Persistence of monoclonal B-cell expansion and intraclonal diversification despite virus eradication in patients affected by hepatitis C virus-associated lymphoproliferative disorders

We investigated 23 hepatitis C virus (HCV)-infected patients with overt lymphoproliferative diseases (15 cases) or monoclonal B lymphocytosis (8 cases) treated with direct agent antiviral (DAAs) per clinical practice. DAA therapy yielded undetectable HCV-RNA, the complete response of cryoglobulinemia vasculitis and related signs, whilst the presence of B-cell clones (evaluated by flow cytometry, IGHV, and BCL2-IGH rearrangements), detected in 19/23 cases at baseline, was maintained (17/19). Similarly, IGHV intraclonal diversification, supporting an antigen-driven selection mechanism, was identified in B-cell clones at baseline and end of follow-up. DAA therapy alone, despite HCV eradication and good immunological responses, was less effective on the pathological B-cell clones.

Clinico-Pathological, Cytogenetic and Molecular Profiles of Primary Cutaneous Diffuse Large B-Cell Lymphomas

We analyzed the clinico-pathological, cytogenetic and molecular features of 18 Primary Cutaneous Diffuse Large B-Cell Lymphoma (PCDLBCL), and 15 DLBCL secondarily localized to the skin (SCDLBCL), highlighting biologic similarities and differences between the two groups. PCDLBCL were sub classified after histopathological review as PCDLBCL-Leg type (PCDLBCL-LT, 10 cases) and the PCDLBCL-not otherwise specified (PCDLBCL, NOS, 8 cases). Immunohistochemistry for Hans' algorithm markers, BCL2, and MYC was performed. The molecular study included the determination of the cell of origin (COO) by Lymph2Cx assay on Nano string platform, FISH analysis of IgH, BCL2, BCL6, and MYC genes, as well as the mutation analysis of MYD88 gene. At immunohistochemistry, BCL2 and MYC hyper expression was more frequent in LT than in NOS cases and, according to Hans' algorithm, PCDLBCL LT were mostly of the non-GC type (8/10), whereas in PCDLBCL NOS the GC type prevailed (6/8). The determination of COO using Lymph2Cx supported and further confirmed these results. At FISH analysis, all but one LT cases versus 5 out of 8 PCDLBCL NOS showed at least one gene rearrangement among IgH, BCL2, MYC or BCL6. In addition, MYD88 mutations were more frequently present in LT than in NOS subtypes. Interestingly, MYD88- mutated patients were older, with a non-GC phenotype and had worse OS, compared to MYD88 WT cases. Overall, SCDLBCL did not show, at the genetic and expression level, different profiles than PCDLBCL, even if they bear a significantly worse prognosis. At survival analysis, the most important prognostic factors in PCDLBCL patients were age and MYD88 mutation, whereas relapse and high Ki67 expression were relevant in SCDLBCL patients. Our study comprehensively analyzed the clinico-pathological and molecular features of PCDLBCL LT, PCDLBCL-NOS, and SCDLBCL, underlining the differnces among them and the importance of properly identifying these entities at the time of diagnosis.

Improving the international prognostic index score using peripheral blood counts: Results of a large multicenter study involving 520 patients with diffuse large B cell lymphoma

The main purpose of this study was to assess whether it is possible to improve the prognostic impact of international prognostic index (IPI) score by combining it with peripheral blood counts. Thus, we evaluated the prognostic power of lymphocyte, neutrophil, and monocyte counts in 520 patients with diffuse large B cell lymphoma treated with R‐CHOP, confirming that these parameters have a strong impact on overall survival (OS). Using revised IPI (R‐IPI), 44% of patients were categorized as poor‐risk and showed an OS at 5 years of 46%. As OS at 5 years of the 520 patients is 67%, it is clearly evident that R‐IPI tends to overestimate the proportion of patients with poor prognosis. Accordingly, in an attempt to improve the discriminating power of R‐IPI, we evaluated and compared three different scores by combining the neutrophil lymphocyte ratio (NLR) and absolute monocyte count (AMC) with the following values: (a) IPI score 3‐5, (b) age > 60 years and performance status, (c) age  ≥ 65 years and LDH > ULN. The three indexes studied, had a similar 5 years OS for the high‐risk group (46%‐52%), but the proportion of patients classified as poor‐risk were 37%, 20%, and 32%, respectively, which are lower than 44% identified with R‐IPI. Thus, while R‐IPI overestimates the number of high‐risk patients, after applying our models, it is possible to recognize patients who are truly at high‐risk. Of the three scores, the most accurate appears to be that based on NLR, AMC, LDH > ULN and age ≥ 65 years, which identifies 32% of high‐risk patients, correlating well with what is seen in clinical practice.

Immunomodulation with granulocyte–macrophage colony-stimulating factor and interleukin 2 in an experimental model of sepsis

Background

Previous studies have demonstrated that immunomodulation with granulocyte–macrophage colony-stimulating factor (GM-CSF) reduces the mortality rate in an experimental model of sepsis, decreases levels of tumour necrosis factor in the serum and in the liver, and enhances neutrophil activity. It was also demonstrated recently that immunoprophylaxis with interleukin (IL) 2 can reduce the mortality rate in rats that have undergone caecal ligature and puncture (CLP). In fact, IL-2 is the major activator of the specific immune response (B and T lymphocytes). The aim of this study was to investigate whether IL-2 and GM-CSF together might further decrease the mortality rate in an experimental model of peritonitis in rats, which resembles the clinical situation of bowel perforation and mixed bacterial peritonitis.

Methods

Peritonitis was induced by CLP in four groups of Sprague–Dawley male rats (250 g). Each group included 30 rats. Group 1 underwent CLP and postoperative antibiotic therapy with tobramycin and clindamycin (12·5 μg g−1 day−1 and 4 mg g−1 day−1 respectively for 72 h after operation). Group 2 underwent preoperative intraperitoneal IL-2 injection (1.000.000 units), then CLP and postoperative antibiotic therapy with the same regimen. Group 3 underwent CLP and intraperitoneal GM-CSF injection (l ng g−1 day−1 for 48 h after operation). Group 4 received IL-2, CLP and GM-CSF with the same regimen and antibiotic therapy. Deaths were recorded within 72 h after CLP.

Results

After CLP group 1 (antibiotics) had a mortality rate of 70 per cent; group 4 (IL-2, GM-CSF, antibiotics) had a mortality rate of only 3 per cent which was significantly lower than in that in group 2 (IL-2 and antibiotics) and group 3 (GM-CSF and antibiotics), 33 and 25 per cent respectively (P < 0·0001).

Conclusion

Only one of 30 rats that had CLP and were treated with IL-2, GM-CSF and antibiotics died. Immunomodulation offers a new option in the treatment of sepsis related to peritonitis; in this experimental model treatment with IL-2 and GM-CSF enhanced host resistance to sepsis and decreased the mortality rate.

[Acute cholecystitis and gallbladder neoplasms: the experience of 2215 cases]

The authors have retrospectively analysed 2215 surgical procedures for gallbladder stones. The global incidence of gallbladder neoplasm has been 5%. This rate rises to 11% considering female patients over 60 years old. In this group, a gallbladder carcinoma was contemporary present in 17.4% of acute cholecystitis. Cholecystectomy may be suggested in every patients with gallstones, even asymptomatic, particularly if some risk factors are present.

[Gastric leiomyoblastoma: report of our case load]

Leiomyoblastoma of the stomach is a rare nosological entity (0.3% of all gastric tumors). During the last 13 years, the authors observed 7 of such tumors. In this paper, our cases are presented: these are discussed (together with a revision of the literature), particularly focusing on anatomo-pathological, diagnostic and therapeutic problems.

[Epidemiology of severe thoracic trauma at a multiregional urban hospital. Analysis of 5 years]

The authors re-examined 198 cases of severe chest trauma presented in their hospital in 1983-1987. They analyse the clinical conditions, the diagnostic and therapeutic procedures, the results and complications and evaluate each patient according to the ISS code to compare them with the literature data, for the dead patients they classify the lesions according to the autoptic examinations. They confirm in this the validity of the ISS that can be well correlated with: mortality, length of survival and length of hospitalisation, they indicate important prognostic factors such as: age, association with extra thoracic lesions and number of intrathoracic lesions. Plotting the mortality in function of the time, they stress the need for an expert team in the first hours after trauma to manage such patients.

[Surgical therapy of perforated duodenal ulcers: suture versus highly selective vagotomy. Immediate and remote results (case series from 1978 to 1990)]

The aim of this study was to compare the results of high selective vagotomy and simple suture in the treatment of perforated duodenal ulcer. Among 150 patients admitted in our institute from 1978 to 1990, 96 were treated with simple suture while 54 underwent high-selective vagotomy (42 with pyloroplasty). In our study with high-selective vagotomy we had no surgical mortality and low morbidity. The overall clinical results according to the Visick evaluation, were recorded as excellent or good, in 90.9% cases in the group of patients treated with high-selective vagotomy versus 40% in the group with simple suture, after a similar period of follow-up. The recurrence of ulcers after high-selective vagotomy was of 6%, compared with 32.6% in simple suture patients. The results of high-selective vagotomy performed for perforated duodenal ulcers were compared with those of a group of duodenal ulcers not complicated treated with high-selective vagotomy too; the better results of this last group may be due to higher technical difficulties in presence of peritonitis. High selective vagotomy is therefore a safe procedure in the management of perforated duodenal ulcer, and moreover obtains good long-term results in the control of peptic disease.

[Heller's extramucosal cardiomyotomy under endoscopic control. The long-term results]

Twenty-five patients underwent Heller cardiomyotomy with Nissen fundoplication, made through an abdominal incision under endoscopic control. Long term results were evaluated according to clinical, radiological, manometric and 24-hour esophageal pH-metric studies. Clinical results were excellent in 44% of the patients, good in 40%, fair in 4% and bad in 12%. The four unsatisfactory results are due to recurrence of dysphagia in one case and to appearance of GER in the others. Postoperative X-ray controls and manometric tests showed a significative decrease in the esophageal diameter, in resting and post swallowing LES and esophageal body pressure. The 24-hour pH test showed an abnormal percentage of time with pH less than 4 in two patients, and a direct connection with clinical and endoscopic results. Endoscopic control of myotomy allows us to define precisely the extension of the functional stenosis and to eliminate completely the dysphagia. In the postoperative evaluation the 24-hour pH monitoring allows an early identification of GER, and the prevention of possible complications even in the absence of any clinical sign.

[Comparison of mechanical and manual anastomoses in emergency gastric resection]

Hundred and twenty-one patients underwent emergency subtotal gastrectomy for complications related to peptic ulcer (86) and malignant diseases (35). According to the type of anastomosis performed (manual or mechanical) patients were divided into two groups: 81 with hand-sutured anastomoses (double layer) and 40 with stapled anastomoses. The latter were more commonly used in the Roux-en-Y reconstruction and Billroth 1 gastrectomy. Median operating time (192' versus 190'), hospital stay (15.2 versus 13.5 days), postoperative complications (38% versus 32.5%) and anastomotic or duodenal stump leakage (7.4% versus 5%) showed no significant difference between groups. Therefore, in emergency subtotal gastrectomy mechanical anastomoses allow to obtain results comparable to the more used manual ones.

[Surgical treatment of 100 patients with perforated pyloric ulcer. Immediate and follow-up results]

The aim of this study was to assess the results of different surgical treatments in 100 patients admitted from 1972 to 1984 with perforated pyloric ulcer. Forty-six patients were treated with simple suture, thirty-two patients underwent high selective vagotomy with pyloroplasty, 13 patients were submitted to truncal vagotomy with pyloroplasty and 9 to gastrectomy. This study has shown that high selective vagotomy and pyloroplasty for perforated pyloric ulcer can be performed as safely as simple closure. The overall clinical results according to the Visick classification were recorded as excellent or very good in 85 per cent of patients treated with high selective vagotomy with pyloroplasty versus 38 per cent with similar results in simple closure patients. We conclude that high selective vagotomy with pyloroplasty is not less effective for treatment of pyloric perforated ulcer than for duodenal ulcer; simple closure should be reserved for patients treated long time after perforation and with advanced age or in patients with serious associated pathology.