The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

PURPOSE

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention.

METHODS

A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases.

RESULTS

A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings.

CONCLUSIONS

Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Malignancy risk in Bethesda class IV thyroid nodules in an iodine deficient region

Background

According to the latest guidelines, in patients with high-risk nodules with indeterminate cytology, diagnostic lobectomy should be the preferable surgical approach in the absence of factors that suggest a total thyroidectomy.

Methods

This retrospective observational study has as its main aim the evaluation of the cases that underwent surgery, for Bethesda class IV nodules in our iodocarent geographical area. Particular attention was paid to carcinoma incidence, preoperative nodule size, histological characteristics of the neoplasm, surgical approach and eventual need of radiometabolic treatment. A total of 320 patients were included that underwent surgery for Bethesda IV nodules, between January 2010 and December 2020, at the General Surgical Clinic of the University Hospital of Parma, Italy.

Results

A total of 230 total thyroidectomies (71.9%) and 90 lobectomies (28.1%) were performed. Our data showed a strong impact of the 2015 ATA Guidelines on the surgical approach choice, with a progressive propensity towards a conservative approach and an increase of lobectomies from 7.2% to 41.5% after the new guidelines introduction. However, in our sample the percentage of lobectomies remains below 50%; this data is certainly influenced by the number of cases of multinodular pathology, often bilateral, in our geographical area. The nodules malignancy rate resulted 28.8%. Our data showed that increasing size correlated with an increasing malignancy rate (P<0.01), and follicular carcinomas were found to be larger than papillary carcinomas (P<0.001). A statistically significant correlation also emerged between nodule size increase and local/lymphovascular invasion (P<0.05). On the other hand, there was no statistically significant correlation between nodule size and multifocality, and between nodule size and presence of lymph node metastases. Out of the patients where it was possible to find this data, 66% underwent radioiodiometabolic treatment: 59% with papillary carcinoma, and 85% with follicular carcinoma.

Conclusions

In patients with Bethesda IV thyroid nodules, diagnostic lobectomy should be the preferable surgical approach in absence of factors that suggest total thyroidectomy. In our opinion, total thyroidectomy remains the first choice in large nodules (≥4 cm) as these nodules have a high malignancy rate, greater local/lymphovascular invasion and a consequent frequent indication for post-operative radiometabolic treatment.

Quality indicators for hyperthermia treatment: Italian survey analysis

AIM

Nowadays, no Quality Indicators (QI) have been proposed for Hyperthermia treatments. Starting from radiotherapy experience, the aim of this work is to adapt radiotherapy indicators to Hyperthermia and to propose a new specific set of QI in Hyperthermia field.

MATERIAL AND METHODS

At first, radiotherapy quality indicators published in literature have been adapted to hyperthermia setting. Moreover, new specific indicators for the treatment of hyperthermia have been defined. To obtain the standard reference values of quality indicators, a questionnaire was sent to 7 Italian hyperthermia Institutes with a list of questions on physical and clinical hyperthermia treatment in order to highlight the different therapeutic approaches.

RESULTS

Three structure, five process and two outcome QI were selected. It has been possible to adapt seven indicators from radiotherapy, while three indicators have been defined as new specific indicators for hyperthermia. Average values used as standard reference values have been obtained and proposed.

CONCLUSION

The survey performed on 7 Italian centres allowed to derive the standard reference value for each indicator. The proposed indicators are available to be investigated and applied by a larger number of Institutes in which hyperthermia treatment is performed in order to monitor the operational procedures and to confirm or modify the reference standard value derived for each indicator.

Hypofractionated Radiation Therapy for Inoperable Advanced Stage Non-small Cell Lung Cancer

Aims and Background

Inoperable advanced stage lung cancer is usually treated by radiation therapy. Although a minority of patients may achieve prolonged survival with aggressive therapeutic approaches, most patients present with adverse prognostic factors that do not allow curative treatment. For these cases palliation of symptoms becomes the main treatment purpose, and short treatment schedules are commonly employed.

Methods

Fifty-two inoperable patients with stage IIIB or IV non-small cell lung cancer (NSCLC) were treated with a hypofractionated schedule of radiotherapy. Initially all patients received 20 Gy in five fractions, and approximately one month after irradiation completion patients underwent clinical and radiological evaluation. Those that achieved a >50% reduction in tumor load and respiratory symptoms were submitted to a second similar short course of radiotherapy.

Results

Thirty-three (63%) patients received only one course of radiotherapy. After the first evaluation, 19 patients (37%), all stage IIIB, fulfilled the criteria to receive a total dose of 40 Gy. Survival rates at one and two years were 33% and 0%, respectively, in the group of patients that received 20 Gy, and 52% and 21% respectively, in the group treated with 40 Gy. Two-year survival rates were 10% for stage IIIB and 0% for stage IV patients. Among the patients that were irradiated with a dose of 20 Gy, a subjective reduction of dyspnea and cough and remission of hemoptysis were observed in 97%, 82% and 80% cases, respectively. Complete remission of dyspnea and coughing was observed in 17 (89%) and 14 (74%) patients treated with two irradiation courses. Only mild toxicity was recorded.

Conclusions

Our treatment schedule achieved symptom control in the majority of patients. Early evaluation after 20 Gy allowed selection of responsive patients that could benefit from more prolonged treatment.

Concomitant Radiotherapy with Protracted 5-fluorouracil Infusion in Locally Advanced Carcinoma of the Pancreas: A Phase Ii Study

Aims and Background

To evaluate the efficacy of combined radiation therapy and continuous infusion of 5-fluorouracil in patients with locally advanced carcinoma of the pancreas.

Methods

Between January 1992 and June 1999, 31 patients with locally advanced adenocarcinoma of the pancreas were treated in our Institute. In 20 patients, the tumor (65%) was located in the head of the pancreas and in 11 (35%) in the body or tail; 13 cases also showed involved nodes. Radiation therapy consisted in a median dose of 63 Gy in 33-36 fractions applied to the tumor and regional lymph nodes. Chemotherapy with 5-fluorouracil in continuous infusion, 250 mg/m2 daily, was administered in the first and fifth week of the radiation therapy. Thereafter, 22 patients received 3-10 cycles of adjuvant chemotherapy with same doses. Median follow-up of the series was 20 months. The toxicity of the treatment was scored according to WHO criteria. All patients underwent nutritional assessment at the time of radiochemotherapy.

Results

The median overall survival was 15.2 months (range, 4-42). At restaging, 17 cases (55%) showed no change and 14 (45%) a partial remission. At the end of radiochemotherapy in 8 (26%) of the cases there was indication for pancreatectomy, which was executed in 4 patients. At the time of the study, 2 patients (6.4%) were surgically proven disease free. Eleven of the 13 cases (85%) presenting involved nodes showed that the enlarged lymph nodes had disappeared. Nineteen patients (61%) are alive with clinical evidence of disease and 2 cases are alive with liver metastases; 8 patients (26%) died for disease. In 74% of cases there was complete pain control. Tolerance to the regimen was good. Nutritional assistance was evaluated and was found to be correlated to survival.

Conclusions

The results of the series confirm a good tolerance with low acute toxicity. Tumor down-staging and resectability rates were high, together with prolonged survival and a good quality of life.

Patterns of CT lung injury and toxicity after stereotactic radiotherapy delivered with helical tomotherapy in early stage medically inoperable NSCLC

OBJECTIVE

To evaluate toxicity and patterns of radiologic lung injury on CT images after hypofractionated image-guided stereotactic body radiotherapy (SBRT) delivered with helical tomotherapy (HT) in medically early stage inoperable non-small-cell lung cancer (NSCLC).

METHODS

28 elderly patients (31 lesions) with compromised pulmonary reserve were deemed inoperable and enrolled to undergo SBRT. Patterns of lung injury based on CT appearance were assessed at baseline and during follow up. Acute (6 months or less) and late (more than 6 months) events were classified as radiation pneumonitis and radiation fibrosis (RF), respectively.

RESULTS

After a median follow-up of 12 months (range, 4-20 months), 31 and 25 lesions were examined for acute and late injuries, respectively. Among the former group, 25 (80.6%) patients showed no radiological changes. The CT appearance of RF revealed modified conventional, mass-like and scar-like patterns in three, four and three lesions, respectively. No evidence of late lung injury was demonstrated in 15 lesions. Five patients developed clinical pneumonitis (four patients, grade 2 and one patient, grade 3, respectively), and none of whom had CT findings at 3 months post-treatment. No instance of symptomatic RF was detected. The tumour response rate was 84% (complete response + partial response). Local control was 83% at 1 year.

CONCLUSION

Our findings show that HT-SBRT can be considered an effective treatment with a mild toxicity profile in medically inoperable patients with early stage NSCLC. No specific pattern of lung injury was demonstrated.

ADVANCES IN KNOWLEDGE

Our study is among the few showing that HT-SBRT represents a safe and effective option in patients with early stage medically inoperable NSCLC, and that it is not associated with a specific pattern of lung injury.

From water to aquaretics: a legendary route

Man is water. When life appeared on earth, the primordial cell had a simple structure and could immediately ascertain from the surrounding aquatic environment the substances for nutrition and oxygen, without any need for structural complexity. As part of evolution, during the transition from aquatic to terrestrial life, vertebrates had to fight against dehydration as well as fish in the sea. In this complex mechanism of osmoregulation, the structure and function of some osmoregulatory hormones have been maintained during the evolution of species, from fish to man. Within the homeostatic mechanism, the renin-angiotensin-aldosterone system (RAAS) is crucial in the regulation of renal reasorption of water and sodium. It is also involved in the regulation of renal plasma flux, blood volume and blood pressure. Vasopressin plays a hormonal function in the mechanisms of water homeostasis acting through Aquaporins (AQP), channel-proteins that allow bi-directional water transport across cell membranes.

Apelin beyond kidney failure and hyponatremia: a useful biomarker for cancer disease progression evaluation

Apelin regulates angiogenesis, stimulating endothelial cell proliferation and migration. It is upregulated during tumor angiogenesis, and its overexpression was reported to increase tumor growth. Furthermore, apelin controls vasopressin release and body fluid homeostasis. The aim of this study was to examine the correlations between apelin expression and clinical outcomes in oncologic patients, such as cancer disease progression and patient's survival. Apelin levels were evaluated in a cohort of 95 patients affected by different varieties of cancer. Partial remission and stable disease were assigned to the 'no progression' group, comparing it with the progressor group. Patients were followed up for 2 years. Receiver operating characteristics analysis was employed for identifying the progression of the oncologic disease and Kaplan-Meier curves assessed the survival. Adjusted risk estimates for progression endpoint were calculated using Cox proportional hazard regression analysis. Oncologic patients had higher apelin levels compared with healthy subjects, and apelin was closely related to the stages of the disease. In the hyponatremia group, apelin values were significantly higher than patients with eunatremia. After the follow-up of 24 months, 41 patients (43%) reached the endpoint. Progressor subjects presented significantly increased apelin values at baseline compared with non-progressor. Univariate followed by multivariate Cox proportional hazard regression analysis showed that apelin predicted cancer progression independently of other potential confounders. In patients with cancer, apelin closely reflects the stage of the disease and represents a strong and independent risk marker for cancer progression.

Proteinuric effect of transcranial magnetic stimulation in healthy subjects and diabetic patients with stage 3-4 CKD

BACKGROUND

Many authors have investigated the numerous connections between the nervous system and kidneys, and recent literature has indicated that these similar systems are interconnected. Recent scientific works have shown that there is similarity between the cerebral cortex 'viscera representation' and the 'motor omunculus'. We studied the connection between the brain and kidney in vivo using repetitive transcranial magnetic stimulation (rTMS). Proteinuria and albuminuria were used as markers of renal response in patients with diabetes (DP) and in a group of healthy subjects (HSs) who received rTMS for 5 consecutive days.

METHODS

The study population consists of the following four groups: Group A (HS stimulated), Group B (HS sham), Group C (DP stimulated) and Group D (DP sham). All subjects in Groups A and C underwent rTMS delivered at a frequency corresponding to 90% of the threshold at rest for 5 consecutive days. All subjects in Groups B and D underwent rTMS delivered with the coil placed on the scalp without delivering electromagnetic stimuli, while another coil at a distance of ∼2 m emitted stimuli at a very low intensity. This strategy ensured that brain stimulation would not occur, so that the subjects felt the vibrations produced by the click of the TMS coil. The proteinuria and albuminuria of 24 h and creatinine clearance were measured at time 0 (T0), after the first session (T1), at the end of the treatment (T5) and 24 h after the last stimulation (Post 24 h).

RESULTS

In Group A, there was a statistically significant increase in albuminuria (5.65 ± 0.52 versus 12 ± 0.55 mg/24 h, P = 0.0001) and proteinuria (6.05 ± 0.48 versus 13.1 ± 0.60 mg/24 h, P = 0.0001) at the end of the treatment (T5) compared with the baseline values (T0). In Group C, the albuminuria was statistically higher at T5 than the baseline T0 (416.22 ± 181 versus 677.25 ± 280 mg/24 h, P = 0.04), as was proteinuria (561.37 ± 86 versus 865.125 ± 104 mg/24 h, P = 0.0001); in Group C, the increase in albuminuria (T0 versus post 24 h, P = 0.02) and proteinuria (T0 versus 24 h post, P = 0.0002) persisted at 24 h post. In Groups B and D, statistically significant changes were not found in proteinuria (Group B T0 versus T5, P = 0.61; Group D: T0 versus T5, P = 0.66) and albuminuria (Group B T0 versus T5, P = 0.15; Group D T0 versus T5, P = 0.44) measured at the same times.

CONCLUSIONS

Consecutive rTMS is able to induce a statistically significant increase in albuminuria and proteinuria in HS and DP. A functional link between the brain and kidney is possible. For the first time, the results have indicated an increase of proteinuria in subjects undergoing transcranial stimulation.

"Normoalbuminuric" diabetic nephropathy: tubular damage and NGAL

The aim of this study was to demonstrate that neutrophil gelatinase-associated lipocalin (NGAL) increased before the onset of microalbuminuria in patients with type 1 diabetes mellitus (T1DM), representing an important biochemical parameter with high sensitivity and specificity to make a precocious diagnosis of "normoalbuminuric" diabetic nephropathy (DN). Serum NGAL (sNGAL) and urinary NGAL (uNGAL) levels were evaluated in a cohort of fifty patients affected by T1DM. They had no signs of clinical nephropathy. Thirty-five healthy subjects (HS) were recruited. sNGAL levels were significantly higher compared with those measured in HS [193.7 (103.2-405.4) vs. 46.4 (39.8-56.2) ng/ml; p < 0.0001], as were uNGAL levels [25.5 (14.2-40.2) vs. 6.5 (2.9-8.5) ng/ml; p < 0.0001]. sNGAL was found to be directly correlated with glycated hemoglobin. uNGAL also positively correlated with albuminuria, whereas an inverse correlation was found with uric acid. After multivariate analysis, significance was maintained for the correlation between uNGAL and microalbuminuria. In ROC analysis, sNGAL showed a good diagnostic profile such as uNGAL. NGAL increases in patients with T1DM, even before diagnosis of microalbuminuria representing an early biomarker of "normoalbuminuric" DN with a good sensitivity and specificity. NGAL measurement could be useful for the evaluation of early renal involvement in the course of diabetes.

Role of radiotherapy for high grade gliomas management

We have analyzed the therapeutic standard options for high grade gliomas, with particular attention to the different radiation therapy modalities and techniques and their application considering the natural history of the disease. Of the several therapeutic options, surgical resection remains the initial treatment of choice for patients with high grade glioma; of all adjuvant treatments tested, radiotherapy offers the greatest magnitude of survival benefit, so radiotherapy, which must be started within 6 weeks of surgery, is mandatory for practically all patients with high grade gliomas. In this paper we perform an overview considering the integration between the different therapeutic modalities, with particular attention to the radiation therapy role in the management of high grade gliomas.

Management of oncologic transplant recipient: the profile of the radiation oncologist

Long-term survival after organ transplantation is increasing. As a result, many physicians may encounter various solid organ cancers during follow up. We review papers who address their attention on those malignancies and their treatment. Aim of this work is to discuss the role of radiotherapy especially when helped by new technologies in the management of brain, skin, head and neck, lung, breast, prostate and anal cancer. In our institution we are used to treat such patients by Helical Tomotherapy in order to avoid graft and to limit high risk toxicity. As example, we include a scalp and pelvic irradiation in which high dose conformality is linked to best organ sparing.

Levels of neutrophil gelatinase-associated lipocalin in 2 patients with crush syndrome after a mudslide

Neutrophil gelatinase-associated lipocalin is one of the most promising biomarkers for the diagnosis of acute kidney injury. An increase in the level of neutrophil gelatinase-associated lipocalin is a good predictor of acute kidney injury and is associated with an increase in the serum level of creatinine. Two victims of a mudslide in Messina, Italy, initially had crush syndrome followed by development of acute kidney injury. The development of acute kidney injury is the second most common cause of death after large earthquakes and other natural disasters, but at the same time, crush-related acute kidney injury is one of the few life-threatening complications of crush injuries that can be reversed if diagnosed early and treated. In this case, measuring the level of neutrophil gelatinase-associated lipocalin enabled early diagnosis of acute kidney injury and anticipation of the changes in levels of conventional markers such as creatinine.

Renal complications in oncohematologic patients

The aim of the present paper was to review recent developments in the management of patients with acute kidney injury or chronic kidney disease occurring secondary to either cancer itself or its therapy, with a focus on infiltration of the renal parenchyma, myeloma, tumor lysis syndrome, glomerular disease, thrombotic microangiopathy, chemotherapy-associated thrombotic microangiopathy, biphosphonate-induced renal diseases, acute kidney injury, and chronic kidney disease after hematopoietic cell transplantation. Further studies are awaited because a better knowledge of renal complications, which frequently occur in patients with oncohematologic diseases, would be conducive to making an early diagnosis and providing prompt therapy.

A new therapy for kidney injury: regeneration

Because of progressive population ageing and epidemic diffusion of type 2 diabetes mellitus in industrialized Countries, we are attending a growing incidence of end stage renal disease. This phenomenon has induced researchers to study potential alternative methods of renal function replacement. Actually, only dialytic methodics and renal transplant make possible survival of patients with terminal uremia, but both these therapeutic approaches show important limitations. The ideal solution would be represented by the possibility to "regenerate" the injured organ. This is the purpose of Regenerative Nephrology, a new medical domain which tries to develop new therapies through stimulation and induction in humans of regenerative processes already observed in other species, like reptiles and fishes. Such an ambitious and fascinating purpose requires a deep knowledge of the intricate networks which regulate the production of the hormones and mediators involved in the tissue regenerative processes. In this field the kidney embryonic development phases can represent a fundamental study model to acquire information about the reparative mechanisms of the structure and function of this excretory organ.

Obestatin: a new element for mineral metabolism and inflammation in patients on hemodialysis

BACKGROUND

Obestatin plays a key role in the process of energy balance maintenance with an anorectic effect. The main aim of the study was to evaluate obestatin in uremic patients to determine whether it is correlated with nutritional and inflammatory status.

METHODS

We studied plasma obestatin in uremic patients (n = 50) undergoing hemodialysis therapy and in healthy subjects. Plasma obestatin was measured using an ELISA kit.

RESULTS

Obestatin levels in uremic patients were lower than in healthy subjects (p < 0.0001). Patients with a body mass index (BMI) >23 had lower obestatin levels than those with a BMI <23 (p = 0.001). After multivariate analysis, direct correlations were maintained between obestatin and high-sensitivity C-reactive protein (β = 0.68, p < 0.0001) and total alkaline phosphatases (β = 0.30, p = 0.03), while inverse correlations were found with iron (β = -0.32, p = 0.002) and calcium-phosphorous product (β = -0.40, p = 0.001).

CONCLUSIONS

Based on the present observational data, obestatin might be implicated in the inflammatory state and the disturbances of calcium/phosphate metabolism of hemodialysis patients. However, further studies are warranted to determine whether this hormone plays a key role in contributing to malnutrition and to the chronic inflammatory process.

Docosahexaenoic acid reverts resistance to UV-induced apoptosis in human keratinocytes: involvement of COX-2 and HuR

The dramatic increase in the incidence of nonmelanoma skin cancer over the last decades has been related to the augmented exposure to ultraviolet (UV) radiation (UVR). It is known that apoptosis is induced as a protective mechanism after the acute irradiation of keratinocytes, whereas apoptotic resistance and carcinogenesis may follow the chronic exposure to UVR. We found that not all the human keratinocytes lines studied underwent apoptosis following acute exposure to UVR (10-60 mJ/cm(2)). Whereas UVR induced apoptosis in the HaCaT cells, NCTC 2544 and nr-HaCaT cells showed apoptosis resistance. The cytokeratin pattern of the apoptosis-resistant cells indicated that they possessed a degree of differentiation lower than that of HaCaT cells. They also showed an enhanced expression of cyclooxygenase-2 (COX-2), an early marker of carcinogenesis in various tissues, including skin. n-3 polyunsaturated fatty acids have drawn increasing interest as nutritional factors with the potential to reduce UVR carcinogenesis, and since they are apoptosis inducers and COX-2 inhibitors in cancer cells, we investigated the ability of n-3 polyunsaturated fatty acids to influence the resistance to UVR-induced apoptosis in keratinocytes. We observed that docosahexaenoic acid (DHA) reverted the resistance of nr-HaCaT cells to UVR-induced apoptosis, increasing the Bax/Bcl-2 ratio and caspase-3 activity, and reduced COX-2 levels by inhibiting the expression of the human antigen R (HuR), a known COX-2 mRNA stabilizer in keratinocytes. The transfection of nr-HaCaT cells with HuR siRNA mimicked the proapoptotic effect of DHA. Overall, our findings further support the role of DHA as a suitable anticarcinogenic factor against nonmelanoma skin cancers.

[From oxygen to erythropoietin, as a protagonist of the skin-brain-kidney axis]

Erythropoietin synthesis is one of the essential adaptive responses to a hypoxic environment. In mammals, a renal oxygen sensor capable of stimulating erythropoietic hormone synthesis through a transcriptional factor called HIF (hypoxia-inducible factor) has long been identified. Recent research has demonstrated that cerebral astrocytes and skin keratocytes can also produce erythropoietin as a response to different oxygen concentrations. Therefore, it is possible to hypothesize a skin-brain-kidney link which, through erythropoietin production, modulates the oxygen contribution to tissues. Moreover, the results are not so unambiguous and further research on the pleiotropic effects of erythropoetin would be opportune.