Sentinel Lymphadenectomy in Cutaneous Melanoma

Aims and Background

In the last ten years validation of the sentinel lymph node (SLN) concept has led to modification of the surgical approach for patients with intermediate-risk cutaneous melanoma.

Methods and Study Design

Forty-eight patients affected by cutaneous melanoma with a Breslow thickness between 0.65 and 4 mm were enrolled in the study. Approximately 2 mCi of radiotracer and 1 mL of vital blue dye were injected in each patient around the site of the primary lesion. Lymphoscintigraphy was performed until the lymphatic basin and the respective SLN were localized. The whole surgical procedure consisted of enlargement of the surgical margins followed by localization and excision of the SLN(s) by using both radiotracer and vital dye. Whenever the SLN proved to be histologically positive for metastasis, complete regional lymphadenectomy was performed.

Results

Within 15 minutes of radiotracer administration the lymphatic basin was localized in all 48 patients by lymphoscintigraphy. Vital dye and radiotracer successfully allowed SLN localization and excision in 46 of 48 patients (97%); in one case the SLN was detected by radiotracer alone. The SLN proved to be metastatic in six (13%) of 46 evaluable patients; interestingly, in three of them the presence of metastatic cells was revealed only by immunohistochemistry. All patients with tumor-positive SLNs had primary lesions with a Breslow thickness = 2 mm.

Conclusions

Sentinel lymphadenectomy is able to identify lymph node involvement in patients with cutaneous melanoma with a Breslow thickness >1 mm, thus avoiding the risks associated with radical regional lymphadenectomy. Lymphoscintigraphy proved to be an important tool to obtain correct preoperative localization of the drainage basin, especially for melanomas located on the face and trunk.

Minimal Sentinel Node Procedure for Staging Early Breast Cancer

Aims and Background

Sentinel lymph node dissection (SLND) has recently been evaluated as a new staging technique for early breast cancer. To minimize the extent of surgery, the feasibility of eradicating primary breast lesions and the relative sentinel lymph nodes (SLN) under regional anesthesia was evaluated in this study.

Methods and Study Design

A selected population of 76 patients with suspected operable breast cancer and no clinically palpable lymph nodes was enrolled in the study. Intra- and perilesional administration of a radiotracer was performed. Lymphoscintigraphy was carried out to confirm the drainage pathway and locate the SLN. The following day, after inducing a nervous block induction of the ipsilateral intercostal nerves, we performed the surgical procedure with the help of a hand-held gamma-detecting probe. In case the primary lesion was diagnosed as invasive carcinoma by frozen section, the SLN and the remaining axillary lymph nodes (non-SLNs) were removed. The status of SLN and non-SLNs was compared.

Results

The primary breast lesion was located and excised in all cases (identification rate: 100%). Lymphoscintigraphy positively identified SLNs in 40/45 (89%) patients; in five patients no lymphatic drainage was detected. In 38 cases an average of 1.5 SLNs and 14 non-SLNs per patient were removed and pathologically analyzed; the remaining two patients showed SLNs in the internal mammary chain, which were not excised. Twenty-nine percent of the patients showed metastatic disease in the lymph nodes examined. Of all patients with affected nodes, 55% had cancer cells only in the SLN. No false negatives (skip metastases) were found. No immediate or long-term anesthesia-related complications (eg pleural lesions, intravascular injection) were observed.

Conclusions

Our data confirm the feasibility of single radiotracer administration for both occult lesion and SLN localization as well as the usefulness of SLND in staging early breast cancer. Regional anesthesia resulted in easy management and good patient compliance. This time-saving procedure allowed the completion of the whole surgical plan, reducing the recovery time without modifying the effectiveness of surgery.

Abstract PD2-17: Dual energy: Potentialities of contrast enhanced mammography in breast desease diagnosis and follow-up

Purpose: Contrast-enhanced Dual-Energy digital mammography (DE) is a recently

used investigation that consists in acquiring low and high energy images after

intravenous injection of iodinated contrast medium. The purpose of this study is to describe our experience about the role of DE in the diagnosis and follow-up of breast cancer.

Materials and Methods: 50 patients, with heterogeneous breast pattern, already studied

by mammography and ultrasound, were selected. They underwent DE mammography: 17

for mammographic or ultrasonographic suspicious findings (9/17 also examined with MRI), 21 for loco-regional staging (21/21 studied with MRI), 10 for oncologic follow-up (6/10 also underwent MRI). DE has been interrupted in two cases due to technical problems. Exclusion criteria of the study were: breast implants, pregnancy or lactation and contraindications to administration of contrast medium. DE results were compared with the post-operative or post-bioptical (Tru-cut or Vacuum Assisted Biopsy) histological findings.

Results: DE showed a sensitivity of 76% in evaluation of Patients with mammographic or ultrasonographic suspicious findings: in comparison with MRI (9 patients), DE had a 55 % specificity (vs 22% of MRI). In locoregional staging DE proved to be more accurate than MRI in dimensional evaluation of unifocal cancer: DE accuracy was 91% vs 62% of MRI, which overestimated the size of most of lesions. In the count of tumor foci number in case of multifocal/multicentric disease MRI corresponded in 9/11 cases with histology (vs 3/11 cases of DE). DE showed a sensitivity of 100% and a 85.7% specificity in assessing oncologic follow-up Patients: in the comparison between DE and MRI (6 patients), DE got 1 false positive result, while MRI 3.

Conclusion: DE can be a valuable diagnostic tool to help conventional techniques; it is also a possible alternative to MRI in some selected type of patients or where MRI is not available.

Citation Format: Cossu E, Costano E, Di Trapano R, Pensabene MC, Di Stefano C, Fosi S, Fiaschetti V, Portarena I, Buonomo O. Dual energy: Potentialities of contrast enhanced mammography in breast desease diagnosis and follow-up [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-17.

Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block

Breast surgery is frequently associated with postoperative pain, nausea and vomiting, that result in increased patient's suffering, prolongation of hospital stays and related costs. Thoracic paravertebral nerve block (TPVB) is a viable option to the classic multimodal analgesia in breast surgery as it enhances surgical anesthesia and postoperative analgesia. In this review, we report the results of a number of studies on the role of TPVB in breast surgery. This technique is associated with a superior control of the pain, a reduction in opioids consumption after surgery, a decrease in postoperative nausea and vomiting, and an overall decrease in length of hospital stay. In particular, TPVB seems to provide the most benefits in patients undergoing an unilateral or bilateral mastectomy followed by immediate reconstruction. Some studies also suggest that the use of regional anesthesia-analgesia could attenuate perioperative immunosuppression and minimize metastases in breast cancer patients. TPVB can be also coupled with other regional anesthetic techniques such as pectoral nerve block (PNB), thus increasing the reduction in postsurgical pain, opioids consumption and length of hospital stays.

Comparative study of oncoplastic versus non-oncoplastic breast conserving surgery in a group of 211 breast cancer patients

OBJECTIVE

Breast conserving surgery (BCS) followed by radiotherapy is the standard of care for most patients with early breast cancers; however, the aesthetic outcomes of this procedure is not always desirable. Oncoplastic breast surgery is an innovative approach that aims at the safe and effective treatment of the cancerous lesion while achieving the best possible aesthetic outcome. The aim of this study was to evaluate and compare oncoplastic and non-oncoplastic procedures.

PATIENTS AND METHODS

A retrospective observational study was conducted on a group of patients who underwent oncoplastic or non-oncoplastic breast surgery at the Breast Unit of the University of Rome Tor Vergata.

RESULTS

Out of 211 patients, 154 (73%) underwent non-oncoplastic surgery, while 61 (27%) underwent an oncoplastic procedure. The percentage of patients requiring re-excision was twice greater for women in the non-oncoplastic group: 12.9% vs. 6.5% in the oncoplastic group. The rate of complications was higher in the oncoplastic group compared to the non-oncoplastic one (4.9% vs. 1.3%). The size of the tumor, the number of the patients receiving post-operative radiation, the interval between surgery and radiotherapy and follow-up were similar between the two groups.

CONCLUSIONS

Oncoplastic surgery represents a valid alternative to breast conserving surgery for patients with breast cancer, with only minimal differences in long-term complications and similar results in terms of local recurrence and number of metastasis.

Use of Flavonoids for the treatment of symptoms after hemorrhoidectomy with radiofrequency scalpel

OBJECTIVES

Control of postoperative symptoms is of paramount importance in proctologic surgery. Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of the flavonoids have been reported in several studies. They have been used to treat a variety of conditions including chronic venous insufficiency, lymphedema and hemorrhoids. Numerous trials, assessing the effect of phlebotonics in treating the symptoms and signs of haemorrhoidal disease, suggest that there is a potential benefit. Our trial was conducted to evaluate whether the flavonoids reduce postoperative bleeding, pain and other symptoms after hemorrhoidectomy.

PATIENTS AND METHODS

We compared the results obtained in 24 patients undergoing open hemorrhoidectomy with radiofrequency scalpel. Our study cohort was randomized in two groups: the Group A received flavonoids in the postoperative period, the Group B has constituted the control group, without administration of study drug. Follow-up outpatient visits were performed on 7, 15 and 30 postoperative day (POD). During the visits the patients expressed trough a list of specific questions, based on a scoring system (1 to 10), their opi-nion about the extent of postoperative symptoms as pain, bleeding, tenesmus, pruritus and perianal weight.

RESULTS

We observed that the results obtained after 7 days of surgery are similar in both study groups. Even after 15 and 30 days no significant changes were observed between the two groups about pain and bleeding. Instead, we observed significant differences regarding tenesmus (group A: 8.0±1.1 vs Group B: 5.4 ± 1.5 at 15 POD, p < 0.05; group A: 9.1±0.8 vs Group B: 5.7 ± 0.9 at 30 POD, p < 0.05), pruritus (group A: 7.1 ± 1.4 vs Group B: 4.8 ± 1 at 15 POD, p < 0.05; group A: 9.5 ± 0.5 vs Group B: 6.6 ± 0.8 at 30 POD, p < 0.05) and perianal weight (group A: 7.2 ± 0.9 vs Group B: 6.2 ± 0.8 at 15 POD, p < 0.05; group A: 9.75 ± 0.4 vs Group B: 7.3 ± 0.9 at 30 POD, p < 0.05).

CONCLUSIONS

Our results confirm the usefulness of this drug to reduce the prevalence and the importance of post-hemorrhoidectomy symptoms and make more comfortable the postoperative period.

A neglected giant subcutaneous leiomyosarcoma of the shoulder: a case report

Superficial leiomyosarcoma is an exceeding uncommon malignant tumor, which can be located either cutaneous or subcutaneous tissues. It may occur anywhere in the body, but there is a predilection for the thighs. The distinction between cutaneous or subcutaneous, increased mass size (> 5 cm) and depth are considered to have worst prognosis in terms of recurrence and metastasis. We report a rare case of an 81-year-old woman, presented with a 20-cm leiomyosarcoma of the shoulder. The patient reported that the mass was completely asymptomatic and its growth was slow. A CT study showed a lesion closely apposed to the head of the humerus and revealed no a clear relationship with the surrounding muscles. There was no regional lymphadenopathy or the evidence of metastatic disease. After tumor resection, a large skin and soft-tissue defect was remained and the repair was performed by myocutaneous rotational free flap of latissimus dorsi. The conclusion of the histological analysis was: subcutaneous leiomyosarcoma pT2--grade 1+ (NCI system). The delayed diagnosis and the surgical treatment and giant size of soft tissue leiomyosarcoma may adversely affect the final result.

Pathological classification of DCIS and planning of therapeutic management

BACKGROUND

Ductal intraepitelial neoplasia (DIN) represents a spectrum of disease that may progress from usual hyperplasia to ductal carcinoma in situ (DCIS) grade 3. The aim of the study was to asses the correlation between the DIN classification and the surgical treatment including sentinel lymph node biopsy (SLNB).

PATIENTS AND METHODS

In this retrospective study, 229 patients with DIN had undergone conservative or radical surgical treatment and SLNB in cases of DIN1C-DIN3.

RESULTS

Breast conservative surgery was the definitive treatment in 80% of the cases. The H&E evaluation of excised sentinel nodes was negative for metastatic disease; nevertheless the immunohistochemical (IHC) evaluation revealed the presence of metastatic cells in 6 patients (3.7%).

CONCLUSION

In cases of DIN lesions SLNB is not indicated. The only reason SLNB should be considered is when there is an evidence of invasive foci at definitive histology or when radical mastectomy is proposed.

The use of an equine collagen fleece (Gentafleece®) in T1 breast cancer surgery: preliminary results

Abstract #4147

Introduction: A prospective multicentric randomized study is being conduced by Breast Cancer Surgical Group of Rome in order to evaluate the benefits of the use of equine collagen (Gentafleece®) on surgical and aesthetic outcome in T1 breast cancer patients.&#x2028; Materials and Methods: One hundred and sixty T1 breast cancer patients have been randomized in two groups by four Roman Institutions in order to evaluate the potential clinical benefits of the use of equine collagen and gentamicine fleece (Gentafleece®). The parameters we studied and compared into the Gentafleece® and control group were: patients'satisfaction, seroma, hematoma, infections, fibrosis and aesthetic result. Both the groups underwent clinical and Ultrasound evaluations after One, Two, and Six months.&#x2028; Results: Belonging to Gentafleece® group, seroma was detected in 7 (5,6%) pts, hematoma in 4 (3,2%) cases, fibrosis and surgical suture aesthetic distortions in 14 (11,2%) pts. On the other hand, in control group were found: 20 (16%) cases of hematoma; 32 (25,6%) cases of seroma; 22 (17,6%) cases were represented by parenchimal fibrosis associated to surgical suture distortions. One case (0,8%) of so defined “reactive megalomasty” occurred in a patient previously treated by neo adjuvant chemotherapy (Gentafleece® group). One case (0,8%) of dermatitis occurred in the same group. In many cases the complete healing of surgical suture was anticipated into first Group. Infection or suture dehiscences occurred in two cases (1,6%) treated by Gentafleece® beside 13 cases (10,4%) of the control group.&#x2028; Discussion: This preliminary study seems to demonstrate that Gentafleece®, equine collagen and gentamicine fleece, is able to reduce the impact of seromas, ematomas, parenchimal fibrosis and surgical sutures and parenchimal aesthetic distortions in according to collagenic properties of cicatrization and hemostatic response. Furthermore Gentafleece® affords a significative antiinfective protection against surgical infection or suture dehiscence.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4147.

Sirolimus in kidney transplantation from marginal donors

Nephrotoxicity caused by calcineurin inhibitors can lead to either delayed graft function or long-term decline of renal function after kidney transplantation. Therefore, recipients of renal transplants from marginal donors require non-nephrotoxic immunosuppression. Eighteen patients received kidney transplants from marginal donors, with a calcineurin inhibitor-free immunosuppressive regimen, based on basiliximab, mycophenolate mofetil, steroids, and sirolimus. Renal graft biopsy was performed in all cases before surgery. Mean follow-up was 11.8 months. We report immediate renal function in 9 patients, delayed graft function in 5 and acute tubular necrosis in 4 patients. One patient was successfully treated for biopsy-proven acute rejection. Hypercholesterolemia and hypertriglyceridemia were the most common adverse effects (n = 13) associated with arthralgia (n = 2) and thrombocytopenia (n = 2). Five patients underwent a switch to tacrolimus, due to sirolimus-induced side effects. Immunosuppression without the use of calcineurin inhibitors is a safe and effective regimen in kidney transplantation, although sirolimus-related side effects still represent a morbidity factor in these patients.

[Intraoperative radiolocalization of intraductal breast carcinoma: sentinel lymph node evaluation]

Sentinel lymph node biopsy and intraoperatory radiolocalization (RLI) are fast becoming the standard surgical treatment for invasive breast cancer. Actually, it seems, they have the same rule in "high risk" DCIS of the breast.

Serum tissue polypeptide specific antigen (TPS): a complementary tumor marker to CA 15-3 in the management of breast cancer

The efficacy of CEA and CA15-3 tumor markers in monitoring breast cancer was evaluated in 1365 patients with either benign (n = 534) or malignant (n = 831) breast diseases. Thirty-nine breast cancer patients were monitored before and after neoadjuvant chemotherapy. Three hundred forty-nine patients were monitored during post-surgical follow-up for either a minimum of 5 years or until time of recurrence. Twenty-one patients with metastases were also monitored during chemotherapy. Elevated CA 15-3 and TPS levels were found in 28.6% and 30.0% of patients. CA 15-3 and TPS sensitivities rose to 71.9% and 66.3% in metastatic patients, respectively. The addition of TPS to CA 15-3 increased the sensitivity up to 44.4% in the overall population, and to 87.6% in patients with metastases. During post-surgical follow-up CA 15-3 was elevated in 65.7% and TPS in 61.3% of patients with recurrence. The combination of TPS and CA 15-3 increased the overall sensitivity by 12.7%. Longitudinal monitoring of metastatic patients undergoing chemotherapy demonstrated that, when positive, both CA 15-3 and TPS paralleled response to treatment. TPS monitoring may provide additional value when used in combination with CA15-3 during post-surgical follow-up of breast cancer patients.

Impact of donor-specific antibodies on chronic rejection occurrence and graft loss in renal transplantation: posttransplant analysis using flow cytometric techniques

BACKGROUND

Improvements in immunosuppressive therapy have greatly reduced acute rejection (ARj) episodes, ensuring better short-term graft outcome, but have not modified long-term survival in renal transplantation. It is now well accepted that chronic rejection (CRj) can be determined by both immune and/or nonimmune mechanisms. The aim of this study was to evaluate the importance of the posttransplant humoral immune response towards mismatched HLA graft antigens in CRj occurrence and graft outcome.

METHODS

Serum samples from 120 nonpresensitized renal transplant recipients were prospectively screened for 1 year after surgery by means of flow cytometry cross-match (FCXM) and FlowPRA beads (microbeads coated with purified HLA class I and class II antigens) assays. All transplants were followed-up for 2 years or until graft removal.

RESULTS

FCXM monitoring identified donor-specific antibodies (DS-Abs) in 29 (24.2%) of 120 transplanted patients. Correlation with clinical data highlighted a higher incidence of ARj in DS-Abs-positive patients compared to negative patients (62% vs. 13%, P<0.00001). Furthermore, graft failure occurred more frequently among FCXM-positive patients than among negative patients (34% vs. 1%, P<0.00001). The deleterious effect of DS-Abs on graft function was confirmed by serum creatinine levels 2 years after transplantation. These were in fact higher in subjects producing DS-Abs than in subjects with only ARj (mean creatinine: 2.5+/-1.3 mg/dL vs.1.7+/-0.5 mg/dL, P=0.04). FlowPRA analysis of DS-Ab HLA specificity highlighted the presence of anti-HLA class I antibodies in 85% of FCXM-positive patients, who also presented with a higher incidence of HLA-B mismatches than FCXM-negative patients (1.23+/-0.66 vs. 0.92+/-0.59, P=0.02).

CONCLUSIONS

Flow cytometric techniques are precious tools for investigating the activation of the humoral response against HLA antigens of the graft in renal transplantation. DS-Abs production has a worse impact on organ function and survival than ARj episodes. These findings represent further proof of the threat posed by DS-Abs on long-term graft function and draw attention to the need for a specific immunosuppressive therapy aimed at counteracting the different kinds of immune activation toward graft.

HLA class I residue mismatch and renal graft outcome

Donor-recipient HLA matching was retrospectively evaluated in 111 cadaveric renal transplants using Takemoto's ten-residue model in which HLA class I antigens are clustered by crossreactive group (CREGs) on the basis of amino acid sequence homology and the sharing of a particular public epitope. The grade and type of HLA residue mismatching were correlated to posttransplant, class I donor-specific antibody production (monitored by flow cytometry crossmatch), rejection occurrence and clinical outcome during the 1st year posttransplant. In 52 patients with 0 mismatchings (MMs) we observed a low incidence of rejection (11.1%) and antibody production (11.1%) for 0 CREG MM grade, while 1 MM was enough to increase immune response against graft (rejection 35%; antibodies 30%). Moreover, a significant correlation was observed between Q144, E163, Q62 and L82/R82 epitopes and the incidence of acute rejection and antibody production ("immunogenic" residues) in patients grouped for a single residue mismatch.

Radioguided-surgery of early breast lesions

BACKGROUND

Radioguided-surgery has been recently proposed in patients with clinically occult breast lesions. This study aimed to evaluate the feasibility of correctly locating and eradicating, by a single intralesional injection of a radiotracer, any breast lesion and, in the case of malignancy, to perform simultaneous sentinel lymph node (SLN) biopsy procedure.

PATIENTS AND METHODS

Sixty-three women with early breast lesions were enrolled: 42 were invasive carcinomas, 16 in situ ductal carcinomas (DCIS) and 5 fibroadenomas.

RESULTS

Scintigraphic images clearly identified the lesions in all patients while SLN/s were evident in 88% of them. At surgery all the breast lesions were easily radiolocalized and eradicated with minimum surgical trauma and, for those patients with invasive carcinomas, the SLN technique was performed in 86% of them. No skip metastases were found.

CONCLUSION

A single intralesional administration of radiotracer is an easy and reliable procedure to simultaneously locate and remove both the non-palpable breast lesion and the SLN when primary malignancy was intraoperatively confirmed.

Novel clinical approaches in monoclonal antibody-based management in colorectal cancer patients: radioimmunoguided surgery and antigen augmentation

Surgery, the most effective treatment for colon and rectal cancer, is based on empirical knowledge of the patterns of tumor spread, gross findings at laparotomy, and histologic confirmation of tumor-free margins. In spite of the many technical improvements in surgery, there has not been a significant change in cure rates for colon and rectal cancers. In fact, one-half of affected patients will not survive 5 years. It is in this arena of treatment for primary colon and rectal cancer patients that radioimmunoguided surgery (RIGS) technology may provide the most benefit. RIGS is an intraoperative procedure for detection of carcinoma lesions that are targeted with a radiolabeled monoclonal antibody (MAb) to provide the surgeon with immediate intraoperative definition of tumor margins and identification of occult disease. To optimize this technique, our studies were designed to increase tumor uptake by higher affinity CC-49 (a second-generation MAb) and to increase tumor antigen expression using biological response modifiers (BRMs). The ability of BRMs, such as interferons (IFNs), to enhance the expression of tumor-associated antigens, may play an important role in an adjuvant setting for MAb-based treatment. Preclinical and clinical data provided evidence for the use of IFN as an adjuvant to enhance MAb-targeting of human carcinoma lesions. A combination protocol with IFN and RIGS is ongoing at our institution.

Novel clinical approaches in monoclonal antibody-based management in colorectal cancer patients: radioimmunoguided surgery and antigen augmentation

Surgery, the most effective treatment for colon and rectal cancer, is based on empirical knowledge of the patterns of tumor spread, gross findings at laparotomy, and histologic confirmation of tumor-free margins. In spite of the many technical improvements in surgery, there has not been a significant change in cure rates for colon and rectal cancers. In fact, one-half of affected patients will not survive 5 years. It is in this arena of treatment for primary colon and rectal cancer patients that radioimmunoguided surgery (RIGS) technology may provide the most benefit. RIGS is an intraoperative procedure for detection of carcinoma lesions that are targeted with a radiolabeled monoclonal antibody (MAb) to provide the surgeon with immediate intraoperative definition of tumor margins and identification of occult disease. To optimize this technique, our studies were designed to increase tumor uptake by higher affinity CC-49 (a second-generation MAb) and to increase tumor antigen expression using biological response modifiers (BRMs). The ability of BRMs, such as interferons (IFNs), to enhance the expression of tumor-associated antigens, may play an important role in an adjuvant setting for MAb-based treatment. Preclinical and clinical data provided evidence for the use of IFN as an adjuvant to enhance MAb-targeting of human carcinoma lesions. A combination protocol with IFN and RIGS is ongoing at our institution.

Advantages of Neoral conversion in renal transplant patients

BACKGROUND

Sandimmun Neoral is a microemulsion formulation of Sandimmun cyclosporin (Cya) with predictable pharmacokinetics, superior absorption and less dependent upon bile production. Recently Neoral replaced the old Cya in the clinical ground.

METHODS

The aim of this study was to assess the effectiveness, safety and advantages of this conversion in 90 adult renal transplant patients with stable renal function transplanted at least 24 months earlier. There were 48 males and 42 females with a mean age of 39 years (range: 18-56). Mean interval from transplant to conversion was 3.6 years (range: 2.7-5.4). Conversion rate was 1:1. Mean Neoral dose at conversion was 3.8 mg/kg/day (range: 2.1-5.7).

RESULTS

One month after conversion mean Neoral dose was 3.4 mg/kg/day (range: 2.2-3.9) and at six months was 3.2 mg/kg/day (range: 2.1-4). Serum creatinine and CyA trough levels remained stable. We did not observe rejection episodes or infections. The incidence of side effects due to CyA was slightly increased and there were not differences in terms of arterial pressure values and number of antihypertensive drugs given.

CONCLUSIONS

The conclusion is drown that conversion to Neoral is safe and results in rapid attainment of therapeutic trough levels. Six months after conversion the mean Neoral dose was decreased of 0.6 mg/kg/die per patient.

[Diverticulosis of the gallbladder. A case report and review of the literature]

We report a case of diffuse diverticulosis of the gallbladder in a 32 year old patient, who presents epigastric pains and decayed general conditions. With the suspicion of a primitive tumor of the gallbladder, we make a cholecystectomy and the intraoperative histological examination shows a "diffuse diverticulosis of the gallbladder wall"; it displays micro-stones inside diverticulums, too. The patient, after the surgical treatment, has no problem and he gets back to his normal weight. The literature shows the rarity of this disease; its etiopathogenesis is connected with congenital factors. In our opinion, the many terms used (cholecystitis glandularis proliferans, hypertrophic, adenomyomatosis) to define those conditions are not appropriate for our case but rather for the gallbladder's chronic inflammation characterized by the Rokitansky-Ashoff sinuses.

Systemic administration of recombinant interferon alfa in carcinoma patients upregulates the expression of the carcinoma-associated antigens tumor-associated glycoprotein-72 and carcinoembryonic antigen

PURPOSE

The ability of interferons (IFNs) to enhance tumor-associated antigen expression may be an important approach to enhance the efficacy of some monoclonal antibody (MAb)-based protocols for tumor diagnosis and/or therapy. The present study was designed to determine whether systemic IFN alpha-2a administration (via the intramuscular [IM] route) could upregulate the expression of tumor-associated glycoprotein-72 (TAG-72) and/or carcinoembryonic antigen (CEA) at histologically confirmed sites of carcinoma.

PATIENTS AND METHODS

Eighteen patients diagnosed with gastrointestinal (GI) carcinoma received systemic IFN alpha-2a according to four dose schedules. In cohorts I and II, patients received two injections of 3 or 6 x 10(6) U IFN alpha-2a per injection, respectively. Patients in cohorts III and IV received the same doses of IFN alpha-2a, 3 and 6 x 10(6) U, respectively, but three injections were given. Tumor and normal colonic mucosa biopsies were obtained from each patient by endoscopy before IFN alpha-2a and after IFN alpha-2a at surgery. The levels of TAG-72 and CEA expression were measured by (1) immunohistochemistry and reported as percent antigen-positive tumor cells, as well as the relative staining intensity, and (2) a quantitative radioimmunoassay.

RESULTS

TAG-72 and CEA levels were consistently increased in tumor biopsies taken from patients in cohorts III and IV. For example, of 10 patients treated in cohorts III and IV, eight had enhanced TAG-72 expression when measured either as percentage TAG-72-positive tumor cells or as an increased MAb staining intensity following IFN alpha-2a. CEA expression in tumor biopsies from seven of 10 patients in cohorts III and IV was also elevated following IFN alpha-2a treatment. Quantitative analysis of TAG-72 and CEA levels in tumor biopsies confirmed higher tumor antigen levels following IFN alpha-2a administration. No such increases in TAG-72 or CEA levels were observed in tumor samples taken from patients in cohorts I and II. CEA or TAG-72 expression in samples of histologically confirmed normal colonic mucosa showed little or no change after IFN alpha-2a treatment.

CONCLUSION

Systemic IFN alpha-2a administration can upregulate TAG-72 and CEA expression at distal tumor sites, which may play an important role in immunodiagnosis and therapy.

Tumor markers as targets for selective diagnostic and therapeutic procedures

Monoclonal antibodies (MAbs) that are reactive with tumor associated antigens (TAAs) have led to many of the recent advances made in tumor immunology. At the present time, many of these MAbs have already been used in various aspects of patient management and in better understanding the biology of carcinoma cell populations. Because of their diversity, specificity and biological activity, these MAbs are potentially ideal agents for a variety of applications in malignant disorders such as, clinical diagnosis using serum assays, immunocytopathological analyses of effusions or fine-needle aspiration specimens, immunoscintigraphy, radioimmunoguided surgery and, with additional development, site directed immunotherapy. Nevertheless, their clinical application shows advantages and limitations. Optimization of their clinical use is actually under evaluation in several Institutions, including our Department. Many innovations have been developed over the last decade which may enhance their clinical efficacy. In this view, an optimal tumor targeting for diagnostic or therapeutic applications may require a better choice of radiotracer, generation of new molecules and the characterization of TAAs at the target level.

Intraoperative radioimmunolocalization of an anti-CEA MAb F(Ab')2 (FO23C5) in CEA serum-negative colorectal cancer patients

Serum positivity to an antigen recognized by the monoclonal antibody (MAb) which will be administered is frequently being used as a predictive criterion for positive MAb tumor localization. In the present study, which is based on our previous data that clearly showed no correlation between quantitative levels of CEA in sera and in carcinoma tissues, we selected a population of 12 primary colorectal carcinoma patients which were serum CEA-negative. The main purpose was to assess the potential diagnostic use of Radioimmunoguided Surgery (RIGS) with an anti-CEA FO23C5 F(Ab')2 MAb and its clinical value in this series of patients. In all RIGS patients, the MAb localized to histologically confirmed tumor; this included 96% of primary tumor tissues, 29% of lymph nodes and one occult liver metastasis. Thus, serum CEA positivity should not be a criterion for the use of anti-CEA MAbs for the diagnosis of colon cancer, since the serum CEA level is not indicative of CEA expression in tumors.

Clinical value of radiolabeled monoclonal antibodies in the management of carcinoma patients

A significant number of monoclonal antibodies, suitable for in vivo management of carcinoma patients, have been recently developed and evaluated in clinical trials. They can be used successfully either for imaging or for radioimmunotherapy, although their clinical application shows advantages and limitations. With the advent of genetic engineering, it has become feasible to design molecules (i.e. chimeric and humanized antibodies, single-chain) to circumvent drawbacks or enhance a certain property. Several radionuclides can actually be used to be linked to monoclonal antibodies, including radiometallic isotopes which need bifunctional chelators. Coupling these radiometals to proteins will greatly increase diagnostic and therapeutic possibilities. The ability of radiolabeled monoclonal antibodies to localize tumors, markedly contributed to the development of a new intraoperative approach termed "Radioimmunoguided Surgery". This system, being used to better define tumor margin resection as well as occult tumor sites, is of importance in postoperative decision-making. Optimization of this technique is actually under evaluation at our Institution, especially in combination with Biological Response Modifiers.

Monoclonal antibodies in the management of carcinoma patients

The use of monoclonal antibodies (MAbs) in the clinical management of carcinoma patients is reported in the present review. Among the various MAbs generated, MAb B72.3 (LTIB, National Cancer Institute, U.S.A.) has been extensively used in clinical trials either for antigen identification (TAG-72) in sera, or for tumor localization in carcinoma patients. Serum assay results, in colorectal cancer patients, showed the usefulness of the MAb B72.3 in monitoring the clinical course of the malignant disease. Its specific tumor localization (70% of the biopsy specimens) and the immunoscintigraphy studies, after in vivo administration, have also been discussed. The positive results obtained, markedly contributed in the development of a new intraoperative methodology termed "radioimmunoguided surgery".

[Cancer of the breast and the receptor status]

Correlation between survival and hormonal receptor status in patients with breast cancer is still controversial. The results of a study carried out, from 1973 to 1988, on 55 patients (average age 56.7) affected with breast cancer and submitted to radical (Halsted) mastectomy, are reported. Estradiol receptors (ER) and progesterone receptors (PR) were determined using the dextran-coated charcoal (DCC) method and the enzymatic immuno assay (EIA). The threshold value for defining the ER positivity was 10 f/mole/mg of cytosol protein and 50 f/mole/mg for PR positivity. Forty-one patients resulted as ER+, 31 were also PR+. Moreover, 41 patients were treated with tamoxifen (10 mg x 2 die per os). In a 15-year follow-up, no significant difference in survival rate between patients with receptor-positive tumors or treated with tamoxifen and patients with receptor-negative tumors was recorded.