Hemithyroidectomy versus total thyroidectomy in the intermediate-risk differentiated thyroid cancer: the Italian Societies of Endocrine Surgeons and Surgical Oncology Multicentric Study

The surgical treatment of the intermediate-risk DTC (1-4 cm) remains still controversial. We analyzed the current practice in Italy regarding the surgical management of intermediate-risk unilateral DTC to evaluate risk factors for recurrence and to identify a group of patients to whom propose a total thyroidectomy (TT) vs. hemithyroidectomy (HT). Among 1896 patients operated for thyroid cancer between January 2017 and December 2019, we evaluated 564 (29.7%) patients with unilateral intermediate-risk DTC (1-4 cm) without contralateral nodular lesions on the preoperative exams, chronic autoimmune thyroiditis, familiarity or radiance exposure. Data were collected retrospectively from the clinical register from 16 referral centers. The patients were followed for at least 14 months (median time 29.21 months). In our cohort 499 patients (88.4%) underwent total thyroidectomy whereas 65 patients (11.6%) underwent hemithyroidectomy. 151 (26.8%) patients had a multifocal DTC of whom 57 (10.1%) were bilateral. 21/66 (32.3%) patients were reoperated within 2 months from the first intervention (completion thyroidectomy). Three patients (3/564) developed regional lymph node recurrence 2 years after surgery and required a lymph nodal neck dissection. The single factor related to the risk of reoperation was the histological diameter (HR = 1.05 (1.00-1-09), p = 0.026). Risk stratification is the key to differentiating treatment options and achieving better outcomes. According to the present study, tumor diameter is a strong predictive risk factor to proper choose initial surgical management for intermediate-risk DTC.

Modulating the extension of thyroidectomy in patients with papillary thyroid carcinoma pre-operatively eligible for lobectomy: reliability of ipsilateral central neck dissection

PURPOSE

Pre-operative work-up and macroscopic intraoperative inspection could overlook occult central neck nodal metastases in patients with papillary thyroid carcinoma (PTC). An occult N1a status is able to change the initial risk stratification in small, clinically unifocal PTC potentially scheduled for thyroid lobectomy (TL) making total thyroidectomy (TT) the preferable option. We aimed to verified the reliability of an intraoperative management protocol based on frozen section examination (FSE) of ipsilateral central neck nodes (IpsiCND) to identify, among patients scheduled for TL, those who could benefit of a more extensive surgical resection (TT plus bilateral central neck dissection -CND-).

METHODS

Thirty PTC patients preoperatively classified as T1N0 underwent TL plus IpsiCND-FSE (TL-group). In case of positive FSE, TT plus bilateral CND was accomplished during the same surgical procedure. A comparative analysis was performed between TL-group and a control group (C-group), who underwent TT plus IpsiCND-FSE, matched by a propensity score analysis.

RESULTS

Nodal metastases (>2 mm) were found at final histology in 5/30 patients in the TL-group and in 6/30 in the C-group (p = 1.00). Micrometastases (≤2 mm) were retrieved in 5/30 TL-group patients and in 4/30 C-group patients (p = 1.00). Final histology staged as pN1a 10 (33.3%) patients for each group. FSE correctly identified five patients with occult nodal metastases >2 mm (16.6%) in TL-group, who underwent TT plus bilateral CND during the same surgical procedure. No permanent complications occurred. At a mean follow-up of 22.2 months, no local and/or nodal recurrence were observed.

CONCLUSIONS

Intraoperative assessment of N status obtained with IpsiCND plus FSE allows for an accurate risk stratification. IpsiCND plus FSE real time modulated thyroidectomy seems a safe and effective surgical strategy reducing the need of a subsequent completion surgery and, theoretically, the risk of local recurrence.

Klebsiella pneumoniae acquisition in ICUs: patient-based and laboratory-based surveillance

Klebsiella pneumoniae - and especially multidrug-resistant K. pneumoniae - represents a global threat for Public Health, due to its high dissemination in Intensive Care Units (ICUs) and its association with mortality. Here, we investigated the molecular epidemiology of multidrug-resistant K. pneumoniae strains in ICUs from Catania, Italy.

We used data and samples from the Italian Nosocomial Infections Surveillance in ICUs - SPIN-UTI project, which has been surveying the epidemiology and the risk of Healthcare-associated infections (HAIs) in Italian ICUs. The SPIN-UTI network adopted the ECDC protocols for patient-based HAI surveillance. In a sample of ICUs the patient-based surveillance was integrated with a laboratory-based surveillance of MDR K. pneumoniae isolates. K. pneumoniae isolates were genotyped by multilocus sequence typing (MLST), and patterns of K. pneumoniae acquisition (i.e. carriage, colonization and infection) were identified using standard definitions.

Our analysis included 155 patients who stayed in two ICUs for a total of 2254 days, from October 2016 to March 2017. Trauma patients were more likely to be infected with K. pneumoniae than other patients (OR = 5.9; 95%CI=2.4-14.8; p = 0.004). A total of 109 K. pneumoniae strains were isolated from different sites of 39 patients, which in turn were defined as 45.2% colonization, 25.8% infection, and 29% carriage. 79.3% K. pneumoniae isolates resistant to carbapenems and 100% resistant to penicillins and cephalosporins. The MLST identified two major clonal groups: the ST395 and the ST37, which represented respectively the 65.6% and the 21.3% of typed isolates.

Surveillance of colonization and infection by high-risk clones might help in implementing appropriate strategies, which are crucial to reduce the spread of K. pneumoniae in ICUs.

*Study Group AOU 'Policlinico-Vittorio Emanuele', Catania, Italy: Patrizia Bellocchi, Giacomo Castiglione, Alida Imbriani, Marinella Astuto, Giuseppa La Camera, Agata Sciacca

Key messages

Multidrug-resistant K. pneumoniae still represents a threat for Public Health in Italy and globally, due to its high dissemination in intensive care units. Surveillance of colonization and infection by high-risk clones might help in reducing the spread of Klebsiella pneumoniae.

Overview of three-year trends of antimicrobial consumption and resistance in Sicilian hospitals

Background

Antimicrobial resistance (AMR) is one of the ten threats identified by the WHO in 2019. In order to face this issue and in the framework of the National Action Plan on Antimicrobial Resistance (PNCAR) 2017-2020, the Sicilian Health Authority has implemented a surveillance system of antibiotic consumption in the hospital sector and in the community and of antibiotic resistance in the Sicilian hospitals. The aim of the present work is to report the results of three-year surveillance.

Methods

From 2015 to 2017, data on antibiotic consumption have been collected from pharmacies of participating hospitals. AMR data on seven bacterial pathogens isolated in blood and cerebrospinal fluid have been collected from hospital laboratories, using routine clinical antimicrobial susceptibility tests. Antibiotic consumption was expressed as Defined Daily Dose (DDD) per 100 patient-days. Antibiotic resistance rates (RRs) were calculated as the number of non-susceptible isolates divided by the total number of isolates multiplied by 100.

Results

The most commonly consumed antibiotics in participating hospitals were fluoroquinolones in 2015, penicillins in 2016, and beta-lactams in 2017, respectively. RRs of Klebsiella pneumoniae significantly increased for all antimicrobial classes (p < 0.001), but carbapenems. By contrast, RRs of Escherichia coli resistant to third-generation cephalosporins and carbapenems showed significant decreasing trends (p < 0.001).

Conclusions

The implementation of the Sicilian surveillance system provides Sicilian reference data to monitor trends and target interventions and policies for reducing the threat of AMR. Recently, using toolkits of the ECDC-EAAD initiative adapted with regional surveillance data, an educational campaign “Obiettivo Antibiotico” - https://www.obiettivoantibiotico.it/ - was designed and launched to raise awareness of prudent use of antibiotics in the general public and in healthcare professionals in Sicily.

Key messages

Inappropriate antimicrobial consumption observed in Sicilian hospitals contributes to the emergence and selection of AMR. Surveillance system of antimicrobial consumption and AMR can help identify strategies for preventing spread of multi-drug resistant microorganisms.

Improved biomonitoring of airborne contaminants by combined use of holm oak leaves and epiphytic moss

Concentrations of 12 elements (Ca, Cd, Cr, Cu, Fe, K, Mg, Mn, Na, Ni, Pb and Zn) and 16 EPA-listed PAHs were detected in Quercus ilex leaves and the epiphytic moss Leptodon smithii collected at urban, periurban and extraurban holm oak stands, in two Italian Regions (Campania and Tuscany). Levels of environmental contaminants were generally higher in leaves and moss from urban areas than periurban and extraurban ones and samples from Campania had the highest PAH content. The epiphytic moss accumulated higher concentrations of trace elements than leaves and the latter showed a higher accumulation capability for PAHs, especially for those with low molecular weight. The different bioaccumulation in leaves and moss were explained in terms of their distinctive morphological and ecophysiological characteristics. The combined approach seems a promising tool for the monitoring of a wide range of pollutants in Mediterranean urban and extraurban environments.

The transcriptional landscape of the mammalian genome

This study describes comprehensive polling of transcription start and termination sites and analysis of previously unidentified full-length complementary DNAs derived from the mouse genome. We identify the 5' and 3' boundaries of 181,047 transcripts with extensive variation in transcripts arising from alternative promoter usage, splicing, and polyadenylation. There are 16,247 new mouse protein-coding transcripts, including 5154 encoding previously unidentified proteins. Genomic mapping of the transcriptome reveals transcriptional forests, with overlapping transcription on both strands, separated by deserts in which few transcripts are observed. The data provide a comprehensive platform for the comparative analysis of mammalian transcriptional regulation in differentiation and development.

Physical map of the D6S149-D6S193 region on chromosome 6Q27 and its involvement in benign surface epithelial ovarian tumours

A detailed long range restriction map of the region defined by markers D6S149 and D6S193 on chromosome 6q27 has been constructed. This was achieved by YAC cloning and contig assembling of the same region. Seven YAC clones were found to span the almost 1000 Kb region flanked by the two markers which on the genetic map resulted to be 1.9 cM apart. With some of the characterized YAC clones we undertook a molecular cytogenetic analysis of 20 benign ovarian tumors. The rationale for this was the recent mapping to a region of chromosome 6q27, flanked by markers D6281 and D6S133, of a locus for the SV40-mediated immortalization of human cells (SEN6 gene). Noteworthy we found that the the D6S149-D6S193 region (comprised in the larger D6S281-D6S133 physical interval) was altered in all samples analysed adding support to the occurrence of a immortalization step in this type of tumors.

Genomic structure and organization of kringles type 3 to 10 of the apolipoprotein(a) gene in 6q26-27

Apolipoprotein(a) [apo(a)] is a highly polymorphic glycoprotein covalently linked to the apolipoprotein B-100 of LDL in a particle called lipoprotein(a) [Lp(a)]. High plasma levels of Lp(a) are associated with coronary as well as peripheral atherosclerosis. Plasma levels of Lp(a) show a remarkable variation ranging from 0.1 mg/dl to over 100 mg/dl. The apo(a) gene shows a size polymorphism which resides in the variable number of kringle domains which resemble plasminogen kringle IV. Ten different types of kringle IV repeats have been described, nine of which (kringle IV type 1 and type 3-10) are each supposed to be present in a single copy. The other kringles, namely kringle IV type 2 repeats, vary in number from 3 to 42 between apo(a) alleles and form the basis for the apo(a) size polymorphism. Although an inverse relationship has been observed between the number of kringle type 2 repeats and plasma levels of Lp(a), there are exceptions to this general finding. Indeed, several individuals have been described with similar apo(a) size alleles but very different plasma levels of Lp(a). Genetic studies have linked these differences to the apo(a) locus on 6q26-27, outlining the importance, besides the kringle type 2 repeats, of other regions of the apo(a) gene in contributing to the interindividual differences in the plasma concentration of Lp(a). One of the candidate regions is represented by the non-repeated type-3 to type-10 kringles which are invariably present in each apo(a) allele and whose structural integrity is playing a critical role in the correct assembly of the Lp(a) particle. Biochemical studies with recombinant wild type and mutagenized apo(a) cDNAs with several alterations of the non-repeated kringles have well documented this latter point. As a starting point to search for genetic variations in these kringles associated with different levels of Lp(a), we are presenting the genome organization of type-3 to 10 kringle along with specific PCR primers for easy analysis from genomic DNA. Restriction as well as partial sequencing analyses of the type-3 to 10 kringles region has also provided interesting clues as to the different evolutionary origin of these types of kringle with respect to the polymorphic type-2 kringles.

Mammalian Rh/T2/S-glycoprotein ribonuclease family genes: cloning of a human member located in a region of chromosome 6 (6q27) frequently deleted in human malignancies

We describe the cloning of a novel human gene belonging to the Rh/T2/S-glycoprotein class of extracellular ribonucleases. This gene is present in a single copy in the human genome and has been mapped to 6q27, a region of the human genome prone to rearrangements associated with several human malignancies. The predicted open reading frame of the human cDNA encodes a protein of 191 amino acids, and the pattern of expression is ubiquitous. Some of the sequence features of this gene, in particular those corresponding to the bipartite RNase motif of the active site, are perfectly conserved between distant species such as human and the plant Lycopersicon esculentum. No mammalian homologues have been described so far, and this report presents for the first time both the human and the mouse sequences of the corresponding members of this class of highly conserved extracellular ribonucleases.