Tezepelumab: patient selection and place in therapy in severe asthma

Asthma is a disease characterised by heterogeneous and multifaceted airway inflammation. Despite the availability of effective treatments, a substantial percentage of patients with the type 2 (T2)-high, but mainly the T2-low, phenotype complain of persistent symptoms, airflow limitation, and poor response to treatments. Currently available biologicals target T2 cytokines, but no monoclonal antibodies or other specific therapeutic options are available for non-T2 asthma. However, targeted therapy against alarmins is radically changing this perspective. The development of alarmin-targeted therapies, of which tezepelumab (TZP) is the first example, may offer broad action on inflammatory pathways as well as an enhanced therapeutic effect on epithelial dysfunction. In this regard, TZP demonstrated positive results not only in patients with severe T2 asthma but also those with non-allergic, non-eosinophilic disease. Therefore, it is necessary to identify clinical features of patients who can benefit from an upstream targeted therapy such as anti-thymic stromal lymphopoietin. The aims of this narrative review are to understand the role of alarmins in asthma pathogenesis and epithelial dysfunction, examine the rationale underlying the indication of TZP treatment in severe asthma, summarise the results of clinical studies, and recognise the specific characteristics of patients potentially eligible for TZP treatment.

Comparison between clinical trials and real-world evidence studies on biologics for severe asthma

In recent years, the more widespread availability of biological drugs with specific mechanisms of action has led to significant breakthroughs in the management of severe asthma. Over time, numerous randomised clinical trials have been conducted to evaluate the efficacy and safety of these biologics and define the eligibility criteria of patients suitable for various therapeutic options. These studies were conducted under controlled conditions not always applicable to real life. For this and other reasons, real-world evidence and pragmatic studies are required to provide useful information on the effectiveness of biological drugs and their safety, even in the long term. Because differences in outcomes have sometimes emerged between clinical trials and real-life studies, it is important to clarify the causes of these discrepancies and define the significance of the results of studies conducted in the course of daily clinical practice. Thus, a scientific debate is ongoing, and no consensus has been reached. The purpose of this narrative review is to analyse the differences between randomised trials and real-world evidence studies, focusing on their roles in guiding clinicians among different therapeutic options and understanding the reasons for the large discrepancies often found in the results obtained.

Usefulness of sleep events detection using a wrist worn peripheral arterial tone signal device (WatchPAT™) in a population at low risk of obstructive sleep apnea

Due to the high prevalence of obstructive sleep apnea (OSA), it is recommended to use in-laboratory polysomnography (PSG) or a home sleep apnea test (HSAT) in uncomplicated adult subjects at high risk of OSA. The aims of the present study were to compare a HSAT device, a wrist worn peripheral arterial tone signal device (WatchPAT™-200 [WP]) with PSG and respiratory polygraphy (RP) in a low-risk population of OSA. A total of 47 adult subjects at low risk of OSA were simultaneously examined with the three different approaches in a single night. The sleep studies were scored independently and in a blinded fashion, then the results and the parameters (Respiratory Disturbance Index, apnea-hypopnea index [AHI] and oxygen desaturation index of 3%) were compared with several statistical analyses. The agreement between the sleep tools and correlation for the assessed parameters were analysed and compared with Bland and Altman plots and Pearson's coefficient (WP versus PSG, r = 0.86). For the severity of OSA ranked according to PSG, the Cohen's k was 0.60 and 0.82 for WP and RP, respectively. Specificity was higher for RP compared to WP for identifying the presence of OSA (AHIPSG cut-off ≥5 events/hr: 0.85 versus 0.73), while was quite similar in identifying patients who were more likely to be treated (AHIPSG cut-off ≥15 events/hr: 0.94 versus 0.96). Assessing the costs and the simplicity of the examination, the results of our present study demonstrate the usefulness of WP compared to PSG, especially in screening and follow-up for the ability to exclude subjects from treatment with continuous positive airway pressure (AHI <15 events/hr) in a population with a low pre-test risk of moderate-to-severe OSA.

Does a Self-etching Ceramic Primer Improve Bonding to Lithium Disilicate Ceramics? Bond Strengths and FESEM Analyses

OBJECTIVE:

To compare the effect of hydrofluoric acid (HF) vs self-etching ceramic primer on resin cement microshear bond strength (μSBS) and ultramorphology of lithium disilicate (LD) ceramic.

METHODS AND MATERIALS:

LD (IPS e.max CAD, Ivoclar Vivadent) blocks (14×4×2 mm³) were polished to 1200 grit and assigned to nine groups (n=5): CON: control, no LD surface treatment; IVO: 5.0% HF (IPS Ceramic Etching Gel, Ivoclar Vivadent); VIT: 5.0% HF (Vita Ceramics Etch, VITA Zahnfabrik); FGM: 5.0% HF (Condac Porcelana, FGM); ULT: 9.0% HF (Porcelain Etch, Ultradent); PRM: 9.6% HF (Premier Porcelain Etch Gel, Premier); BIS: 9.5% HF (Porcelain Etchant, Bisco Inc); DEN: 10.0% HF (Condicionador de Porcelanas, Dentsply Brazil); and MEP: self-etching ceramic primer (Monobond Etch & Prime, Ivoclar Vivadent). For all HF groups and control, an MDP-containing silane solution (MB⁺, Monobond Plus, Ivoclar Vivadent) was applied on rinsing the HF gel and air drying. Three transparent matrices for each specimen were filled with light-cured resin cement (Variolink Veneer, Ivoclar Vivadent). After storage in water for 48 hours at 37°C, specimens were tested in shear mode to measure μSBS. Mode of failure was analyzed at 50×. Statistical analysis included one-way analysis of variance and the Duncan post hoc test (α=0.05). Thirty-six additional LD specimens were assigned to the same experimental groups (n=4) and observed under a field-emission scanning electron microscope (FESEM) at magnifications ranging from 10,000× to 100,000×.

RESULTS:

IVO resulted in statistically higher mean μSBS than all the other groups. MEP resulted in statistically lower μSBS than all HF groups. The failure mode for MEP was predominantly adhesive. The most frequent failure mode for the HF groups was mixed. CON resulted in 100% pretesting failures. For FESEM, no retentive pattern was observed for CON specimens. MEP resulted in the least pronounced etching pattern, few areas around crystals exhibited a slight increase in retention pattern compared to the control group. All HF gels created microporosities on the LD surface with distinct etching patterns. VIT and DEN resulted in an LD ultramorphology that suggested overetching.

CONCLUSIONS:

HF etching followed by a silane solution resulted in higher bond strengths than a self-etching ceramic primer. Some HF gels may cause overetching of the LD intaglio surface.

Expression of the atypical chemokine receptor D6 in human alveolar macrophages in COPD

BACKGROUND

D6 is an atypical chemokine receptor involved in chemokine degradation and resolution of acute inflammatory responses in mice. Emerging evidence suggests that D6 might behave differently in human chronic inflammatory conditions. We, therefore, investigated the involvement of D6 in the immune responses in COPD, a chronic inflammatory condition of the lung.

METHODS

D6 expression was quantified by immunohistochemistry in surgical resected lung specimens from 16 patients with COPD (FEV(1), 57% ± 6% predicted) and 18 control subjects with normal lung function (nine smokers and nine nonsmokers). BAL was also obtained and analyzed by flow cytometry, immunofluorescence, and molecular analysis for further assessment of D6 involvement.

RESULTS

D6 expression in the lung was mainly detected in alveolar macrophages (AMs). The percentage of D6(+) AMs was markedly increased in patients with COPD as compared with both smoker and nonsmoker control subjects (P < .0005 for both). D6 expression was detected at both transcript and protein level in AMs but not in monocyte-derived macrophages. Finally, D6 expression was positively correlated with markers of immune activation (CD8(+) T lymphocytes, IL-32, tumor necrosis factor-α, B-cell activating factor of the tumor necrosis factor family, phospho-p38 mitogen-activated protein kinase) and negatively with lung function (FEV(1), FEV(1)/FVC).

CONCLUSIONS

D6 is expressed in AMs from patients with COPD, and its expression correlates with the degree of functional impairment and markers of immune activation. Upregulation of D6 in AMs could indicate that, besides its known scavenger activity in acute inflammation, D6 may have additional roles in chronic inflammatory conditions possibly promoting immune activation.

Deficient antiviral immune responses in childhood: distinct roles of atopy and asthma

BACKGROUND

Impaired immune response to viral infections in atopic asthmatic patients has been recently reported and debated. Whether this condition is present in childhood and whether it is affected by atopy per se deserves further investigation.

OBJECTIVE

We sought to investigate airway interferon production in response to rhinovirus infection in children who are asthmatic, atopic, or both and its correlation with the airway inflammatory profile.

METHODS

Bronchial biopsy specimens and epithelial cells were obtained from 47 children (mean age, 5 ± 0.5 years) undergoing bronchoscopy. The study population included asthmatic children who were either atopic or nonatopic, atopic children without asthma, and children without atopy or asthma. Rhinovirus type 16 induction of IFN-λ and IFN-β mRNA and protein levels was assessed in bronchial epithelial cell cultures. The immunoinflammatory profile was evaluated by means of immunohistochemistry in bronchial biopsy specimens.

RESULTS

Rhinovirus type 16-induced interferon production was significantly reduced in atopic asthmatic, nonatopic asthmatic, and atopic nonasthmatic children compared with that seen in nonatopic nonasthmatic children (all P < .05). Increased rhinovirus viral RNA levels paralleled this deficient interferon induction. Additionally, IFN-λ and IFN-β induction correlated inversely with the airway T(H)2 immunopathologic profile (eosinophilia and IL-4 positivity: P < .05 and r = -0.38 and P < .05 and r = -0.58, respectively) and with epithelial damage (P < .05 and r = -0.55). Furthermore, total serum IgE levels correlated negatively with rhinovirus-induced IFN-λ mRNA levels (P < .05 and r = -0.41) and positively with rhinovirus viral RNA levels (P < .05 and r = 0.44).

CONCLUSIONS

Deficient interferon responses to rhinovirus infection are present in childhood in asthmatic subjects irrespective of their atopic status and in atopic patients without asthma. These findings suggest that deficient immune responses to viral infections are not limited to patients with atopic asthma but are present in those with other T(H)2-oriented conditions.

Percutaneous endoscopic jejunostomy in patients with gastroparesis following lung transplantation: feasibility and clinical outcome

The aim of the present study was to describe success rates, complications, and outcome in patients who underwent percutaneous endoscopic jejunostomy (PEJ) because of gastroparesis due to previous lung transplantation. Between October 2008 and May 2011, 14 attempts at PEJ placement were made in 12 patients in our center. Of the 14 attempts, 11 were successful, giving a technical success rate of 78.6 %. Median duration of followup was8.5 months (2–15 months). No immediate complications were reported. Two severe complications occurred during follow up (one volvulus and one jejunocolic fistula). Jejunal nutrition was well tolerated in most of patients (9 /10). PEJ insertion is a feasible technique, which could help to provide nutritional support for patients with gastroparesis and previous lung transplantation.

Mast cell infiltration discriminates between histopathological phenotypes of chronic obstructive pulmonary disease

RATIONALE

COPD is a complex disease with heterogeneous manifestations. Attempts have been made to define different phenotypes that could guide toward better disease understanding. We described before that smokers can develop either panlobular (PLE) or centrilobular emphysema (CLE). The latter has worse small airways remodeling and narrowing, which account for the airflow obstruction similar to asthma.

OBJECTIVES

Because of the small airways involvement in CLE similar to asthma, we hypothesized a role for mast cells in CLE but not in PLE. Hence, we investigated mast cell infiltration, along with overall inflammation, and their relation with hyperreactivity and emphysema type in COPD.

METHODS

We studied lung function, emphysema type, mast cells, and overall inflammation in small airways and alveolar walls, along with alveolar wall thickening in 67 subjects undergoing lung resection (59 smokers, 8 nonsmokers).

MEASUREMENTS AND MAIN RESULTS

Twenty-seven smokers had CLE, 24 had PLE, and 8 had no emphysema. Mast cells were significantly increased in CLE compared with PLE and control subjects. Especially relevant was the mast cell increase in airway smooth muscle in CLE, which related significantly to airway hyperreactivity. CD4(+)T cells, neutrophils, and macrophages, but not eosinophils and CD8(+)T cells, were significantly higher in CLE than PLE. Alveolar wall thickness was increased in all smokers, but significantly more in CLE.

CONCLUSIONS

The pathological phenotypes of COPD CLE and PLE show important differences in their overall inflammation with a protagonism of mast cells, which are related to airway reactivity. These findings highlight the distinctness of these COPD phenotypes and the role of mast cells in the pathophysiology of COPD.

Buried bumper syndrome: low incidence and safe endoscopic management

AIMS

Buried bumper syndrome (BBS) is a rare long-term complication of percutaneous endoscopic gastrostomy (PEG) and consists of a progressive impaction of the inner bumper of the tube in the mucosa of gastric wall. The aim of our study was to report our own experience with BBS, focusing on its incidence and endoscopic management.

PATIENTS AND METHODS

Medical records of a large group of 879 patients having undergone PEG insertion (2002-2009) were retrospectively reviewed. All PEG's were followed by our special Nutrition Support Team. Patients presenting with BBS during their follow-up were included in the study.

RESULTS

Only eight patients (8/879; 0.9%) developed BBS, which was confirmed during gastroscopy. Median time between PEG insertion and BBS diagnosis was 22.0+/-22.28 months. Five patients underwent successful treatment with: 1) flexible guide wire insertion through the internal orifice of the PEG to define its anatomical settings, 2) cruciform incisions of the gastric mucosa with a needle-knife starting at the center of the mucosal dome covering the internal bumper, and reaching its edges, 3) extrusion and complete extraction of the inner bumper through the gastric tract. No complications were observed. Median hospital stay related to BBS lasted 4.0+/-3.67 days. In two patients with peristomal abscess and deeply migrated bumper surgery was needed.

CONCLUSIONS

Cruciform mucosal incisions with needle-knife is a safe endoscopic technique to treat the BBS that could avoid surgery in most of the cases. Preventive measures applied after PEG insertion and continued during the follow-up may result in a distinctly lower prevalence of BBS.

Noneosinophilic asthma in children: relation with airway remodelling

Noneosinophilic asthma is increasingly recognised as an important clinical-pathological phenotype in adults. However, this entity has scarcely been investigated in children. In particular, it is unknown whether airway remodelling would develop in children with non-eosinophilic asthma to the same degree as in children with eosinophilic disease. We analysed bronchial biopsies from 80 children undergoing bronchoscopy for appropriate clinical indications: 21 with noneosinophilic asthma, 34 with eosinophilic asthma and 25 control children. Features of airway remodelling - basement membrane thickening, epithelial loss and angiogenesis - and immune activation - inflammatory infiltrate, interleukin (IL)-4, IL-5, transforming growth factor (TGF)-β, TGF-β receptor type II - were quantified by histology and immunohistochemistry. The main components of airway remodelling were present in children with noneosinophilic asthma just as in those with eosinophilic disease. Indeed, compared with control children, both noneosinophilic and eosinophilic asthmatic children had thickened basement membrane, increased epithelial loss and higher number of vessels. Moreover, in both groups of asthmatics, expression of IL-4 and IL-5 was increased, while that of TGF-β receptor type II was reduced, compared with controls. This study demonstrates that structural changes typical of asthma develop in asthmatic children even in the absence of a prominent eosinophilic infiltrate, indicating that other mechanisms, besides eosinophilic inflammation, may promote airway remodelling early in life.

Lessons from a 20 year experience of Home Parenteral Nutrition in adult patients

BACKGROUND

Home Parenteral Nutrition (HPN) is a method commonly used in patients with Chronic Intestinal Failure (CII) related to benign or malignant diseases. We report the experience from a 20 year programme of HPN in a single academic centre.

METHODS

In this study, we have reviewed characteristics and outcome of a group of patients enrolled in a HPN program between 1987 and 2007. Focus was given to the prevalence and severity of cholestasis in these patients as well as on their oral food behaviour.

RESULTS

In 20 years, 125 patients were included in a HPN programme; 65 patients had benign diseases (BD) and 60 advanced cancer (AC). Short bowel was the most common indications in patients with BD. Almost 40% of patients with BD were weaned off HPN. Median survival was excellent in BD patients and extremely short in AC. Death related to HPN was very rare. Cholestasis has been observed in 84% of patients but it was mild to moderate in the majority of cases. Hyperphagia was observed in 50% of the patients with BD on long-term HPN.

CONCLUSIONS

This study confirms that HPN is the first line therapy in CII due to BD. Patients with AC should be carefully selected. Cholestasis is frequent but mostly without clinical impact. Half of the patients with CII due to BD become hyperphagic allowing to reduction of parenteral intake. The role of a multidisciplinary nutrition support team is essential for optimizing HPN.

Correlation of computed tomography densitometry and pathological grading of emphysema with the variation of respiratory function after lobectomy for lung cancer

The presence of emphysema may lead to an underestimation of postoperative respiratory function after lobectomy when evaluated by standard functional assessment. The aim of the study was to assess the correlation between computed tomography (CT) densitometry, pathological grading of emphysema and variation of pulmonary function after lobectomy for lung cancer. Forty-one patients entered the study. Respiratory function was assessed preoperatively and after a mean period of 4.04 months following surgery. Postoperative function remained unchanged or increased after surgery in nine patients (Group A). In the remaining 32 patients (Group B) postoperative function was reduced after surgery. Preoperative forced expiratory volume in 1 s (FEV(1))% was 68.5+/-13.1% in Group A and 91.7+/-21.0% in Group B. CT densitometry of the lobe to be resected was -877.8+/-57.6 HU in Group A and -827.5+/-64.4 HU in Group B. Pathological grading of emphysema of the resected lobe (range 0-10) was 4.1+/-2.2 in Group A and 3.1+/-1.2 in Group B. A significant correlation was observed (Spearman rank correlation) between the variation of FEV(1) and preoperative FEV(1) (P=0.003; r=-0.455), CT quantitative assessment (P=0.036; r=-0.430) and pathological grading (P=0.008; r=0.673). Patients with a higher degree of emphysema had a lower reduction of respiratory function after lobectomy and CT densitometry and pathological grading of emphysema correlated with the variation in respiratory function.

[Sentinel lymph-node biopsy for breast cancer. Analysis of 235 cases and review of the literature]

Sentinel lymph-node biopsy for breast cancer has been rapidly adopted in clinical practice. At the present time few prospective randomised studies exist, the false negative rate is variable and its role with regard to prognosis is not well known. The aim of this study was to evaluate the elements of sentinel lymph-node biopsy that have yet to be clearly defined, by reference to the literature and our own experience. From September 1999 to July 2005, we considered 235 consecutive patients undergoing sentinel lymph-node biopsy. We used the radioactive tracer in 143 cases, and the radiotracer combined with vital blue dye in 89 cases. Vital blue dye was used alone in only 3 cases. In 224 cases the sentinel lymph-node biopsy was performed in a single session, using frozen sections to evaluate the sentinel node. The identification rate obtained was 97.9% with the radiotracer, 100% with the combined procedure and 66.7% with vital blue alone. The sentinel node proved positive in 52 cases. The frozen sections correctly predicted the positive result of the definitive histopathological analysis in 26 cases and correctly predicted a negative result in 172. We discuss the indications and methods of sentinel lymph-node biopsy, analysing our own data and those reported in the literature.

Ethical aspects of percutaneous endoscopic gastrostomy placement for artificial nutrition and hydratation

Of the many decisions that family members and physicians must make about medical care in patients with advanced disease and perceived poor quality of life, none is more heart-wrenching than the decision about artificial nutrition and hydratation. The endoscopist often is placed in a precarious position when percutaneous endoscopic gastrostomy tube placement is requested in such patients. Clinical decision-making between the patient, the family and the physician should be consistent with legal and ethical principles. The purpose of this article is to provide an evaluation of medical and ethical issues regarding the decision on placing a percutaneous endoscopic gastrostomy tube for various indications, as well as suggesting strategies to optimize the decision-making process.

Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience

BACKGROUND

Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks.

METHODS

A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia.

RESULTS

Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture.

CONCLUSIONS

Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

Calibrated lateral internal sphincterotomy for chronic anal fissure

Lateral internal sphincterotomy is an effective procedure for the treatment of anal fissure, but may affected anal continence. We describe a procedure aimed at tailoring the division of the sphincter according to the degree of the hypertonia and to the sphincter length in order to offer an effective and safe treatment for chronic anal fissure.

METHODS

The internal sphincter was divided on the basis of anal manometry results. The average of maximum values of resting pressure determined by the stationary motility protocol was considered the reference parameter to measure hypertonia. Mild hypertone was considered to be 50-60 mmHg, moderate hypertone 60-80 mmHg, and severe hypertone >80 mmHg. In case of mild hypertone, 20% of the internal sphincter was divided; in case of moderate hypertone; 40% and 60% for severe hypertone. Calibrated lateral internal sphincterotomy is the division of the internal sphincter based on these parameters. Over 5 years, 388 patients underwent this procedure (197 men, 191 women) with a median age of 43 years (range, 18-80).

RESULTS

Postoperative complications consisted of abscess in 4 patients (1.0%), hemorrhage in 2 patients (0.5%), and pain in 6 patients (1.5%). Follow-up data are available for 261 patients (67.3%). Two months after surgery, 9 patients (3.4%) complained of persistent or recurring pain with or without fissure and 1 (0.4%) complained of gas incontinence. At postoperative manometry, 12 patients (4.6%) revealed persistence of anal resting pressure over 40 mmHg, 9 patients (3.4%) were still symptomatic and 97.6% were cured at a median follow-up of 8 months. An anal resting pressure lower than 30 mmHg was found in 10 patients (3.8%), only one of whom was incontinent.

CONCLUSIONS

Calibrated sphincterotomy may represent an effective and safe procedure for the treatment of chronic anal fissure.

Axillary sentinel lymph nodes in breast cancer: a single lymphatic pathway drains the entire mammary gland

AIM

To report the pattern of lymphatic mapping following intrasubdermal injections of radiocolloid and of blue dye in different sites of the breast.

METHODS

Prior to surgery 137 breast cancer patients underwent intrasubdermal injection of 30-50 MBq 99mTc-colloidal albumin over the tumour site (ISI group). Ten minutes before surgery, 2 ml patent blue was injected in the subareolar area (SAI group) in 117/137 patients, while 20 patients received intrasubdermal blue-dye in the quadrant opposite the tumour site (OQI group). The different injection routes were considered concordant when the hottest sLN was also blue.

RESULTS

In 134/137 patients radiocolloid drained to one or more axillary nodes, while blue nodes were found in 98/117 SAI patients and in 17/20 OQI patients. Multiple hot nodes were found in 63/134 cases and multiple blue nodes in 35/115. In patients in whom both tracers reached the axilla, the hottest node was also blue in 108/115 cases (93/98 SAI and 15/17 OQI patients). In the seven discordant cases, the hottest node was not blue, but in two cases the blue node was also radioactive.

CONCLUSIONS

Superficial lymphatic drainage from the breast most frequently merges to a single axillary lymph node, irrespective of the site of tracer injection. In a few cases different injection sites identify different, often closely interconnected sLNs.

Role of axillary sentinel lymph node biopsy in patients with pure ductal carcinoma in situ of the breast

BACKGROUND

Sentinel lymph node (SLN) biopsy is an effective tool for axillary staging in patients with invasive breast cancer. This procedure has been recently proposed as part of the treatment for patients with ductal carcinoma in situ (DCIS), because cases of undetected invasive foci and nodal metastases occasionally occur. However, the indications for SLN biopsy in DCIS patients are controversial. The aim of the present study was therefore to assess the incidence of SLN metastases in a series of patients with a diagnosis of pure DCIS.

METHODS

A retrospective evaluation was made of a series of 102 patients who underwent SLN biopsy, and had a final histologic diagnosis of pure DCIS. Patients with microinvasion were excluded from the analysis. The patients were operated on in five Institutions between 1999 and 2004. Subdermal or subareolar injection of 30-50 MBq of 99 m-Tc colloidal albumin was used for SLN identification. All sentinel nodes were evaluated with serial sectioning, haematoxylin and eosin staining, and immunohistochemical analysis for cytocheratin.

RESULTS

Only one patient (0.98%) was SLN positive. The primary tumour was a small micropapillary intermediate-grade DCIS and the SLN harboured a micrometastasis. At pathologic revision of the specimen, no detectable focus of microinvasion was found.

CONCLUSION

Our findings indicate that SLN metastases in pure DCIS are a very rare occurrence. SLN biopsy should not therefore be routinely performed in patients who undergo resection for DCIS. SLN mapping can be performed, as a second operation, in cases in which an invasive component is identified in the specimen. Only DCIS patients who require a mastectomy should have SLN biopsy performed at the time of breast operation, since in these cases subsequent node mapping is not feasible.

Effect of vegetarian diet on homocysteine levels

OBJECTIVE

To compare fasting total plasma homocysteine (tHcy) levels in vegans, lacto-ovovegetarians and control subjects, and to evaluate the relationships between tHcy levels and nutritional variables in vegetarians.

METHODS

The study was conducted on 45 vegetarian subjects: 31 vegans (19 males, 12 females, mean age 45.8 +/- 15.8 years); 14 lacto-ovovegetarians (6 males, 8 females, mean age 48.5 +/- 14.5 years), and 29 control subjects (19 males, 10 females, mean age 43.4 +/- 16.7 years). tHcy was evaluated by high-performance liquid chromatography. Serum vitamin B(12) and folate were analyzed by automated chemiluminescence systems. Clinical records, nutritional and anthropometric variables were collected for all vegetarian subjects.

RESULTS

tHcy was significantly higher in vegetarian subjects than in controls (23.9 +/- 21.3 vs. 11.6 +/- 4.9 micromol/l, p < 0.001). The prevalence of hyperhomocysteinemia was higher in vegetarians than in controls (53.3 vs. 10.3%, p < 0.001). Serum vitamin B(12) levels were lower in vegetarians than in control subjects (171.2 +/- 73.6 vs. 265.0 +/- 52.2 pmol/l, p < 0.01; normal range 220-740 pmol/l). In vegetarian subjects, significant inverse correlations were found between tHcy and serum vitamin B(12) levels (r = -0.776, p < 0.001) and between tHcy and serum folate levels (r = -0.340, p < 0.05). Positive correlations were found between tHcy and mean red cell volume (r = 0.44, p < 0.01) and between tHcy and fat-free mass (r = 0.36, p < 0.05).

CONCLUSION

Vegetarian subjects presented significantly higher tHcy levels, higher prevalence of hyperhomocysteinemia, and lower serum vitamin B(12) levels than controls.

[Medullary carcinoma of the thyroid: a clinical contribution]

The authors report 20 cases of medullary thyroid carcinoma over the period from 1980 to 2000. Two patients turned out to be inoperable and 18 patients underwent total thyroidectomy, associated with dissection of the central lymphatic compartment in 5 patients and with dissection of the central and lateral lymphatic compartments in 10 patients with clinical or instrumental evidence of cervical lymphadenomegaly. Serum calcitonin levels proved to be a reliable marker for the diagnosis of persistence or recurrence of the disease. The follow-up, lasting from 1 to 208 months, demonstrated that in 7 cases in which serum levels of calcitonin underwent normalization there was no recurrence of disease. Among 11 cases with persistence of high calcitonin levels, 6 died and only 2 presented no evidence of metastases. On the basis of our analysis of the cases reported, total thyroidectomy associated with dissection of the central lymphatic compartment is an adequate treatment for patients in stages I and II. The authors regard routine dissection of the lateral lymphatic compartment as unadvisable.

[Fournier's gangrene in a patient with Hodgkin's disease: a clinical case]

The authors report a case of Fournier's gangrene in a 54-year-old patient subjected 6 days earlier to chemotherapy for mediastinal Hodgkin's disease. The patient had fever and reported the onset of worsening pain and heat sensations in the inguinal, perineal and scrotal areas. Objectively, there was local oedema followed by the onset of crepitation. The patient had a very low white blood cell count (900/cu.mm). The Patient underwent emergency surgery with multiple, communicating incisions in the inguinal, perineal and scrotal areas, with the removal of necrotic tissue and daily washing with physiological solution and 12% H2O2. He also received antibiotic treatment with metronidazole and gentamicin and 5 cycles of high-pressure oxygen therapy, with disappearance of pain and fever and good local tissue repair.

[Appendiceal mucocele associated with colonic neoplasm. Report of 2 cases and review of the literature]

Appendiceal mucocele is a rare entity frequently associated with colorectal cancer. We report two cases of mucocele associated with colorectal tumours. The first case (male, 64 yrs) is an appendiceal mucinous cystadenoma found incidentally during surgery for colon cancer. There is no evidence of disease after a 4-year follow-up. The second case (male, 66 yrs) is a mucocele associated with mucosal hyperplasia that was found during surgery for acute appendicitis with a periappendicular abscess. Endoscopic follow-up showed a rectal adenocarcinoma that was initially treated with local excision with T.E.M.. Examination of the pathology specimen documented vascular invasion and the patient underwent curative colorectal resection. The preoperative radiological and endoscopic diagnostic procedures and the current therapeutic approaches described in the literature are reviewed. The relevance of the association between appendiceal mucocele and colorectal cancer is emphasized. Thorough investigation of the colorectal tract is recommended after diagnosing an appendiceal mucocele.

Resting metabolic rate and thermogenic effect of food in vegetarian diets compared with Mediterranean diets

The purpose of our work is to compare the resting metabolic rate (RMR) and thermogenic effect of food (TEF) in a group of vegetarians and a group of subjects consuming a Mediterranean diet. The composition of the diets was similar. Thirty-two subjects were studied: 16 vegetarians (age 34 +/- 9 years, BMI 21 +/- 2) and 16 omnivors (age 30 +/- 5 years, BMI 22 +/- 3). All were in excellent general health. Each subject consumed a dish of pasta (100 g) and bread (30 g) after RMR had been measured. TEF was measured over the next 3 h and calculated as the incremental area above RMR. Energy (vegetarians and omnivors 7,727 +/- 3,516 vs 8,970 +/- 2,273 kJ/day, respectively) and carbohydrate (vegetarians and omnivors 285.1 +/- 141.3 vs. 300.1 +/- 74 g/day, respectively) intakes of the 2 groups were similar. The vegetarian group consumed a higher quantity of fiber (30.5 +/- 16.7 vs. 16.5 +/- 7.9) and a lower amount of protein (44.9 +/- 18.3 vs. 70.1 +/- 14.9) than the omnivorous group. No significant differences were observed in RMR (4.23 +/- 0.96 vs. 4.06 +/- 0.54 kJ/min) and TEF (0.50 +/- 0.25 vs. 0.38 +/- 0.25 Delta kJ/min) between the groups. Results did not change after correcting for weight, age and gender. Our study failed to show any significant differences in RMR and TEF between vegetarians and subjects consuming a Mediterranean diet. We conclude that vegetarianism per se is not accompanied by a difference in RMR and TEF when the carbohydrate content of the diet is similar to a control group of nonvegetarians.