Update of the mortality study of workers exposed to polychlorinated biphenyls (Pcbs) in two Italian capacitor manufacturing plants

BACKGROUND

PCB carcinogenicity to humans is still controversial. Cohort mortality studies in PCB-exposed workers reported elevated risks for the following causes of death: liver, stomach, digestive, brain, prostate cancers and non-Hodgkin lymphoma.

OBJECTIVES

The purpose of this study was to update as of December 2006 the mortality experience of two Italian cohorts of workers employed in the manufacture of capacitors impregnated with PCBs.

METHODS

Age-gender-and calendar period adjusted Standardized Mortality Ratios (SMRs) and 95% Confidence Intervals (CI) were calculated using regional rates. Analyses by duration of employment and time since first employment were performed Results: Vital status was ascertained for 98.9% of the study subjects. Mortality from biliary tract cancer among males (SMR 3.91; 95%CI 1.47-10.41), digestive cancer "not otherwise specified" in the whole cohort (SMR 2.54; 95%CI 1.21-5.34), and brain cancer in Plant I (SMR 2.13; 95%CI 1.02-4.48), were significantly increased. Increased risks were also observed for Hodgkin's and non-Hodgkin lymphoma. No linear associations between mortality and duration of employment or latency were observed for these cancers. Mortality from stomach cancer did not differ from expectation in the whole cohort, however an increasing risk with increasing duration of employment was detected (p for trend=0.02).

CONCLUSIONS

The current update suggests possibly increased cancer risks in PCB-exposed workers, affecting in particular the digestive system, brain, and lymphohemopoietic tissue. However the limited sample size, the lack of clear trends with duration of employment or with latency period, preclude to derive definite conclusions about PCB exposure and the increased cancer risks.

Measurable urinary albumin predicts cardiovascular risk among normoalbuminuric patients with type 2 diabetes

Micro- or macroalbuminuria is associated with increased cardiovascular risk factors among patients with type 2 diabetes, but whether albuminuria within the normal range predicts long-term cardiovascular risk is unknown. We evaluated the relationships between albuminuria and cardiovascular events in 1208 hypertensive, normoalbuminuric patients with type 2 diabetes from the BErgamo NEphrologic Diabetes Complication Trial (BENEDICT), all of whom received angiotensin-converting enzyme inhibitor (ACEI) therapy at the end of the trial and were followed for a median of 9.2 years. The main outcome was time to the first of fatal or nonfatal myocardial infarction; stroke; coronary, carotid, or peripheral artery revascularization; or hospitalization for heart failure. Overall, 189 (15.6%) of the patients experienced a main outcome event (2.14 events/100 patient-years); 24 events were fatal. Albuminuria independently predicted events (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.02-1.08). Second-degree polynomial multivariable analysis showed a continuous nonlinear relationship between albuminuria and events without thresholds. Considering the entire study population, even albuminuria at 1-2 μg/min was significantly associated with increased risk compared with albuminuria <1 μg/min (HR, 1.04; 95% CI, 1.02-1.07). This relationship was similar in the subgroup originally randomly assigned to non-ACEI therapy. Among those originally receiving ACEI therapy, however, the event rate was uniformly low and was not significantly associated with albuminuria. Taken together, among normoalbuminuric patients with type 2 diabetes, any degree of measurable albuminuria bears significant cardiovascular risk. The association with risk is continuous but is lost with early ACEI therapy.

Bowel ultrasound and mucosal healing in ulcerative colitis

BACKGROUND AND AIM

Mucosal healing (MH) after short-term medical treatment is being considered as an important step in the therapeutic work-up of inflammatory bowel disorder (IBD) patients due to the potential prognostic role of MH in predicting disease outcome. However, IBD patients are reluctant to be re-endoscoped during follow-up; therefore, there is a need for non-invasive alternative index of MH which can replace endoscopy in clinical practice. We evaluated bowel ultrasound (US) as a surrogate of colonoscopy in a series of consecutive patients with active ulcerative colitis (UC).

PATIENTS AND METHODS

83 patients with moderate to severe UC requiring high-dose steroids were initially recruited; endoscopic severity of UC was graded 0-3 according to Baron score, and US severity was also graded 0-3 according to the colonic wall thickening and the presence of vascular signal at power Doppler. 74 patients responsive to steroids and then maintained on 5-ASA compounds were followed up with repeated colonoscopy and bowel US at 3, 9 and 15 months from entry. Concordance between clinical, endoscopic and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of Truelove, Baron and US scores measured at 3 and 9 months on the development of a UC relapse (Baron score 2-3) at 15 months.

RESULTS

An inconsistent concordance was found over time between 0 and I Baron scores and Truelove score (weighted kappa between 0.38 and 0.94), with high and consistent concordance between 0 and I Baron scores and US scores (weighted kappa between 0.76 and 0.90). On logistic regression analysis, a moderate/severe Baron score, regardless of their Truelove score, at 3 months was associated with a high risk of endoscopic activity at 15 months (OR 5.2; 95% CI: 1.6-17.6); similarly, patients with severe US scores (2-3) at 3 months had a high risk of severe endoscopic activity at 15 months (OR 9.1; 95% CI: 2.5-33.5).

DISCUSSION

In expert hands bowel US may be used as a surrogate of colonoscopy in evaluating the response to high-dose steroids in severe forms of UC. US score after 3 months of steroid therapy accurately predicts clinical outcome of disease at 15 months.

[Introductional results of a mortality study in 471 ex-exposed workers to PCBs]

This study concerned a group of ex-workers (372 males and 99 females) from a firm situated in Bergamo (Italy) that ceased its activity at the beginning of the Nineties. From an introductory analysis of the results, we found out that there isn't excess in the death-rate for liver and bile ducts cancers among the males of this group. Among them, for what concerns the other tumoral pathologies, such as leukaemia and stomach tumors, the information allowed to verify an excess of mortality. However, this increase hasn't result statistically significant. On the contrary, it came out that there is an excess of risk for intestine tumors: standardized death-rate of 2.58. In accordance with the information collected, for the future it will be necessary to carefully examine the research in order to verify the existence of a direct connection to the exposure at PCB and study the incidence (not only for mortality) of these neoplasms.

Extensive vascular invasion is a marker of risk of relapse in encapsulated non-Hurthle cell follicular carcinoma of the thyroid gland: a clinicopathological study of 18 consecutive cases from a single institution with a 11-year median follow-up

AIMS

To determine the prognostic value of certain clinicopathological features in a series of 18 consecutive cases of encapsulated follicular carcinoma (EFC) of the thyroid gland with long follow-up.

METHODS AND RESULTS

Eighteen consecutive cases of EFC were retrieved from 1975 to 1993. Gender, age at onset, type of surgery, presence of capsular and/or vascular invasion, number of involved vessels, tumour size, and TNM/pTNM classification were evaluated and correlated with disease outcome. None of the cases presented with distant metastases. Extensive vascular invasion (defined as more than four capsular vessels involved) was present in two cases. After a median follow-up of 133 months, all patients were alive. Three cases had relapsed in lung and bone. In two out of these three cases, extensive vascular invasion was present. Radioiodine therapy was curative in two of three of the relapsed cases.

CONCLUSIONS

EFC is a low-risk carcinoma, with no patients' deaths after a median follow-up of 11 years. Extensive vascular invasion should be considered as a risk factor for relapse. A conservative surgical approach is recommended. Since relapses may occur up to 14 years after the initial surgery, life-long follow-up is advisable.

Minimally invasive (encapsulated) follicular carcinoma of the thyroid gland is the low-risk counterpart of widely invasive follicular carcinoma but not of insular carcinoma

Minimally invasive (encapsulated) follicular carcinoma (MIFC), widely invasive follicular carcinoma (WIFC), and insular carcinoma (IC) are three distinct types of thyroid carcinomas composed of follicular cells, IC representing the poorly differentiated counterpart. Our aim was to test whether there is a time-dependent relationship among these three entities, in particular whether MIFC is the low-risk form of the entire group. We used overall survival analysis and multiple correspondence analysis (MCA), the latter exploring the clinicopathological characteristics at onset (sex, age, TNM/pTNM classification). The study included 18 MIFCs, 29 WIFCs, and 27 ICs. On the basis of both overall survival and MCA, WIFC emerged as the high-risk counterpart of MIFC, occurring in older age, with a larger size, a widespread growth into the thyroid parenchyma, and presenting with distant metastases. In both types of follicular carcinoma distant metastases involved only lung and bone, and there was no tendency for local spread beyond the thyroid capsule or nodal metastases. By contrast, IC confirmed to be a distinct high-risk lesion, showing both follicular and papillary-related biological behavior characteristics.

Bowel ultrasound in assessment of Crohn's disease and detection of related small bowel strictures: a prospective comparative study versus x ray and intraoperative findings

BACKGROUND AND AIM

Despite the fact that bowel ultrasound (US) has recently been proved to be useful in the assessment of bowel diseases, uncertainty persists as to its diagnostic role in patients with complicated Crohn's disease (CD). Therefore, we have prospectively investigated the accuracy of US compared with x ray procedures and intraoperative findings in detecting small bowel strictures complicating CD as well as its reliability in assessing disease extent and location within the bowel.

METHODS

A series of 296 consecutive patients with proven CD admitted to L Sacco University Hospital between 1997 and 1999, having undergone complete radiographic evaluation (including small bowel x ray, colonoscopy, or double contrast barium enema), were enrolled in the study. Bowel US was performed in each patient by two experienced operators unaware of the results of other diagnostic procedures. The accuracy of US in detecting strictures compared with x ray studies was determined separately in two different groups of patients: 211 patients treated conservatively (non-operative CD) and 85 patients who were candidates for surgery for CD complications or unresponsiveness to medical therapy (operative CD).

RESULTS

Overall sensitivity and specificity of US in assessing the anatomical distribution of CD were 93% and 97%, respectively. The extent of ileal disease measured at US correlated well with that determined by x ray (r=0.52, p<0.001) in medically treated patients as well as with that measured intraoperatively in surgical patients (r=0.64, p<0.001). One or more stenoses were detected in 75 patients (35.5%) at small bowel enteroclysis in the non-operative CD group compared with 70 (82%) in the operative CD series. Sensitivity, specificity, and positive predictive values of bowel US in the detection of strictures were 79%, 98%, and 95% in non-operative CD patients and 90%, 100%, and 100% in operative CD cases, respectively.

CONCLUSIONS

In experienced hands, bowel US is an accurate technique for assessing CD extent and location and is very helpful in detecting small bowel strictures, especially in very severe cases that are candidates for surgery. The use of bowel US is therefore justified as a primary investigation in CD patients in whom complications are suspected.

Adenocarcinoma of the lower third of the rectum: metastases in lymph nodes smaller than 5 mm and occult micrometastases; preliminary results on early tumor recurrence

BACKGROUND

The number of examined lymph nodes and metastases in lymph nodes smaller than 5 mm (small lymph nodes) are a determining factor in the stage of rectal cancer although the clinical significance of occult micrometastases is controversial. We are reporting our preliminary results on the identification and prognostic utility of metastases in small lymph nodes and occult micrometastases.

METHODS

We searched small metastatic lymph nodes in 101 cases of adenocarcinoma of the lower third of the rectum. We used the manual technique to dissect mesorectal fat and occult micrometastases in the lymph nodes of 52 Dukes' A and B patients, using a pool of anticytokeratin antibodies.

RESULTS

Forty-five percent of the metastatic lymph nodes were smaller than 5 mm in diameter and determined the Dukes' stage in 15 (30.6%) of 49 Dukes' C patients. Occult micrometastases were found in 21 (40.4%) patients: five recurred but vascular invasion, positive distal margin of the rectum, and positive circumferential margin of the mesorectum were present.

CONCLUSIONS

Small metastatic lymph nodes, vascular invasion, positive distal margin of the rectum, and positive circumferential margin of the mesorectum were found to be more important than occult micrometastases in predicting early recurrence of rectal cancer.

Analysis of SYT-SSX fusion transcripts and bcl-2 expression and phosphorylation status in synovial sarcoma

Synovial sarcomas (SS) are characterized by a chromosomal translocation t(X;18)(p11.2;q11.2) which usually fuses the SYT gene from chromosome 18 to SSX1 or SSX2 genes on chromosome X. Also, a variant SYT-SSX4 fusion gene has recently been shown in a single SS case. In addition to these cytogenetic changes, bcl-2 expression, as assessed by immunohistochemistry, has been reported to be an almost general constitutive alteration of SS. In the present work, we analyze a series of 36 SS surgical samples (from 34 patients) by RT-PCR for the presence of the SYT-SSX1 or the SYT-SSX2 fusion transcript. The analysis was extended to SYT-SSX4 on SYT-SSX1-negative and SYT-SSX2-negative cases only. Our results showed a significant correlation between the SYT-SSX2 fusion and the monophasic SS histologic subtype. SYT-SSX1 fusion transcripts were present in both monophasic and biphasic tumors. The SYT-SSX4 fusion type was detected in a single monophasic SS. In the same series of SS cases, we also confirmed and extended the previously reported constitutive expression of bcl-2 protein, by using both immunohistochemical and western blot analysis. Moreover, we demonstrated that the BCL-2 gene is not rearranged or amplified at genomic level, indicating that the high levels of bcl-2 expression observed in SS might result from transcriptional activation of the gene and/or protein stabilization. Finally, we show that bcl-2 is not phosphorylated in tumors from patients who had been preoperatively treated with radio/chemotherapy, in tumors from untreated patients, or in an SS cell line (CME-1) after in vitro treatment with cytotoxic concentrations of DNA-damaging agents or taxanes. These data indicate that SS cells are unable to activate an apoptosis pathway involving bcl-2 phosphorylation/inactivation and may provide a possible explanation for the limited effectiveness of conventional pharmacological treatments of this tumor type.

Gene product immunophenotyping of neuroendocrine lung tumors. No linking evidence between carcinoids and small-cell lung carcinomas suggested by multivariate statistical analysis

Fifty-three neuroendocrine lung tumors (24 carcinoids, one atypical carcinoid, five large-cell neuroendocrine carcinomas, and 23 small-cell lung carcinomas) were investigated for immunocytochemical expression of several gene products, i.e., p53, Rb, bcl-2, c-kit, mdm-2, cdk-4, p21 proteins, and proliferation index as assessed by MIB-1. The goal of the study was to explore the relationships between histotypes in light of their own gene product-based immunophenotypical profiles. To this aim we applied the multiple correspondence analysis, which is an exploratory statistical multivariate technique that converts a data matrix into a particular type of graphic display in which the rows and columns are depicted as points. Such statistical analysis displayed that some categories of the gene product-based immunophenotyping variables are grouped in the plot identifying three groups: the first group related to carcinoids, the second to small-cell carcinomas, and the third to large-cell neuroendocrine carcinomas. These data support the evidence that carcinoids and small-cell carcinomas are two distinct, apparently immunogenotypically unrelated entities among neuroendocrine lung tumors and that atypical carcinoids and large-cell neuroendocrine carcinomas seem not to represent intermediate steps between them.

Prognostic value of clinicopathologic characteristics including neuroectodermal differentiation in osseous Ewing's sarcoma family of tumors in children

AIMS AND BACKGROUND

The aim of the present study was to determine the relationship between clinico-pathologic parameters, including neuroectodermal differentiation, and their impact on survival in a series of pediatric patients with osseous tumors of the Ewing's sarcoma family admitted to the Pediatric Department of the Istituto Nazionale Tumori of Milan.

METHODS

Seventy-three patients were enrolled. The variables analyzed were sex, age, site of primary tumor, serum lactate dehydrogenase (LDH) level at diagnosis, involvement of periosseous soft tissues by primary tumor, presence of metastatic disease, status of disease after the treatment plan, as well as the presence of mitoses, morphologic and immunocytochemical neural markers, and neuroendocrine markers in the primary tumor.

RESULTS

Neural and neuroendocrine markers were not significantly associated with any of the other parameters. In the univariate analysis, significant risk factors related to unfavorable outcome were elevated LDH, metastatic disease, lack of complete remission after treatment, presence of mitoses and of morphological neural markers; immunocytochemical neural and neuroendocrine markers lacked prognostic value. In the multivariate analysis, only LDH levels and the status of disease following the treatment were retained.

CONCLUSIONS

LDH level at diagnosis might be a useful marker to identify different risk levels; neuroectodermal differentiation might have no clear-cut impact on the clinical management of osseous Ewing's sarcoma family of tumors.

Differentiation in paediatric peripheral primitive neuroectodermal tumours of bone. A critical contribution to its assessment

Differentiation was studied in 73 paediatric peripheral primitive neurorectodermal tumours (pPNETs) of bone observed during 1974 through 1992. The presence of rosettes, pseudorosettes, and/or a rosette-like arrangement of tumour cells (the morphological neural marker, MNM) occurred in 29% of these cases. NSE and N-CAM were expressed by nearly all tumours; synaptophysin was present in 30% of cases, not significantly associated with the MNM status. Neuroendocrine (NE) markers were present in 25% (chromogranin B, secretogranin II) to 40% (chromogranin A, 7B2 protein) of cases. Focal expression of cytokeratins, S100 protein and/or desmin was also noted in a minority of cases. In univariate statistical analysis, only the presence of MNM conferred a significantly higher (about twofold) risk of death than its absence. This study demonstrates the occurrence of at least one immunocytochemical N and/or NE differentiation marker in all pPNETs of bone and a focal expression of cytokeratins, S100 protein and/or desmin in a minority of cases. Synaptophysin and MNM were present each in less than 1/3 of the cases, and no association was noted between them. Statistical analyses highlighted the prognostic role of MNM per se and discourage the sole use of immunocytochemistry in the assessment of neuroectodermal differentiation for prognostic purposes in paediatric pPNETs of bone.

Argyrophilia and chromogranin A and B immunostaining in patients with sporadic medullary thyroid carcinoma. A critical appraisal of their prognostic utility

The purpose of the present study was to evaluate the prognostic utility of tumour argyrophilia and chromogranin A (CgA) and B (CgB) immunocytochemical expression in patients with sporadic medullary thyroid carcinoma. To this end, the histo-immunocytochemical data on a consecutive series of 99 such tumours were submitted to statistical analysis. In univariate analysis, a significantly increased risk of disease progression and death was present in patients with CgA-poor and CgB-poor tumours, respectively. Multivariate analyses were performed by adding the histo-immunocytochemical variables to the final (reference) models obtained in earlier work on the same case series, in which 18 clinicopathological variables had been taken into account. This addition did not change the prognostic impact of the variables considered in the two reference models; it did, however, increase the prognostic information for overall survival, since the adjunctive contribution of CgB immunocytochemical expression (as assessed by the likelihood ratio test) was statistically significant. It is concluded that the chromogranin B immunostaining pattern of the primary tumour allows the distinction of patients with an increased risk of death. Argyrophilia and expression of chromogranin A seem instead to be of no prognostic value in patients with sporadic medullary thyroid carcinoma.

Skin blood flow during vasoconstrictive and vasodilative stimuli in essential hypertension patients: a laser Doppler flowmetry study

In order to compare the extent of the elicited vasoconstrictive and vasodilative response at the microcirculatory level in essential hypertension (EH), we measured the skin blood flow by means of a laser Doppler flowmeter (LDF). Thirty-four mild-to-moderate EH patients were enrolled. Twenty-two sex- and age-matched healthy subjects were selected as a control group. The LDF measurements were carried out with the probe over the fingertip of the distal phalanx at baseline conditions (Rest flow, RF), after an ischaemic test (post-ischaemic peak flow) and during an arithmetic stress test (AT). The flow was expressed in arbitrary units. The data were processed using the Perisoft computer program. The relative flows after the ischaemic test (Rel F1) and during the AT (Rel F2) were expressed as a percentage of the previous RF values (RF1 and RF2, respectively). During the AT, the lag time was calculated (in seconds). As compared to the control subjects, RF was significantly lower in the EH group (p < 0.01). During the AT, the EH patients showed a statistically lower mean Rel F2 decrease compared to the control subjects (p < 0.01). No statistically significant difference occurred in the Rel F1 and lag time. These data suggest that the vasoconstrictive capacity of the precapillary vessels is impaired in patients with hypertension.

Prognostic impact of thyroid lymphocytic infiltration in patients with medullary thyroid carcinoma

A retrospective search for lymphocytic infiltration of the thyroid was performed on archival paraffin specimens from 95 cases of thyroid medullary carcinoma observed at a single institution during a 30-year period. A mild lymphocytic infiltration of the nonneoplastic thyroid tissue, mainly concentrated at the edge of the tumor mass, was observed in 33 cases, while in a further 24 cases a moderate to marked lymphocytic infiltration, resembling that seen in chronic lymphocytic thyroiditis, was homogeneously distributed all over the gland, with no apparent relationship to the site of the primary tumor. Virtually no lymphocytic infiltration was detected inside of any of the tumors. The presence of chronic lymphocytic thyroiditis seemed to be a characteristic of the host rather than a tumor-induced event. Statistical univariate analysis of relapse-free survival and overall survival showed that lack of chronic lymphocytic thyroiditis marked those patients with an increased risk of disease recurrence and death. However, the observed risk for survival was statistically nonsignificant, whereas that for disease recurrence was significant and remained in a multivariate model of statistical analysis.

Multivariate analysis of prognostic factors in sporadic medullary carcinoma of the thyroid. A retrospective study of 109 consecutive patients

BACKGROUND

Because of the rarity of medullary thyroid carcinoma, adequate information for determination of the prognostic characteristics and clinical course of this disease can be obtained only from a database that serves a large population.

METHODS

A retrospective review of 109 patients with sporadic medullary thyroid carcinoma was conducted; all were diagnosed and treated at a single institution over a 30-year period. The series included 57 males and 52 females with a median follow-up of 5.3 years. Statistical univariate analysis of relapse free survival and overall survival was done for 18 clinicopathologic variables, including sex, age, TNM staging, completeness of surgical resection, postoperative calcitoninemia, histologic subtype, tumor size, thyroid capsule invasion, amyloid, katacalcin, calcitonin, and calcitonin gene-related peptide immunostaining patterns of the primary tumor.

RESULTS

Risk factors for unfavorable outcome were male sex, age > 60 years, incomplete tumor resection, mixed cell subtype, tumor size > 4 cm, extrathyroid tumor invasion, lack of amyloid, N1 and M1 categories, and heterogeneous calcitonin and katacalcin immunostaining pattern. In the multivariate analysis, only capsule status, M category, and age at diagnosis remained in the final model for overall survival. In the final model for relapse free survival, capsule status remained, together with sex and amyloid status.

CONCLUSIONS

Extrathyroid tumor invasion, the presence of distant metastases, and age > 60 years are characteristic of patients at high risk of death from disease sooner, whereas extrathyroid invasion, male sex, and the absence of amyloid characterize patients who are at high risk for recurrence. Extrathyroid tumor invasion appears to be the worst prognostic factor and may allow for the breakdown of patients into two categories, amenable to different therapeutic regimens.

Papillomavirus, p53 alteration, and primary carcinoma of the vulva

Twenty-nine samples from 28 cases of vulvar squamous cell carcinoma, of which 13 fulfilled the criteria of the bowenoid subtype (mean age 45 years, range 31-68) and 16 of the usual subtype of invasive squamous cell carcinoma (ISCC) (mean age 67.5 years, range 34-83) were investigated for human papillomavirus (HPV) DNA, TP53 alterations, and mdm2 and bcl-2 gene product deregulation. Microscopically all the bowenoid subtype cases (group I) showed a high-grade intraepithelial (VIN 3, carcinoma in situ) lesion associated with early invasive carcinoma in six cases and overt invasive carcinoma in one. By contrast, no evidence of early carcinoma was present in the ISCCs (group II). By in situ hybridization and/or Southern blot hybridization or polymerase chain reaction (PCR), HPV DNA was detected in all cases of group I and in four of 16 cases (25%) of group II, two only by Southern blot after PCR. By single-strand conformation polymorphism and immunocytochemistry only wild-type TP53 and absence of detectable p53 product, respectively, were found in all cases of group I, i.e., in high-risk HPV-positive carcinomas, whereas mutations and/or p53 overexpression accounted for 75% in group II, i.e., in mainly HPV-negative carcinomas. The TP53 gene mutations observed in invasive carcinomas were significantly related to node-positive cases (p = 0.04). Taken together and in agreement with in vitro data, these results support the view that an alteration of TP53, gained either by interaction with viral oncoproteins or by somatic mutations, is a crucial event in the pathogenesis of vulvar carcinomas, but that TP53 mutations are mainly associated with disease progression. Finally, a preliminary immunocytochemical analysis seems to speak against the possible involvement of both MDM2 and BCL-2 gene products in the development of vulvar carcinoma.