The Endoscopic Endonasal Dacryocystorhinostomy (eDCR) in the Immunocompromised Patient.

We present the clinical case of a 51-year-old male patient, affected by common variable immunodeficiency (CVID). In his history recurrent orbital cellulitis, exacerbation of chronic right dacryocystitis, lacrimal sac empyema with periodic episodes of dacryocutaneous fistolization. The coexistence of these particular immunological defects and the lack of literature about similar cases required an accurate evaluation of each step of the diagnostic and therapeutic approach. We performed an endoscopic endonasal dacryocystorhinostomy with "cold" instruments. No surgical complications were observed in the immediate postsurgical period. We balanced the necessity of a follow-up based on frequent office evaluation and the current pandemic emergency, in order to not expose the patient to an additional infectious risk. The discussion will focus on several aspects: the adequacy of radiological, the "cold" surgical technique, the choice of avoiding endocanalicular prostheses. We will discuss also about the use of oral and topical therapy, avoiding probable post-surgical infectious complications.

[Carcinoid of the appendix. A case report]. / Il carcinoide dell'appendice. Caso clinico.

A case of a young male operated on for acute appendicitis due to a carcinoid of the base is reported. Since the tumor was infiltrating the resection margin of the appendix, the patient was later treated with a right hemicolectomy. Carcinoid tumor is unusual, but can be encountered several times during the career of a surgeon (1/200-300 appendicectomy). The tumor is more frequent in women (2-4:1), located at the tip of the appendix (62-78%) and has a diameter less than 1 cm in 70-95% of cases. It is more frequently diagnosed incidentally after an operation for acute appendicitis and occasionally during other procedures (colectomy, cholecystectomy, salpingectomy). Liver metastases are rare (< 2%), related to the dimension of the primitive tumor (21-100% when > 2 cm) and can cause a "carcinoid syndrome": flush, diarrhea bronchoconstriction, cardiac valve disease. Diagnosis is made by the pathologist and staging by conventional radiologic procedures (TAC, US), dosage of neuroendocrine mediators such as 24 hours urinary 5-HIAA. Nowadays 111In-octreotide scintigraphy (SRS) has an 86% sensitivity to detect the carcinoid and is useful for staging and for planning a surgical intervention. Simple appendectomy is adequate treatment for appendiceal carcinoids less than 1 cm in diameter. Adequate treatment for tumors greater than 2 cm is right hemicolectomy. A point of controversy is what to do for tumors in the 1 to 2 cm range. It seems that appendectomy alone is sufficient except in those cases when mesoappendiceal invasion is identified. When surgical margins after appendectomy are not free of tumor, additional surgery seems warranted. Carcinoid tumor of the appendix has a good prognosis with a 5-year-survival rate, of 85.9-100%. When liver metastases are encountered octreotide can relieve symptoms and sometimes the progression of the disease.

[Tension-free hernioplasty in the treatment of inguinal hernia in the adult: our experience with local anesthesia and a review of the literature]. / Ernioplastica "tension-free" nel trattamento dell'ernia inguinale dell'adulto: la nostra esperienza in anestesia locale e revisione della letteratura.

BACKGROUND: In the last years the real innovation in the treatment of groin hernia is represented by tension-free hernioplasty under local anaesthesia, based on the techniques of Lichtenstein and Trabucco, which use synthetic prosthesis (polypropylene) to restore the floor of inguinal tract and enable an early deambulation and return to work. METHODS: In 21 months the authors have treated, only under local anaesthesia, 100 patients, 95 men and 5 women; the age ranged from 18 to 82 years; some of them suffer from systemic pathology (7 patients with cardiovascular diseases, 1 with epilepsy, 3 with pulmonary diseases, 1 with liver cirrhosis). All patients underwent short-term antibiotic prophylaxis. No mortality was recorded. The mean follow-up was 12.5 months with only one little and low recurrence detected. RESULTS: Good results were obtained also in terms of intraoperative complication (nausea, vomiting, bradycardia, pain) and post-operative complications, (ecchymosis of scrotum and penis, edema of the scrotum, swelling of the skin suture, subcutaneous hematoma, inguinal pain, fever), not life-threatening, well tolerated and resolved spontaneously. CONCLUSIONS: The authors stress the advantages of local anaesthesia, the economic spare due, to one day hospital stay, the safety of the technique also in patients with severe general diseases (0.9-1% in USA). The authors survey the international literature confirming the great effectiveness of tension-free inguinal hernioplasty, in particular in terms of recurrences (Trabucco 0-0.025%, Amid 0.1%).

Hemophagocytic syndrome in a case of splenic large B-cell lymphoma.

A case of splenic large B-cell lymphoma with hemophagocytic syndrome is reported. The difficulties of diagnosis are emphasized especially when peripheral lymph nodes or bone marrow lymphomatous infiltration are not present. Diagnostic criteria for hemophagocytic syndrome and their relationship with the pathogenesis of the disease are also stressed.

[Clinical usefulness of the immunophenotypic study of circulating lymphocytes in leukemic lymphoproliferative diseases]. / Considerazioni sulla utilità clinica dello studio immunofenotipico dei linfociti circolanti nelle malattie linfoproliferative leucemizzate.

The immunophenotypes (IF) on peripheral lymphocytes of 24 B-CLL in different stage, 2 PLL and 14 leukemic B-non Hodgkin lymphomas were investigated. As regard to B-CLL and PLL, the results are similar to those reported so far. In stage A and B of B-CLL the IF appear less variable than in advanced stages where a decrease of CD21+ and an increase of both CD25+ and CD38+ lymphocytes were observed. In the lymphocytic, small cleaved cell lymphomas and splenic lymphomas, the peripheral IF correspond to the theoretical ones of respective lymphoma tissues. On the contrary they disagree in three cases of large cells, mixed small and cleaved cell, immunoblastic lymphomas. These features are discussed.

The discriminating analysis in the differential diagnosis of monoclonal gammopathies.

The clinical diagnosis is not always easy in monoclonal gammopathies. Therefore we used discriminating analysis to obtain diagnosis statistically sure. The parameters considered were kappa-lambda ratio, marrow plasma cells percentage and labeling index, CD3, CD4, CD8 lymphocytic absolute values. The plasma cells percentage and their labeling index make the differential diagnosis between MM and MGUS or SMM and MGUS feasible and quite correct. Additional immunological parameters should be used for the diagnosis between SMM and MM.

Kappa/lambda ratio on peripheral blood lymphocytes and bone marrow plasma cell labeling index in monoclonal gammopathies.

Bone marrow plasma cell labeling index (L.I.), kappa/lambda ratio, CD4+ and CD8+ subpopulations were studied in patients with smoldering multiple myeloma (SMM), active myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS). The loss of the light chain isotype suppression (LCIS) and a high labeling index (L.I.) allowed us to distinguish all MM patients from SMM patients. On the contrary, a low L.I. and a normal kappa/lambda ratio were found in most kappa and lambda MGUS. A significant difference in the kappa/lambda ratio was noted between MGUS and K-SMM. A significant decrease in CD4+ and a significant increase in CD8+ were not observed in patients with LCIS. The kappa/lambda ratio together with the plasma cell L.I. could be useful parameters for distinguishing active MM from SMM, especially in the cases with a border line L.I.

Primary brain malignant non-Hodgkin lymphoma: report of a case treated with chemotherapy in combination with radiotherapy.

Primary brain lymphomas are usually treated with surgery in combination with radiotherapy, whereas only a few cases have been treated with chemotherapy. We describe a case of a 68-year-old man with an immunoblastic primary cerebral lymphoma first treated with surgery and radiotherapy and subsequently with chemotherapy consisting of cyclophosphamide, adriamycin, vincristine and prednisone (CHOP). In this case immunological study of the peripheral blood and cerebrospinal fluid (CSF) lymphocytes confirmed that a primary brain lymphoma may be an intrinsic cerebral neoplasm with different forms of spreading within the central nervous system (CNS). The period of survival of our patient is equivalent to that of patients treated with radiotherapy alone or in combination with surgery. This suggests the need for further investigation in this field.

Lymphocyte populations and T cell subpopulations in blood of patients with non-Hodgkin lymphomas.

Lymphocytic populations and T cell subsets were studied in the blood of patients with nonleukemic non-Hodgkin lymphoma. A statistically significant decrease of both the T lymphocytes and the OKT4-, OKT8-binding cells was detected in low-grade malignant lymphomas (LGML). A significant decrease of the T cell population and of the OKT4-binding cells was also found in high-grade malignant lymphomas (HGML); in these, the OKT8-binding cells were not lowered. The amount of the circulating B lymphocytes was not found to be altered both in HGML and in LGML.

Spontaneous complete remission of CLL. Report of a case studied with monoclonal antibodies.

A case of complete spontaneous remission of CLL in a 76-year-old woman is reported. Despite the complete remission, the study of the peripheral blood T lymphocytic subsets by the aid of monoclonal antibodies has showed, however, that the ratio between helper-induced and suppressor cytotoxic T cells is still impaired (0.81) as we can see in overt B-CLL. The cause of the remission and its possible connection with the imbalanced distribution of the T lymphocytic subsets is discussed.