Advances in Urinary Diversion: From Cutaneous Ureterostomy to Orthotopic Neobladder Reconstruction-A Comprehensive Review

Bladder cancer ranks as the 10th most prevalent cancer globally with an increasing incidence. Radical cystectomy combined with urinary diversion represents the standard treatment for muscle-invasive bladder cancer, offering a range of techniques tailored to patient factors. Overall, urinary diversions are divided into non-continent and continent. Among the first category, cutaneous ureterostomy and ileal conduit represent the most common procedures while in the second category, it could be possible to describe another subclassification which includes ureterosigmoidostomy, continent diversions requiring catheterization and orthotopic voiding pouches and neobladders. In this comprehensive review, urinary diversions are described in their technical aspects, providing a summary of almost all alternatives to urinary diversion post-radical cystectomy.

Unlocking Precision Medicine: Liquid Biopsy Advancements in Renal Cancer Detection and Monitoring

Renal cell carcinoma (RCC) remains a formidable diagnostic challenge, especially in the context of small renal masses. The quest for non-invasive screening tools and biomarkers has steered research towards liquid biopsy, focusing on microRNAs (miRNAs), exosomes, and circulating tumor cells (CTCs). MiRNAs, small non-coding RNAs, exhibit notable dysregulation in RCC, offering promising avenues for diagnosis and prognosis. Studies underscore their potential across various biofluids, including plasma, serum, and urine, for RCC detection and subtype characterization. Encouraging miRNA signatures show correlations with overall survival, indicative of their future relevance in RCC management. Exosomes, with their diverse molecular cargo, including miRNAs, emerge as enticing biomarkers, while CTCs, emanating from primary tumors into the bloodstream, provide valuable insights into cancer progression. Despite these advancements, clinical translation necessitates further validation and standardization, encompassing larger-scale studies and robust evidence generation. Currently lacking approved diagnostic assays for renal cancer, the potential future applications of liquid biopsy in follow-up care, treatment selection, and outcome prediction in RCC patients are profound. This review aims to discuss and highlight recent advancements in liquid biopsy for RCC, exploring their strengths and weaknesses in the comprehensive management of this disease.

Comparing Cardiovascular Adverse Events in Cancer Patients: A Meta-analysis of Combination Therapy with Angiogenesis Inhibitors and Immune Checkpoint Inhibitors versus Angiogenesis Inhibitors Alone

Anti-VEGF (vascular endothelial growth factor) agents were associated with increased risk of several cardiovascular events, while one meta-analysis did not show any significantly increased risk of cardiotoxicity associated with the use of immune checkpoint inhibitors (ICIs). This meta-analysis of randomized-controlled trials (RCTs) was designed to compare cardiovascular toxicity of anti-VEGF agents plus ICI vs anti-VEGF agents without ICIs. A systematic search of the literature was conducted to include all full papers reporting about phase II and III randomized controlled trials (RCTs) conducted in patients with solid malignancies randomized to an anti-VEGF agent plus an ICI vs. an anti-VEGF agent without an ICI. Overall incidences of cardiovascular events were compared between these two treatment groups estimating the corresponding odds ratios. This analysis suggests that ICIs may increase the risk of cardiovascular toxicities associated with anti-VEGF therapies. Further research, including real world studies, is warranted.

Multidisciplinary Approach to the Diagnosis and Therapy of Mycosis Fungoides

Mycosis fungoides is the most common primary cutaneous T-cell lymphoma, characterized by skin-homing CD4+ T cells derivation, indolent course, and low-grade of malignancy. Mycosis fungoides's classic type typically onsets with cutaneous erythematous patches, plaque, and tumor. In WHO-EORTC classification, folliculotropic mycosis fungoides, pagetoid reticulosis, and granulomatous slack skin are recognized as distinct variants of mycosis fungoides, because of their clinical and histological features, behavior, and /or prognosis. Mycosis fungoides often shows diagnostic difficulties, due to its absence of specific features and lesional polymorphism. A patient's treatment requires staging. In about 10% of cases, mycosis fungoides can progress to lymph nodes and internal organs. Prognosis is poor at advanced stage and management needs a multidisciplinary team approach. Advanced stage disease including tumors, erythroderma, and nodal, visceral, or blood involvement needs skin directed therapy associated with systemic drugs. Skin directed therapy includes steroids, nitrogen mustard, bexarotene gel, phototherapy UVB, and photochemiotherapy, i.e., total skin electron radiotherapy. Systemic therapies include retinoids, bexarotene, interferon, histone deacetylase inhibitors, photopheresis, targeted immunotherapy, and cytotoxic chemotherapy. Complexity of mycosis fungoides associated with long-term chronic evolution and multiple therapy based on disease stage need a multidisciplinary team approach to be treated.

Adult- and late-onset male hypogonadism: the clinical practice guidelines of the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE)

PURPOSE

To provide the evidence-based recommendations on the role of testosterone (T) on age-related symptoms and signs remains.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) and the and the Italian Society of Endocrinology (SIE) commissioned an expert task force to provide an updated guideline on adult-onset male hypogonadism. Derived recommendations were based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Clinical diagnosis of adult-onset hypogonadism should be based on a combination of clinical and biochemical parameters. Testosterone replacement therapy (TRT) should be offered to all symptomatic subjects with hypogonadism after the exclusion of possible contraindications. T gels and the long-acting injectable T are currently available preparations showing the best efficacy/safety profile. TRT can improve all aspects of sexual function, although its effect is limited in more complicated patients. Body composition (reducing fat mass and increasing lean mass) is improved after TRT, either in subjects with or without metabolic syndrome or type 2 diabetes. Conversely, the role of TRT in improving glycometabolic control is more conflicting. TRT can result in increasing bone mineral density, particularly at lumbar site, but no information on fracture risk is available. Limited data support the use of TRT for improving other outcomes, including mood frailty and mobility.

CONCLUSIONS

TRT can improve sexual function and body composition particularly in less complicated adult and in aging subjects with hypogonadism. When hypogonadism is adequately diagnosed, T appropriately prescribed and subjects correctly followed up, no short-term increased risk of adverse events is observed. Longer and larger studies are advisable to better clarify TRT long-term efficacy/safety profile.

One-stage resection of primary colorectal cancer and hepatic metastases using the Habib Device: analysis of 40 consecutive cases treated in a Unit of general surgery

BACKGROUND

More than 50% of patients with colorectal cancer (CRC) present or develop hepatic metastases (HM). The intraoperative use of the Habib 4X^® radio frequency probe device is safe in resetting HM and allows a one-stage resection of both CRC and HM with a similar mortality rate than a two-stage surgical treatment.

METHODS

After an exhaustive residential training at the reference center for hepato-biliary surgery of the Imperial College of London, we treated at our unit of general surgery 40 consecutive patients with CRC and HM with the one-stage resection, using the Habib 4X^® intraoperative radiofrequency probe device to reset HM.

RESULTS

None of the 40 patients died during the intra-operatory and post-operatory periods, none presented liver failures during the postoperative course nor complication related to the Habib's resection procedure (e.g. bleeding, abscess, bile leak). The amount of intra-operative liver bleeding was minimal. New HM arose in 10 (25%) cases, with a mean disease-free interval of 13 months, but the hepatic tissue close to previous resections remained cancer-free. The 69.7% of patients were disease-free at month 24 of the post-operative follow-up and 5-year rate was about 70%.

CONCLUSIONS

The data suggest that surgeons well trained at a reference center for hepato-biliary surgery may perform with excellent results the one-stage CRC and HM resection with the Habib 4X^® device even in a Unit of general surgery.

Epidemiological and clinical aspects of hepatitis B virus infection in Italy over the last 50 years

A relevant gradual reduction of both the incidence rate of acute hepatitis B (AHB) and prevalence of chronic hepatitis B has occurred in Italy in the last 50 years, due to substantial epidemiological changes: Improvement in socioeconomic and hygienic conditions, reduction of the family unit, accurate screening of blood donations, abolition of re-usable glass syringes, hepatitis B virus (HBV)-universal vaccination started in 1991, use of effective well tolerated nucleo(t)side analogues able to suppress HBV replication available from 1998, and educational mediatic campaigns against human immunodeficiency virus infection focusing on the prevention of sexual and parenteral transmission of infections. As an example, AHB incidence has gradually decreased from 10/100000 inhabitants in 1985 to 0.21 in 2020. Unfortunately, the coronavirus disease 2019 (COVID-19) pandemic has interrupted the trend towards HBV eradication. In fact, several HBV chronic carriers living in the countryside have become unable to access healthcare facilities for screening, diagnosis, clinical management, and nucleo(t)side analogue therapy in the COVID-19 pandemic, mainly for anxiety of becoming infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), movement restrictions, and reduced gains from job loss. In addition, one-third of healthcare facilities and personnel for HBV patients have been devolved to the COVID-19 assistance.

What hides beneath the scar: sexuality and breast cancer what women don't say: A single-center study

BACKGROUND

Breast is a symbol of femininity, motherhood and sexuality. Breast cancer (BC) is the leading cause of cancer death in women worldwide and most frequent cancer in Italy: in 2019, 53.500 new cases were diagnosed. BC and its treatment, the disturbances of body image, and mental health problems such as anxiety and depression could influence sexuality. Very often the aspect of sexuality in BC is likely not to be fully investigated: cultural barriers may also contribute to lack of attention to these issues. In Italy, there are very few Breast Units that provide the figure of the sexologist and psycho-oncologist.

METHODS

We enlisted 141 BC patients (pts), mean age was 54 years afferent to Breast Unit S. Maria Goretti Hospital, Latina, from March 2019 to March 2020. All pts had undergone surgical intervention. Participants were invited to complete a structured questionnaire, which included four close-up questions regarding self-image, sexual activity, sexual satisfaction, analyzing these aspects before and after BC and its treatments. Finally the participants were asked if they needed the sexologist and psycho-oncologist.

RESULTS

Only 2/141 pts (1.41%) refused to participate in our study. Of 139 participants, 68 (48.92%) had disturbances of body image, 26 (18.7%) had sexuality greatly negatively affected, and 103 (74.1%) every kind of sexual dissatisfaction after BC. 38 pts (27.3%) would require the help of the sexologist. 135 ( 97%) would require the help of the psycho-oncologist. Despite the negative influence in their body-image and sexuality, few pts require the help of the sexologist, but nearly all pts require the help of the psycho-oncologist.

CONCLUSION

In our study nearly all pts require the help of the psycho-oncologist, but few pts of the sexologist. Further studies will be needed to understand the reasons for this disparity: at the moment we are carrying out another project following this illustration, with the aim of understanding why this disparity.

Prostate Cancer Diagnosis, Treatment and Outcomes in Patients with Previous or Synchronous Colorectal Cancer: A Systematic Review of Published Evidence

The management of patients with prostate cancer (PCa) and previous or synchronous colorectal cancer (CRC) represents a challenging issue. A systematic review was performed in May 2022 to summarize available evidence about the diagnosis, management, and outcomes of these patients. Twenty-seven studies involving 252 patients were identified. Overall, 163 (64.7%) and 89 (35.3%) patients had synchronous and metachronous PCa and CRC, respectively. In patients with synchronous diseases, PCa treatment involved active surveillance in 1 patient, radical prostatectomy (RP) in 36 patients, radiotherapy (RT) in 60 patients, RP plus RT in 1 patient, proton beam therapy in 1 patient, and cryoablation in 1 patient. In patients with previous CRC treatment, prostate biopsy was mostly performed by transrectal approach (n = 24). The trans-perineal and suprapubic approaches were adopted in 12 and 6 cases, respectively. Surgical PCa treatment in these cases involved endoscopic extraperitoneal RP, robot-assisted RP, and not otherwise specified RP in 30, 15, and 2 cases, respectively. Biochemical recurrence rates ranged from 20% to 28%. Non-surgical PCa treatment options included brachytherapy, RT plus androgen deprivation therapy, and RT alone in 23, 2 and 4 patients, respectively. PCa specific survival was reported by one study and was 100%.

Immune Checkpoint Inhibitors as a Neoadjuvant/Adjuvant Treatment of Muscle-Invasive Bladder Cancer: A Systematic Review

Simple Summary

Bladder cancer is the ninth most common cancer worldwide. Immune checkpoint inhibitors, a novel class of immunotherapy drugs that restore natural antitumoral immune activity, have been applied to improve the overall survival and to reduce the morbidity and mortality of bladder cancer both in neoadjuvant and adjuvant settings. However, some patients do not respond to checkpoint inhibitors. Consequently, the capability for identifying patients eligible for this type of immunotherapy represent one of the efforts of ongoing studies. We aim to summarize the most recent evidence on immune checkpoint inhibitors in neoadjuvant and adjuvant setting in the treatment of muscle-invasive bladder cancer.

Abstract

Bladder cancer is the ninth most common cancer worldwide. Over 75% of non-muscle invasive cancer patients require conservative local treatment, while the remaining 25% of patients undergo radical cystectomy or radiotherapy. Immune checkpoint inhibitors represent a novel class of immunotherapy drugs that restore natural antitumoral immune activity via the blockage of inhibitory receptors and ligands expressed on antigen-presenting cells, T lymphocytes and tumour cells. The use of immune checkpoint inhibitors in bladder cancer has been expanded from the neoadjuvant setting, i.e., after radical cystectomy, to the adjuvant setting, i.e., before the operative time or chemotherapy, in order to improve the overall survival and to reduce the morbidity and mortality of both the disease and its treatment. However, some patients do not respond to checkpoint inhibitors. As result, the capability for identifying patients that are eligible for this immunotherapy represent one of the efforts of ongoing studies. The aim of this systematic review is to summarize the most recent evidence regarding the use of immune checkpoint inhibitors, in a neoadjuvant and adjuvant setting, in the treatment of muscle-invasive bladder cancer.

Metastasis-Directed Radiation Therapy with Consolidative Intent for Oligometastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis

Simple Summary

Patients with oligometastatic urothelial carcinoma represent a challenging subset of subjects to manage. Herein we summarized evidence about the role of metastasis-directed radiation therapy in this clinical setting. Available preliminary evidence supports the role of metastasis-directed radiation therapy as a safe and efficacious option as it has the potential to facilitate local disease control and overall survival. However, in the absence of data from high-quality trials, definitive recommendations cannot be provided, and patients should be counseled on an individual basis.

Abstract

The management of patients with oligometastatic urothelial carcinoma (UC) represents an evolving field in uro-oncology, and the role of metastasis-directed therapies, including metastasectomy and metastasis-directed radiation therapy (MDRT), is gaining increasing attention. Herein, we summarize available evidence about the role of MDRT with consolidative intent in oligometastatic UC patients. A systematic review was performed in December 2021. Six studies involving 158 patients were identified. Most patients (n = 120, 90.2%) had a history of bladder cancer and the most frequent sites of metastases were lymph nodes (n= 61, 52.1%) followed by the lungs (n = 34, 29%). Overall, 144 metastases were treated with MDRT. Median follow-up ranged from 17.2 to 25 months. Local control rates ranged from 57% to 100%. Median Overall Survival (OS) ranged from 14.9 to 51.0 months and median progression-free survival ranged from 2.9 to 10.1 months. Rates of OS at one and two years ranged from 78.9% to 96% and from 26% to 63%, respectively. Treatment-related toxicity was recorded in few patients and in most cases a low-grade toxicity was evident. MDRT with consolidative intent represents a potential treatment option for selected patients with oligometastatic UC.

Promoting Laparoscopic Anterior Approach for a Very Low Presacral Primary Neuroendocrine Tumor Arising in a Tailgut Cyst

Background: Tailgut cysts are rare congenital lesions that develop in the presacral space. As they can potentially conceal primary neuroendocrine tumors, surgical excision is suggested as the treatment of choice. However, specific management guidelines have yet to be developed. A posterior approach is usually preferred for cysts extending to the third sacral vertebral body. Conversely, a transabdominal approach is preferred for lesions extending upward to achieve an optimal view of the surgical field and avoid injuries. Case report: Here, we report a case of a 48-year-old man suffering from perianal pain and constipation. Digital rectal examination and magnetic resonance imaging revealed a presacral mass below the third sacral vertebral body. A laparoscopic transabdominal presacral tumor excision was performed. The final histological diagnosis was a rare primary neuroendocrine tumor arising from a tailgut cyst. The postoperative course was uneventful, and no signs of recurrence were observed at the six-month follow-up. Conclusions: This study may help establish more well-grounded recommendations for the surgical management of rectal tumors, demonstrating that the laparoscopic transabdominal technique is safe and feasible, even for lesions below the third sacral vertebral body. This approach provided an adequate view of the presacral space, facilitating the preservation of cyst integrity, which is essential in cases of malignant pathologies.

Epithelioid Hemangioma of the Nose: A Challenging Diagnosis

Epithelioid hemangioma is a rare reactive vasoproliferative disease presenting with painless vascular nodules in the dermal and subcutaneous tissues of the head and neck. Clinical diagnosis can be difficult as, in most cases, the only symptom is a progressively tender swelling next to a vessel course. Thus far, few cases of epithelioid hemangioma localized to the nose have been described in the literature. Herein, we present a case of a 47-year-old woman with just such a lesion of the nose, focusing on its diagnosis and treatment.

Fournier's Gangrene in Patients with Oncohematological Diseases: A Systematic Review of Published Cases

Patients suffering from hematological malignancies are at increased risk of Fournier's gangrene (FG) due to immunosuppression caused by the disease itself or by disease-related treatments. A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in June 2021. We included full papers that met the following criteria: original research, human studies, and describing clinical presentation, treatment, and outcomes of FG in patients with oncohematological diseases. We identified 35 papers published from 1983 to 2021 involving 44 patients (34 males, 8 females) aged between 4 days and 83 years. The most common malignant hematological disorders were acute myeloid leukemia (n = 21) and acute lymphocytic leukemia (n = 9). In 10 patients FG represented the first presentation of hematological malignancy. Scrotum (n= 27) and perineum (n = 11) were the sites most commonly involved. Pseudomonas aeruginosa (n = 21) and Escherichia coli (n = 6) were the most commonly isolated microorganisms. Surgery was performed in 39 patients. Vacuum-assisted closure and hyperbaric oxygen therapy were adopted in 4 and in 3 patients, respectively. Recovery was achieved in 30 patients. FG-related mortality was observed in 11 patients. FG should be carefully considered in patients with oncohematological diseases.

SARS-CoV-2 infection affects the lower urinary tract and male genital system: A systematic review

PubMed, Scopus, and ISI Web of Knowledge databases were searched to identify studies published up to December 2020 on the involvement of urinary and male genital systems in COVID‐19. Sixteen studies involving a total of 575 patients (538 males and 37 females) were included in this systematic review. The COVID‐19 phase was available for 479 patients: 426 in the acute and 53 in the recovery phase. De novo lower urinary tract symptoms (LUTS) were observed in 43 patients and deterioration of pre‐existing LUTS in 7. Bladder hemorrhage was observed in three patients and acute urinary retention in one. Regarding the male genital system, scrotal discomfort was observed in 8 patients, swelling in 14, pain in 16, and erythema in 1; low flow priapism was observed in 2 patients. Ultrasound examination identified acute orchitis in 10 patients, acute epididymitis in 7, and acute epididymo‐orchitis in 16. A case–control study reported that patients with moderate COVID‐19 show a significant reduction in sperm concertation, the total number of sperms per ejaculate, progressive motility, and complete motility. In contrast to what is known from the first studies on the subject, this review also includes subsequent studies that give evidence of the involvement of the lower urinary tract and male genital system in COVID‐19.

How Fear of COVID-19 Can Affect Treatment Choices for Anaplastic Large Cell Lymphomas ALK+ Therapy: A Case Report

Background: The t (2; 5) chromosomal rearrangement of the ALK gene with nucleophosmin 1 gene (NPM1), resulting in an NPM1–ALK fusion, was first demonstrated in 1994 in anaplastic large cell lymphoma, (ALCL), a T-cell lymphoma responsive to cyclophosphamide, abriblastine, vincristine and prednisone in approximately 80% of cases; refractory cases usually respond favorably to brentuximab vedotin. These treatments are regarded as a bridge to allogeneic hematopoietic stem cell transplantation (allo-SCT). Nowadays, transplant procedures and the monitoring of chemotherapy patients proceed very slowly because the SARS-CoV-2 pandemic has heavily clogged the hospitals in all countries. Results: A 40-year-old Caucasian woman was first seen at our clinical center in June 2020. She had ALCL ALK+, a history of failure to two previous therapeutic lines and was in complete remission after 12 courses of brentuximab, still pending allo-SCT after two failed donor selections. Facing a new therapeutic failure, we requested and obtained authorization from the Italian drug regulatory agency to administer 250 mg of crizotinib twice a day, a drug incomprehensibly not registered for ALCL ALK +. Conclusions: The response to crizotinib was optimal since no adverse event occurred, and CT-PET scans persisted negative; this drug has proved to be a valid bridge to allo-SCT.

Renal involvement in COVID-19: focus on kidney transplant sector

INTRODUCTION

Kidney transplant recipients and patients on the waiting list for kidney transplant who acquire SARS-CoV-2 infection are at serious risk of developing severe COVID-19, with an increased risk of mortality for the their immunosuppressive state; other risk factors for mortality have been identified in some comorbidities such as obesity, diabetes, asthma and chronic lung disease.

MATERIALS AND METHODS

The COVID-19 pandemic has led to a sharp reduction in kidney transplants in most countries, mainly due to the concern of patients on the waiting list for their potential increased susceptibility to acquire SARS-CoV-2 infection in healthcare facilities and for the difficulties of transplant centers to ensure full activity as hospitals have had to focus most of their attention on COVID-19 patients. Indeed, while the infection curve continued its exponential rise, there was a vertical decline in kidney donation/transplant activity.

CONCLUSION

This review article focuses on the damage induced by SARS-CoV-2 infection on kidney and on the adverse effect of this pandemic on the entire kidney transplant sector.

Outcomes of Renal Stone Surgery Performed Either as Predonation or Ex Vivo Bench Procedure in Renal Grafts from Living Donors: A Systematic Review

AIMS

We aimed to summarize available evidence about intraoperative and postoperative donors' and recipients' outcomes following stone surgery in renal grafts from living donors performed either before donation or as ex vivo bench surgery at the time of living-donor nephrectomy.

METHODS

A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in September 2020. We included full papers that met the following criteria: original research, English language, human studies, and describing the results of stone surgery in renal grafts from living donors performed either before transplantation or as ex vivo bench surgery.

RESULTS

We identified 11 studies involving 106 patients aged between 22 and 72 years. Predonation and bench stone surgery was performed in 9 (8.5%) and 96 (90.6%) patients, respectively. Predonation stone surgery involved extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy in 8, 1, and 1 patient, respectively. The overall success rate of predonation stone surgery was 78%, and the complication rate was 0%. Bench stone surgery involved ureteroscopy, pyelolithotomy, or a combination of both in 79 (82.3%), 10 (10.4%), and 7 (7.3%) cases, respectively, with an overall success rate of 95.8% and an overall complication rate of 9.37%.

CONCLUSIONS

Predonation and bench stone surgery in grafts from living donors represents efficacious and safe procedures. Further studies on wider series with a longer follow-up are required.

Gastroenterological complications in kidney transplant patients

Kidney transplantation is the surgical operation by which one of the two original kidneys is replaced with another healthy one donated by a compatible individual. In most cases, donors are recently deceased. There is the possibility of withdrawing a kidney from a consenting living subject. Usually, living donors are direct family members, but they could be volunteers completely unrelated to the recipient. A much-feared complication in case of kidney transplantation is the appearance of infections. These tend to arise due to immune-suppressor drugs administered as anti-rejection therapy. In this review, we describe the gastrointestinal complications that can occur in subjects undergoing renal transplantation associated with secondary pathogenic microorganisms or due to mechanical injury during surgery or to metabolic or organic toxicity correlated to anti-rejection therapy. Some of these complications may compromise the quality of life or pose a significant risk of mortality; fortunately, many of them can be prevented and treated without the stopping the immunosuppression, thus avoiding the patient being exposed to the risk of rejection episodes.

PET-guided Switch from Immunotherapy to Targeted Therapy in a Metastatic Melanoma Patient: a personalized approach

An early identification of non-responders in oncology is of crucial importance to rapidly switch treatment regimens. Here we report a positron emission tomography, (PET)-guided switch from immunotherapy to targeted therapy in a patient affected by metastatic melanoma. We describe the case of a 78-years-old male patient diagnosed with nodular melanoma, submitted to baseline PET/CT with 18fluorodeoxyglucose (18F-FDG) that showed cutaneous and skeletal metastases (stage IV). The patients started immunotherapy with pembrolizumab. A PET/CT performed 3 months after the start of immunotherapy demonstrated progressive metabolic disease both at skeletal and cutaneous level, confirmed also by the biopsy. As patients resulted positive for BRAF V600k mutation, treatment regimen was rapidly switched to combined anti-BRAF/MEK targeted therapy. The PET/CT performed 3 months later, showed almost complete metabolic response. Ten months after the beginning of targeted therapy, the patient continues to present a durable metabolic response. PET/CT with 18F-FDG may help in monitoring the response to treatment in metastatic melanoma thus defining personalized therapeutic pathways.

Curcumin dietary supplementation ameliorates disease phenotype in an animal model of Huntington's disease

Huntington's disease (HD) has traditionally been described as a disorder purely of the brain; however, evidence indicates that peripheral abnormalities are also commonly seen. Among others, severe unintended body weight loss represents a prevalent and often debilitating feature of HD pathology, with no therapies available. It correlates with disease progression and significantly affects the quality of life of HD patients. Curcumin, a naturally occurring polyphenol with multiple therapeutic properties, has been validated to exert important beneficial effects under health conditions as well as in different pathological settings, including neurodegenerative and gastrointestinal (GI) disorders. Here, we investigated the potential therapeutic action that curcumin-supplemented diet may exert on central and peripheral dysfunctions in R6/2 mice, a well-characterized HD animal model which recapitulates some features of human pathology. Maintenance of normal motor function, protection from neuropathology and from GI dysfunction and preservation of GI emptying and conserved intestinal contractility, proved the beneficial role of life-long dietary curcumin in HD and corroborated the potential of the compound to be exploited to alleviate very debilitating symptoms associated with the disease.

Physical activity in elderly kidney transplant patients with multiple renal arteries

INTRODUCTION

Kidney transplantation (KT) is the gold standard for treatment of patients with end- stage-renal disease. To expand the donor reserve, it is necessary to use marginal/suboptimal kidneys.

METHODS

We retrospectively evaluated the short/long-term outcome of 34 KT elderly patients who received allografts with vascular abnormalities (MRA group), in comparison with 34 KT patients who received a kidney with a single renal artery (SRA group) pair-matched by age, length of time on dialysis, comorbidity and donor age.

RESULTS

All participants completed the International Physical Activity Questionnaire at KT, and then 4, 8, and 12 weeks after transplantation. Our data indicate that kidney with vascular anatomical variants may be successfully transplanted, since the overall rate of surgical complications was 20.6% in the SRA group and 17.6% in the MRA group and that the 5-year survival rate after KT was 100% in both groups.

CONCLUSIONS

The data also underline that individualized physical activity programs induced similar excellent results in both groups, improving physical capacities, arterial pressure, lipid metabolism, insulin sensitivity, quality of life and physical and mental status.

Relation Between Wound Complication and Lymphocele After Kidney Transplantation: A Monocentric Study

INTRODUCTION

Wound complication frequently arises after kidney transplantation and its risk factors are well known. In a previous paper we analyzed these factors, and in this new retrospective study we evaluate the influence of lymphocele in the development of wound complications.

PATIENTS AND METHODS

From January 2000 to December 2018, 731 consecutive kidney transplants have been performed in our center. We have analyzed the incidence of wound complication and lymphocele and their risk factors.

RESULTS

Out of 731 kidney transplants, we have observed wound complications in 115 patients (15.7%) and lymphocele in 158 patients (21.7%). Of these, 70 patients developed both complications (9.5%), but 6 patients have been excluded because they were in therapy with mammalian target of rapamycin inhibitors. Twenty-nine patients (45.3%) presented a first level and 35 patients (54.7%) showed second level wound complications. Lymphocele was the only present factor in just 3 cases (4.6%). The other patients showed diabetes in 28 cases (43.7%), overweight/obesity in 38 (59.3%), delayed graft function in 17 (26.5%), and 60 years or more in 38 (57.8%). The association has been found in 30 out 64 patients treated with tacrolimus (46.8%) and in 34 with cyclosporine (53.1%); 40 patients did not receive muscular layer's reconstruction (62.5%).

CONCLUSION

Our experience shows that lymphocele alone is not a predisposing factor for wound dehiscence after kidney transplantation, and they often coexist because they share the same risk factors, the most important being obesity, diabetes and delayed graft function, older age, and surgical techniques. No relation has been observed with calcineurin inhibitor therapy.

Primary Cutaneous DLBCL Non-GCB Type: Challenges of a Rare Case

Several types of B-cell lymphomas, including both primary cutaneous lymphomas and systemic lymphomas, may affect the skin, with partially overlapping clinical, morphological and immunohistochemical features. Currently, the World Health Organization (WHO) classification of primary cutaneous B-cell lymphomas does not include diffuse large B-cell lymphomas (DLBCL) and considers leg-type DLBCL the only primary cutaneous DLBCL. Here we report the case of a 72-year-old white woman with a primary cutaneous neoplasm comprised of large cells with round nuclei, irregularly clumped chromatin and one or more inconspicuous nucleoli. The immunohistochemistry demonstrated positivity for CD20 and MUM1, with no significant genetic translocations detected by fluorescence in-situ hybridization. After staging, we considered this neoplasm a primary cutaneous DLBCL with a non-germinal center phenotype, not otherwise specified, inconsistent with a leg-type DLBCL. Because of this view, we underscore the need for greater knowledge of the molecular landscape of B-cell lymphomas in order to reconsider the classification of such neoplasms in the skin.

An Anecdotal Case Report of Chronic Lymphatic Leukemia with del(11q) Treated with Ibrutinib: Artificial Nourishment and Physical Activity Program

Chronic lymphatic leukemia (CLL) is the most frequent type of leukemia in western countries and when association with del(11q) is correlated with a worse prognosis. We reported the clinical case of an 80-year-old patient with CLL related to del(11q) and a BMI of 16.4 kg/m2, who presented a voluminous mass in abdominal cavity (23 × 14 × 4 cm) which occupied the whole of the mesentery and the retroperitoneal space, treated with ibrutinib, adequate nutrition, and a program of physical activity. He showed a great improvement under ibrutinib therapy and took to artificial nourishment and adequate muscle rehabilitation until he recovered his autonomy. In August 2018, a 5-days-a-week training program was started: Physical activity for at least 20 min consisting of a fast walk in the open air three times a week and a moderate physical activity in the remaining two days of at least 20 consecutive minutes (cycling at a regular pace, carrying light weights). The exercise program included also aerobic, upper and lower limb resistance training, chore stability and stretches. The physical condition further improved and remained excellent throughout the follow-up period. In December 2018, his clinical condition was quite normal; a CT showed a great decrease of all lymphoadenomegaly, and FISH test did not show del(11q). He continued to cultivate his land, while still being treated with ibrutinib. The combination of the right therapy, adequate nutrition, and muscle rehabilitation is the best solution to improve the clinical condition of old cachectic CLL del(11q) patient.

Endoscopic Treatment and Pulmonary Rehabilitation for Management of Lung Abscess in Elderly Lymphoma Patients

Background: The management of lung abscess may be a challenge in elderly patients undergoing chemotherapy and/or radiotherapy for previous malignancy. Herein, we reported a case series of elderly patients with previous lymphoma undergoing endoscopic treatment followed by pulmonary rehabilitation for lung abscess. Methods: Our study population included a consecutive series of elderly patients with previous lymphoma and lung abscess. Suppurative infection was refractory with specific antibiotic therapy. In all cases, drainage was endoscopically inserted in lung abscess via video-bronchoscopy. This strategy allowed performing daily therapy with the installation of gentamicin directly into the abscess cavity. All patients underwent a respiratory rehabilitation program to speed up convalescence and allow early discharge. Results: After positioning the catheter through a bronchoscopic route and subsequent washing with gentamicin, all the patients in our study showed an improvement in clinical conditions with resolution of fever within a few days of starting the procedure with normalization of blood tests (mean hospital length 7 ± 0.73 days). A follow-up chest computed tomography scan showed a resolution of lung abscess within a mean of 27 ± 1.53 days. Conclusions: Endoscopic treatment with a rehabilitation program may be a valuable strategy for the management of lung abscess that is refractory to standard antibiotic therapy. Further and larger studiesshould be done to confirm our results.

Primary Cutaneous Anaplastic Large Cell Lymphoma (pcALCL) in the Elderly and the Importance of Sport Activity Training

Primary cutaneous anaplastic large cell lymphoma (pcALCL) is part of a spectrum of cutaneous CD30+ lymphoproliferative disease that also includes lymphomatoid papulosis. It often occurs in elderly patients, presenting at a median age of 60 years, although it may occur at any age. It is a CD30+ T-cell neoplasm composed of large cells with anaplastic, pleomorphic, or immunoblastic morphology, with exclusively cutaneous onset and localization. The clinical course of pcALCL is predominantly indolent. Most elderly patients with lymphoma tend to have a sedentary lifestyle, which has a negative effect on their quality of life (QoL) and survival. Several studies indicate that exercise has a positive impact on QoL because it reduces peak oxygen consumption, improves physical capacity, increases self-esteem, reduces accumulated stress, and promotes relaxation. Therefore, particularly in indolent lymphomas, it is necessary to indicate a program of physical activity to be practiced systematically. Complete surgical excision and local radiotherapy are the first line gold standard in pcALCL with a solitary lesion.

Lymphomatoid papulosis

Lymphomatoid papulosis (LyP) is a non-aggressive skin disorder characterized by papulonodular injuries, sometimes necrotic, often scattered, relapsing, which frequently regress spontaneously. LyP represents about 12% of cutaneous lymphomas. The etiology of LyP is unknown. Based on its histopathology, in 2018, the World Health Organization (WHO) classified LyP into six types with similar prognosis (A,B,C,D,E and DUSP22). Once the diagnosis of LyP has been made, having an excellent prognosis, this pathology must be managed mainly with a "watch and wait" strategy. Treatment should be given only in the presence of diffuse, symptomatic lesions with disfiguring evolution, with the aim of reducing time of resolution and preventing recurrences or the formation of new lesions.

Differential Diagnosis: Retroperitoneal Fibrosis and Oncological Diseases

Retroperitoneal fibrosis is a connective disease of the auto-inflammatory/auto-immune type of the retroperitoneum with unknown etiology and pathological mechanism. The manifestations of the pathology can be local or systemic. Amongst the local symptoms, the dull and constant pain in the hips, back or abdomen is the most frequent.

We report here a case of a 47-year-old woman, whose pathogenic mechanism could be related to an “IgG4-related disease” disorder as suggested by an increased serum level of this subclass of IgG and the positive immunohistochemistry.

The diagnosis is not easy, because this pathology generates masses; adenomegalies with retro peritoneal development, that makes it similar to lymphomas or metastases from ovarian tumors.

Use of Rituximab in NHL Malt Type Pregnant in I° Trimester for Two Times

Administration of rituximab, one of the basic drugs for the therapy of B-cell lymphoproliferative diseases, during pregnancy has been suspected to cause developmental fetal events, particularly if given during the first trimester of pregnancy. Therefore, use in pregnancy is not permitted. Howe ver, several cases of pregnant women being treated with rituximab are reported herein; an exception is often made in cases with grave illness. We describe an exceptional case of a woman with non-Hodgkin lymphoma of the mucosa-associated lymphoid tissue type where rituximab was given as a single agent without interruption during two consecutive pregnancies. This case can certainly supply important indications on the safety of rituximab.

Cancer- and Non-cancer Related Chronic Pain: From the Physiopathological Basics to Management

The prevalence of chronic pain is between 33% to 64% and is due to cancer pain, but it has also been observed in non-cancer patients. Chronic pain is associated with lower quality of life and higher psychological distress and depressive/anxiety disorders in patients without a history of disorder. In this study we evaluated in clinical practice the effectiveness of the intrathecal pump in 140 patients who underwent pain therapy at our Center. These patients were consecutively enrolled from January 2010 to July 2018. Follow-up was carried out over these eight years regarding the infusion modalities. Pain relief was obtained in 71 (50,7%) patients out of the 140 that experienced satisfactory pain control globally. Intrathecal therapy is one of the best options for chronic severe refractory pain. The greatest advantage of this therapy is due to the possibility of treating the pain with minimal dosages of the drug, avoiding the appearance of troublesome side effects.

Thyroid function in Klinefelter syndrome: a multicentre study from KING group

PURPOSE

The prevalence and the etiopathogenesis of thyroid dysfunctions in Klinefelter syndrome (KS) are still unclear. The primary aim of this study was to evaluate the pathogenetic role of hypogonadism in the thyroid disorders described in KS, with the scope to distinguish between patients with KS and hypogonadism due to other causes (Kallmann syndrome, idiopathic hypogonadotropic hypogonadism, iatrogenic hypogonadism and acquired hypogonadotropic hypogonadism after surgical removal of pituitary adenomas) called non-KS. Therefore, we evaluated thyroid function in KS and in non-KS hypogonadal patients.

METHODS

This is a case-control multicentre study from KING group: Endocrinology clinics in university-affiliated medical centres. One hundred and seventy four KS, and sixty-two non-KS hypogonadal men were enrolled. The primary outcome was the prevalence of thyroid diseases in KS and in non-KS. Changes in hormonal parameters were evaluated. Exclusion criterion was secondary hypothyroidism. Analyses were performed using Student's t test. Mann-Whitney test and Chi-square test.

RESULTS

FT4 was significantly lower in KS vs non-KS. KS and non-KS presented similar TSH and testosterone levels. Hashimoto's thyroiditis (HT) was diagnosed in 7% of KS. Five KS developed hypothyroidism. The ratio FT3/FT4 was similar in both groups. TSH index was 1.9 in KS and 2.3 in non-KS. Adjustment for differences in age, sample size and concomitant disease in multivariate models did not alter the results.

CONCLUSIONS

We demonstrated in KS no etiopathogenic link to hypogonadism or change in the set point of thyrotrophic control in the altered FT4 production. The prevalence of HT in KS was similar to normal male population, showing absence of increased risk of HT associated with the XXY karyotype.

Colorectal Cancer in the Elderly Patient: The Role of Neo-adjuvant Therapy

Background

Neoadjuvant chemoradiotherapy has a significant role in downstaging cancer. It improves the local control of the disease and can make conservative resection of rectal cancer possible.

Methods

We enrolled 114 patients with subperitoneal rectal cancer who underwent neoadjuvant chemoradio-therapy and radical excision with total mesorectal excision (TME). The primary endpoint was oncological outcomes and the secondary endpoint was surgical outcomes.We evaluate the experience of a multidisciplinary team and the role of neoadjuvant chemoradiotherapy in integrated treatment of cancer of the subperitoneal rectum.

Results

Surgical procedures performed were abdominal perineal resection in 4 cases (3.5%), anterior resection in 89 cases (78%), Hartmann’s procedure in 5 cases (4.4%), and ultralow resection with coloanal anastomosis and diverting stoma in 16 patients (14%).

Local recurrence occurred in 6 patients (5.2%), the overall survival was 71.9% at 5 years and disease-free survival was about 60%.

Conclusions

The effect of pathological downstaging amounted to 58.8%, including cPR. The pathologic complete remission occurred in 8.8% of cases.

The outcomes of neoadjuvant therapy can be achieved when this treatment is associated with correct surgical technique with TME and the prognosis is defined by an anatomopathological examination performed according to Quirke’s protocol.

Thyroid hemiagenesis associated with multinodular goiter and Hashimoto's thyroiditis

Thyroid hemiagenesis is a rare congenital abnormality in which one of the thyroid lobes is not developed. It can be associated with various thyroid diseases, such as Grave's disease, nodular goiter and thyroid neoplasm, rarely with hyperparathyroidism. We report a case of a 50-year old woman with left thyroid lobe agenesis diagnosed by ultrasonography and scintigraphy. Right thyroidectomy was performed and the histopathological examination showed diffuse hyperplasia, multinodular goiter and Hashimoto's thyroiditis. To our knowledge, this is the first description of multinodular goiter and Hashimoto's thyroiditis in a patient with thyroid hemiagenesis.

Familial Polyposis Coli: The Management of Desmoid Tumor Bleeding

Background

There is currently no standard treatment for desmoid tumors (DTs) associated with familial polyposis coli (FAP). Familial adenomatous polyposis in DT patients is sometimes a life-threatening condition.

Methods

We enrolled all consecutive patients with FAP treated at Unit of General Surgery and Transplant, University of Naples Federico II and evaluated the incidence of DTs on FAP between 1996 and 2016.

Results

We observed 45 consecutive patients with FAP; of these 5 were DT-FAP-associated. All 5 cases with FAP were young women, age 25 to 65 years, previously treated by colectomy. Of these, 4 patients presented a parietal localization and had been treated with a wide surgical exeresis; one patient had an intra-abdominal, mesenteric tumor that was unresectable at laparotomy. We performed CT-guided drainage, ureteral stenting, medical therapy (sulindac+tamoxifene), and chemotherapy (dacarba-zine+doxorubicine).All patients were alive and underwent follow-ups for 5 years post-surgery; only 1 patient with parietal localization showed a local relapse after 2 years.

Conclusions

We propose a modulated approach to the single patient with FAP, with surgery as treatment of choice for parietal localization disease and integrating different kinds of therapies (surgery alone or associated with RT, CT) for the intra-abdominal tumor.

Ethical Issues in the Use of Suboptimal Kidneys for Transplants: An Italian Point of View

The shortage of organs leads to the need for utilizing suboptimal kidneys for transplantation. The distinction between optimal, marginal, and suboptimal kidneys leads surgeons to face not only technical problems but also ethical and legal issues related to clinical advantages offered by the transplant of a nonstandard kidney and the acquisition of consent. Between 1999 and 2015, we performed 658 transplants, 49 (7.5%) using suboptimal kidneys. All patients were alive and with vital graft throughout follow-up. We did not encounter any major surgical complications. From a technical point of view, our experience and literature review confirm that transplant of suboptimal kidney leads to good clinical results but exposes patients to a increased risks of surgical complications. Therefore, these interventions must take place in hospitals fully prepared for this type of surgery and performed by experienced transplant surgeons with proper matching between organ and recipient. Considering the insufficient resources available, from an ethical and legal point of view, doctors play an essential role in optimizing the use of these kidneys by avoiding wastage of organs, ensuring that transplants are done in suitable patients, and that patients are fully informed and aware of the risks and benefits associated with the specific suboptimal kidney being transplanted. We believe that, in highly specialized centers, the number of suboptimal kidney transplants should be increased, as their use has shown good clinical results and carries fewer ethical issues compared with marginal kidneys. Further, suboptimal kidneys may also be proposed for use in young patients with end-stage renal disease.

New food approaches to reduce and/or eliminate increased gastric acidity related to gastroesophageal pathologies

OBJECTIVE

Gastroesophageal reflux disease is very common in industrialized countries and rapidly and significantly increasing even in developing countries. The approach in this study is one not commonly found to date in the scientific literature. To assess the ability of reduced-carbohydrate diets and foods that are enriched with acid potential of hydrogen (pH; lemon and tomato) to quickly and exponentially reduce symptoms that are related to conditions such as gastritis and gastroesophageal reflux and unrelated to Helicobacter pylori.

METHODS

After the administration of an anamnestic test, 130 patients were selected including 73 women and 57 men, 21 to 67 y, and with a gastritis diagnosis for 92 patients (56 women, 36 men) and reflux gastritis for 38 patients (17 women, 21 men). Study participants followed three dietary treatments in succession. Each treatment lasted 2 wk and treatments were separated by 2 wk of washout. The patients followed a diet that consisted primarily of proteins and fats and included the exponential reduction of glycides (simple and complex). In addition, the treatment provided for the daily intake of the juice of two lemons and approximately 100 g of fresh orange tomato without seeds eaten either raw or cooked and peeled.

RESULTS

During treatment and at the end of 2 wk of treatment, the patients reported significant improvements including an almost total disappearance of symptoms that were related to the disease in question.

CONCLUSIONS

This study shows that a carbohydrate-free diet and/or highly hypoglycidal diet that is enriched with acid pH foods appears to lead to a decrease in the pH of the gastric contents, thus inhibiting the further production of hydrochloric acid with a reduction or disappearance of heartburn symptoms that are typical of gastroesophageal diseases.

Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review

BACKGROUND

There are not guidelines for surgical management of malignant bowel obstruction (MBO) caused by peritoneal carcinomatosis (PC), mainly when it involves elderly; so its treatment is still debated.

AIM

To outline indications and benefits of palliative surgery for obstructive carcinomatosis and determine what prognostic factors, including age, have independent and significant association with outcome.

METHODS

We conducted English-language MEDLINE and EMBASE searches of articles published between 1998 and 2016, which reported outcome data after palliative surgery for MBO due to PC. We excluded all articles lacking of surgical cohort and those with main interest in conservative treatment. Of 1275 articles identified, 12 satisfied selection criteria and were included in our analysis.

RESULTS

Overall, these studies involved 548 patients undergoing palliative surgery for MBO caused by PC. The median age was 58 (range 19-93). Relief of symptoms was achieved in 26.5-100% of cases. Postoperative morbidity ranged between 7 and 44%. Mortality was high (6-22%). The median survival was longer in surgical patients than in those receiving conservative therapy (8-34 vs 4-5 weeks). Factors associated with surgery failure were poor performance status, diffuse carcinomatosis, previous radiotherapy, and obstruction of small bowel. Old age was significantly associated with a poor prognosis upon univariate analysis, while this association vanished upon multivariate analysis.

CONCLUSIONS

Surgical palliation can provide relief of obstructive symptoms as well as improved survival in well-selected patients, even if elderly.

Complicated diverticulitis in kidney transplanted patients: analysis of 717 cases

INTRODUCTION

This study aims to investigate possible risk factors for diverticulitis in kidney transplant recipients affected by colonic diverticulosis.

METHODS AND RESULTS

We investigated 717 patients transplanted between 2000 and 2010. Diverticular disease was endoscopically diagnosed in 17 of 717 examined patients. Eight patients were diagnosed with autosomal dominant polycystic kidney disease (ADPKD); 9 of 17 patients underwent emergency surgery. We performed Hartmann's procedure on all patients, with a second stage performed at least 6 months later.

DISCUSSION

Although the incidence of colonic diverticular perforation in kidney transplanted patients is similar to that observed in the general population, perforation in immunosuppressed patients is associated with a higher morbidity/mortality rate. In our study, the incidence of perforation is 1.25% (9 of 717), with almost half of the cases observed in patients with ADPKD (4 of 9). Such an observation is consistent with published data, in which patients with ADPKD are reported to more frequently develop colonic diverticulosis and its complications. One possible explanation might be related to a belated diagnosis of diverticulitis, which could initially simulate an inflammatory disease as a consequence of renal cysts. Also, steroids seem to be a predisposing factor for colonic perforation in these patients.

CONCLUSIONS

A timely surgery can significantly reduce mortality. In cases of elective surgery, mortality and morbidity are similar to those of immunocompetent patients; accordingly, this is the goal to be pursued. Early signs and symptoms are often masked by immunosuppressive therapy. In these patients, surgeons should always perform (1) abdominal computed tomography scanning and, in the presence of diverticulitis, reduce or withdraw immunosuppressive therapy; and (2) early surgery, with Hartmann's procedure being, in our opinion, the best choice. Before transplantation, elective surgery for colonic resection should be considered in patients with ADPKD or with a history of 1 or more episodes of acute diverticulitis who then regressed with medical therapy.

Prevention of fluid effusion in kidney transplantation with the use of hemostatic biomaterials

BACKGROUND

Fluid effusion (blood, lymph, or urine) in kidney transplantation may give rise to several complications, directly, such as hematoma, seroma, lymphocele, and/or urinoma, or consequently, such as increased infection risk, longer hospital stay, graft compression--with or without functional impairment--and necessity of further hospitalizations. The aim of this study was to evaluate effectiveness of hemostatic biomaterials in prevention of fluid effusions, especially lymphocele in kidney transplant patients.

METHODS

We selected 40 patients who underwent kidney transplantation from 2009 to 2012 in which we used hemostatic biomaterials, and compared their results with those of other transplant patients from our center in which we did not used these biomaterials. Evaluated parameters were: fluid effusion, graft function, quality and quantity of drainage, blood count, and operative time.

RESULTS

There was no difference in operative time. The incidence of complications on which biomaterials can have a role decreased; particularly, we observed a reduction from 24.21% to 7.5% of fluid effusions (lymphocele). There was no evidence of complications due to biomaterials.

CONCLUSIONS

Hemostasis is important in surgery, and in kidney transplantations lymphostasis also has a significant role. In addition to the traditional hemostatic methods, recently some biomaterials, with the purpose of providing atraumatic hemostasis, were added. In our experience they are easy to use, and their use has proved to be effective for both hemostasis and lymphostasis with consequent reduction of fluid effusions.

Multiple splenic hamartomas and familial adenomatous polyposis: a case report and review of the literature

Introduction

Splenoma or splenic hamartoma is a rare primary splenic tumor most often discovered radiologically and incidentally. Splenic hamartomas have a strong association with solid and hematological malignancies and, in rare cases, with tuberous sclerosis, but to the best of our knowledge no reports of splenic hamartomas associated with familial adenomatous polyposis have been documented, although it is recognized that familial adenomatous polyposis presents a variety of extracolonic manifestations.

Case presentation

We report on a very rare case of multiple splenic hamartomas in a 46-year-old white woman who had previously undergone surgery for restorative proctocolectomy for familial adenomatous polyposis. A computed tomography scan of her spleen revealed multiple small lesions which measured less than 1cm in diameter. A splenectomy was performed and a histologic examination of the splenectomy specimen revealed the presence of multiple hamartomas.

Conclusion

Incidence, differential diagnosis, diagnostic procedures, pathologic findings and treatment of splenic hamartomas are discussed here and hamartomas are considered in a differential diagnosis of splenic tumors. A splenectomy is indicated in cases where malignancy cannot be excluded and in cases of associated hematologic disorders. To the best of our knowledge our patient is the first reported case to have splenic hamartomas identified in a familial adenomatous polyposis-affected patient with mutation in exon 15 of the APC gene. At this time it is not possible to correlate with certainty our multiple splenic hamartomas and familial adenomatous polyposis case as a clinical manifestation of the mutation of APC gene; however, we believe that this case report could be important for further observation of similar cases in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s13256-015-0627-3) contains supplementary material, which is available to authorized users.

Immunosuppression and Multiple Primary Malignancies in Kidney-Transplanted Patients: A Single-Institute Study

Immunodeficiency is associated with higher cancer incidence. However, it is unknown whether there is a link between immunodeficiency and development of multiple primary malignancies. In the present study we analyse this link focusing on kidney-transplanted patients, as they are at higher risk of developing cancer due to the chronic assumption of immunosuppressants. We followed up 1200 patients who underwent kidney transplantation between 1980 and 2012. A total of 77/1200 kidney-transplanted patients developed cancer and 24 of them developed multiple cancers. Most multiple cancers were synchronous with a nonsignificant association between cancer and rejection episodes. In the general cancer population, one-ninth of patients are at higher risk of developing a second tumor over a lifetime; hence it would be reasonable to conclude that, from a merely theoretical and statistical viewpoint, long-term transplanted patients potentially have a higher risk of developing MPMs. However, data did not confirm this assumption, probably because these patients die before a second primary malignancy appears. Despite many observations on the increased incidence of different tumor types in immunodeficient patients and despite immunosuppression certainly being a predisposing factor for the multicancer syndrome, data so far are not robust enough to justify a correlation between immunodeficiency and multiple primary malignancies in transplanted patients.

Lactic dehydrogenase and cancer: an overview

Despite the intense scientific efforts made, there are still many tumors that are difficult to treat and the percentage of patient survival in the long-term is still too low. Thus, new approaches to the treatment of cancer are needed. Cancer is a highly heterogeneous and complex disease, whose development requires a reorganization of cell metabolism. Most tumor cells downregulate mitochondrial oxidative phosphorylation and increase the rate of glucose consumption and lactate release, independently of oxygen availability (Warburg effect). This metabolic rewiring is largely believed to favour tumor growth and survival, although the underlying molecular mechanisms are not completely understood. Importantly, the correlation between the aerobic glycolysis and cancer is widely regarded as a useful biochemical basis for the development of novel anticancer strategies. Among the enzymes involved in glycolysis, lactate dehydrogenase (LDH) is emerging as a very attractive target for possible pharmacological approaches in cancer therapy. This review addresses the state of the art and the perspectives concerning LDH both as a useful diagnostic marker and a relevant molecular target in cancer therapy and management.

Perioperative care of elderly outpatients. A review

INTRODUCTION

Epidemiological data show a continuous expansion of elderly population in Europe. Older individuals require more medical services relative to their younger counterparts. The aim of this review was to summarize the most recent considerations in regards to preoperative assessment, postoperative outcomes, patient satisfaction and cost-effectiveness analysis of day surgery in the elderly.

METHODS

This review considered studies that included older patients who were undergoing day surgery general procedures (such as inguinal hernia repair, excision of breast lump, haemorrhoidectomy). The interventions of interest to this review included selection criteria, perioperative care, management of postoperative pain.

RESULTS

According to a large number of studies, old age does not constitute a contraindication for elderly to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management. Hospitalization of older patients is frequently associated with postoperative cognitive dysfunction (POCD). Management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease-drug and drug-drug interactions. Early studies evaluating approaches to facilitating the recovery process have demonstrated the benefits of multimodal analgesic techniques.

CONCLUSIONS

A lot of studies show that even elderly patients can successfully undergo day surgery procedures by implementing evidence-based perioperative care programs, minimizing operative duration and tissue trauma and providing a comfortable setting.