Impact of 2 years of COVID-19 pandemic on ovarian cancer treatment in IRCCS-AUSL of Reggio Emilia

OBJECTIVE

To assess compliance with the 2019 regional recommendation to centralize epithelial ovarian cancer (EOC) patients and to assess whether the COVID-19 pandemic has affected the quality of care for EOC patients.

METHODS

We compared data from EOC patients treated before the introduction of the 2019 regional recommendation (2018-2019) with data obtained from EOC patients treated after the regional recommendation was adopted during the first 2 years of the COVID-19 pandemic (2020-2021). Data were retrieved from the Optimal Ovarian Cancer Pathway records. R software version 4.1.2 (the R Foundation for Statistical Computing, Vienna, Austria) was used for the statistical analysis.

RESULTS

251 EOC patients were centralized. The number of EOC patients centralized increased from 2% to 49% despite the COVID-19 pandemic. During the COVID-19 pandemic, there was an increase in the use of neoadjuvant chemotherapy and interval debulking surgery. There was an improvement in the percentage of Stage III patients without gross residual disease following both primary and interval debulking surgery. The percentage of EOC cases discussed by the multidisciplinary tumor board (MTB) increased from 66% to 89% of cases.

CONCLUSION

Despite the COVID-19 pandemic, centralization has increased and the quality of care has been preserved thanks to the MTB.

Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization

The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.

Needleoscopic-assisted risk-reducing bilateral salpingo-oophorectomy in BRCA1/2 mutation carriers: Peri-operative outcomes and psychological impact

OBJECTIVE

To investigate the role of needleoscopic-assisted laparoscopy in terms of surgical impact and psychological outcomes in RR-BSO for BRCA1/2 patients.

STUDY DESIGN

Prospective monocentric trial conducted at the Division of Gynecologic Oncology, "Fondazione Policlinico Universitario A. Gemelli" IRCSS in Rome. Between March 2016 and March 2018, 26 consecutive patients were prospectively enrolled in the study and underwent RR-BSO. Peri-operative surgical variables were collected. The psychological interview was performed at the discharge and during the first post-operative follow-up visit (between 30 and 60 days after surgery).

RESULTS

We reported a median OT of 18.5 min (range, 15-37), a median EBL of 0 mL (0-20), and no conversion to laparoscopy or laparotomy. The median VAS score was "at rest" of 2, 3, and 1; while under "Valsalva maneuver" was 4, 3, 2, respectively at 2, 4, and 24 h. 77% (20/26) of the whole population had a previous diagnosis of breast cancer. All patients expressed great cosmetic satisfaction both at discharge and after 30/60 days, with an 84.6% of score 5 and a 15.4% of score 4. The highest number of "score 5", concerning the cosmetic outcomes, were clustered in the subgroup of breast cancer survivors with a 95% of score 5 versus 50% of score 5 in patients with no previous breast cancer (p = 0.0073). Similarly, the maximal psychological advantage of the ultra-MIS approach was revealed in the breast cancer survivors (70% of score 5 versus 16% of score 5, p = 0.02).

CONCLUSIONS

The use of 2.4 mm instruments raises the possibility of decreasing post-operative incisional pain, reducing hospitalization, and ensuring better cosmetic and psychological outcomes without increasing complications. The full psychosomatic benefit of ultra-MIS within BRCA mutation carriers is revealed in breast cancer survivors, probably due to the comparison with the mutilating and invasive previous breast surgery.

Characteristics and patterns of care of endometrial cancer before and during COVID-19 pandemic

Objective

Coronavirus disease 2019 (COVID-19) outbreak has correlated with the disruption of screening activities and diagnostic assessments. Endometrial cancer (EC) is one of the most common gynecological malignancies and it is often detected at an early stage, because it frequently produces symptoms. Here, we aim to investigate the impact of COVID-19 outbreak on patterns of presentation and treatment of EC patients.

Methods

This is a retrospective study involving 54 centers in Italy. We evaluated patterns of presentation and treatment of EC patients before (period 1: March 1, 2019 to February 29, 2020) and during (period 2: April 1, 2020 to March 31, 2021) the COVID-19 outbreak.

Results

Medical records of 5,164 EC patients have been retrieved: 2,718 and 2,446 women treated in period 1 and period 2, respectively. Surgery was the mainstay of treatment in both periods (p=0.356). Nodal assessment was omitted in 689 (27.3%) and 484 (21.2%) patients treated in period 1 and 2, respectively (p<0.001). While, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) has increased during the COVID-19 pandemic (46.7% in period 1 vs. 52.8% in period 2; p<0.001). Overall, 1,280 (50.4%) and 1,021 (44.7%) patients had no adjuvant therapy in period 1 and 2, respectively (p<0.001). Adjuvant therapy use has increased during COVID-19 pandemic (p<0.001).

Conclusion

Our data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of EC patients. These findings highlight the need to implement healthcare services during the pandemic.

The prevalence of patients with early-stage endometrial cancer (EC) has been lower during coronavirus disease 2019 (COVID-19) pandemic than before its onset. Further evidence is needed to assess the impact of COVID-19 pandemic on survival outcomes of EC patients.

Impact of a Province-wide Endometrial Cancer Guideline on Daily Practice

BACKGROUND/AIM

Most women are managed by a general gynaecologist rather than being centralized in an oncogynaecology unit, resulting in different clinical management. In 2006, a hub & spoke model was introduced in the Provincial Healthcare System of Reggio Emilia, and shared guidelines were written. We aimed to verify the adherence to guidelines and the consequent improvements in quality care.

PATIENTS AND METHODS

All patients who underwent a hysterectomy for endometrial cancer in the Reggio Emilia Province hospitals from 2000 to 2016 were included in the study. Clinical and pathological data were carefully recorded for each patient included.

RESULTS

This study included 132 and 277 patients in the periods before and after the implementation of the guideline, respectively. In the post-guideline period, the use of hysteroscopy, magnetic resonance, laparoscopy and adjuvant treatment significantly increased.

CONCLUSION

Common shared guidelines and a clinical audit can help in improving centralization, resulting in an increased quality of care.

Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser Conization: A 5-year follow-up study

OBJECTIVE

Conization aims to remove pre-neoplastic lesions of the uterine cervix. Several techniques for conization have been compared, but evidence regarding the most effective therapeutic option is scant. Here, we aimed to compare the recurrence rate following laser conization and loop electrosurgical excision procedure (LEEP) in patients with high-grade cervical dysplasia (HSIL/CIN2+).

METHODS

This is a retrospective multi-institutional study. Medical records of consecutive patients with HSIL/CIN2+ undergoing conization between 2010 and 2014 were retrieved. A propensity-score matching (PSM) was applied in order to reduce allocation bias. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models.

RESULTS

Overall, 2966 patients had conization over the study period, including 567 (20%) and 2399 (80%) patients having laser conization and LEEP, respectively. Looking at predictors of recurrence, diagnosis of CIN3 (HR:3.80 (95%CI:2.01,7.21); p < 0.001) and HPV persistence (HR:1.81 (95%CI:1.11,2.96); p < 0.001) correlated with an increased risk of recurrence. After applying a PSM we selected 500 patients undergoing laser conization and 1000 undergoing LEEP. Patients undergoing LEEP were at higher risk of having positive surgical margins in comparison to patients undergoing laser conization (11.2% vs. 4.2%). The risk of having persistence of HPV was similar between the two groups (15.0% vs. 11.6%;p = 0.256). Five-year recurrence rate was 8.1% and 4% after LEEP and laser conization, respectively (p = 0.023). HPV persistence was the only factor associated with [5-]year recurrence after both laser conization (p = 0.003) and LEEP (p = 0.001).

CONCLUSIONS

HPV persistence is the only factor associated with an increased risk of recurrence after either laser conization or LEEP. Owing to the lack of data regarding obstetrical outcomes, we are not able to assess the best therapeutic option for women with cervical dysplasia.

Cervical ripening balloon: An off-label but effective use to manage massive hemorrhage during outpatient cervical conization

A double‐balloon catheter may be very helpful in managing a major hemorrhage following outpatient conization.

Evaluation of survival of patients with hepatocellular carcinoma: A comparative analysis of prognostic systems

BACKGROUND AND AIM

There are several prognostic systems that address different aspects of the patient and the tumour and can guide the management of patients with hepatocellular carcinoma (HCC). This study aimed to evaluate and compare the eight staging systems for a group of patients in a public service in Brazil.

METHODS

Patients with HCC were retrospectively analysed between 2000 and 2012. The prognostic systems Okuda, The Cancer of the Liver Italian Program (CLIP), the Chinese University Prognostic Index (CUPI), Groupe d'Etude et de Traitément du Carcinome Hepatocellulaire (GRETCH), the modified TNM-based Japan Integrated Score (JIS) combined with alpha-fetoprotein and Child-Turcotte-Pugh (CTP), the TNM system, and the Barcelona Clinic Liver Cancer Classification (BCLC) were applied to these patients and compared through model fit measurements, likelihood scores, and the Akaike Information Criterion (AIC).

RESULTS

A total of 247 patients were studied. The average survival time was 60 months. The TNM, Okuda, CLIP, GRETCH, modified JIS, and BCLC systems were well correlated with one another and individually important to the prediction of survival among the patients studied. However, in the statistical analysis, the CUPI delivered the best predictive performance (AIC = 566; log-likelihood = -281,240).

CONCLUSION

Although the CUPI system was demonstrated to be the most appropriate HCC staging system for the studied population, the choice of an ideal system is a controversial subject, and future studies with larger numbers of patients are necessary for the validation of the CUPI system as the method of choice for other populations.

The anti-Müllerian hormone (AMH) acts as a gatekeeper of ovarian steroidogenesis inhibiting the granulosa cell response to both FSH and LH

PURPOSE

Anti Müllerian Hormone (AMH) has a negative and inhibitory role in many functions of human granulosa-lutein cells (hGCs) including notoriously the reduction of the aromatase CYP19A1 expression induced by follicle-stimulating hormone (FSH). No data have been provided on the possible role of AMH in modulating the response to luteinizing hormone (LH) (alone or combined with FSH) as well as its effect on other enzymes involved in steroidogenesis including aromatase P450scc. The aim of this study was to investigate the role of AMH as regulator of the basal and stimulated steroids production by hGCs.

METHODS

Primary culture of hGCs were incubated with hormones AMH, LH, and FSH, alone or in combination. The CYP19A1 and P450scc messenger RNA (mRNA) expression, normalized by housekeeping ribosomal protein S7 (RpS7) gene, was evaluated by reverse transcriptase quantitative PCR (RT-qPCR). Each reaction was repeated in triplicate. Negative controls using corresponding amount of vehicle control for each hormone treatment were performed.

RESULT

AMH did not modulate the basal mRNA expression of both aromatase genes at any of the concentrations tested. Meanwhile, the strong mRNA induction of CYP19A1 and P450scc generated by a 24-h gonadotropin treatment (alone and combined) was suppressed by 20 ng/ml AMH added to culture medium.

CONCLUSIONS

These findings contribute in clarifying the relationship between hormones regulating the early phase of steroidogenesis confirming that AMH is playing a suppressive role on CYP19A1 expression stimulated by gonadotropin in hGCs. Furthermore, a similar inhibitory effect for AMH was observed on P450scc gene expression when activated by gonadotropin treatment.

iPad-based primary 2D reading of CT angiography examinations of patients with suspected acute gastrointestinal bleeding: preliminary experience

OBJECTIVE

To evaluate the effectiveness of the iPad (Apple Inc., Cupertino, CA) for two-dimensional (2D) reading of CT angiography (CTA) studies performed for suspected acute non-variceal gastrointestinal bleeding.

METHODS

24 CTA examinations of patients with suspected acute gastrointestinal bleeding confirmed (19/24, 79.2%) or ruled out (5/24, 20.8%) by digital subtraction angiography (DSA) were retrospectively reviewed by three independent readers on a commercial picture archiving communication system (PACS) workstation and on an iPad with Retina Display® 64 GB (Apple Inc.). The time needed to complete reading of every CTA examination was recorded, as well as the rate of detection of arterial bleeding and identification of suspected bleeding arteries on both devices.

RESULTS

Overall, the area under the receiver operating characteristic curve, sensitivity, specificity, positive- and negative-predictive values for bleeding detection were not significantly different while using the iPad and workstation (0.774 vs 0.847, 0.947 vs 0.895, 0.6 vs 0.8, 0.9 vs 0.944 and 0.750 vs 0.667, respectively; p > 0.05). In DSA-positive cases, the iPad and workstation allowed correct identification of the bleeding source in 17/19 cases (89.5%) and 15/19 cases (78.9%), respectively (p > 0.05). Finally, the time needed to complete reading of every CTA study was significantly shorter using the iPad (169 ± 74 vs 222 ± 70 s, respectively; p < 0.01).

CONCLUSION

Compared with a conventional PACS workstation, iPad-based preliminary 2D reading of CTA studies has comparable diagnostic accuracy for detection of acute gastrointestinal bleeding and can be significantly faster.

ADVANCES IN KNOWLEDGE

The iPad could be used by on-call interventional radiologists for immediate decision on percutaneous embolization in patients with suspected acute gastrointestinal bleeding.

The ovarian follicular pool and reproductive outcome in women

Both quantitative and qualitative aspects of the ovarian reserve are inversely related to age, hence the relationship existing between low quantity and low quality may be only indirect and depending on their strong relationship with the third variable, namely women's age. However the possibility exists that they may also be directly related. The objective of this study was to investigate the relationship between ovarian reserve and female reproductive outcome. Eight published studies reporting histological data on the human ovaries have been carefully reviewed. Only studies where the reproductive history of women was reported have been included for the analysis. The non-growing follicle count was plotted versus age and the best fit line through the data was calculated. All patients were assigned as to be above or below the calculated median hence differentiating women with high or low ovarian reserve for their age. A similar number of pregnancies ended in miscarriage in women with low and high ovarian reserve. The number of deliveries per woman in both the groups was not statistically different. The results of the study do not support the hypothesis that quality and quantity of the follicular pool are directly related.

Desmoplastic small round cell tumor (DSRCT) arising in the ovary: report of a case diagnosed at an early stage and review of the literature

BACKGROUND

Desmoplastic small round cell tumor (DSRCT) is a rare sarcoma tumor affecting mainly young adult males. It rarely has an ovarian involvement.

CASE

A 29-year-old woman presented to her gynecologist for amenorrhoea. The laboratory results demonstrated a menopausal status and the ultrasound revealed a large mass of the right ovary. The right ovary was completely removed by laparoscopy. Pathology, cytology and immunochemistry revealed a DSRCT. In January 2009 a left salpingo-oophorectomy and a right salpingectomy were performed via laparoscopy. After 35 months from diagnosis there was no clinical evidence of disease recurrence.

CONCLUSION

DSRCT is a rare ovarian tumor in adolescence with a general poor outcome. Every ovarian mass regardless of age should be approached with caution.

Neuroprotective properties of marrow-isolated adult multilineage-inducible cells in rat hippocampus following global cerebral ischemia are enhanced when complexed to biomimetic microcarriers

Cell-based therapies for global cerebral ischemia represent promising approaches for neuronal damage prevention and tissue repair promotion. We examined the potential of marrow-isolated adult multilineage-inducible (MIAMI) cells, a homogeneous subpopulation of immature human mesenchymal stromal cell, injected into the hippocampus to prevent neuronal damage induced by global ischemia using rat organotypic hippocampal slices exposed to oxygen-glucose deprivation and rats subjected to asphyxial cardiac arrest. We next examined the value of combining fibronectin-coated biomimetic microcarriers (FN-BMMs) with epidermal growth factor (EGF)/basic fibroblast growth factor (bFGF) pre-treated MIAMI compared to EGF/bFGF pre-treated MIAMI cells alone, for their in vitro and in vivo neuroprotective capacity. Naïve and EGF/bFGF pre-treated MIAMI cells significantly protected the Cornu Ammonis layer 1 (CA1) against ischemic death in hippocampal slices and increased CA1 survival in rats. MIAMI cells therapeutic value was significantly increased when delivering the cells complexed with FN-BMMs, probably by increasing stem cell survival and paracrine secretion of pro-survival and/or anti-inflammatory molecules as concluded from survival, differentiation and gene expression analysis. Four days after oxygen and glucose deprivation and asphyxial cardiac arrest, few transplanted cells administered alone survived in the brain whereas stem cell survival improved when injected complexed with FN-BMMs. Interestingly, a large fraction of the transplanted cells administered alone or in complexes expressed βIII-tubulin suggesting that partial neuronal transdifferentiation may be a contributing factor to the neuroprotective mechanism of MIAMI cells.

CT and MRI in monitoring response: state-of-the-art and future developments

The present review is aimed at updating the reader with the current role of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of tumor response, contextualizing the imaging methods advantages and limitations. CT has been the most frequent and widely adopted diagnostic tool. The main advantages of such method include wide availability, high reproducibility, capability to contemporarily evaluate soft tissues, bone and lung parenchyma, besides being easy to perform. Its main limitation is related to the use of ionizing radiation. MRI has emerged as a feasible alternative to CT, particularly in patients with contraindications to the use of iodinated contrast agents, with advantages related to its high soft tissues contrast. The disadvantages are based on its operational complexity and the many technical variables involved which may influence and compromise the reproducibility and broad implementation of the method. New criteria for evaluation of tumor response have recently been proposed, contemplating lately developed drugs and therapeutic strategies that demand the utilization of functional parameters. In this context, the technological developments incorporated in the CT and MRI imaging techniques, such as perfusion analysis, diffusion studies (DW-RM) and MR spectroscopy (MRS), among others, have provided relevant information regarding the tumor response to targeted therapies, anticipating dimensional alterations and guiding physicians in the course of the treatment. Despite such developments, further efforts are needed to establish reproducible protocols, functional response criteria and time intervals for response evaluation in order to allow a definitive incorporation of these new technologies in the assessment of tumor response.

Evaluation of the lateral pterygoid muscle using magnetic resonance imaging

OBJECTIVES

The aims of this study were to evaluate the visibility of the lateral pterygoid muscle (LPM) in temporomandibular joint (TMJ) images obtained by MRI, using different projections and to compare image findings with clinical symptoms of patients with and without temporomandibular disorders (TMD).

METHODS

In this study, LPM images of 50 participants with and without TMDs were investigated by MRI. The images of the LPM in different projections of 100 TMJs from 35 participants (70 TMJs) with and 15 participants (30 TMJs) without clinical signs and symptoms of TMD were visible and analysed.

RESULTS

The oblique sagittal and axial images of the TMJ clearly showed the LPM. Hypertrophy (1.45%), atrophy (2.85%) and contracture (2.85%) were the abnormalities found in the LPM. TMD signs, such as hypermobility (11.4%), hypomobility (12.9%) and disc displacement (20.0%), could be seen in TMJ images. Related clinical symptoms, such as pain (71.4%), articular sounds (30.4%), bruxism (25.7%) and headache (22.9%), were observed.

CONCLUSIONS

Patients with TMD can present with alterations in the LPM thickness. Patients without TMD also showed alterations, such as atrophy and contracture, in TMJ images. Recognition of alterations in the LPM will improve our understanding of clinical symptoms and pathophysiology of TMD, and may lead to a more specific diagnosis of these disorders.

Hormonal and ultrasound markers of ovarian function in a woman with a balanced 1;11 translocation

OBJECTIVE

To present a case of a poor responder woman with a rare balanced autosomal translocation.

DESIGN

Case report.

SETTING

Infertility center in a university teaching hospital.

PATIENT(S)

A 34-year-old white woman with primary infertility.

INTERVENTION(S)

Laboratory and ultrasound evaluation, karyotype analysis, ovarian stimulation with gonadotropins.

MAIN OUTCOME MEASURE(S)

Markers of ovarian reserve and ovarian response to gonadotropin stimulation.

RESULT(S)

The patient was a carrier of a balanced translocation (1;11) (q23;p11.2). The hormone ovarian reserve markers (FSH, anti-Mullerian hormone, inhibin B) were within the normal range. The antral follicle count (AFC) was measured twice and only in one occasion did it reach the lower limit of the normal range. Furthermore, the patient had regular menstrual cycles. However, ovarian response to the administration of a maximal dose FSH was extremely poor.

CONCLUSION(S)

Patients with balanced autosomal translocations should be counseled regarding their increased risk for poor response even if markers of ovarian reserve are in the range of normality.

Chronic hepatosplenic schistosomiasis mansoni: magnetic resonance imaging and magnetic resonance angiography findings

PURPOSE

To evaluate the hepatosplenic manifestations and the portal venous system in patients with chronic infection by Schistosoma mansoni.

MATERIAL AND METHODS

A cross-sectional observational study was performed in 28 patients with chronic hepatosplenic schistosomiasis submitted to magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the abdomen. Images were interpreted independently by two radiologists to determine the reproducibility of image interpretation and who evaluated the presence of morphological alterations in the liver and spleen, such as hepatosplenomegaly, hepatic fissure widening, periportal fibrosis, and the presence of siderotic nodules. Interobserver and intra-observer agreement were measured with the kappa and intraclass correlation tests. Evaluation of venous collateral pathways and portal and splenic veins was done in consensus by both examiners.

RESULTS

Observers identified enlargement of the left lobe (78.5-92.8%) and caudate-to-right-lobe ratio (78.5-92.8%), irregularity of hepatic contours (89.2-96.4%), fissure widening (89.2-100%), and splenic siderotic nodules (84.2%). Splenomegaly, heterogeneity of hepatic parenchyma, peripheral hepatic vessels, and periportal fibrosis were observed in 100% of patients. MRI findings presented almost perfect interobserver (kappa = 0.65-1) and intra-observer (kappa = 0.73-1 for observer 1, and kappa = 0.65-1 for observer 2) agreement for the variables analyzed. MRA showed the presence of collateral pathways in the majority of patients (71.4%) along with widening of portal and splenic veins.

CONCLUSION

Using MRI, hepatosplenic alterations in schistosomiasis are characterized by heterogeneity of hepatic parenchyma, presence of peripheral perihepatic vessels, periportal fibrosis, splenomegaly, siderotic nodules, and the presence of venous collateral pathways.

Magnetic resonance cholangiography in the diagnosis of biliary complications after orthotopic liver transplantation

OBJECTIVE

The aim of our study was to evaluate the role of magnetic resonance cholangiography (MRC) in the diagnosis of biliary tract complications (BC) after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Among 21 OLT patients who underwent routine follow-up MRC using a breath-hold T2-weighted turbo spin-echo sequence with half-Fourier acquisition (HASTE), 5 had an elevated serum alkaline phosphatase level. Diagnostic confirmation was obtained with endoscopic retrograde cholangiography (ERC) (n = 11), surgery (n = 3), or clinical and laboratory follow-up of at least 1 year (n = 8).

RESULTS

In 13 patients, no abnormality of the biliary tract was detected using MRC. In 8 patients, anastomotic strictures were diagnosed, 7 of which were confirmed at surgery or using ERC. One patient with normal findings at MRC and abnormal liver function test results was found to have a stricture at ERC. All patients with normal MRC and liver function tests had 1 year of uneventful follow-up and were considered true-negative cases. We found that MRC had 87.5% sensitivity, 92.3% specificity, 87.5% positive predictive value, 92.3% negative predictive value, and 90.4% accuracy for the diagnosis of BC.

CONCLUSION

MRC is a valuable examination to detect BC after OLT. It provides useful information for planning interventional procedures.

Cooperative actions of hepatocyte growth factor and 1,25-dihydroxyvitamin D3 in osteoblastic differentiation of human vertebral bone marrow stromal cells

Bone formation and remodeling require continuous generation of osteoprogenitor cells from bone marrow stromal cells (MSC), which generate and respond to a variety of growth factors with putative roles in hematopoiesis and mesenchymal differentiation. In this study we examine the interaction of two such factors on the maturation of skeletal components. We previously reported that these factors, hepatocyte growth factor (HGF) and 1,25-dihydroxyvitamin D(3) (vitD(3)), act together to increase alkaline phosphatase in chondroblasts. We now describe the cooperative effect of these agents on MSC isolated and cultured from human vertebral bone marrow. MSC (passages 3-9) isolated from bone marrow cells of human vertebrae (T1-L5) from 22-36-year-old normal donors were first expanded in vitro and then plated in the presence or absence of 10 ng/mL HGF and/or 10 nmol/L vitD(3), for 7-18 days. HGF treatment increased cell proliferation 2.5-fold, with no effect on alkaline phosphatase activity. Whereas vitD(3) treatment inhibited cell growth by 50%, alkaline phosphatase activity was stimulated eightfold, although no mineralization was observed. HGF together with vitD(3) increased cell proliferation 1.5-fold and alkaline phosphatase activity 13-fold over untreated control. Moreover, mineralization was detected only with this combination. Our findings provide evidence that HGF in concert with vitamin D may promote growth and differentiation of human MSC into osteogenic cells.

Right hepatic segmentectomy for the treatment of intrahepatic biliary stones due to ascaris lumbricoides: report of a case

We report herein the case of a 46-year-old woman investigated for recurrent acute cholangitis. Ultrasound, endoscopic retrograde cholangiopancreatography, and computed tomography scan revealed dilatation and multiple images suggestive of intrahepatic biliary stones in the ducts that drained segments V and VI of the liver. Endoscopic treatment was attempted unsuccessfully, and based on the severity of the last crisis of cholangitis a laparotomy was performed. A right hepatic lobectomy including segments V and VI was carried out without any complications, resulting in complete relief of symptoms. Pathological examination of the liver demonstrated the presence of worm nests in the liver parenchyma with chronic granulomatous lesions.

2-Methoxyestradiol induces G2/M arrest and apoptosis in prostate cancer

Few therapeutic treatment options are available for patients suffering from metastatic androgen-independent prostate cancer. We investigated the ability of the estrogen metabolite 2-methoxyestradiol to inhibit the proliferation of a variety of human prostate cancer cell lines in vitro and to inhibit the growth of androgen-independent prostate cancer in a transgenic mouse model in vivo. Our results showed that 2-methoxyestradiol is a powerful growth inhibitor of LNCaP, DU 145, PC-3, and ALVA-31 prostate cancer cells. Cell flow cytometry of 2-methoxyestradiol-treated DU 145 cells showed a marked accumulation of cells in the G2/M phase of the cell cycle and an increase in the sub-G1 fraction (apoptotic). In addition, staining for annexin V, changes in nuclear morphology, and inhibition of caspase activity support a role for apoptosis. More importantly, we showed that 2-methoxyestradiol inhibits prostate tumor progression in the Ggamma/T-15 transgenic mouse model of androgen-independent prostate cancer without toxic side effects. These results in cell culture and an animal model support investigations into the clinical use of 2-methoxyestradiol in patients with androgen-independent prostate cancer.

Inhibition of gap-junctional communication induces the trans-differentiation of osteoblasts to an adipocytic phenotype in vitro

Osteoblasts and adipocytes are thought to differentiate from a common stromal progenitor cell. These two phenotypically mature cell types show a high degree of plasticity, which can be observed when cells are grown under specific culture conditions. Gap junctions are abundant among osteoblastic cells in vivo and in vitro, whereas they are down-regulated during adipogenesis. Gap junctional communication (GJC) modulates the expression of genes associated with the mature osteoblastic phenotype. Inhibition of GJC utilizing 18-alpha-glycyrrhetinic acid (AGRA) blocks the maturation of pre-osteoblastic cells in vitro. Moreover, cytoplasmic lipid droplets are detectable at the end of the culture period, suggesting that GJC inhibition may favor an adipocytic phenotype. We used several human osteoblastic cell lines, as well as bone-derived primary osteoblastic cells, to show that confluent cultures of human osteoblastic cells grown under osteogenic conditions developed an adipocytic phenotype after 3 days of complete inhibition of GJC using AGRA or oleamide, two dissimilar nontoxic reversible inhibitors. Development of an adipogenic phenotype was confirmed by the accumulation of triglyceride droplets and the increase in mRNA expression of the adipocytic markers peroxisome proliferator-activated receptor gamma2 and lipoprotein lipase. Glycyrrhizic acid, a noninhibitory AGRA analog, or alpha-bromopalmitate, a nondegradable fatty acid, had no effect. Modulation of skeletal GJC may represent a new pharmacological target by which inhibition of marrow adipogenesis can take place with the parallel enhancement of osteoblastogenesis, thus providing a novel therapeutic approach to the treatment of human age-related osteopenic diseases and postmenopausal osteoporosis.

Gap-junctional communication is required for the maturation process of osteoblastic cells in culture

Osteoblastic cells in long-term culture undergo a phenotypic maturation process leading to extracellular matrix (ECM) production and bone nodule (BN) formation. Cell-to-cell communication via gap junctions (GJC) can be detected between osteoblastic cells within 24 h of plating. We evaluated, in long-term cultures of osteoblastic cells, the effect of inhibiting GJC on the phenotypic maturation process and the expression of specific genes associated with this process. MC3T3-E1 cells were plated, and, after 24 h (day 0), cells were exposed to 18-alpha-glycyrrhetinic acid (AGA), a nontoxic reversible inhibitor of GJC. GJC, alkaline phosphatase (AP) activity, BN formation, and the relative level of transcripts encoding osteocalcin (OC), bone sialoprotein (bSP), osteopontin (OP), collagen alpha1 type I (alpha1ICol), and elongation factor-1a (EF1a) were evaluated on day 0 and every 4-7 days thereafter through day 30. GJC was assessed by fluorescent dye transfer. Gene expression was analyzed by northern blot and semiquantitative reverse transcription-polymerase chain reaction. GJC was detectable at day 0 and increased with time in culture. AGA (100 micromol/L) strongly inhibited GJC at all timepoints tested. Moreover, AGA-exposed cells showed a dose-dependent decrease in AP activity and a delay in the appearance of BN. This delayed phenotypic expression coincided with an inhibitory effect on the expression of the osteoblast-specific genes OC and bSP. Expression of alpha1ICol mRNA was also affected, but to a lesser extent, whereas OP and EF1a were not affected. Similar results were obtained with oleamide, an additional reversible inhibitor of GJC. In contrast, cells exposed to either vehicle or 100 micromol/L glycyrrhizic acid (a noninhibitory glycoside of 18-beta-glycyrrhetinic acid) were indistinguishable from untreated cells for all parameters evaluated. We conclude that GJC inhibition interferes with the maturation process of osteoblastic cells in culture, possibly by affecting signals regulating the expression of genes involved in the maturation/differentiation of the osteoblastic phenotype.

Gap-junctional communication mediates parathyroid hormone stimulation of mineralization in osteoblastic cultures

Previously we showed that physiological levels of parathyroid hormone (PTH) can increase the mineralization of extracellular matrix (ECM) by osteoblast-like cells in vitro. In this study, we assess the role of gap-junctional intercellular communication (GJC) in the PTH-enhanced mineralization of ECM in MC3T3-E1 cells, a murine culture model of osteoblastic differentiation. Messenger RNA and protein for connexin 43 (Cx43), the major component of MC3T3-E1 gap junctions, and GJC increased as the cells progressed toward a mature phenotype. Immunocytochemistry showed accumulation of Cx43 at the area of close contact between cells. The timing of the PTH treatment that increased matrix mineralization in these cells coincided with the highest expression of Cx43 and GJC. Administration of 18-alpha-glycyrrhetinic acid (AGA) promptly blocked GJC in cultures of MC3T3-E1 cells in a dose-dependent and reversible manner at all times tested during the culture period. Treatment with AGA, but not with an inactive analog, reversed the PTH-induced ECM mineralization. These data suggest that GJC mediates anabolic actions of PTH related to osteoblast-mediated mineralization.

Anabolic or catabolic responses of MC3T3-E1 osteoblastic cells to parathyroid hormone depend on time and duration of treatment

We have investigated signaling (cAMP) and anabolic responses (mineralization of extracellular matrix [ECM]) to parathyroid hormone (PTH) in long-term (30 days) cultures of MC3T3-E1 cells, a murine model of osteoblast differentiation. Expression of PTH/PTH-related peptide receptor (PTH1R) mRNA is detected early and remains relatively constant for 2 weeks with somewhat higher levels observed during the second half of the culture period. In contrast to the relatively stable PTH1R mRNA expression, the cAMP response to PTH varies markedly with no response at day 5 and a marked response (80-fold versus control) by day 10. Responsiveness to PTH remains elevated with fluctuations of 30- to 80-fold stimulation throughout the remainder of the culture period. The timing and duration of PTH treatment to achieve in vitro mineralization of ECM was evaluated. When continuous PTH treatment was initiated before day 20, mineralization decreased. If continuous PTH treatment began on or after day 20, mineralization was unaffected. However, if treatment began on day 20 and then stopped on day 25, mineralization on day 30 was increased 5-fold. This mineralization response to intermittent PTH was confirmed in primary cultures of murine and human osteoblastic cells. These data provide a potential basis for understanding the differential responses to PTH (anabolic versus catabolic) and indicate the developmental temporal variance of anabolic and catabolic responses. Since cAMP signaling was relatively unchanged during this interval (day 10-30) and stimulation of adenylate cyclase only partially mimicked the PTH effect on increased mineralization, other signaling pathways are likely to be involved in order to determine the specific anabolic response to short-term PTH treatment during the differentiation process.

Age-related osteogenic potential of mesenchymal stromal stem cells from human vertebral bone marrow

Mesenchymal stem cells (MSCs) residing in bone marrow (BM) are the progenitors for osteoblasts and for several other cell types. In humans, the age-related decrease in bone mass could reflect decreased osteoblasts secondary to an age-related loss of osteoprogenitors. To test this hypothesis, BM cells were isolated from vertebral bodies of thoracic and lumbar spine (T1-L5) from 41 donors (16 women and 25 men) of various ages (3-70 years old) after death from traumatic injury. Primary cultures were grown in alpha modified essential medium with fetal bovine serum for 13 days until adherent cells formed colonies (CFU-Fs). Colonies that stained positive for alkaline phosphatase activity (CFU-F/ALP+) were considered to have osteogenic potential. BM nucleated cells were plated (0.5, 1, 2.5, 5, or 10 x 106 cells/10-cm dish) and grown in dexamethasone (Dex), which promotes osteoblastic differentiation. The optimal plating efficiency using BM-derived cells from donors of various ages was 5 x 106 cells/10-cm dish. BM-derived cells were also grown in the absence of Dex at this plating density. At the optimal plating density, in the presence of Dex, the number of CFU-F/ALP+ present in the BM of the younger donors (3-36 years old) was 66.2 +/- 9.6 per 106 cells (mean +/- SEM), but only 14.7 +/- 2.6 per 106 cells in the older donors (41-70 years old). With longer-term culture (4-5 weeks) of these BM cells in medium containing 10 mM beta-glycerophosphate and 100 microg/ml ascorbic acid, the extracellular matrix mineralized, a result consistent with mature osteoblastic function. These results demonstrate that the number of MSCs with osteogenic potential (CFU-F/ALP+) decreases early during aging in humans and may be responsible for the age-related reduction in osteoblast number. Our results are particularly important in that the vertebrae are a site of high turnover osteoporosis and, possibly, the earliest site of bone loss in age-related osteoporosis.

Severe hypoxia enhances the formation of erythroid bursts from human cord blood cells and the maintenance of BFU-E in vitro

Incubation in severe hypoxia (1% oxygen) increased the number of erythroid bursts generated from full-term CD34+, or premature mononucleated, human cord blood (CB) cells, in semisolid cultures containing stem cell factor (SCF), interleukin (IL)-3 and erythropoietin (EPO). Severe hypoxia also enhanced the maintenance of erythroid burst-forming units (BFU-E) in CB cell liquid cultures. These positive effects of hypoxia on the maintenance and cloning efficiency of BFU-E did not extend to the other progenitors assayed. Hypoxia, on the other hand, markedly reduced the size and level of hemoglobinization of bursts and, in liquid cultures, suppressed the growth factor-stimulated numerical increase in BFU-E and inhibited the expression of CD36, a marker of erythroid colony-forming units and maturing erythroid precursors. However, when transferred to clonal assays incubated in air, cells from liquid cultures incubated in hypoxia or in air generated fully expanded and hemoglobinized bursts, suggesting that in hypoxia the clonogenic potential of BFU-E was maintained and the development of erythroid clones reversibly inhibited. These results indicate that hypoxia inversely regulates two subsequent phases of erythropoiesis, i.e., it enhances the maintenance of BFU-E and the early development of erythroid clones but inhibits the terminal expansion and maturation of these clones. The cloning of CB cells selected for CD34 positivity, when compared with that of the total population of mononucleated CB cells, revealed that the early development of erythroid bursts was either hypoxia-enhanced or hypoxia-insensitive, reflecting the existence of two different types of BFU-E. Hypoxia-enhanced BFU-E are relatively immature, are maintained in hypoxia but not in air, and account for a large part of CD34+ BFU-E and for a high percentage of the BFU-E in premature CB. Hypoxia-insensitive BFU-E are mostly CD34- and are largely predominant in full-term CB, and most probably correspond to a more mature type of BFU-E.

Apoptotic and antiproliferative effects of gemcitabine and gemcitabine plus Ara-C on blast cells from patients with blast crisis chronic myeloproliferative disorders

BACKGROUND

Blast phase of chronic myeloid leukemia (CML) as well as the rare acute transformation of other chronic myeloproliferative disorders constitute forms of leukemia that are particularly refractory, even to aggressive chemotherapy. Many attempts have thus been made to identify new drugs that could be active in these diseases. We wanted to evaluate whether gemcitabine (dFdC), a pyrimidine analogue widely employed in lung cancer chemotherapy, was able to block in vitro proliferation of bcr/abl-positive and bcr/abl-negative blast cells in primary culture. We already showed that gemcitabine is active in inhibiting proliferation and inducing apoptosis of HL60 cells.

METHODS

We studied the influence of dFdC on the proliferative potential of blasts by means of tritiated thymidine uptake, colony formation in semisolid medium and cell cycle parameters at flow cytometry. The efficacy of dFdC in inducing apoptosis was evaluated by flow cytometry (A0 peak) and by DNA agarose gel electrophoresis.

RESULTS

We demonstrated that dFdC already inhibits tritiated thymidine uptake at doses of 10 microM after 72 hours of culture, and that this effect is dose dependent. The addition of Ara-C 5 microM in the culture medium of dFdC provoked a synergistic inhibitory effect. Consistent results were obtained when cell cycle distribution was studied. In fact, cell incubation in the presence of dFdC resulted in a significant decrease of cells in S phase, although with a certain heterogeneity among cases. The antileukemic activity of dFdC appeared to be specific since it was mediated through apoptosis. We could demonstrate the appearance of the pre-G1 apoptotic peak at cytofluorimetric analysis, and the characteristic DNA fragmentation pattern at agarose electrophoresis in all 10 cases after treatment with different doses of dFdC. Induction of apoptosis was maximal for the highest doses of dFdC (100 mM) and for the combination of dFdC and Ara-C.

INTERPRETATION AND CONCLUSIONS

Following incubation with Gemcitabine leukemic blasts from chronic myeloproliferative disorders are induced to accumulate intracytoplasmatic and nuclear Ara-C and undergo apoptosis. These observations suggest that gemcitabine could be considered a candidate drug, capable of being used in polychemotherapy of refractory acute phase chronic myeloproliferative disorders.

Tomographic aspects of xanthogranulomatous pyelonephritis and related complications

The authors present their experience involving seven patients with histopathologic diagnosis of xanthogranulomatous pyelonephritis who were submitted to preoperative computed tomography (CT). The results are the following: a) stones (86 percent of the cases), b) increase in renal volume, c) hydronephrosis, d) density measurements (from 14 to 29 HU), e) enhancement found in all cases, f) extrarenal involvement (all cases). CT has shown to be a reliable method in characterizing xanthogranulomatous xyelonephritis and extrarenal involvement.

Effects of fludarabine and gemcitabine on human acute myeloid leukemia cell line HL 60: direct comparison of cytotoxicity and cellular Ara-C uptake enhancement

This study was designed to compare the effects of fludarabine and gemcitabine on cytosine arabinoside (Ara-C) uptake and retention, and their specific cytotoxicity on HL 60 human acute myeloid leukemia cells. The leukemic blasts were exposed to either drug at equimolar concentrations (10 microM) for 3 h and further incubated with Ara-C (5 microM), added immediately (day 0) or after an interval of 24 h in cells were kept in a drug free medium (day 1). On day 0, leukemic cells exposed to fludarabine 10 microM had a significant (P<0.01) increase in Ara-C uptake (297 +/- 11 pmol/10(7) cells) with respect to control cells (not pre-treated: 195 +/- 10 pmol/10 (7) cells). After treatment of leukemic cells with fludarabine, cytoplasmic Ara-C peaked after 180 min of exposure, as well as nuclear bound Ara-C. At the same time, a significant decrease in the number of S-phase leukemic cells, consistent with depressed [3 H]TdR uptake was observed. Although on day 0 gemcitabine 10 microM did not have potentiating effects on Ara-C uptake, it showed a high degree of intrinsic cytotoxicity as a single agent(clear from cell cycle distribution, [3H]TdR uptake, plating efficiency (PE) data and percentage of apoptotic cells). Cells exposed to gemcitabine, on the other hand, showed on day 1 a significant increase in Ara-C uptake (2.4 x control values in the cytoplasmic and 3x in the nuclear fractions) and a reduced number of S-phase blasts, [3H]TdR uptake and PEs, as well as an increased apoptotic cell death. Evidently, it is possible to modulate Ara-C uptake by leukemic cells with gemcitabine. Although this effect is similar to that demonstrated with fludarabine, its kinetics and time of efficacy are different and also, because of its intrinsic higher cytoxicity and lack of important side effects, gemcitabine could be considered a suitable candidate for Ara-C association therapy in acute leukemia.

Daunorubicin impairs 1-beta-D-arabinofuranosylcytosine uptake

Daunorubicin (DNR) and 1-beta-D-arabinofuranosylcytosine (Ara-C) act in a schedule-dependent fashion on leukemic cells. The present study was undertaken to determine whether the inhibition exerted by DNR on Ara-C cytotoxicity on HL 60 cells could be accounted for by an impairment of its uptake. After 250 ng/ml DNR treatment for 30 min, the time course of Ara-C uptake was measured, up to 128 min of incubation at 37 degrees C and at 4 degrees C, compared with controls. We found that DNR inhibits Ara-C uptake both at 37 and 4 degrees C, mostly acting on passive diffusion.

Esophageal squamous cell carcinoma: MRI evaluation of mediastinum

Thirty-two patients with esophageal spinocellular (squamous cell) carcinoma were studied with superconductive magnet in order to evaluate local and extraluminal extent, as well as mediastinal lymph node spread of the disease. In the absence of adenopathy, the localized tumors were considered susceptible to surgical treatment. All patients were operated on within 21 days. The resectability criteria were correctly evaluated in 75% of cases; sensitivity and specificity were 86 and 67%, respectively. Unsatisfactory results were obtained in the evaluation of mediastinal adenopathies. We conclude that magnetic resonance imaging (MRI) is useful in the preoperative evaluation of resectability criteria in patients with esophageal squamous cell carcinoma.

Local recurrence of rectosigmoid cancer: what about the choice of MRI for diagnosis?

Local recurrence is a frequent event in the natural history of rectosigmoid cancer. The diagnostic possibilities, as well as the limits of computed tomography (CT) and transrectal ultrasonography (TRU), are well known in these conditions. The aim of our study was to define the possible role of magnetic resonance imaging (MRI). We considered 15 examinations carried out in 14 patients, seven of which were obtained before and after Gd-DTPA administration. MRI demonstrated a 93.3% accuracy, 100% sensitivity, and 83.3% specificity in relation to the presence of local recurrence. The presence of pelvic recurrence was suggested on the basis of morphological and signal criteria. The use of paramagnetic contrast gave additional information in four of seven patients. The use of Gd-DTPA may be most beneficial in patients suspected of recurrence, within 6 months of their last treatment, where the diagnosis is more difficult.