SD follow-up was 22.89 +/- 10.87 months (range, 9-60 months). Six patients developed new pulmonary metastases after a mean interval of 13.6 months; 3 of these patients relapsed in the unexplored hemithorax after 6, 9, and 12 months, respectively.

CONCLUSIONS

The use of the transxiphoid VAT approach was safe, applicable in many instances, and effective in detecting occult metastases by manual bilateral palpation. The advantages of a VAT procedure can be coupled with those provided by a radical operation.

Implication of laminin and collagen type IV expression in the progression of breast carcinoma

BACKGROUND

The prognostic variability in breast cancer patients prompted the authors to investigate specific biological markers for the identification of high-risk breast cancer groups. In the present study, attention was focused on the interaction between tumor cells and the extracellular matrix, an important requisite in the metastatic process.

MATERIALS AND METHODS

Fifty-six primary breast carcinoma specimens obtained by mastectomy or quadrantectomy plus axillary dissection were examined with immunohistochemistry, for the determination of laminin, collagen type IV and hormone receptor expression and with static cytometry, for the determination of the DNA content.

RESULTS

Laminin and collagen type IV expression was observed on the membrane and in the cytoplasm of neoplastic cells. Laminin and collagen type IV were present, respectively, in 85.4% and 73.8% of the cases which showed recurrence.

CONCLUSION

The results of this study have shown that high expression of laminin and collagen type IV may have a value in the prognosis of disease free survival and may be linked to other classical clinical, histological and biological parameters in the evaluation of breast cancer patients.

E-cadherin and alpha-catenin expression during tumor progression of cervical carcinoma

OBJECTIVE

The objective of this study was to determine whether a relationship between the E-caherin molecule and the E-cadherin-associated cytoplasmic molecule, alpha-catenin, could provide additional information in the neoplastic progression of cervical cancer.

METHODS

In this study we investigated by immunohistochemistry E-cadherin (E-cad) and alpha-catenin (alpha-cat) expression in 57 cervical biopsy samples representative of normal exocervical epithelium, viral (human papillomavirus (HPV) infection) and dysplastic lesions (low- and high-grade lesions), and invasive squamous cell carcinoma. The presence of immunostaining and the pattern of distribution of these molecules were correlated with the histological diagnosis (normal cervical epithelium vs HPV, cervical intraepithelial neoplasia (CIN), and invasive carcinoma).

RESULTS

The correlation between alpha-cat expression and the histological diagnosis was statistically significant (chi2 test, P < 0.0077); moreover, E-cad and alpha-cat distributions were significantly correlated with the histological classification (P < 0.0001 and P < 0.0043, respectively).

CONCLUSION

These results suggest that not only E-cad but also alpha-cat are associated with the loss of differentiation in CIN and squamous cell carcinomas; thus the coexpression of E-cad and alpha-cat may represent a discriminant of malignant potential and could provide an additional criterion to define high-grade CIN.

Skin metastases in lung cancer: analysis of a 10-year experience

We reviewed our 10-year experience in skin metastases from lung cancer. We identified a total of 26 patients with 49 resected skin metastases. Skin metastases were synchronous in 6 patients, 3 of whom underwent primary simultaneous resection, and solitary in 6 (6/26=23.07%). Negative prognostic factors were primary non-resectability (p=0.001), small cell lung cancer (p=0.032), simultaneous discovery of other cutaneous (p=0.048) or extracutaneous (p=0.0005, Wald test p<0.002, Odds ratio =14.37) metastases. Skin metastasis represented the unique distant localization in almost one quarter of our cases that represent the best-survivor category: in these patients skin metastasectomy is justified.

Pulmonary metastasectomy: might the type of resection affect survival?

BACKGROUND AND OBJECTIVES

Metastasectomy proved to be the choice treatment in the case of pulmonary metastasis. In this study we assessed the impact on survival of three types of resection: minimal by laser or conventional device and lobectomy.

METHODS

We considered 85 patients who underwent lung metastasectomy for tumors that originated from various sites. Fifty-two minimal resections were accomplished in 34 patients by conventional (diathermy dissection or stapler suture line) device, 59 resections in 29 by Nd:YAG laser. Lobectomies were 22. Minimum follow up required was 2 years.

RESULTS

The 3-year Kaplan-Meier survival rate was 63%, 44%, 53% for laser, conventional resections and lobectomy. The 5-year survival was 40%, 28%, 26% respectively. Among the groups there was no significant difference (P = 0.15). Laser patients showed shorter periods of air leakage and hospital stay.

CONCLUSIONS

The type of resection did not disclose statistically significant differences on survival. Minimal surgery, especially by laser device, is recommended for less morbidity.

Thoracoscopic completion thymectomy in refractory nonthymomatous myasthenia

BACKGROUND

The aim of this study was to assess the efficacy of thoracoscopic completion thymectomy in patients with refractory nonthymomatous myasthenia.

METHODS

Eight patients were operated upon after transcervical (n = 6) or transsternal (n = 2) thymectomy. The mean interval between operations was 129 months. Every patient was completely disabled despite treatment with large dosages of prednisone in combination with pyridostigmine (n = 5) or azathioprine (n = 3) and with repeated plasma exchanges.

RESULTS

Gross (n = 5) or microscopic (n = 3) residual thymic tissue was found in all patients. There was no mortality, but morbidity included 2 patients with postoperative myasthenic crisis requiring reintubation and mechanical ventilation. The mean hospital stay was 4.75 days. The mean follow-up was 28.3 months. At the last follow-up, 6 patients had achieved symptomatic improvement as expressed by significant change in mean Osserman class (3.37 versus 2.12, p = 0.03), and prednisone dosage (43 versus 20 mg/d, p = 0.03). Conversely, there was no difference in dosage of pyridostigmine and azathioprine or in number of exchange cycles.

CONCLUSIONS

Our results suggest that thoracoscopic completion thymectomy may be beneficial for selected patients with refractory nonthymomatous myasthenia.

Reduction pneumoplasty versus respiratory rehabilitation in severe emphysema: a randomized study. Pulmonary Emphysema Research Group

BACKGROUND

The purpose of the study was to determine in a prospective randomized trial the independent short-term physiologic impact of reduction pneumoplasty (RP) on respiratory rehabilitation (RR).

METHODS

Sixty patients eligible for RP were randomly selected by computer to receive either RP (n = 30) or comprehensive RR (n = 30). Pulmonary function tests, analysis of blood gas levels, measurement of respiratory muscle strength (maximal inspiratory and expiratory pressures), 6-minute walk test (6MWT), and incremental treadmill test (ITT), were performed at baseline and at 3 and 6 months.

RESULTS

Two treatment-related deaths occurred after RP and one after RR. At 6 months dyspnea index, maximal inspiratory pressure, 6MWT, ITT, and PaO2 were significantly improved in both groups whereas forced expiratory volume in 1 second and residual volume were significantly improved only in the surgical arm. In addition at 6 months, dyspnea index, 6MWT, maximal ITT, and PaO2 improved significantly more after RP than after RR.

CONCLUSIONS

In our study short-term improvements in dyspnea index, oxygenation, inspiratory muscle strength, and exercise capacity occurred after either RP and RR. However dyspnea index, PaO2, and exercise capacity improved more after RP than after RR whereas pulmonary function improved only after RP.

Morphologic grading of emphysema is useful in the selection of candidates for unilateral or bilateral reduction pneumoplasty

OBJECTIVE

Radiologic morphology of emphysema proves useful in the selection of candidates for bilateral reduction pneumoplasty. We developed a simple morphologic grading system capable of identifying subsets of patients who had maximal functional improvement after unilateral or bilateral operation.

METHODS

Fifty-two patients who underwent unilateral (n=34) or bilateral (n=18) reduction pneumoplasty were evaluated. Emphysema morphology was visually scored by digital roentgenograms and high-resolution computed tomography. In each lung, severity of emphysema (ES), heterogeneity (DHT) and hyperinflation (DHF) degrees, were assessed. Asymmetric ratio of emphysema (ARE) between the lungs was expressed as: higher ES/lower ES scores. Morphometric data were correlated with absolute preoperative-postoperative FEV(1) change (DeltaFEV(1)).

RESULTS

No difference was found between the unilateral and the bilateral group for ES and DHT. DHF was greater in the bilateral group (3.1 vs. 2.7, P=0.02) whereas ARE was greater in the unilateral group (1.29 vs. 1. 05, P=0.0001). Stepwise logistic regression extracted as best predictors of maximal DeltaFEV(1), ARE (odds ratio=238, Wald test P=0.04) in the unilateral group, and DHT (odds ratio=24, P=0.03) in the bilateral group. Unilateral group DeltaFEV(1) was greater in patients with ARE>/=1.3 (0.44 vs. 0.24 l, P=0.02). Bilateral group DeltaFEV(1) was greater in patients with DHT>1 (0.50 vs. 0.31 l, P=0. 03). No difference was found when comparing DeltaFEV(1) resulting from unilateral RP and ARE>/=1.3, and bilateral RP (0.44 vs. 0.41 l, not significant).

CONCLUSIONS

This morphologic grading system identified subsets of patients who had maximal functional benefit from unilateral or bilateral reduction pneumoplasty and might be useful in the preoperative screening of candidates for either approach.

Thoracoscopic thymectomy in autoimmune myasthesia: results of left-sided approach

BACKGROUND

We undertook to analyze the results of video-assisted thoracoscopic thymectomy through a left-sided approach in patients with autoimmune myasthenia.

METHODS

Between 1993 and 1997, 31 patients underwent thoracoscopic thymectomy by a uniform left-sided approach. There were 8 men and 23 women with a mean age of 34 +/- 12 years.

RESULTS

Preoperative duration of disease was 14.8 +/- 11 months. There were no operative deaths or major complications. The mean hospital stay was 5.2 +/- 2.8 days. Mean follow-up was 39.6 +/- 15 months and was 100% complete. At 48 months, remission and improvement rates were 36% and 96%, respectively. Shorter duration of symptoms (< 12 months) correlated with improved outcome (13 of 13 patients versus 10 of 14 patients; p = 0.036). Age, sex, Osserman class, corticosteroid therapy, presence of ectopic thymic tissue, and temporary postoperative symptom increase (deterioration) did not affect outcome.

CONCLUSIONS

Thoracoscopic thymectomy facilitated the goal of early thymectomy. Through a left-sided approach, improvement or remission was achieved in more than 95% of the patients. Thoracoscopic thymectomy should be considered a valid less invasive alternative to the most radical open approaches.

Endocervical atypical glandular cells of undetermined significance. I. Morphometric and cytologic characterization of cases that "cannot rule out adenocarcinoma in situ"

OBJECTIVE

To determine whether evaluating morphologic features through morphometry and cytology can lead to a more-satisfactory characterization of endocervical atypical glandular cells of undetermined significance (AGUS) cases that "cannot rule out adenocarcinoma in situ" (AIS).

STUDY DESIGN

Fifty-seven endocervical AGUS cases showing incomplete criteria of AIS were morphometrically compared to five smears with normal endocervical columnar cells (ECC) and to five histologically confirmed endocervical adenocarcinoma cases. For each atypical nucleus, the area and shape were measured. Twenty-five cytologic criteria were used to review the AGUS and neoplastic smears.

RESULTS

AGUS nuclei showed an intermediate value in terms of area and shape as compared to the values of normal and neoplastic nuclei. In particular, AGUS nuclear enlargement (136.626 micron 2) was about twice the area of normal nuclei and half the value of the area of neoplastic nuclei (P < .0000). AGUS nuclei also had the greatest variability in size and shape, indicating that anisonucleosis may be a morphologic discriminator of endocervical AGUS. The cytologic features useful in discriminating AGUS from neoplastic smears were: presence of normal ECCs, singly or in sheets (P < .001); absence of necrosis (P < .001); bare atypical cells (P < .001); papillary groups (P < .01); anisonucleosis (P < .05); irregular chromatin distribution (P < .05); and hyperchromasia (P < .01).

CONCLUSION

Morphometry and cytology led to a better characterization of endocervical AGUS cases that "cannot rule out AIS."

Endocervical atypical glandular cells of undetermined significance. II. Morphometric and cytologic analysis of nuclear features useful in characterizing differently correlated subgroups

OBJECTIVE

To evaluate whether some nuclear features analyzed by morphometry and cytology may be useful in characterizing differently correlated endocervical atypical glandular cells of undetermined significance (AGUS) subgroups.

STUDY DESIGN

Fifty-four endocervical AGUS smears were subclassified into four subgroups on the basis of their different correlation: not otherwise specified subgroup (NOSs), tamoxifen (Ts), human papillomavirus infection (HPVs) and laser therapy (LTs). Area and shape of the atypical nuclei detected were morphometrically measured. The smears were then cytologically reviewed, and the shape and grade of expression of hyperchomasia in AGUS nuclei were analyzed.

RESULTS

AGUS cases due to T therapy showed the largest nuclear area (148.845 micron 2; P < .0000) and the greatest anisonucleosis objectively measured by morphometry. HPVs had the shape that most differed from perfectly circular (15.341 versus 14.1) and showed the highest grade of expression of nuclear density. LTs and NOSs were less well characterized than the other subgroups.

CONCLUSION

Analysis of nuclear features by morphometry and cytology was useful in characterizing the AGUS subgroups Ts and HPVs.

Immunohistochemical expression of p53, nm23-HI, Ki67 and DNA ploidy: correlation with lymph node status and other clinical pathologic parameters in breast cancer

BACKGROUND

The different clinical evolution of breast cancer with similar pathological characteristics prompted the authors to investigate the prognostic significance of different biological markers.

METHODS

Seventy-one primary breast carcinoma specimens obtained by mastectomy or quadrantectomy were examined for the determination of the p53, nm23 and Ki67 expression, with immunohistochemistry, and the DNA content, with static cytometry.

RESULTS

p53 protein was expressed as nuclear staining in 58% of the cases and was associated with high levels of Ki67, non-diploid lesions and lymph-node status. Positive staining for nm23 was significantly correlated only with histologic grading. A predictive role in disease recurrence was demonstrated only in patients with a high Ki67 nuclear expression.

CONCLUSIONS

From these data, we may conclude that, besides all the other traditional clinical morphological parameters, a panel of different biological markers, such as Ki67 and the determination of p53 expression, may be utilized to further characterize breast cancer and its biological behavior.

Mediastinoscopy in superior vena cava obstruction: analysis of 80 consecutive patients

BACKGROUND

Prejudices against mediastinoscopy in superior vena cava obstruction still remain. Hereby we analyze risk/benefit balance in a large series of patients.

METHODS

Eighty consecutive patients underwent cervical mediastinoscopy for caval obstruction, 51 after uncertain diagnosis obtained by lesser techniques, 17 after ineffective chemotherapy (n = 9) or radiotherapy (n = 8). In 12 patients we immediately performed mediastinoscopy as an urgent procedure. In addition the examination was combined with left anterior mediastinotomy (n = 7) for staging purposes.

RESULTS

No perioperative mortality was recorded. Five patients had significant bleeding, but only one required sternotomy. Definitive diagnosis was obtained in all patients: 50 lung cancer, 17 lymphoma, 7 invasive thymoma, 3 postradiation fibrosis, 2 metastatic lymph nodes from renal carcinoma, and 1 fibrosing mediastinitis. Specific therapy had excellent effects in 71 patients, negligible in 7, and adverse in 2. Postmediastinoscopy brachial venous pressure had a mean significant decrease (p < 0.0001). Lung cancer was the sole variable significantly associated with unfavorable outcome (p < 0.0004).

CONCLUSIONS

Mediastinoscopy should be routinely included after less invasive procedures in the diagnostic program because it is simple, low risk, and effective.

Application of the upgraded image superimposition system (SIAS) to the assessment of sperm kinematics

Dedicated software for semiautomatic objective motility assessment, based on image superimposition (SIAS), was upgraded in order to allow automatic reading of sperm tracks whilst keeping the advantages of visual check instead of the digital images of classic computer-aided sperm analysis (CASA) systems. The new system is very fast and accurate and allows an excellent reading of sperm motility in standard semen analysis. Moreover, using this system, an attempt was made to define numerically straight-line velocity (VSL), curvilinear velocity (VCL) and linearity (LIN) in each WHO sperm motility class. At 21 frames sec-1, ROC curves analysis determined the following: Class 1 (typical of WHO grade 'a'): VSL > or = 23 microns sec-1 and LIN > or = 0.58; class 2 (typical of WHO grade 'b'): VSL > 10 and < 23 microns sec-1 and LIN > or = 0.58; class 3: VSL > 10 microns sec-1 and LIN < 0.58 (this additional class was added to differentiate nonstraight progressive motility from classes 1 and 2); class 4 (typical of WHO grade 'c'): VSL < or = 10 microns sec-1. The numerical definition of sperm motility classes may contribute towards standardization in the objective evaluation of sperm kinematics.

Carbon and hemosiderin-laden macrophages in sputum of traffic policeman exposed to air pollution

In this study, we evaluated (a) quantitative modifications of dust cells and siderocytes and (b) qualitative modifications (i.e., cellular changes and inflammatory infiltrate) in sputum of 164 traffic policemen occupationally exposed to environmental pollution in an urban area. Such modifications were correlated with time of exposure and smoking habits. Seventy-three (45%) of the policemen were smokers, and a control group of 119 nonexposed individuals (24% smokers) who resided in a rural district near Perugia, Italy, were examined. The sputa, which was collected for 3 d, were smeared on glass slides stained according to Papanicolaou's and Perl's methods. The mean numbers of dust cells in the sputa policemen and the rural population were 103.8 and 12.48, respectively (p < .0001). The numbers of dust cells were highest in policemen who smoked (relative risk = 3.95; p < .006). The mean numbers of siderocytes in policemen and the rural population were 0.99 and 5.31, respectively (not statistically significant, Mann-Whitney test). The difference between the number of subjects with hemosiderin-laden macrophages in traffic policemen and in the control group was small, but it was significant statistically (p < .004). In traffic policemen, it was related to smoking and time of exposure to air pollution, whereas in the control population it was related to heart-pulmonary diseases. In this study, we observed a synergistic effect between smoking and environmental pollution. In addition, less than 5 y of exposure can caused significantly increased (a) numbers of macrophages and (b) inflammatory infiltrate in sputa. The results of the cytological diagnosis revealed a statistically significant difference between policemen and the rural population (p < .001). The cytological exam of sputa and correlations with smoking within each population were not statistically significant. In conclusion, macrophage count in sputum is a sensitive and reproducible method for investigators to verify pulmonary changes that may be observed before they can be measured by functional tests.

DNA ploidy and TLI in association with other prognostic parameters in breast cancer

DNA ploidy and thymidine-labeling index (TLI) have been introduced as prognostic indicators to characterize the biological behavior of breast cancer for the selection of patients eligible for adjuvant therapy. The aim of this study was to evaluate the prognostic significance and correlation between ploidy status, TLI and other common histopathologic parameters such as histotype, stage, grading, lymph node metastasis, hormone receptors and recurrence. DNA ploidy and TLI were assessed for 68 breast cancer patients, 27 to 85 years of age. DNA histograms, analyzed with static cytometry, were: diploid in 21(31%) and non diploid in 47 (70%). High TLI values were observed in 16 cases (24%), medium values in 46 cases (68%) and low values in 6 cases (8.5%). DNA ploidy and TLI showed a statistically significant correlation, as independent parameters, with recurrence (respectively, p = 0.0267 and p < 0.0001). Therefore, DNA ploidy and TLI may be considered additional prognostic parameters to be utilized besides all the other clinical-pathologic data for the assessment of these lesions, and to plan therapeutic strategies.

Unilateral thoracoscopic reduction pneumoplasty for asymmetric emphysema

OBJECTIVE

We prospectively analyzed the surgical and functional results of unilateral thoracoscopic reduction pneumoplasty which we performed by choice in patients with asymmetric emphysema.

METHODS

Between October 1995 and June 1997, 119 emphysematous patients were examined and 34 were operated upon. Among these, 14 selected patients with asymmetric distribution of emphysema in the lungs underwent unilateral reduction pneumoplasty (ten right, and four left). There were 13 males and one female, with a mean age of 62 years. Eligibility criteria included bullous and non-bullous end-stage emphysema with severe limitation to daily activity.

RESULTS

No patient required conversion to thoracotomy. Mean operative time ranged between 70 and 240 min with a mean of 103 min. There was no postoperative mortality but five patients developed one or more complications: five prolonged air leaks (>7 days); two pulmonary infections; one empyema. No patient required postoperative mechanical ventilation. Median hospital stay was 8 days. At the 3-month follow-up the mean FEV1 increased from 0.8 l to 1.2 l (P < 0.001). Mean FVC increased from 2.6 l to 2.9 l (P < 0.001). The Medical Research Council dyspnea score decreased from a mean of 3.2 to 1.8 (P < 0.001).

CONCLUSIONS

Asymmetric distribution is a frequent finding in patients with severe emphysema. Unilateral thoracoscopic reduction pneumoplasty may represent an ideal approach in this selected group of patients.

The value of the Nd:YAG laser for the surgery of lung metastases in a randomized trial

OBJECTIVE

A prospective randomized trial was established in our department to compare the usefulness of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in resection of lung metastases. We report the results of the first 45 patients after a minimum of 2 years of follow-up.

DESIGN

Randomized prospective trial from March 1987 to March 1995.

SETTING

University teaching hospital.

PATIENTS

Forty-five patients underwent resection for pulmonary metastases with two different techniques chosen at random: 23 patients were treated with an Nd:YAG laser (group A) and 22 patients with a traditional diathermic device (group B).

INTERVENTIONS

A total of 71 pulmonary lesions were resected by minimal excision, 41 by laser and 30 by diathermy. Sixty-three lesions were diagnosed as active metastases from various sites.

RESULTS

No deaths occurred during surgery. Eight patients (6 in group B) developed minor complications. In two patients from group B, lesions recurred at the resection site. The use of Nd:YAG laser was not associated with a significantly longer survival (log rank test, p=0.49). Laser resection allowed more tissue sparing (mean ratio lesion diameter/volume resected, 0.94 vs 1.11, p<0.008). Univariate and multivariate analyses revealed the importance of laser use in reducing the number of days of postoperative air leakage (3.91 vs 5.00 days) and hospital stay (7.50 vs 9.90 days).

CONCLUSIONS

Laser use significantly reduced tissue loss, postoperative air leakage, and hospital stay. Influence on long-term survival was not statistically proven.

Predictive value of early postoperative esophagoscopy for occurrence of benign stenosis after cervical esophagogastrostomy

BACKGROUND AND STUDY AIMS

Benign anastomotic stenosis (BAS) represents a frequent complication following esophagectomy and cervical esophagogastrostomy for cancer. This study was undertaken to evaluate through early postoperative esophagoscopy the morphologic change of the anastomosis which could be related to BAS development.

PATIENTS AND METHODS

Thirty-nine patients who underwent subtotal esophagectomy and cervical esophagogastrostomy were prospectively evaluated. The analyzed factors were: age; sex; the anastomotic size; the presence and number of endoscopically visible stitches; the presence and percentage of mucosal ulcerations involving the anastomotic suture line; the presence of anastomotic leak or dehiscence; the vascularization of the gastric tube; the patency of pylorus.

RESULTS

No complications related to the early esophagoscopy were observed. Twelve patients (30.7 %) developed a stenosis postoperatively. The univariate analysis demonstrated anastomotic leak (p < 0.006), more than one endoscopically visible stitch (p < 0.0003), and mucosal ulceration involving more than 50% of the anastomosis (p<0.00009) as factors significantly correlated with BAS development. However stepwise logistic regression extracted the presence of ulcerations involving more than 50% of the anastomosis as the most important independent factor in predicting BAS development (Odds Ratio = 9.03+/-5.5, p = 0.009). All patients who developed a BAS were treated with early pneumatic dilatations, with an 83.3% success rate after a mean of 3.6 sessions.

CONCLUSIONS

Early postoperative esophagoscopy seems a safe and effective tool for the monitoring of the anastomosis healing after cervical esophagogastrostomy. The presence of extended mucosal ulcerations appeared as the most important factor in predicting BAS formation.

High glucose level unmasks a genetic predisposition to enhanced extracellular matrix production in mesangial cells from the Milan normotensive strain

A growing body of evidence indicates that the individual genetic background plays a role in the pathogenesis of diabetic glomerular disease by either favoring or protecting against injury produced by hyperglycemia. Two genetically related rat strains, the Milan normotensive strain (MNS) and the Milan hypertensive strain (MHS) display different susceptibilities to develop glomerulosclerosis with age. Glomerular sclerosing lesions occur in the MNS rats, which remain normotensive throughout their entire life-span, but not in the MHS rats, despite the presence of arterial hypertension. Previous studies have reported that extracellular matrix production and cell proliferation increased with donor-aging in mesangial cells isolated from MNS rats, but not in those from MHS rats, thus suggesting the existence of an inherited defect in the regulation of cell and matrix turnover, which translates into an abnormal response to growth-promoting stimuli favoring the development of glomerulosclerosis. In the study presented here, it was hypothesized that, in addition to donor-aging, other independent risk factors for the development of glomerular disease, such as metabolic injury by hyperglycemia, would be able to trigger and/or precipitate the occurrence of these changes in mesangial cells from the susceptible normotensive strain, but not in those from the protected hypertensive strain. To test this hypothesis, mesangial cells obtained from these rat strains (before the onset of either glomerulosclerosis or hypertension) were used to assess the effects of prolonged (4 wk) exposure to high (30 mmol/L) versus normal (5.5 mmol/L) glucose concentrations on extracellular matrix and cytokine production and cell proliferation. The accumulation and/or gene expression of the matrix components fibronectin, laminin, and collagen IV, and of the cytokines insulin-like growth factor-I (IGF-I) and transforming growth factor-beta (TGF-beta) did not change under normal glucose and increased progressively in response to high glucose in both MNS and MHS cells. These increases, with the exception of the increment in TGF-beta gene expression, were significantly more pronounced in MNS cells than in MHS cells. In contrast, the proliferative response to serum was not affected by high glucose, but increased in MNS cells, and decreased, although not significantly, in MHS cells during the 4-wk period, thus mimicking the changes previously observed in these rat strains as a function of age. These results indicate that high glucose unmasks a genetic tendency to produce increasing amounts of extracellular matrix, not yet evident under normal glucose conditions, and suggest that a genetically determined propensity of mesangial cells to hyperrespond to chronic hyperglycemia may be implicated in the pathogenesis of diabetic glomerular disease.

En bloc minimal laser resection for T3-chest wall lung cancer in patients with poor pulmonary function

OBJECTIVE

To analyze the value of en bloc minimal laser resection in patients with marginal function with non-small cell lung cancer invading the chest wall.

DESIGN

Retrospective study from March 1987 to December 1993.

SETTING

University teaching hospital.

PATIENTS

Study group consists of 10 patients with impaired pulmonary function (FEV1 < or = 1.3 L and forced expiratory flow between 25% and 75% < or = 0.8 L/s) operated on for lung cancer invading the chest wall. There were 7 men and 3 women; ages ranged between 51 and 77 years (mean, 66.2 years). None of the patients had tumors greater than 3 cm or involving the first 2 ribs as well as clinical N2 or T4 disease.

INTERVENTIONS

All patients underwent en bloc chest wall combined with minimal resection. Parenchyma dissection was accomplished by Nd:YAG laser encompassing the lesion at distance of 2.0 cm. The median number of ribs resected was 1.6 and no patients required chest wall reconstruction. Local postoperative radiation therapy beginning within 1 month after resection was always performed.

RESULTS

Tumor resection was considered complete in every case. Four patients had adenocarcinoma, three had squamous cell carcinoma, and three had large cell carcinoma. Currently, 7 patients had NO, 2 had N1, and 1 had N2 disease. There was no perioperative mortality. Postoperative complications were prolonged air leak (n = 2) and atelectasis (n = 1). At the present moment, 6 patients are alive, 5 of whom are free from tumor, 2 with a follow-up longer than 5 years. Three patients died: 2 from disseminated disease, after 47 months and 32 months, respectively, and the third at 27 months from another cause. One patient was unavailable for follow-up. Only 1 patient had a local recurrence, 15 months later, and he underwent a new, successful, limited resection.

CONCLUSIONS

These findings suggest that en bloc minimal laser resection can offer an acceptable risk/benefit ratio in the case of patients who cannot tolerate a lobectomy.

nm23 and p53 expression

Breast cancer is a common malignancy and the modalities and the aggressiveness of treatment strategies are variable and depend on information regarding the biological characteristics and behavior of an individual tumor. Therefore, to improve overall survival it is important to identify and select lymph node negative patients at high risk who would benefit from adjuvant therapy. Besides prognostic factors such as lymph node status, hormone receptor status and histopathologic parameters, nm23 antimetastatic gene and the p53 protein were studied in 32 breast cancer patients. Positive staining for nm23 was inversely associated with lymph node involvement in 82.4% of the cases. Most of the non-diploid lesions (70.8%) showed a high protein expression. Positive immunostaining for p53 was present in 28.1% of the cases and was strongly correlated with prognostic indicators such as necrosis and histologic grading. Tumor grade, DNA ploidy and lymph node metastasis were not significantly correlated with p53 protein expression. In this study, all the prognostic indicators studied, satisfactorily explain the important characteristics of the biologic behaviour of breast cancer, but the detection of lymph node metastasis is still the most accurate prognostic factor utilized for a predictive role in disease recurrence.

Statistical evaluation of the persistence of acquired hypersensitivity by standardized patch tests

Numerous studies have focused attention on the influence of various biological and environmental factors on contact hypersensitivity. In order to evaluate the persistence and/or modification of allergic contact sensitivity to a number of common contact sensitizers, the same standardized patch tests were repeated on 174 subjects with contact sensitivity after a time lapse of 5 years (1987-1992). In 18.4% of the cases, 1 or more sensitivities were lost; 28.7% of the patients had a higher number of positive patch tests after 5 years, while the remaining 52.9% of the patients showed no change in the number of positive patch tests. In 88%, the positive allergens were unchanged, whereas in the remaining 12% of the subjects, they showed 1 or more variations. The association between the allergens most often positive was calculated for both the 1st and the 2nd patch test results. Moreover, to evaluate the frequency of an allergen's positivity, we studied the disappearance of old sensitivities and the appearance of new sensitivities by the McNemar test. Cobalt chloride was the only allergen with a significant frequency of new positivities over the period of observation (p < 0.01). Logistic regression analysis was performed to evaluate the possible influence of positive tests to other allergens, and of some clinical findings associated with contact dermatitis, on the sensitivity to cobalt chloride in 1987 and in 1992.

Aneuploid polyclonality in image analysis

Solid tumors such as colorectal adenocarcinomas consist of biologically diverse cell subpopulations. Nuclear DNA content of tumor cells in colorectal carcinomas may be studied with different techniques of intranuclear DNA quantification. In the current study, the DNA ploidy of samples obtained from 68 patients with colorectal carcinoma (age ranging from 46 to 86 years, mean age 66 years), treated with radical surgery, between the years 1992 and 1995 was analyzed. DNA ploidy was assessed using a CAS 200 image analyzer and was evaluated on neoplastic tissue and undamaged healthy mucosa obtained from the edges of the surgical resection. Approximately 150-300 cells were analyzed for each sample. The aim of this study was to evaluate the prognostic significance of the polyclonal cases correlated with lymph node infiltration and disease free-survival. The pathological stage according to the TNM classification was compared to ploidy: an increase in multiple stemlines was observed in stage III cases, i.e., a progression towards aneuploidy and multiple stemlines was significantly associated with lymphatic metastasis (p<0.0003). Concerning distant metastasis, we found a correlation between stage IV and polyclonality. A significant correlation was observed between disease-free survival and aneuploid and polyclonal cases (p<0.0053). In polyclonal cases a nine fold greater relapse risk compared to the non-polyclonal cases was observed (p<0.0004). In two cases, the adeno-carcinoma of the sigma was polyclonal and its hepatic metastasis contained the predominant aneuploid clone with the same cytometric characteristics (DNA index) of the original lesion.