Sustained post-rituximab B-cell depletion is common in ANCA-associated vasculitis and is affected by sex and renal function

OBJECTIVE

Despite the increasing use of rituximab in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), it remains unclear what the optimal dosing is, especially for maintenance of remission. A deeper understanding of post-rituximab B-cell repopulation patterns may aid better-tailored treatment.

METHODS

This is a monocentric, retrospective study including ANCA-positive AAV patients receiving a single course of rituximab induction. CD19+ B cells were longitudinally monitored with flow cytometry. B-cell repopulation was defined as CD19+ >10 cells/μL.

RESULTS

Seventy-one patients were included, the majority with microscopic polyangiitis (75%), myeloperoxidase-ANCA positivity (75%) and with renal involvement (79%). During a median follow-up of 54 months since the first rituximab infusion, 44 patients (62%) repopulated B cells, with a median time to repopulation of 39 months (range 7-102). Patients experiencing B-cell depletion lasting longer than the overall median time to repopulation (39 months) exhibited a lower risk of flare and higher risk of serious infection. In multivariate Cox regression, higher estimated glomerular filtration rate (eGFR) [hazard ratio (HR) 1.84, 95% confidence interval (CI) 1.13-2.98 per 30 mL/min/1.73 m2 eGFR] and female sex (HR 2.70, 95% CI 1.37-5.31) were independent predictors of increased rate of B-cell repopulation.

CONCLUSION

A subset of AAV patients develop sustained post-rituximab B-cell depletion, which associates with reduced risk of flare and increased risk of serious infection in the long term. Preserved renal function and female sex are associated with faster B-cell repopulation. These observations further highlight the need to personalize immunosuppression to improve clinical outcomes.

Heterogeneity in regional changes in body composition induced by androgen deprivation therapy in prostate cancer patients: potential impact on bone health-the BLADE study

BACKGROUND

It is not clear whether changes in body composition induced by androgen deprivation therapy (ADT) in prostate cancer (PC) patients are uniform or vary in the different body districts and whether regional lean body mass (LBM) and fat body mass (FBM) could have an impact on bone health.

OBJECTIVE

To prospectively evaluate the regional changes in LBM and FBM in PC patients submitted to degarelix; to explore the relationship of regional body composition and bone mineral density (BMD) and bone turnover markers.

DESIGN, SETTING, AND PARTICIPANTS

29 consecutive non metastatic PC patients enrolled from 2017 to 2019. FBM, LBM and bone mineral density (BMD) evaluated by dual-energy x-ray absorptiometry (DXA) at baseline and after 12-month of ADT. Alkaline phosphate (ALP) and C-terminal telopeptide of type I collagen (CTX) assessed at baseline, 6 and 12 months.

INTERVENTION

All patients underwent degarelix administration.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

T-test or sign test and Pearson or Spearman test for continuous variables were used when indicated.

RESULTS AND LIMITATIONS

Median percent increase in FBM ranged from + 14.5% in trunk to + 25.4% in the left leg after degarelix. LBM changes varied from + 2% in the trunk to - 4.9% in the right arm. LBM in both arms and legs and their variations after degarelix directly correlated with ALP and inversely correlated with CTX. Lean mass of limbs, trunk and legs significantly correlated with BMD of the hip, lean mass of the trunk significantly correlated with spine BMD. These are post-hoc analysis of a prospective study and this is the main limitation.

CONCLUSIONS

an heterogeneous change in body composition among body district is observed after ADT and bone turnover is influenced by lean mass and its variation. A supervised physical activity is crucial to maintain general physical performance and preserving bone health.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

FC061: Renal Function is a Major Determinant of B-Cell Repopulation Following Rituximab Induction in Anca-Associated Vasculitis

BACKGROUND AND AIMS

Rituximab is increasingly used to induce and maintain remission in ANCA-associated vasculitis (AAV). However, it remains unclear what the optimal dosing regimen is, especially in the setting of maintenance. Clinical trials have shown that vasculitis flares are unlikely as long as B-cell depletion in peripheral blood is sustained, with some evidence supporting a rituximab redosing strategy guided by B-cell-count monitoring. A better understanding of B-cell kinetics following rituximab treatment can facilitate personalized treatment approaches. This study aims to (1) describe B-cell repopulation in AAV patients treated with rituximab induction, and (2) identify clinical features predictive of B-cell repopulation.

METHOD

This is a single-centre, retrospective study, including AAV patients on no baseline immunosuppression who were treated with rituximab induction between December 2009 and March 2018 in the Nephrology Unit of Spedali Civili, Brescia. Only patients with available longitudinal B-cell monitoring for at least 6 months following rituximab were considered. B-cell counts were determined as CD19 + cells in peripheral blood using flow cytometry (Beckman Coulter Navios©).

B-cell repopulation following rituximab was defined as CD19 + cell count &gt;10 cells/μL, with a documented CD19 + count ≤ 10 cells/μL within the preceding year. For each patient, CD19 + cell counts were followed up to the earliest event among the following: (1) B-cell repopulation, (2) retreatment with rituximab or other induction agents, or (3) most recent observation available.

Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. Flares were defined as active disease retreated with rituximab or cyclophosphamide and classified as major if one or more major items of the BVAS score v3 were present.

Predictors of time to B-cell repopulation were assessed using uni- and multivariate analysis with log-rank test and Cox proportional hazards regression, respectively.

RESULTS

The study cohort included 64 patients. The main clinical characteristics are summarized in Table 1. During a median follow-up of 33.4 months (range 7.5–101.7 months), B-cell repopulation was observed in 36 patients (56.2%). Median time from rituximab induction to B-cell repopulation was 39.8 months [95% confidence interval (95% CI) 33.8–69.7]. Gender, ANCA subtype, rituximab dose, steroid pulses, plasma exchange and methotrexate/azathioprine maintenance were not significantly associated with time to B-cell repopulation. In contrast, B-cell repopulation was significantly slower in patients who were older (median time to repopulation 51.6 months in patients ≥ mean age of 66.8 years old versus 33.9 months in &lt; mean age; P = 0.044), who had microscopic polyangiitis (median 51.6 months), as opposed to granulomatosis with polyangiitis (median 33.9 months; P = 0.012) and who had lower eGFR at the time of rituximab (69.7 months in eGFR &lt; median of 18.3 mL/min/1.73 m2 versus 28.4 months in eGFR ≥ median; P = 0.001, Figure 1). Of these three predictors, only eGFR remained significantly associated with time to B-cell repopulation in a multivariate Cox regression model (hazard ratio for B-cell repopulation in eGFR ≥ median: 2.74, 95% CI 1.31–5.72).

During sustained B-cell depletion, six vasculitis flares were observed, of which one was major (rise in creatinine &gt; 30%) and the rest were minor (n = 4 worsening of urine abnormalities, n = 1 retro-orbital pain).

CONCLUSION

A substantial proportion of AAV patients treated with a single course of rituximab shows sustained B-cell depletion. Renal function emerged as the main independent predictor of B-cell repopulation, with delayed B-cell repopulation in people with kidney impairment. Only one major vasculitis flare was observed during sustained B-cell depletion. These data support the idea that longitudinal monitoring of B-cell counts can be a useful biomarker to guide rituximab dosing for maintenance in AAV, especially in patients with kidney impairment.

SARS-CoV-2 infection in dialysis and kidney transplant patients: immunological and serological response

Background

Dialysis and kidney transplant patients with moderate-severe COVID-19 have a high mortality rate, around 30%, that is similar in the two populations, despite differences in their baseline characteristics. In these groups, the immunology of the disease has been poorly explored.

Methods

Thirty-two patients on dialysis or with kidney transplant and SARS-CoV-2 infection requiring hospitalization (COV group) were included in our study. Lymphocyte subsets, dendritic cell (DC) counts and monocyte activation were studied. SARS-CoV-2 anti-spike/anti-nucleocapsid were monitored, and baseline cytokines and chemokines were measured in 10 patients.

Results

The COV group, compared to healthy subjects and uninfected dialysis/kidney transplant controls, showed lower numbers of CD4 + and CD8 + T cells, Natural-Killer (NK), B cells, plasmacytoid and myeloid DCs, while the proportion of terminally differentiated B-cells was increased. IL6, IL10, IFN-α and chemokines involved in monocyte and neutrophil recruitment were higher in the COV group, compared to uninfected dialysis/kidney transplant controls.

Patients with severe disease had lower CD4 + , CD8 + and B-cell counts and lower monocyte HLA-DR expression. Of note, when comparing dialysis and kidney transplant patients with COVID-19, the latter group presented lower NK and pDC counts and monocyte HLA-DR expression. Up to 60 days after symptom onset, kidney transplant recipients showed lower levels of anti-spike antibodies compared to dialysis patients.

Conclusions

During SARS-CoV-2 infection, dialysis and kidney transplant patients manifest immunophenotype abnormalities; these are similar in the two groups, however kidney transplant recipients show more profound alterations of the innate immune system and lower anti-spike antibody response.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01214-8.

MO245OUTCOME OF DIFFERENT INDUCTION REGIMENS IN ANCA-ASSOCIATED GLOMERULONEPHRITIS ACCORDING TO THE HISTOPATHOLOGICAL CHARACTERISTICS: THE REASSESS STUDY*

Background and Aims

Renal involvement in ANCA-associated vasculitis (AAV) impacts significantly on patients’ prognosis. The role of different induction regimens on remission rates and long-term renal outcomes according to renal histological characteristics has not been explored yet.

Method

AAV patients with biopsy-proven renal involvement were collected retrospectively from eleven centers and stratified according to the induction regimen employed: Rituximab (RTX), Cyclophosphamide (CYC) or both (RTX-CYC). Kidney biopsies were classified according to the Berden and Brix classifications.

Renal remission rate was assessed 6 months after the induction regimen and defined as a renal Birmingham Vasculitis Activity Score (BVAS) of 0.

Among patients who achieved remission at 6 months, renal relapse was defined as a renal-BVAS&gt;0 associated with an increase in immunosuppressive treatment.

ESRD was defined as an eGFR&lt;15 ml/min/1,73m2, need for dialysis or renal transplant.

Results

323 patients were identified and followed-up for a median time of 36 months (IQR 18-72). The cohort included 38% patients with GPA and 62% with MPA, 53% patients were MPO-ANCA and 41% PR3-ANCA positive. The median baseline eGFR in the overall cohort was 19 ml/min/1,73m2 (IQR 12- 34). 58% of patients were treated with CYC, 24% with RTX-CYC and 18% with RTX.

According to the Berden classification, 24% biopsies were classified as Focal, 31% as Crescentic, 33% as Mixed and 12% as Sclerotic. The Brix score was assessable in 270/323 (84%) patients: 17%, 52% and 31% were respectively in the Low, Medium and High-risk class.

The overall renal remission at 6 months was 90%; according to the Berden classification, 94% patients achieved remission in the Focal, 88% in the Crescentic, 91% in the Mixed and 86% in the Sclerotic class. According to the Brix risk score, 88% patients achieved remission in the High risk, 91% in the Medium and 96% in the Low-risk class. According to induction regimen employed, 91%, 90% and 90% patients achieved remission in the RTX, CYC and RTX plus CYC group respectively.

In a logistic regression model adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria at onset, the induction regimen employed was not predictive of renal remission at 6 months, neither in Berden Focal plus Crescentic and Mixed plus Sclerotic classes, nor in Brix High and Low plus Medium risk classes.

Of the 185 patients with at least 6 months of follow-up available after remission, 25% experienced a renal relapse. In a Cox regression model adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria at onset, the induction regimen or histological score were not predictive of renal relapse. In the unadjusted survival analysis with the Kaplan-Maier curve, patients in the Crescentic group treated with RTX had a shorter ESRD-free survival compared to the CYC group (p=0.033) and the RTX-CYC group (p=0.044); figure 1:

This was confirmed also with a Cox regression analysis adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria when comparing the RTX group with the CYC one (HR 8.30 [95% CI 1.64 to 42.01], p=0.011); figure 2:

While the eGFR changes over time in the Focal plus Crescentic and Mixed plus Sclerotic classes showed a similar trend between treatment groups, in the Crescentic class the median eGFR values in the RTX group tended to be lower compared to the CYC and the RTX-CYC ones; figure 3:

The rate of severe infections in the RTX, CYC and RTX-CYC group was respectively 6.3, 8.5 and 8.8 per 100 patient-years during the first 12 months.

Conclusion

in a retrospective multicenter survey, response rates and relapse risk after different induction regimens in AAV patients with renal involvement were comparable in the overall cohort and in the different histopathological subgroups.

Although in a small subset of patients, the ESRD-free survival in the Crescentic class was shorter in the RTX group compared to the CYC one.

A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection

The SARS-CoV-2 epidemic is pressuring healthcare systems worldwide. Disease outcomes in certain subgroups of patients are still scarce, and data are needed. Therefore, we describe here the experience of four dialysis centers of the Brescia Renal COVID Task Force. During March 2020, within an overall population of 643 hemodialysis patients, SARS-CoV-2 RNA positivity was detected in 94 (15%). At disease diagnosis, 37 of the 94 (39%) patients (group 1) were managed on an outpatient basis, whereas the remaining 57 (61%) (group 2) required hospitalization. Choices regarding management strategy were made based on disease severity. In group 1, 41% received antivirals and 76% hydroxychloroquine. Eight percent died and 5% developed acute respiratory distress syndrome (ARDS). In group 2, 79% received antivirals and 77% hydroxychloroquine. Forty two percent died and 79% developed ARDS. Overall mortality rate for the entire cohort was 29%. History of ischemic cardiac disease, fever, older age (over age 70), and dyspnea at presentation were associated with the risk of developing ARDS, whereas fever, cough and a C-reactive protein higher than 50 mg/l at disease presentation were associated with the risk of death. Thus, in our population of hemodialysis patients with SARS-CoV-2 infection, we documented a wide range of disease severity. The risk of ARDS and death is significant for patients requiring hospital admission at disease diagnosis.

The Veneto Region's Barrett's Oesophagus Registry: aims, methods, preliminary results

BACKGROUND

The natural history of Barrett's Oeosphagus is not completely clarified and Barrett's Oeosphagus Registries are considered useful tools to expand our knowledge on this disease. A Barrett's Oeosphagus Registry has been therefore established in the Veneto Region and neighbouring provinces.

AIMS

The aims of the Registry are to assess the demographical, endoscopical and histological characteristics of Barrett's Oeosphagus patients; the prevalence of non-invasive neoplasia and Barrett's Adenocarcinoma and the timing and incidence of Barrett's Oeosphagus progression to malignancy.

METHODS

An interdisciplinary committee of endoscopists, pathologists and information technology experts was established in 2004 to design a website-based Barrett's Oesophagus Registry for the Veneto Region and neighbouring north-eastern Italian provinces. Protocols for endoscopies and biopsies and standard reports were carefully defined.

RESULTS

In the first 18 months, 397 patients with endoscopically visible and histologically proven Barrett's Oeosphagus were enrolled in the Registry; the median age of these patients was 66 years (male:female=3:1). Most patients (75%) had a Short Segment of Barrett's Oesophagus (<or=3 cm) and only 1 in 4 had a Long Segment of Barrett's Oesophagus (>3 cm). Long Segment of Barrett's Oesophagus patients were 5 years older than the Short Segment of Barrett's Oesophagus patients (p<0.05), suggesting a progression from Short Segment of Barrett's Oesophagus to Long Segment of Barrett's Oesophagus. Though no data are available on the incidence of non-invasive neoplasia or Barrett's Adenocarcinoma (i.e., progression to cancer at least 12 months after enrolment), the prevalence of neoplastic lesions (found within 12 months of enrolment) was 5% for Short Segment of Barrett's Oesophagus and 19% for Long Segment of Barrett's Oesophagus, indicating that a careful multiple-biopsy endoscopic protocol is needed, especially when Long Segment of Barrett's Oesophagus are suspected at endoscopy. The prevalence of Barrett's Adenocarcinoma among patients with non-invasive neoplasia was 1/17 cases of low-grade non-invasive neoplasia and 2/3 cases of high-grade non-invasive neoplasia, indicating that these patients require strict endoscopic and bioptic follow-up.

CONCLUSION

A regional Barrett's Oeosphagus Registry is feasible at a relatively low cost and enables significant data to be collected in a relatively short time. The use of a standardised endoscopic nomenclature and report form, a strict biopsy protocol, a standard report for pathologists improves the quality of endoscopic and histological diagnoses.

Helicobacter pylori in promotion of gastric carcinogenesis

Gastric atrophy and intestinal metaplasia are considered the earliest phenotypic changes in the cascade of events leading from normal mucosa to intestinal-type gastric cancer, and epidemiological evidence links Helicobacter pylori to gastric epithelial malignancies. To evaluate any causal relationship between bacterial infection and atrophic metaplastic lesions, gastric pathology was histologically and histochemically evaluated in 267 consecutive, nonulcerous, untreated subjects, with attention given the phenotypes of intestinal metaplasia. The prevalence of Helicobacter pylori infection was 61%. Intestinal metaplasia (particularly types II and III) was significantly associated with both Helicobacter pylori detection (chi 2 LR: P < 0.002) and increasing age (chi 2 LR: P < 0.002). Using logistic regression analysis, the development of intestinal metaplasia proved more significantly linked with Helicobacter pylori infection [odds ratio = 4.55 (95% confidence interval: 1.51-13.7)], than with age [odds ratio = 1.03 (95% CI: 1.01-1.06)], with no interaction. In conclusion, Helicobacter pylori can be considered among the major causal agents of mucosal lesions involved in the multistep process of gastric carcinogenesis, justifying any attempt to eradicate this bacterial infection.

Benign myxoid hepatocellular tumor: a variant of liver cell adenoma

A case of myxoid hepatocellular adenoma in the non-cirrhotic liver of a 26-year-old man is described. Grossly, the tumor was well circumscribed, rounded and measured 16 cm in diameter. Histologically, the tumor was characterized by nests and strands of polygonal cells embedded in a myxoid extracellular matrix. Electron microscopy confirmed the hepatocellular nature of the neoplastic cells. The patient is alive and well, without evidence of disease, 2 years after a local excision.

Leiomyoma of the renal pelvis: Case report

— Leiomyomas of the renal pelvis are rare benign tumours. Their bladder localization has been described in 160 cases, while their pelvic renal localization, according to our literature review, has been reported in just 6 cases. Of these, 5 underwent a nephroureterectomy and 1 conservative surgery, since the diagnostic preoperative examinations indicated urothelial disease. We report a case of fasciculated renal pelvis leiomyoma, in which the clinical aspect and the preoperative imaging indicated this fact and therefore the possibility of a conservative strategy.

Leiomyosarcoma of the Scrotum

Scrotal leiomyosarcoma is a rare tumour which occurs in the muscular structures of the scrotum. Based on a recently observed case and on literature, the Authors discuss diagnostic and therapeutic problems of this tumour. The few cases observed do not allow definitive conclusions.

[Primary mesothelioma of the pericardium with long-term survival]

We report the case of a 52-year-old man admitted to our Hospital for a massive pericardial effusion already discovered at an X-ray examination of the chest more than one year before, but never submitted to further investigation. Four months after a first surgical intervention of "pericardial windowing" and a drainage of 1700 ml of clear pericardial fluid, the patient was again hospitalized because of cardiac tamponade and underwent open pericardial drainage. At inspection, the pericardium and the myocardial muscle were fused in a single mass that at histological examination was discovered to be a primary mesothelioma of the pericardium, epithelial type. We discuss the clinical course and review the scientific literature inherent in these rare cases of primary neoplastic diseases of the heart.

[Thrombosis of the right atrial appendage. The two-dimensional echocardiographic aspect and the autopsy finding]

We report the case of an 80-year-old man affected by hypertensive cardiomyopathy and already admitted to our Division for recurrent episodes of heart failure. He was eventually hospitalized for septic shock secondary to disseminated pneumonia with concomitant left pleural effusion. At 2D-echo examination, a highly echo-reflectant mass was detected in the retrocardiac space. As the patient died notwithstanding the intensive pharmacological care, an autoptic procedure was performed which showed a massive thrombosis of the right atrial appendage. We discuss the 2D-echo imaging and advance a pathogenetic hypothesis after a review of the current literature.

Bladder Wall Histology and Duration of Obstruction

In BPH patients, obstruction leads to a progressive modification in the structure of the bladder wall, with histo-pathological changes which are often irreversible. In order to detect these changes and their possible correlation with function, muscle biopsies of the bladder were taken from 28 patients during endoscopic resection for benign prostatic hyperplasia. The samples were examined by means of electron microscope to show ultrastructural charges. The magnitude of the lesions can be correlated to function, seriousness and duration of the obstruction. Detecting histo-pathological damage can justify earlier treatment in obstructed BPH patients, in order to avoid those bladder lesions, which are the probable cause of clinical disorders which may persist even after therapy of the adenoma.

Para-urethral vaginal leiomyoma

Only a few cases of para-urethral vaginal leiomyoma have been reported in literature. We describe two additional cases and discuss the differential diagnosis and management.

[Bladder neck cysts: role of transrectal echography]

High frequency probes for transrectal sonography are well tolerated and permit us to study the cervico-urethral unit carefully. We are allowed to single out some rare causes of obstruction, otherwise difficult to diagnose. Bladder neck obstruction secondary to a cyst is one of these. Our case report is about a young patient with complete retention secondary to bladder cyst discovered by transrectal sonography.

[Necrotizing lymphadenitis without granulocytic infiltration or Kikuchi disease. Description of 5 cases]

The authors describe five cases of necrotizing lymphadenitis without granulocyte infiltration or Kikuchi's disease. Of the patients, all young, four were females and one of male sex. In one case serological positivity was found for the anti Toxoplasma antibodies. Histologically they are noted in the lymph node infiltration areas constituted by histiocytes, immunoblasts, lymphocytes and plasmacytoid cells with phenomena of variable degree necrosis. Granulocytes were absent in all. Cytochemistry and immunohistochemistry studies with specific antiserums for the k and lambda chains, the S100 protein and the MB1, MB2 and MT1 antigens, the Lisozyme and the alpha 1 antichymotrypsin, show a prevalent histiocyte population, associated with a modest polyclonal B component and with a T population of variable entity. The plasmacytoid component did not appear reactive to the same antibodies.

[Multinodular keratoacanthoma]

Multinodular Keratoacanthoma is a variant of keratoacanthoma presenting with large annular plaques localized on the photo-exposed surfaces of the aged people. It is characterized by progressive growth of new nodules of keratoacanthoma at the periphery, while partial or complete spontaneous central healing occurs with scar formation. There is no tendency toward spontaneous regression. Multinodular Keratoacanthoma is quite rare. In our opinion only ten cases can be complied from the literature. We report an additional case in a diabetic 87 year old woman. She was previously affected by a vulvar squamous cell carcinoma. No recurrence was observed four months after the surgical excision.

[Skin involvement in Rosai-Dorfman disease. Description of a case]

Sinus Histiocytosis with massive lymphadenopathy is an idiopathic, histologically distinctive disorder that characteristically produces painless cervical lymphadenopathy. Other node groups are frequently involved and mass lesions in extranodal sites occur in approximately 30% of patients. In most cases the disease is chronic and the course is often characterized by exacerbations and remission. We report the case of a 66 years old white woman affected by sinus histiocytosis with massive cervical and inguinal lymphadenopathy. Subcutaneous nodules appeared in her left arm and low back region with the histological features of sinus histiocytosis. Cellular infiltrate was composed predominantly of histiocytes aggregating in granuloma like clusters. These cells had large round or kidney shaped nuclei; cytoplasm was abundant, vacuolated, often containing phagocytized lymphocytes. Multinucleated cells were also observed; reactive plasmocytosis was present in the nodule periphery. During the follow-up the patient maintained good physical conditions, despite a moderate weight loss. The size of her nodules regressed within one year. Immunologic alterations, consisting of polyclonal hypergammaglobulinemia and persistent inversion of T4/T8 lymphocyte ratio, were observed. Sinus histiocytosis usually offers a good prognosis; in our patient infective and/or autoimmune complications could be favoured by advanced age, extranodal involvement and immunological depression.

HBsAg, HBcAg and delta-Ag in liver tissue: simultaneous visualization in a single tissue section by triple immunostaining

The distribution pattern of HBsAg, HBcAg and Delta-Ag was investigated by immunohistochemistry in a series of paraffin embedded liver tissue specimens from 45 subjects with serum HBsAg and anti-Delta antibody positivity. An indirect immunoperoxidase technique was used. Stains for HBsAg, HBcAg and Delta-Ag were alternatively carried out on serial tissue sections and, for the first time, consecutively in a single section (triple immunostaining). Simultaneous presence of all antigens occurred in 7 out of 45 cases, and of two antigens (HBsAg and Delta-Ag) in the remaining 38. Two antigens (either HBsAg and HBcAg or HBcAg and Delta-Ag) could also be shown in the same cell. A series of new observations was forwarded by the successful application of triple immunostaining in the present series: 1) high frequence of simultaneous presence of HBcAg and Delta-Ag (7 out of 45 cases = 16%); 2) cytoplasmic localization of Delta-Ag; 3) localization of HBcAg on the cell membrane of HBsAg positive Ground-Glass (G-G) hepatocytes; 4) Ground-Glass appearance of hepatocytic cytoplasm associated with exclusive content of HBcAg (HBcAg-Ground-Glass: a new variant of G-G-hepatocytes).