20-Year trends of hospitalisation among people with dementia: a region-wide retrospective cohort study from Lombardy, Italy

OBJECTIVES

The aim of this study was to investigate the trends of hospitalisations among people with dementia, linking region-wide hospital and demographic health records.

STUDY DESIGN

A retrospective cohort study was conducted using hospitalisation health records from the Lombardy region in Italy.

METHODS

The study included people aged ≥65 years with a diagnosis of dementia who were hospitalised between 2002 and 2020 in Lombardy, which is the most populated region in Italy with 10 million inhabitants. Using data on resident population, this study computed rates of hospitalisation by calendar year, age, sex and cause of hospitalisation.

RESULTS

In total, 340,144 hospitalised patients with dementia were included in the study. The rate of hospitalisation was 100.6 per 10,000 in 2002 and progressively decreased to 65.1 per 10,000 in 2020. The average age at hospitalisation in 2002 was 78.9 years for men and 81.8 years for women, which increased to 82.0 years and 84.2 years, respectively, in 2020. Respiratory diseases caused 10.4% of all hospitalisations in 2002 and grew steadily to 26.8% in 2020, becoming the leading cause of hospital admissions since 2017.

CONCLUSIONS

Hospitalisation patterns for people with dementia have changed over the last 20 years, reflecting evolving epidemiological trends and the impact of healthcare policies. Region-wide administrative health record data analysis should be further utilised to explore the health needs of people with dementia and inform the planning, implementation and monitoring of effective prevention strategies in this population group.

Trends of hospital admissions and mortality of patients with dementia: descriptive study in Lombardy

Background

In 2017 the amount of people globally affected by dementia was estimated about 50 million and is predicted to increase to 132 million by 2050. Coping with dementia is one of the most important challenges of governmental organizations’ agenda. The objective of this study is to analyse the hospital admissions trends and monitor the overall mortality in a population of older patients with dementia over the last two decades in northern Italy.

Methods

This study is based on the healthcare utilization database of the Lombardy region (Italy), considering on hospital discharge records and death registry flows. Primary or secondary diagnosis at admission of dementia was coded according to the ICD9-CM. We carried out descriptive analyses of hospital admissions’ data from 1 Jan 1999 to 31 Dec 2020 of older patients aged 65 or more. We then conducted a temporal analysis of mortality rate over the study period.

Results

A total of 15,683,024 hospital admissions occurred during the study period. Over the last two decades, the prevalence of dementia among patients admitted to acute care hospitals remained around 1.1-1.3%. Considering the total of 183,268 patients with dementia over the study period, the average age at admission increased from 80.2 in 1999 to 83.3 years old in 2020, whereas annual mortality rate increased from about 1,950 to 3,230 deaths per 10,000 person-years. The mortality rate ratio of patients with versus without dementia fluctuated between 1.28 and 1.70.

Conclusions

Our findings suggest that there is an ever-greater appropriateness of hospitalizations over the last two decades, supported by out-of-hospital care that led patients to hospitalization in increasingly late and serious phases of the disease. The present study has a great future potential as well as limitations, due to the dependence on a correct coding of cases by clinicians according to the ICD9-CM system.

Key messages

• We observed an increased mortality among older people with dementia admitted to hospital over the last two decades.

• Our descriptive study, based on the Lombardy regional healthcare database, provides evidence of an increasing appropriateness of hospitalizations.

Source and symptoms of COVID-19 among hospital workers in Milan

Background

Healthcare workers (HCWs) are commonly infected by SARS-CoV-2 and represent one of the most vulnerable groups. Adequate prevention strategies are necessary to guarantee HCWs’ safety, as well as to prevent dissemination of the infection among patients.

Aims

To describe a case series of SARS-CoV-2-positive HCWs in a large public healthcare organization in Milan (Italy) during the most devastating weeks of the epidemic and analyse the sources, symptoms and duration of SARS-CoV-2 infection.

Methods

This study included 172 SARS-CoV-2-positive HCWs who were infected between the 25th of February and the 7th of April 2020. A nasopharyngeal swab (NPS) and RT-PCR were used to indicate.

Results

Initially, the most common sources of infection were other positive HCWs (49%). Medical doctors and nursing assistants were most frequently infected, with infection rates of 53/1000 and 50/1000, respectively. COVID-19 departments were less affected than internal medicine, surgery, intensive care, or emergency room. The most commonly reported symptom was mild cough, while loss of smell (anosmia) and loss of taste (ageusia) were reported as moderate and severe by 30–40% of HCWs. The time necessary for 50% of workers to recover from the infection was 23 days, while it took 41 days for 95% of HCWs to become virus-free.

Conclusions

HCWs are commonly infected due to close contacts with other positive HCWs, and non-COVID departments were most affected. Most HCWs were asymptomatic or subclinical but contact tracing and testing of asymptomatic HCWs help identify and isolate infected workers.

Agreement Estimate among three Italian Cancer Registries in the Coding of Multiple Primary Cancers

Aims

The aim of the study was to compare agreement on the coding of multiple primary cancers (MPs) between three Italian cancer registries, the Ragusa Cancer Registry (RCR), the Cancer Registry of Romagna (RTRo), and the Tuscany Tumor Registry (RTT), that adhere to different rules for accepting MPs and to study whether coding according to common international rules (IARC-IACR) increased comparability.

Methods

One hundred cases were randomly extracted from the archives of each registry from those recorded as having more than one cancer. For each of the 300 patients, the number of independent cancers was attributed independently by one coder from each registry. The coders coded the series twice: once following the local registry rules and once according to the IARC-IACR rules. The agreement was estimated by couples of coders by means of Cohen's kappa statistics.

Results

The agreement on MP status between coders using local rules and definitions was good between the RTT and RCR (kappa = 0.77) and very good between the RTRo and RCR (kappa = 0.81) and the RTT and RTRo (kappa = 0.96). Exclusion of 23 expected discordant cases increased the agreement. The agreement reached with the use of the IARC-IACR rules was very good (RTRo vs RCR, 0.95; RTT vs RTR, 0.94; RTT vs RTRo, 0.95).

Conclusions

The comparison among the RTT, RTRo and RCR confirmed that the number of tumors considered MPs may be modified depending on the rules adopted. There were minor differences between the RTT and the RTRo since their rules were very similar. Most differences in agreement were with the RCR since its classification was conceptually different from the other two. The result on agreement with IARC-IACR rules is encouraging from the point of view of conducting a cooperative study among different registries on the incidence of MPs.

Prostate Cancer: Population-Based Survival Rates in Central Italy

Aims

To evaluate survival in prostate cancer patients in the Province of Florence where the Tuscany Cancer Registry is active.

Methods

The survival of 777 patients with prostate cancer diagnosed in the period 1985-87 was evaluated. The observed and relative survival rates 1, 3 and 5 years after diagnosis were computed. Also the prognostic effect of age, disease extension, tumor grade, histological verification, place of residence and year of diagnosis were evaluated using univariate and multivariate analysis.

Results

The observed survival was 73.4% 1 year, 42.5% 3 years and 29.2% 5 years after diagnosis. The relative survival was respectively 78.7%, 53.0% and 43.0%. Significant independent risks were evident when the disease was extended out of the prostate, for patients older than 80 years, for high grade tumors and for patients without histological verification.

Conclusion

The 5-year relative survival rate in the province of Florence is similar to those from other European Registries and the Latina Registry, but much lower than the one reported by the SEER program in the US. Data on histological verification percentage, availability of information on disease extension, and tumor grade are discussed as indicators of the quality of the diagnostic approach in comparison with other registries.

Induction of Lung Tumors and Lymphomas in BALB/c Mice by Metronidazole

Metronidazole, which is widely used in the treatment of «Trichomonas vaginalis», «Entamoeba histolytica» and «Giardia lamblia» infections, was administered to BALB/c mice by stomach tube in an aqueous solution at a dose rate of 2 mg/day for 100 days (total 200 mg) to test its carcinogenicity. The treatment induced a significant increase in lung tumors in male mice (p < 0.001) and provoked the appearance of lymphomas in females (p < 0.001). Although there is insufficient evidence to pass judgement on the potential carcinogenicity of metronidazole in man, the results of this and other investigations reported in the literature have demonstrated that metronidazole develops carcinogenic activity in rats and mice.

The Availability of Histologic Grading among 5,923 Italian Cancer Patients and Its Relationship with Survival: A Population-Based Study

Aim

The specific goal of the study was to evaluate the availability of the histologic grading of cancer and its effect on survival in an Italian population-based cancer series.

Methods

Data were drawn from the Tuscany Cancer Registry, active in central Italy since 1985. Among the cases incident during the period 1985 to 1989, bladder, prostate, colon, corpus uteri, rectum and stomach cancers, for which the proportion of graded cases exceeded 50%, were analyzed. Overall, 5,923 cancer cases were included. Ten-year relative survival rates by grade were computed.

Results

Overall, data on histologic grading was available only for 38% of cases. The sites most frequently graded were urinary bladder (80%), prostate (73%), colon (71%), corpus uteri (69%), rectum (65%) and stomach (56%). For all the cancer sites analyzed, the 10-year relative survival rates increased as the histologic grading improved. The grade distribution resulted related also to the disease extension, more limited the extension higher the proportion of well differentiated cases.

Conclusions

Due to the evidenced importance of histologic grading as a valuable prognostic factor, it should be requested by clinicians and reported by pathologists more frequently than has been done in the area.

Ink Spot Lentigo: Singular Clinical Features in a Case Series of Patients

Ink spot lentigo, also known as “reticulated black solar lentigo”, is a melanotic macula commonly described in fair-skinned individuals on sun-exposed areas of the body. Clinically it is a darkly pigmented type of solar lentigo; herein the term “ink spot” lentigo. In contrast to common solar lentigines, ink spot lentigo is reported as a unique lesion. However usually ink spot lentigo appears among several common solar lentigines. We report a series of 5 patients who presented ink spot lentigo with typical dermoscopic pattern but singular clinical features.

Neurocutaneous Melanosis in a Woman with Multiple Brain Melanocytomas, Cutaneous Melanocytosis and Oral Involvement

A 34-year-old female was referred to us for a consultation of her dermatological lesions (pigmented lesions present in her oral cavity and on her right shoulder) in May 2007. These lesions had been present since childhood. Recently, the patient had developed seizures and a headache. An MRI of the brain showed the presence of two intracranial masses. The intracranial tumours were surgically removed whereas skin and mucosal lesions were biopsied. Histological findings of brain tumours were consistent with a diagnosis of “melanocytoma” while cutaneous lesions presented “benign dermal melanocytic infiltrations”. Whole brain irradiation was performed. After 3 months a new melanocytic skin lesion appeared on the scalp with histological picture similar to the other cutaneous ones. At the 5-year follow-up examination no recurrence of intracranial tumour or other skin or mucosal lesions were registered. According to the clinical and histological findings, we classify our case as a form of neurocutaneous melanosis in a young adult patient and we present it for the rarity of this syndrome, for the difficulty of the diagnosis, for the potential aggressive behaviour of intracranial lesions that necessitates a constant attentive follow-up and for the unusual feature of new developing skin lesion during the course of the disease.

Jaw osteonecrosis in patients treated with bisphosphonates: an ultrastructural study

Osteonecrosis of the jaw is a severe bone disorder traditionally associated with periodontal disease, local malignancy, chemotherapy, glucocorticoid therapy, or trauma. Recently a growing number of publications reported the occurrence of osteonecrosis of the jaw in patients undergoing treatment with bisphosphonates. The mechanism by which bisphosphonates might contribute to the development of osteonecrosis of the jaw is far from being fully elucidated. Suppression of bone turnover, infection, tissue hypoxia and cellular toxicity were proposed as possible mechanisms by which bisphosphonates may exert adverse effects on bone metabolism. Here, we studied 25 consecutive patients treated with bisphosphonates for osteoporosis or tumoral pathologies. We provide good evidence of hyperactive osteoclastic bone resorption and suggest a direct cytotoxic effect of bisphosphonates on bone tissue through induction of osteocyte cell death. We also demonstrate that bisphosphonates only have limited adverse effects on bone vascular network.

Eccrine porocarcinoma of the face involving eyelids: a rare case report

Eccrine porocarcinomas (EP) are skin appendage tumors originating from the acrosyringium. Pagetoid form is rare and exceptionally it can involve eyelid. We report a 70-year-old patient presenting a lesion sited on the left cheek region involving the internal canthus, the dorsum of nose and the half inferior eyelid in full thickness. A wide surgical excision was performed and after 2 years of follow up no recurrences have been seen.

Effects of Ginko Biloba and caspase inhibitors on brain ischemia in the Mongolian Gerbil

AIM

Data reported in previous studies and our own previous experience have led us to explore the mechanism of and the degree of protection afforded by Ginko Biloba in a model of cerebral ischemia in the Mongolian Gerbil evaluating histological and neurological effects in this rodent.

METHODS

Mongolian Gerbils were divided into experimental groups: Group A consisted of animals subjected only to experimental ischemia; 5 minutes occlusion of the carotid arteries. Group B consisted of animals subjected to experimental ischemia and to a dose of Ginko Biloba, given intraperitoneally immediately before the surgical procedure. Group C consisted of animals subjected to experimental ischemia and to a dose of Ginko Biloba, given intraperitoneally immediately after the surgical procedure. Group D consisted of animals subjected to experimental ischemia and to a dose of the caspase inhibitors z-VAD.FMK and z-DEVD.FMK injected intracerebroventricularly through the right hemisphere before the surgical procedure. Group E consisted of animals subjected to experimental ischemia and to a dose of caspase inhibitors injected after the surgical procedure. Group F consisted of Sham-operated animals. Histological controls were done by H and E and the TUNEL method in the frontal cortex and caudate-putamen.

RESULTS

The percentage of normal cells was not statistically significant at analysis with H and E, whereas the TUNEL method showed good protection with Ginko Biloba and caspase inhibitors, when the latter is given in the reperfusion phase. These data were in agreement with data obtained at neurological examination.

CONCLUSION

We could say that cellular morphology is in itself an untrustworthy tool for judging the effects of ischemia and protective drugs; the TUNEL method may add important information about the different components of cellular death; the reperfusion phase may be critical for apoptotic phenomena; Ginko Biloba might protect neurons of the frontal cortex from both necrotic and apoptotic death in this model of ischemia.

Skin involvement from micropapillary bladder carcinoma as the first clinical manifestation of metastatic disease

Cutaneous metastases from transitional cell carcinoma (TCC) of the bladder occur infrequently. We report the case of a 68-year-old man presenting with an isolated skin nodule a few weeks after local excision of a micropapillary bladder carcinoma. This rare variant of TCC, which is strikingly reminiscent of the histological pattern of ovarian papillary serous carcinoma, is associated with poor prognosis and apparently high metastatic potential.

Regression of duodenal gastric metaplasia in Helicobacter pylori positive patients with duodenal ulcer disease

BACKGROUND

It is unclear whether the extent of duodenal gastric metaplasia is due to Helicobacter pylori and/or acid.

AIMS

To investigate the role of Helicobacter pylori eradication in the regression of duodenal gastric metaplasia in patients with duodenal ulcer maintained in acid suppression conditions.

METHODS

. Duodenal (anterior, superior inferior walls of first part of duodenum) and gastric antrum biopsies were obtained from 44 Helicobacter pylori positive duodenal ulcer patients. Helicobacter pylori infection was diagnosed by rapid urease test, histology and 13C-Urea Breath Test. Patients were treated with 20 mg omeprazole tid associated with 250 mg clarithromycin and 500 mg amoxycillin four times daily for 10 days and maintained with 20 mg omeprazole daily for 18 weeks. Control endoscopies were performed at 6 and 18 weeks after beginning treatment.

RESULTS

Duodenal gastric metaplasia regression was observed in all (32/32) patients in whom Helicobacter pylori was eradicated, but in only 3 out of 6 patients in whom eradication was not achieved (p<0. 001).

CONCLUSIONS

. The present results suggest that Helicobacter pylori eradication associated with prolonged acid suppression may represent a good therapeutic strategy to achieve duodenal gastric metaplasia regression and highlight the combined role of acid and Helicobacter pylori in the pathogenesis of duodenal gastric metaplasia.

Impairment of gastric secretion modulation in duodenal ulcer and in long-term PPI treatment: quantitative morphologic findings and pathophysiologic implications

Helicobacter pylori affects gastric secretion. This functional effect might have a morphometric counterpart. Therefore, the gastric cell secretory compartment was morphometrically assessed in different pathophysiologic conditions related to Helicobacter pylori infection. Nineteen Helicobacter pylori-positive nonduodenal ulcer subjects, 15 omeprazole chronically treated subjects, and 19 duodenal ulcer patients were studied against 19 controls. Somatostatin, gastrin, enterochromaffin-like, and parietal cell density was assessed in gastric biopsies. No differences in any cell type density were found between Helicobacter pylori-positive nonduodenal ulcer subjects and controls. On the contrary, differences were significant when comparing omeprazole and duodenal ulcer patients to controls (higher density of gastrin, enterochromaffin-like, and parietal cells, lower density of somatostatin cells). In duodenal ulcer a reversion to control values followed Helicobacter pylori eradication and ulcer healing. A direct linear correlation between enterochromaffin-like, gastrin, and parietal cell density was demonstrated. An almost complete map of mucosal cells involved in gastric secretion is provided by this study. The cell density pattern, identical to the omeprazole group, points to an impaired feedback control of secretion in duodenal ulcer. The reversion to control values after Helicobacter pylori eradication and ulcer healing demonstrates the pathogenetic role of Helicobacter pylori-host interaction in these changes.

Long-term prognosis of gastric cancer in a European country: a population-based study in Florence (Italy). 10-year survival of cases diagnosed in 1985-1987

This paper analysed, in a population-based series of 1976 gastric cancers diagnosed in Florence (Italy), from 1985 to 1987, the relationship between prognostic variables (demographic, clinical and pathological) and 10-year survival rates. Gastric cancer was mostly detected in elderly patients (mean age: 70.5 years) and at advanced stages (i.e. approximately 50% of the patients could not undergo radical surgery). Ten-year observed survival was 12.1% (95% confidence interval (CI): 10.6-13.6%) for the whole series and 20.8% (95% CI: 18.3-23.3%) for resected cases; relative survival was, respectively, 20.9% (95% CI: 18.4-23.4%) and 32.0% (95% CI: 28.1-35.9%). Ten-year relative survival was 86% for stage IA (95% CI: 73-99%) and 67% for stage IB (95% CI: 52-82%). Multivariate analysis showed a significantly better prognosis in females and a significantly worse prognosis in patients aged 65 years or more (reference: < or = 59 years). In addition, an independent prognostic effect was observed for pT in the resected cases (reference: pT3; pT1: RR = 0.47, 95% CI: 0.34-0.64; pT2 = 0.71, 95% CI: 0.58-0.87; pT4: RR = 2.02, 95% CI: 1.49-2.75), pN (reference: pN0; pN1: RR = 2.13, 95% CI: 1.70-2.68; pN2-3: RR = 3.14, 95% CI: 2.42-4.07; pN+ no. nodes involved unspecified: RR = 4.26, 95% CI: 3.11-5.83) and surgical margin involvement (reference: not involved; involved: RR = 1.36, 95% CI: 1.08-1.72). In addition, the stage, after adjustment for age, gender and surgical margin involvement, showed a strong independent prognostic value (reference: stage II; IA: RR=0.37, 95% CI: 0.25-0.57; IB: RR=0.70, 95% CI: 0.50-0.98; IIIA: RR = 1.80, 95% CI: 1.40-2.33; IIIB: RR = 2.82, 95% CI: 2.14-3.72; IV: RR = 3.29, 95% CI: 2.36-4.59). In conclusion, on the basis of a large population-based series, our results confirm the prognostic effect on long-term gastric cancer survival of pathological and demographic variables. In addition, the study shows that Italy had a relatively good, long-term survival when diagnosis was performed at early stages. However, only a few cases were diagnosed at stages when cure by radical surgery is more likely (i.e. stage I accounted for approximately 20% of the resected cases and less than 10% of all incident cases).

Expression of nm23 gene in gastric cancer is associated with a poor 5-year survival

The nm23 gene is thought to play a role as an inhibitor of metastatic progression in several human cancers and its down-regulation has been associated with increased metastasis and reduced survival in some studies, though not in others. To better investigate the role of nm23 in gastric cancer (GC), the expression and prognostic impact of this gene was examined in 107 radically operated GC patients in a high risk area. The expression of nm23 was determined immunohistochemically by using the rabbit antibody anti-human nm23 protein. The expression of nm23 was detected in 40.2% (n = 43) of 107 gastric tumours and correlated with a poorer clinical outcome. In a survival analysis at 5 years, patients with nm23-positive tumours had significantly worse prognosis than patients (n = 64) with nm23-negative tumours (p < 0.05). The prognostic significance of nm23 expression was confirmed by multivariate analysis including terms for tumour stage and lymph node involvement. Our results suggest that the expression of the nm23 gene in gastric carcinoma is significantly related to tumour progression and poor prognosis at 5 years.

Red meat, family history, and increased risk of gastric cancer with microsatellite instability

Microsatellite instability (MSI) occurs frequently in sporadic gastric cancer (GC) and may define a distinctive molecular pathway of carcinogenesis. We evaluated the role of dietary risk factors in GC according to MSI status. A large series of 382 GC cases and 561 controls were originally identified in a population-based case-control study carried out in the high-risk area around Florence, Italy; 126 GC patients were typed for MSI status. A MSI+ phenotype was detected in 43 of 126 cases (34.1%), whereas 83 cases were classified as MSI-. A multinomial logistic regression model was used to compare the two subgroups of GC classified according to MSI status in the same analysis, with all of the available population controls. A case-case approach was also used. The risk of MSI+ tumors was positively associated with high consumption of red meat and meat sauce and negatively associated with consumption of white meat. A positive association was also seen with total protein and nitrite intake, whereas no relation was found with micronutrient intake. Risk was especially high among subjects reporting both a positive GC family history and a high consumption of red meat (odds ratio, 25.7; 95% confidence interval, 6.4-102.8). For MSI- tumors, a significant protective effect was associated with frequent consumption of citrus and other fresh fruit, garlic, legumes, vegetables, and olive oil and with high intake of beta-carotene and other antioxidants and sugar, whereas positive associations were seen with protein and sodium intake. In summary, a specific dietary pattern emerged for MSI+ gastric tumors, suggesting that factors related to red meat consumption are involved in this pathway, particularly among individuals with a positive family history. In contrast, the risk of MSI- tumors was strongly reduced by the frequent consumption of fresh fruit and vegetables.

Gastric carcinomas of intestinal type concur with distant changes in the gastric mucosa. A multicenter study in the Atlantic basin

Population studies in the Pacific Basin showed that gastric carcinomas of intestinal type often concur with distant mucosal changes (DMCs). In the present work, the presence of DMCs was investigated in populations dwelling in the Atlantic Basin. A total of 1737 gastrectomy specimens were reviewed: 627 in New York, 435 in Reykjavik, 198 in Buenos Aires, 186 in Florence, 174 in London and the remaining 117 in Stockholm. A total of 17,282 sections were carefully scrutinized. The following DMCs were investigated: intramucosal glandular cysts, gastric cells with ciliated metaplasia, with large or small mucus negative vacuoles, and extensive intestinal metaplasia (IM). The highest frequencies of DMCs were found in Florence for specimens with intestinal type carcinoma: 41.3% had intramucosal cysts, 22.4% had cells with ciliated metaplasia, 12.9% cells with large vacuoles, and 50.9% had high IM. The highest frequency of gastric cells with small vacuoles was recorded in New York (9.1%), also in specimens with intestinal type carcinoma. Significantly lower DMCs percentages were found in specimens with carcinomas of diffuse type, and miscellaneous gastric diseases. The occurrence of DMCs was not influenced to a significant degree by the number of sections available per gastrectomy. Since environmental factors trigger the evolution of intestinal type carcinomas and as DMCs also occurred in specimens without carcinoma-although at a significantly lower rate--it is conceivable that DMCs are also evoked by environmental factors (before a gastric carcinoma ensues). DMCs were found in specimens having intestinal carcinomas either in the cardia, the corpus or the antrum. Thus, DMCs seem to provide the adequate "soil" for the development of gastric carcinomas of intestinal type, independently of the future localization of that tumor in the stomach.

Primary leiomyosarcoma of the pancreas: a case report and review of literature

Primary leiomyosarcoma of the pancreas is a rare tumor for which only 21 reports appear in the world literature. We describe an additional case of pancreatic leiomyosarcoma in a 76-year-old man, who complained of persistent high fever. Histologic examination revealed a pleomorphic spindle cell tumor. Reactivity for muscle-specific actin, alpha-smooth muscle actin, and basement membrane components, along with negative staining for epithelial and neural markers, were consistent with a smooth muscle sarcoma. The patient died of disease 1 year after complete surgical excision. This report highlights the need to use a complete antibody panel in order to accurately immunophenotype pleomorphic malignant tumors of the pancreas. A review of the cases compiled in the literature indicates that pancreatic leiomyosarcoma, like its counterpart arising in deep soft tissues, is an aggressive neoplasm characterized by short survival and a high rate of metastases.

Villous and serrated adenomatous growth bordering carcinomas in inflammatory bowel disease

The histologic phenotype of the dysplastic lesion juxtaposing colorectal carcinomas was assessed in 100 consecutive colectomy specimens: in 50 patients with inflammatory bowel disease (IBD) and in 50 controls (non-IBD patients). Adenomatous growths (AG) were regarded both Dysplasia Associated Lesion or Mass (DALM) and sporadic adenomas. AGs juxtaposing carcinomas were found in 76% (n = 38) of the IBD cases: 52.3% (20 out of 38) were villous, 28.9% (11 out of 38) serrated, 5.3% (2 out of 38) tubular and the remaining 13.2% (5 out of 38) were mixed AGs. Juxtaposing AGs (sporadic adenomas) were also found in 58% (n = 29) of the control cases: 51.7% (15 out of 29) were villous, 6.9% (2 out of 29) tubular, 3.4% (1 out of 9) serrated and the remaining 37.9% (11 out of 29) were mixed. The majority or 81.2% (31 out of 38) of the dysplastic lesions juxtaposing IBD carcinomas were villous or serrated AGs, but only 55.1% (16 out of 29) in control cases. Serrated AGs in particular accounted for nearly 29% of the non-invasive dysplastic lesions abutting IBD carcinomas but only for 3% in control specimens. It would appear that villous and serrated AGs are the most common non-invasive neoplastic lesions from which IBD carcinomas originate.

Dietary and familial determinants of 10-year survival among patients with gastric carcinoma

BACKGROUND

Although the role of diet in gastric carcinoma (GC) causation has been investigated extensively, its association with long term survival has never been explored in detail.

METHODS

The authors assessed the vital status on December 31, 1997 of a series of 382 patients with GC who were interviewed in 1985-1987 in the framework of a population-based case-control study in a high risk area for GC in Italy. Follow-up information at 10 years was available for all but three patients. The risk of dying was evaluated by Cox proportional hazard models, including patient age, gender, social status, disease stage at diagnosis, and lymph node involvement as confounding variables.

RESULTS

The overall survival probability was 0.26 at 5 years and 0.18 at 10 years after interview. The most important predictors were disease stage, lymph node involvement, and histopathologic grading (TNM classification). Overall, a high intake of alcohol was associated with an increased risk of dying (P = 0.02). In contrast, survival was increased in patients with a high intake of alpha-tocopherol (P = 0.04). A positive first-degree family history of GC was reported by 84 patients and tended to be associated with a reduced risk of death. A significant protective trend was found with increasing intake of vegetable fat and starch among these familial cases, with a 50% risk reduction. In contrast, this subgroup showed a two-fold increased risk of dying with a high intake of animal protein, animal fat, and preformed N-nitrosodimethylamine.

CONCLUSIONS

The current results provide evidence that premorbid diet may influence the prognosis of patients with GC, and they suggest that specific pathways for disease progression may exist among familial cases.

[Histopathologic examination of the intervertebral lumbar disk. Evaluation of its usefulness and limitations]

A retrospective clinical-pathological review of 192 lumbar intervertebral discs removed via an interlaminar approach or percutaneous nucleotomy from patients suffering from sciatic pain was carried out in order to assess if routine examination is useful. Only for a case of our series, which showed ill defined features at preoperative neuroradiologic imaging, an intraoperative pathologic examination was necessary. Immunohistochemical study was never required. A routine examination with a hematoxilin-eosin stain was sufficient also to recognize postoperative scar in patients reoperated. In conclusion we think that routine examination of the intervertebral disc is a procedure which is not expensive and useful to assess the nature of the lesion in reoperated patients and in rare cases showing unclear radiologic pattern.

Dietary and familial determinants of 10-year survival among patients with gastric carcinoma

BACKGROUND

Although the role of diet in gastric carcinoma (GC) causation has been investigated extensively, its association with long term survival has never been explored in detail.

METHODS

The authors assessed the vital status on December 31, 1997 of a series of 382 patients with GC who were interviewed in 1985-1987 in the framework of a population-based case-control study in a high risk area for GC in Italy. Follow-up information at 10 years was available for all but three patients. The risk of dying was evaluated by Cox proportional hazard models, including patient age, gender, social status, disease stage at diagnosis, and lymph node involvement as confounding variables.

RESULTS

The overall survival probability was 0.26 at 5 years and 0.18 at 10 years after interview. The most important predictors were disease stage, lymph node involvement, and histopathologic grading (TNM classification). Overall, a high intake of alcohol was associated with an increased risk of dying (P = 0.02). In contrast, survival was increased in patients with a high intake of alpha-tocopherol (P = 0.04). A positive first-degree family history of GC was reported by 84 patients and tended to be associated with a reduced risk of death. A significant protective trend was found with increasing intake of vegetable fat and starch among these familial cases, with a 50% risk reduction. In contrast, this subgroup showed a two-fold increased risk of dying with a high intake of animal protein, animal fat, and preformed N-nitrosodimethylamine.

CONCLUSIONS

The current results provide evidence that premorbid diet may influence the prognosis of patients with GC, and they suggest that specific pathways for disease progression may exist among familial cases.

Hodgkin's disease risk is increased in patients with ulcerative colitis

BACKGROUND & AIMS

All patients diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) residing in Florence, Italy, in 1978-1992 were identified and included in a population-based study of cancer risk evaluation.

METHODS

A total of 920 patients were followed up (median, 11 years), and 64 newly diagnosed malignancies were identified by linkage to the local cancer registry. Expected cases were calculated on the basis of age- and sex-specific cancer incidence rates to estimate relative risks in comparison with the general population.

RESULTS

Overall, cancer incidence rates were not increased. A significant excess risk of Hodgkin's disease was observed among patients with UC (standardized incidence ratio, 9.3; 95% confidence interval [CI], 2.5-23.8). Respiratory tract cancers were significantly reduced to one fourth of the expected rate in patients with UC, but tended to be increased among patients with CD, who had a 50% higher risk of cancer at all sites. Only a nonsignificant, modestly increased risk of colorectal cancer was observed.

CONCLUSIONS

A strongly increased risk of Hodgkin's disease was evident in this first cancer follow-up of a representative series of patients with UC in a Mediterranean country. Two divergent risk patterns of respiratory tract cancers, possibly explained by differences in smoking habits, emerged in the 2 inflammatory bowel diseases.

Helicobacter pylori cag pathogenicity island is associated with enhanced interleukin-8 expression in human gastric mucosa

BACKGROUND

In vitro studies showed that Helicobacter pylori strains carrying the cag pathogenicity island are able to induce epithelial secretion of Interleukin-8.

AIMS

To evaluate the assessment of cag pathogenicity island and the expression of Interleukin-8 in the gastric mucosa of Helicobacter pylori-infected patients and correlate these data with the activity of gastritis and Helicobacter pylori density.

METHODS

cag status was determined by polymerase chain reaction directly on gastric biopsies from 13 Helicobacter pylori+ patients with non-ulcer dyspepsia and 13 Helicobacter pylori+ with duodenal ulcer. Interleukin-8 gene transcription and protein expression were analysed by in situ hybridization and immunofluorescence, respectively. Gastritis activity and Helicobacter pylori density were also investigated.

RESULTS

cag was present in 20/26 of Helicobacter pylori+ patients: in 7/13 non-ulcer dyspepsia (53.8%] and in 13/13 duodenal ulcer patients (100%), (p<0.05). Interleukin-8 mRNA and protein expression in epithelial and inflammatory cells was higher in cag+ than in cag- patients (p<0.005). Gastritis activity significantly correlated with cag (p<0.05) and Interleukin-8 expression (p<0.005]. Helicobacter pylori density was enhanced in cag+ [p<0.005] and correlated with Interleukin-8 expression (p<0.0051.

CONCLUSIONS

The present study demonstrates that in Helicobacter pylori-infected human gastric mucosa, cag+ infection is associated with enhanced Interleukin-8 expression, higher levels of active gastritis and bacterial density, and presence of duodenal ulcer.

Genetic and immunohistochemical analyses of p53 independently predict regional metastasis of gastric cancers

Either p53 gene mutation or immunohistochemical detection of p53 protein has not been consistently shown to have prognostic significance in human cancers, including gastric carcinomas. One hypothesis to explain this inconsistency is that some p53 mutations and p53 protein accumulation are not indicative of tumor progression. To test this hypothesis, we categorized p53 status in 105 gastric carcinomas according to types of mutations, numerical scores of immunohistochemical staining (IHC), or combinations thereof. The p53 status was then correlated with metastasis to liver or peritoneum. Gastric cancers with no p53 mutations were significantly less likely to metastasize than tumors with mutations. Intermediate IHC scores were inversely associated with metastasis. A substantial number of gastric cancers (31 of 105) showed positive p53 immunostaining without detectable mutations (p53-/IHC+), which suggested an accumulation of wild-type p53 protein, and also a significantly lower risk for metastasis. After adjusting for depth of invasion and lymph node involvement, the p53-/IHC+ combination predicted low metastatic risk better than either p53- or IHC+ with intermediate scores. These findings suggest that an accumulation of wild-type p53 protein occurs in gastric cancer cells and represents a stress-response mechanism that lowers metastatic potential.

Calf pseudohypertrophy in a patient with double neurogenic pathology

A pseudohypertrophy of the calf can be rarely associated with neurogenic pathologies as S-1 radiculopathy, poliomyelitis, spinal muscular atrophy, traumatic lesions of peripheral nerves, intraspinal neurinoma. The causes of this particular phenomenon are unknown. The authors present the case of a 52-year-old man with an enlargement of the left calf suffering from a mild form of spinal paralytic poliomyelitis in the early childhood and episodes of severe left sciatica in the last four years. Electromyography demonstrated a pattern of denervation in both legs and an H-reflex absent when the left tibial nerve was stimulated. An open muscle biopsy of the left calf was performed. Light microscopic and ultrastructural examination of the muscle confirmed the presence of a pattern of "neurogenic type" pseudohypertrophy. Our results could be interesting for the understanding of the mechanism of neurogenic pseudohypertrophy. This case suggests that timing of stimulus or "dose" of denervation may be important factors in such a phenomenon.

Intraoperative parathormone measurement in patients with multiple endocrine neoplasia type I syndrome and hyperparathyroidism

Total or subtotal parathyroidectomy is considered the treatment of choice for multiple endocrine neoplasia type I (MEN-I)-associated primary hyperparathyroidism (HPT). However, persistent or recurrent HPT is frequently observed. The development of a rapid two-site immunoradiometric assay (IRMA) method for measuring intact parathormone (PTH) has provided a valuable tool for recognizing possible surgical failures. Our experience includes 16 MEN-I patients (10 females, 6 males) of mean age 35.5 years operated on between 1990 and 1996. Total parathyroidectomy (TPTX) with autotransplantation of parathyroid tissue was the standard treatment. Blood samples for PTH measurement were drawn at the induction of anesthesia (basal value), 10 and 20 minutes after the removal of each gland, and 60 minutes after TPTX. Rapid PTH measurement, which required only 15 minutes of incubation at 37 degrees C, showed a highly significant correlation (p < 0.0001) with the standard method. Circulating PTH levels exhibited a stepwise decrease during TPTX, reaching a mean value of 22.3% of the baseline 20 minutes after removal of the last gland. Two patients showed a prompt decrease of PTH after removal of the single enlarged gland, featuring the kinetics observed in the adenomas. One of these two patients was successfully treated with more conservative surgery. None of the patients showed persistence or recurrence of HPT. In our experience, intraoperative measurement of PTH seems to be a valuable adjunct in both the diagnosis of multiglandular involvement and the prediction of surgical treatment in patients with primary parathyroid hyperplasia.

Parathyroid glands: combination of (99m)Tc MIBI scintigraphy and US for demonstration of parathyroid glands and nodules

PURPOSE

To determine the appropriate choice of imaging techniques for localization of nodular lesions of parathyroid glands.

MATERIALS AND METHODS

First, computed tomographic (CT), magnetic resonance (MR), ultrasonographic (US), and technetium 99m methoxyisobutyl-isonitrile (MIBI) scintigraphic images in 49 patients with primary hyperparathyroidism were retrospectively evaluated. A single-blind, prospective study that included 16 patients with primary hyperparathyroidism was then conducted. MR, US, scintigraphic, and color Doppler US images of the neck were obtained and analyzed.

RESULTS

In the retrospective study, CT, MR imaging, and US had low sensitivity (13%, 17%, and 27%, respectively) and specificity (39%, 65%, and 65%, respectively). Scintigraphy had 57% sensitivity and 85% specificity. In the prospective study, the use of latest-generation MR and US equipment and the participation of experienced operators led to improved sensitivity and specificity for these techniques. The combination of US and scintigraphy resulted in improved sensitivity (96%), specificity (83%), and positive and negative predictive values (88% and 94%, respectively), relative to the results obtained with either method alone. Doppler US was of little help in the setting of small glands.

CONCLUSIONS

The combination of (99m)Tc MIBI scintigraphy and US performed by well-trained operators with up-to-date instruments appeared to be the best diagnostic tool for the preoperative diagnosis of parathyroid disease.

Differing patterns of transforming growth factor-beta expression in normal intestinal mucosa and in active celiac disease

BACKGROUND

Growth-inhibitory autocrine polypeptides such as transforming growth factor (TGF)-beta may play a role in the control of normal epithelial cell proliferation and differentiation. In addition, TGF-beta has a central role in extracellular matrix homeostasis and regulates the immune response at the local level. In this study immunohistochemistry was used to examine the pattern of TGF-beta protein distribution and quantitative reverse transcription-polymerase chain reaction (RT-PCR) to determine levels of TGF-beta messenger RNA expression in normal intestinal mucosa and in the flat mucosa of children with celiac disease.

METHODS

Small intestinal biopsies were performed in children with active celiac disease and in histologically normal control subjects. Frozen sections were single stained using an anti-TGF-beta monoclonal antibody and were double stained for TGF-beta and T cell, macrophages, and the activation marker CD25. Total RNA was extracted from frozen specimens and competitive quantitative RT-PCR performed for TGF-beta mRNA using internal synthetic standard RNA.

RESULTS

In normal intestinal mucosa, by immunohistochemistry, TGF-beta expression was most prominent in the villous tip epithelium, whereas in the lamina propria, weak immunoreactivity was present. The celiac mucosa showed weak and patchy epithelial TGF-beta immunoreactivity. In contrast, an intense staining positivity was present in the lamina propria localized mostly in the subepithelial region where T cells, macrophages, and CD25+ cells were detected by double staining. By quantitative RT-PCR, levels of TGF-beta mRNA transcripts appeared to be increased in celiac intestinal mucosa compared with that in control subjects, although the difference did not reach statistical significance.

CONCLUSIONS

These observations suggest that TGF-beta expression is associated with differentiated enterocyte function. In celiac disease the lower TGF-beta epithelial cell expression could be a consequence of the preponderance of a less differentiated epithelial cell phenotype also present in the surface epithelium. In contrast, the prominent TGF-beta positivity of the subepithelial lamina propria suggests an association with the local immune and inflammatory response, as well as a potential role of these peptides in mesenchymal-epithelial cell interaction.

Inducible nitric oxide synthase expression in vascular and glomerular structures of human chronic allograft nephropathy

Nitric oxide (NO) plays an important role in the cytotoxic mechanisms responsible for acute renal allograft rejection, where macrophages produce high levels of inducible nitric oxide synthase (iNOS). By contrast, both the source and the role of NO in chronic allograft nephropathy (CAN) are still unclear. In this study, the expression of iNOS mRNA and protein was assessed in the kidneys of patients with graft failure due to chronic rejection. As controls, kidney specimens were obtained from patients undergoing nephrectomies for primary renal tumours, and from patients suffering from IgA nephropathy or mesangial-proliferative glomerulonephritis. In normal kidneys, iNOS production was absent or limited to a low signal, while it was found only in the inflammatory infiltrate of kidneys affected by glomerulonephritis, as assessed by immunohistochemistry and in situ hybridization. In contrast, in CAN, iNOS protein was localized not only in inflammatory cells, but also in vascular, glomerular, and, more rarely, tubular structures. Accordingly, in situ hybridization localized iNOS mRNA in both macrophages and lymphocytes, as well as in vascular structures and glomeruli. Double immunostaining for iNOS and a-smooth muscle actin (a-SMA) or von Willebrand factor (vWf) revealed that smooth muscle cells were the main vascular source of iNOS, while both mesangial and inflammatory cells were immunostained at the glomerular level. These data demonstrate that macrophages and lymphocytes are not the only source of iNOS mRNA and protein in human CAN. Vascular smooth muscle and mesangial cells also synthesize iNOS, raising the question of heterogeneous regulation and function of iNOS in this disease.

Estimation of prostate cancer volume by endorectal coil magnetic resonance imaging vs. pathologic volume

OBJECTIVE

Since tumor volume is recognized as an important predictor of clinical stage and disease outcome of prostate cancer, accurate preoperative estimation of tumor volume can play an important role in planning the appropriate treatment and establishing a patient's prognosis. We performed this study to evaluate the accuracy of the endorectal coil magnetic resonance (MR) technique for reliable prediction of tumor volume in patients with prostatic cancer.

MATERIAL AND METHODS

Endorectal coil MR imaging was performed in 57 consecutive men who were suspected to have prostate cancer. Subsequent ultrasound-guided transrectal biopsy revealed prostate cancer in 44 cases. The pathological volume of the surgical specimens of 25 selected patients who underwent radical prostatectomy was retrospectively compared to the volume estimated by endorectal coil MR studies, and the Pearson correlation coefficient was calculated.

RESULTS

In 15 patients the estimated size of the tumor was within 15% of the true tumor volume; in the remaining 10 cases MR imaging tended to underestimate large tumors and overestimate small ones. A significant correlation between the volumes as determined with MR imaging and measurements of surgical specimens was observed (r 0.94; slope 0.82). To our knowledge, this is the best correlation found between pathological volume and tumor volume as evaluated by any other imaging modality.

CONCLUSIONS

Endorectal coil MR imaging is a powerful means of evaluating the prostate gland; however, further improvements in imaging and/or volume calculation are required to provide a more accurate preoperative assessment of prostate cancer volume.

Implications of p53 mutation spectrum for cancer etiology in gastric cancers of various histologic types from a high-risk area of central Italy

Examination of p53 mutation spectra may provide clues to molecular mechanisms involved in different histologic types of gastric cancer. A total of 105 gastric cancer cases classified according to the Laurén's system were selected from a high-risk area around Florence, Italy. Exons 5-8 of the p53 gene were examined for mutations by the polymerase chain reaction-single strand conformation polymorphism technique and DNA sequencing, using DNA from formalin-fixed paraffin-embedded tissues. Mutation frequency was similar in intestinal-type (12/28) and unclassified tumors (9/18), but was significantly lower in diffuse cancers (12/57, P < 0.05). A similar frequency of p53 mutations was observed among tumor stages in both intestinal-type and unclassified cancers, but in diffuse tumors mutations tended to be associated with invasion beyond the muscularis propria. When base changes were considered, G:C-->A:T transitions at CpG sites were the most common mutations for all the three tumor types with 6 of 11 (55%) in intestinal type, 8 of 12 (67%) in diffuse type, and 5 of 8 (63 %) in unclassified tumors. Frequent p53 mutations in both intestinal-type and unclassified tumors support the hypothesis that unclassified tumors represent variants of the intestinal type and suggest that unclassified tumors, like the intestinal type, may also associate with environmental exposures. The predominance of G:C-->A:T transitions at CpG sites, which are associated with methyltransferase-induced DNA methylation at carbon 5 of cytosine, in all three tumor types suggests that the status of DNA methylation may be the major determinant for p53 mutations and may be also equally important in gastric carcinogenesis regardless of histology.

Mutations at coding mononucleotide repeats in gastric cancer with the microsatellite mutator phenotype

We analysed 50 gastric carcinomas (GCs) to verify whether mutations at coding repeats were associated with microsatellite instability (MSI). The tumors included: ten cases with no MSI, 14 cases with MSI = 1 locus, 13 cases with MSI = two loci and 13 cases with MSI > or = 3 loci. We investigated coding repeats within the TGF-beta RII, IGFIIR, BAX, hMSH6, hMSH3 and BRCA2 genes. The TGF-beta RII, IGFIIR, BAX, hMSH6 and hMSH3 repeats were altered in 11 (22%), five (10%), four (8%), 16 (32%) and five (10%) cases respectively. Mutations occurred only in MSI-positive (MSI+) tumors and correlated with increasing MSI levels. No alterations of the BRCA2 repeat were found. Mutations in genes other than hMSH6 were strongly associated to hMSH6 mutations, suggesting a key role of this gene. The non-coding BAT-26 and E-Cadherin 3' UTR poly(A)8/(T)15 repeats were analysed in 44 of the 50 cases. Novel tumor-associated alleles were observed only in MSI-positive GCs and were in most cases associated with mutations at coding repeats. Further investigations with BAT-40 confirmed that four cases manifested mononucleotide repeat alterations restricted to hMSH6 and one case to TGF-beta RII. A subset of tumors with MSI at two or more dinucleotide loci resulted negative for mutations at coding and non-coding mononucleotide repeats.

Substance P and vasoactive intestinal polypeptide but not calcitonin gene-related peptide concentrations are reduced in patients with moderate and severe ulcerative colitis

BACKGROUND AND AIMS

Ulcerative colitis is a chronic inflammatory condition characterized by an altered intestinal immunoinflammatory response. Since increasing evidence indicates that neuropeptides play a key role in the regulation of gastrointestinal immune function, the aims of this study were: a) to determine tissue and plasma levels of Vasoactive Intestinal Polypeptide, Substance P, and Calcitonin Gene-Related Peptide in patients with ulcerative colitis, and b) to ascertain whether a relationship exists between tissue concentrations of neuropeptides and the histological grading of mucosal inflammation.

METHODS

A total of 29 patients with active and 39 with inactive ulcerative colitis, and 16 control subjects took part in the study. Biopsy specimens of colonic mucosa and blood samples were obtained from each subject, and neuropeptide concentrations were measured by sensitive and specific radioimmunoassays.

RESULTS

Both Vasoactive Intestinal Polypeptide and Substance P concentrations were found to be significantly reduced in endoscopic biopsy specimens of patients with ulcerative colitis compared to controls (p < 0.01 and p = 0.05, respectively), and the reduction appeared to be related to the degree of mucosal inflammation; in contrast, Calcitonin Gene-Related Peptide tissue levels were unchanged. In addition, there was no significant difference in the neuropeptide plasma levels between ulcerative colitis patients and control subjects.

CONCLUSIONS

Taken together, our results suggest that the reduction of Vasoactive Intestinal Polypeptide and Substance P is probably a secondary phenomenon, correlated with the degree of mucosal inflammation; whatever the mechanism, the decreased availability of these neuropeptides in the local microenvironment may play an important role in the pathogenesis of ulcerative colitis, by affecting many components of the normal immune response. Moreover, based on our data, the measurement of neuropeptide plasma concentrations does not appear to be a useful tool to monitor disease activity.

Diet, Helicobacter pylori, and p53 mutations in gastric cancer: a molecular epidemiology study in Italy

A series of 105 gastric cancer (GC) cases with paraffin-embedded specimens interviewed in a previous population-based case-control study conducted in a high-risk area around Florence, Italy, was examined for the presence of p53 mutations. Overall, 33 of 105 cases had a mutation (p53+) identified by single-strand conformational polymorphism and confirmed by sequencing (Y-H. Shiao et al., submitted for publication). p53+ cases had a more traditional dietary pattern (i.e., corn meal mush, meat soup, and other homemade dishes) and reported less frequent consumption of raw vegetables (particularly lettuce and raw carrots). A positive association with a high nitrite intake and a negative association with raw vegetables and diffuse type histology persisted in a multivariate analysis. In addition, p53+ cases tended to be located in the upper portion of the stomach and to be associated with advanced age and blood group A. No relation was found between the presence of p53 mutations and histologically defined Helicobacter pylori infection, smoking history, family history of gastric cancer, education, and social class. Of the 33 p53+ cases, 19 had G:C-->A:T transitions at CpG sites. These tumors tended to occur in females and in association with H. pylori infection but not other risk factors. The remaining 14 cases with a p53 mutation had mainly transversions but also two deletions and two transitions at non-CpG sites. These tumors showed a strong positive association with a traditional dietary pattern and with the estimated intake of selected nutrients (nitrite, protein, and fat, particularly from animal sources). The findings of this case-case analysis suggest that p53 mutations at non-CpG sites are related to exposure to alkylating compounds from diet, whereas p53 mutations at CpG sites might be related to H. pylori infection.

[Magnetic resonance with an endorectal coil and a fast spin echo sequence in the staging of prostatic carcinoma. The correlation with histopathological data]

INTRODUCTION

We investigated the accuracy of endorectal coil Magnetic Resonance Imaging (MRI) and Fast Spin Echo (FSE) technique in staging prostate cancer.

MATERIAL AND METHODS

MRI was performed in 70 patients with biopsy proved prostatic cancer. A total of 33 patients subsequently underwent radical prostatectomy. T2-weighted FSE sequences (TR 3400-4100, TE 120, Echo train length 13) were acquired in all patients. Axial, sagittal and coronal 4-5 mm images were obtained with 13-14 cm field of view and 256 x 256 matrix. Additional T1-weighted spin echo images were acquired in 9 patients. Lesion staging on MR images was performed according to the American Urological System. MR data were compared with the pathologic findings of whole-mount sections of the surgical specimens.

RESULTS

Overall accuracy for endorectal coil MR imaging was 60%; ten cases were underestimated and 3 cases were overestimated. The sensitivity and the specificity of endorectal coil MRI in diagnosing capsular penetration were 77% and 81%, respectively. Seminal vesicle invasion was detected with 87% sensitivity and 96% specificity.

CONCLUSIONS

Endorectal coil MRI provides a more accurate preoperative local staging.

Microsatellite instability in gastric cancer is associated with tumor location and family history in a high-risk population from Tuscany

We studied the presence of microsatellite instability (MSI) in a series of 108 gastric cancers (GCs) previously identified in an epidemiological study carried out in a high-risk area around Florence. To investigate associations between MSI and GC family history, 34 cases (31.5%) who had a GC-affected first-degree relative were included in the series. A family history positive for colorectal cancer was reported quite rarely (5.6%). The analysis of 6 microsatellite loci in DNA from paired normal tissue and tumor samples microdissected from paraffin-embedded specimens revealed varying degrees of instability: 56 cases (51.8%) did not show instability at any of the 6 loci; 19 (17.6%) showed instability at 1 locus; 16 (14.8%) showed instability at 2 loci; 11 (10.2%) showed instability at 3 loci; 4 (3.7%) showed instability at 4 loci; and 2 (1.9%) showed instability at 5 loci. The replication error-positive (RER+) phenotype, defined as the presence of MSI at 2 or more loci, had a frequency of 30.6% (33 of 108) and tended to be positively associated with female sex, intestinal histological type, advanced tumor stage, vascular invasion, positive GC family history, and blood group of A type. No correlation emerged between age at diagnosis and RER+ phenotype, whereas a significant association with the RER+ phenotype was shown by the antral location. A multivariate analysis adjusting for a selected group of potential confounding factors confirmed the strong association of the RER+ phenotype with the antral location (P = 0.001) and with a positive GC family history (P < 0.05). Survival analyses at 5 and 8 years showed no difference between RER+ and RER- patients, even when corrected for stage distribution. By the microdissection technique, we also used microsatellite allele patterns to investigate intratumoral heterogeneity and genetic relationships between tumors and adjacent dysplasia and/or intestinal metaplasia. Areas of metaplasia and dysplasia demonstrated MSI only in cases with MSI-positive tumors. In MSI-positive tumors, there was consistent evidence of intratumoral microsatellite allele heterogeneity, indicating the presence of genetically divergent tumor cell clones within the same neoplasm.

Expression of epidermal growth factor, transforming growth factor-alpha and their receptor in the human oesophagus

Increasing evidence indicates that epidermal growth factor and transforming growth factor-alpha are involved in the maintenance of oesophageal mucosal integrity. However, their cellular origin and the exact localization of their receptor in the oesophagus are still unclear. Therefore, we examined the expression of the two growth factors and their shared receptor in the normal human oesophagus at both mRNA and protein level, by immunohistochemistry, in situ hybridization and reverse transcription-polymerase chain reaction. In addition to being expressed in the proliferative compartment of the oesophageal epithelium, the receptor was found in a variety of cells, including smooth muscle cells, submucosal gland cells and the epithelium lining their ducts. Immunohistochemically, the pattern of distribution of epidermal growth factor paralleled that of its receptor. In situ hybridization demonstrated epidermal growth factor mRNA expression in the oesophageal epithelium and submucosal glands. Additionally, amplified transcripts of predicted size were detected by reverse transcription-polymerase chain reaction, thus confirming that authentic transcripts of the growth factor exist in the normal human oesophagus. Transforming growth factor-alpha mRNA and protein expression, while similar to that of epidermal growth factor, predominated in the more differentiated cell layers of the stratified squamous epithelium. These results demonstrate that the normal oesophagus can synthesize both growth factors. Moreover, the peculiar distribution of these peptides and the concomitant expression of their receptor in multiple cell types suggest that the two growth factors may exert diverse physiological functions in the oesophagus and participate in defence and reparative events following mucosal injury.

Combined therapy with 5-aminosalicylic acid tablets and enemas for maintaining remission in ulcerative colitis: a randomized double-blind study

OBJECTIVES

To assess the efficacy of a combination of oral and topical 5-aminosalicylic acid (5-ASA) for the maintenance treatment of ulcerative colitis, we undertook a double-blind randomized clinical trial.

METHODS

Patients aged 18 to 65 yr (with disease extent greater than proctitis only) were eligible for inclusion in the study if they met the following criteria: (a) history of two or more relapses in the last year; (b) achievement of remission in the last 3 months (with maintenance of remission for at least 1 month). Patients enrolled in the study were randomly assigned to one of the two following 1-yr treatments: (1) combined therapy with 5-ASA tablets 1.6 g/day and 5-ASA enemas 4 g/100 ml twice weekly; (2) oral therapy with 5-ASA tablets 1.6 g/day and placebo enemas/twice weekly. The main end point of the study was the maintenance of remission at 12 months.

RESULTS

Upon completion of the study, relapse occurred in 13 of 33 patients in the combined treatment group versus 23 of 36 patients in the oral treatment group (39 vs 69%; p = 0.036). No significant side effects related to treatment were observed in either group. A simplified pharmacoeconomic analysis shows that this form of combined treatment can have a favorable cost-effectiveness ratio.

CONCLUSIONS

Our results indicate that 5-ASA given daily by oral route and intermittently by topical route can be more effective than oral therapy alone. This form of combination treatment can be appropriate for patients at high risk of relapse.

Allelic loss in parathyroid tumors from individuals homozygous for multiple endocrine neoplasia type 1

Homozygosity for the multiple endocrine neoplasia type 1 (MEN1) gene mutation was described in two of three affected siblings of a kindred in which both parents and the third daughter were heterozygotes. Surprisingly, in the two homozygotes, the disease history did not differ from the one of the heterozygotes. In the attempt to unravel genetic differences in parathyroid tumorigenesis between homozygotes and heterozygotes, restriction fragment length polymorphism analysis and microsatellite PCR analysis for loss of heterozygosity (LOH) at the MEN1 gene region on chromosome 11q13 was performed in parathyroid tissues removed at surgery from the mother, her heterozygous sister, and the three siblings. Allelic losses were evidenced in the larger glands of each patient, with a similar pattern of chromosome 11q12-13 losses. The somatic mutation consisted of a large lose of genetic material from chromosome 11. No gross differences exist in the 11q12-13 LOH observed between homozygous and heterozygous carriers. Interestingly, one of the parathyroid tumors from one heterozygote exhibited region of skipped LOH at the 11q12-13 region. The region in the depth of the critical interval retained heterozygosity, whereas those flanking it shared LOH. These findings indicate that inactivation of both copies of the MEN1 gene are not sufficient for parathyroid tumor development in MEN 1 patients and that tumor suppressor genes, other than the MEN1 gene on chromosome 11 or on other chromosomes, can be involved in the pathogenesis of parathyroid tumorigenesis in MEN 1 syndrome.

Retrospective evaluation of c-erbB-2 oncogene amplification using competitive PCR in collecting duct carcinoma of the kidney

PURPOSE

To evaluate retrospectively c-erbB-2 oncogene amplification in paraffin embedded specimens of collecting duct carcinoma of the kidney (CDC) with competitive polymerase chain reaction (PCR).

MATERIALS AND METHODS

Eleven CDC specimens were evaluated with a novel PCR procedure for oncogene amplification measurement, which provides sensitive and accurate results even in presence of low-quality DNA, unsuitable for Southern blot techniques.

RESULTS

c-erbB-2 oncogene amplification was present in 5 out of 11 cases (45%) with a number of copies ranging from 4 to 12. All patients presenting oncogene amplification decreased within one year, while 50% (3/6) of those without amplification are alive with a mean follow-up of 42 months.

CONCLUSIONS

The high incidence of c-erbB-2 oncogene amplification in CDC further characterizes this tumor as a separate entity from renal cell carcinoma, and shows some genetic characteristics in common with transitional cell carcinoma.

Prediction of pathological tumor volume in clinically localized prostate cancer: value of endorectal coil magnetic resonance imaging

The purpose of this study was to determine whether endorectal coil magnetic resonance imaging (MRI) enables accurate assessment of pathologic tumor volume in patients with clinically localized prostate carcinoma. Twenty-four patients with biopsy-proved prostate carcinoma underwent MRI at 0.5 T before radical prostatectomy. Tumor volumes were determined independently on axial fast-spin-echo (SE) T2-weighted MR images and whole-mount pathology slides of the surgical specimens. At pathology, tumor volumes ranged from 0.17 to 9.42 cm3 (mean +/- SD, 3.11 +/- 2.99 cm3). A strong correlation (r = .944) was found between measurements of tumor volume based on MR images and pathological specimens. The error was less than 0.5 cm3 in 14 cases, in the range of 0.5-1 cm3 in 7 cases, and more than 1 cm3 in 3 cases. By using an MR tumor volume of 2 cm3 as cutoff value, extracapsular tumor spread could be predicted with a sensitivity of 81.2%, a specificity of 100%, and an accuracy of 87.5%. Tumor volume determinations based on MR images seem to be accurate enough to be helpful in clinical decision-making.