Diagnostic accuracy of ex vivo fluorescence confocal microscopy in Mohs surgery of basal cell carcinomas: a prospective study on 753 margins.

BACKGROUND: Frozen histological sections are used for intraoperative margin assessment during Mohs surgery. Fluorescence confocal microscopy (FCM) is a new tool that offers a promising and faster alternative to frozen histology. OBJECTIVES: To evaluate prospectively in a clinical setting the accuracy of FCM vs. frozen sections in margin assessment of basal cell carcinoma (BCC). METHODS: Patients with BCC scheduled for Mohs surgery were prospectively enrolled. Freshly excised surgical specimens were examined by FCM and then frozen sections were evaluated. Permanent sections were obtained, in order to validate the sample technique. A blind re-evaluation was also performed for discordant cases. Sensitivity and specificity levels, as well as positive and negative predictive values (PPV and NPV, respectively), were calculated and receiver-operating characteristic curves generated. RESULTS: We enrolled 127 BCCs in as many patients (40·2% females). Seven hundred and fifty-three sections were examined. All BCCs were located in the head and neck area. In evaluating the performance of FCM vs. frozen sections, sensitivity was 79·8%, specificity was 95·8%, PPV was 80·5% and NPV was 95·7% [area under the curve 0·88, 95% confidence interval 0·84-0·92 (P < 0·001)]. Forty-nine discordant cases were re-evaluated; 24 were false positive and 25 false negative. The performance of FCM and frozen sections was also evaluated according to the final histopathological assessment. CONCLUSIONS: We found high levels of accuracy for FCM vs. frozen section evaluation in intraoperative BCC margin assessment during Mohs surgery. Some technical issues prevent the wide use of this technique, but new devices promise to overcome these limitations.

Safety of leucodepleted salvaged blood in oncological surgery: an in vitro model.

Intra-operative blood cell salvage (IOCS) is mainly avoided in onco surgery due to the suspicion that it could increase metastasis' risk. We simulated IOCS followed by leucodepletion: HCT116 (human colorectal cancer) cells were inoculated into packed red blood cells units, and their distribution was evaluated, step-by-step, by flow cytometry and immunohistochemistry. Most of HCT116 cells were lost during washing, and almost completely removed after filtration. IOCS plus leucodepletion could be of great advantage for oncological patients, where allogenic blood transfusion could influence tumour progression.

PCDD/Fs in the soils in the province of Trento: 10 years of monitoring.

This paper presents a 10-year overview of the dioxins and furans (PCDD/Fs) content in soils in the province of Trento (Italy). The aim was to compare the results found in the Valsugana valley where there is a steel-making plant with other locations within the province. During 2002 and from 2005 to 2010, campaigns were carried out in order to obtain a background reference in terms of micropollutants, in view of the possible construction of a municipal solid waste (MSW) incinerator in Trento. In 2009, a campaign was performed for the environmental characterization of the Valsugana valley, the town of Trento and its surroundings, in order to help assess the impact of the steel-making plant. In 2012, another campaign was carried out by the Department of Civil and Environmental Engineering of Trento, in order to monitor the soils in the area around the steel mill. All the campaigns showed relatively low concentrations of PCDD/Fs, both in protected areas and in the areas close to the industrial plants. No critical situations were identified, as also confirmed by an estimation of the potential daily PCDD/F intake by children subject to accidental ingestion of soil.

Evaluating ex vivo fluorescence confocal microscopy images of basal cell carcinomas in Mohs excised tissue.

BACKGROUND: Fluorescence confocal microscopy (FCM) is an emerging technology for rapid imaging of excised tissue, without the need for frozen- or fixed-section processing. Basal cell carcinomas (BCCs) can be detected in Mohs excisions although few studies have described the major BCC findings as seen on FCM. OBJECTIVES: To describe the major BCC findings of excised tissue during Mohs surgery and to correlate them with histopathology. METHODS: Freshly excised tumours and frozen-thawed discarded tissue of BCC during Mohs surgery were analysed by means of FCM. A side-by-side correlation between FCM images and histological sections was performed. The FCM features of overlying skin and adnexal structures were also described. RESULTS: Sixty-four BCC cases were analysed. Distinct BCC types appeared unique in terms of shape and size of tumour islands [bigger in nodular (18/25), smaller and rounded in micronodular (7/7) and tiny cords for infiltrative ones (24/30)] and for the presence of clefting, palisading and increased nucleus/cytoplasm ratio. An excellent correlation was found between FCM and histological findings (Cohen's κ statistics = 0·9). In six cases, the presence of sebaceous glands and intense stroma reaction represented possible confounders. CONCLUSIONS: Fluorescence confocal microscopy is a fast and new imaging technique that allows an excellent visualization of skin structures and BCC findings during Mohs surgery.

Accuracy of tympanic and forehead thermometers in private paediatric practice.

AIM: To compare infrared tympanic and infrared contact forehead thermometer measurements with traditional rectal digital thermometers. METHODS: A total of 254 children (137 girls) aged one to 24 months (median 7 months) consulting a private paediatric practice because of fever were prospectively recruited. Body temperature was measured using the three different devices. RESULTS: The median and interquartile range for rectal, tympanic and forehead thermometers were 37.6 (37.1-38.4)°C, 37.5 (37.0-38.1)°C and 37.5 (37.1-37.9)°C, respectively (p < 0.01). The limits of agreement in the Bland-Altman plots were -0.73 to +1.04°C for the tympanic thermometer and -1.18 to +1.64°C for the forehead thermometer. The specificity of both the tympanic and forehead thermometers for detecting fever above 38°C was good, but sensitivity was low. Forehead measurements were susceptible to the use of a radiant warmer. CONCLUSION: Both the tympanic and forehead devices recorded lower temperatures than the rectal thermometers. The limits of agreement were particularly wide for the forehead thermometer and considerable for the tympanic thermometer. In the absence of valid alternatives, because of the ease to use and little degree of discomfort, tympanic thermometers can still be used with some reservations. Forehead thermometers should not be used in paediatric practice.

Juvenile spring eruption: an outbreak report and systematic review of the literature.

BACKGROUND: Juvenile spring eruption of the helices of the ears is a distinctive sun-induced condition appearing on the light-exposed skin of the ears, typically in boys and young men in early spring. OBJECTIVES: To determine clinical features and outcome of juvenile spring eruption of the ears. METHODS: We report a new outbreak in 14 Swiss-Italian children. A systematic search of the literature was also performed. RESULTS: Five outbreaks in children involved a total of 203 cases (boys, 72%), and three outbreaks in young adults involved 223 male subjects. A further 54 sporadic cases were found: 41 among children (boys, 97%) and 13 among young adult males. The typical presentation included itching and diffuse erythema of both ears starting in the evening after exposure to bright sunlight during cold weather, followed within 24-48 h by papules or blisters. No other organ system was involved. The subjects recovered spontaneously without sequelae within 1-2 weeks. In New Zealand, among 162 school-aged boys, 20 developed the condition. CONCLUSIONS: A limitation is that the analysis was based upon the scanty available literature. Juvenile spring eruption is a self-limiting and generally easy recognizable variant of polymorphic light eruption. Outbreaks tend to appear on sunny and cold spring days. Paediatricians and general practitioners might rapidly develop the skills necessary to clinically appreciate this condition.

Development and validation of an enzyme linked immunosorbent assay for palivizumab serum determination.

Palivizumab (Synagis) is a humanized monoclonal antibody (IgG1K) composed of 95 percent human and 5 percent murine sequences. It is directed to an epitope in the A antigenic site of the F protein of respiratory syncytial virus (RSV). Palivizumab is used for prevention of serious lower respiratory tract disease caused by RSV in pediatric patients who are at increased risk of severe disease and is administered intramuscularly (IM) for a total of 5 monthly doses. Herein, we report on the development and validation of a very sensitive enzyme-linked immunosorbent assay (ELISA) to measure serum concentrations of palivizumab by a rabbit polyclonal antibody specifically produced against the murine sequence. The method was developed and validated according to the guidelines "Guidance for Industry" (1998) and has proved suitable for the determination of palivizumab serum levels in the target infant population. The ELISA assay was successfully applied to test the serum samples in an infant population who received palivizumab intramuscularly; thus, the assay could be used to determine serum levels in palivizumab-treated infants to optimize dosing and scheduling and to study the relationship between dose and clinical response.

Bio-drying of grape marc and other biomass: a comparison.

The winery industry produces every year in the world about 270 millions of hectolitres of wine. A consequent amount of grape marc is then generated that has to be somehow treated and processed. For this reason a technique to treat grape marc (bio-drying) was studied and applied at the University of Trento. Grape marc, as is, is not suitable for direct combustion because of its high water content. By bio-drying the lower heating value has been increased up to the limit for a good combustion. This result allows a decentralized management of a grape marc drying differently from the conventional solutions.

Trends in the management of residual municipal solid waste.

In agreement with European Union directives, the integrated management of municipal solid waste must be developed ensuring a balanced relationship between the streams of selective collection and the one regarding the residual waste. A theoretical scenario is made where the residual municipal solid waste is composed only of non-recyclable fractions. An important aspect concerns the role of the organic fraction as selective collection can significantly decrease its content in the residual waste. This paper focuses on the planning, design and management consequences of this unsteady scenario. The treatments that are considered are: combustion, gasification, pyrolysis, integrated thermal plants, aerobic mechanical-biological treatments, anaerobic mechanical-biological treatments and other types of treatment. The considerations are based on the experience of the authors not only in terms of development of research but also in terms of transfer of the research results to the real scale, and knowledge of the state-of-the-art of the sector.

A contribution for a correct vision of health impact from municipal solid waste treatments.

In agreement with the European Union Directives concerning health risks targets, in the present paper data regarding the health risk from different strategies of waste treatment, in particular concerning dioxin emissions, are presented. Three options are considered for municipal solid waste treatment: incineration (with best available technologies (BATs)), an anaerobic/aerobic treatment and an aerobic treatment before landfilling. The process of biostabilization varies case by case but differences between simplified approaches and BAT solutions have been pointed out. In the paper it is also pointed out how important the local context for the health risk from PCDD/F release is: the height of gas release into the atmosphere, the emitted gas velocity and the temperature of release become the most important parameters (apart from the overall amount released) in areas where the population may be close to the plant or where there is agricultural activity in the proximity. However, all the three solutions give an acceptable risk.

Critical analysis of PCDD/F emissions from anaerobic digestion.

This paper concerns a particular aspect of anaerobic digestion, that is the emission of PCDD/F in different scenarios where this biological process is present. The considered scenarios are: anaerobic digestion of automatically sorted Municipal Solid Waste, source separated organic fraction of Municipal Solid Waste treated in an anaerobic digester, anaerobic process developed in a Municipal Solid Waste sanitary landfill. Not always the emissions taken into account are related to combustion of biogas from anaerobic digestion: the loss of biogas from a landfill causes an uncontrolled emission of PCDD/F. The paper is completed with an analysis of the role of anaerobic digestion in PCDD/F inventories and health risk considerations. Indeed the most detailed inventories offer emission factors useful for a deep understanding of the phenomenon of PCDD/F release into the atmosphere. Concerning health risk, some suggestions in order to decrease it are proposed.

Modelling of PCDD/F release from MSW bio-drying.

In the present work, an experimentation was carried out to study the behaviour of PCDD/F during the process of municipal solid waste (MSW) bio-drying. This process belongs to the biological mechanical treatment (BMT) options and is aimed to the dewatering of MSW thanks to the biological exothermal reactions (thermal drying, on the contrary, needs an external heat source as methane). The result is a decrease of waste weight and an increase of lower heating value (as the energy content refers to a lower amount of waste). Of course, the overall energy availability does not increase, but the characteristics of bio-drying are interesting as a way for refuse derived fuel generation: glass, metals and inert removals are easier after bio-drying. The literature of the sector shows only few data on PCDD/F emission to air from BMT. Anyway, in the present work an original theory has been put forward in order to explain the enrichment of PCDD/F in the air exiting the biological processes. The role of the initial PCDD/F concentration in the ambient air entering the plant is obviously taken into account. The results of the developed experimentation and the following elaborations point out that PCDD/F could be freed from the volatile solids consumed during the process. The different amount of PCDD/F in the waste and the different consumption of volatile solids depending on the biological process can explain the different PCDD/F emission factors available in the literature.

Lower heating value dynamics during municipal solid waste bio-drying.

In agreement with the new European Union directives concerning the valorization of materials and energy recovery, Municipal Solid Waste (MSW) management is, in general based on an integrated approach characterized by a combination of different treatment processes. The bio-mechanical treatment (BMT) of MSW is an increasing option in Europe either as a pre-treatment before landfilling or as a pre-treatment before combustion. In this context the research on the bio-drying process is not fully developed. In the present paper the Lower Heating Value (LHV) dynamics during MSW bio-drying has been assessed. Measurements were made using a pilot scale bio-dryer that allows the recording of data as air flow, temperature (at the entrance, at the exit and inside the waste), and weight loss. An initial characterization of the MSW completes the input data. Results give information on the dynamics of the main process parameters (humidity, volatile solids, ammonia, Lower Heating Value) and also of additional parameters.

Breast granulomatosis with polyangiitis mimicking breast cancer.

Inflammatory lesions of the breast encompass primary reactive processes and local manifestation of systemic diseases. They are very rare and they are generally treated without resort to biopsy. Nevertheless they could be clinically challenge mimicking malignant process and needing surgery to reach a correct diagnosis. Here we describe a rare case of breast granulomatosis with polyangiitis, which presented with radiological and clinical alarming features that immediately raised the suspicious of malignancy leading to breast-conserving surgery.

Cadherin-6 promotes EMT and cancer metastasis by restraining autophagy.

The transdifferentiation of epithelial cells toward a mesenchymal condition (EMT) is a complex process that allows tumor cells to migrate to ectopic sites. Cadherins are not just structural proteins, but they act as sensors of the surrounding microenvironment and as signaling centers for cellular pathways. However, the molecular mechanisms underlying these signaling functions remain poorly characterized. Cadherin-6 (CDH6) is a type 2 cadherin, which drives EMT during embryonic development and it is aberrantly re-activated in cancer. We recently showed that CDH6 is a TGFß target and an EMT marker in thyroid cancer, suggesting a role for this protein in the progression of this type of tumor. Papillary thyroid carcinomas (PTCs) are usually indolent lesions. However, metastatic spreading occurs in about 5% of the cases. The identification of molecular markers that could early predict the metastatic potential of these lesions would be strategic to design more tailored approaches and reduce patients overtreatment. In this work, we assessed the role of CDH6 in the metastatic progression of thyroid cancer. We showed that loss of CDH6 expression profoundly changes cellular architecture, alters the inter-cellular interaction modalities and attenuates EMT features in thyroid cancer cells. Using a yeast two-hybrid screening approach, based on a thyroid cancer patients library, we showed that CDH6 directly interacts with GABARAP, BNIP3 and BNIP3L, and that through these interactions CDH6 restrains autophagy and promotes re-organization of mitochondrial network through a DRP1-mediated mechanism. Analysis of the LIR domains suggests that the interaction with the autophagic machinery may be a common feature of many cadherin family members. Finally, the analysis of CDH6 expression in a unique cohort of human PTCs showed that CDH6 expression marks specifically EMT cells. and it is strongly associated with metastatic behavior and worse outcome of PTCs.

Impact of 2013 ASCO/CAP guidelines on HER2 determination of invasive breast cancer: A single institution experience using frontline dual-color FISH.

PURPOSE: The new ASCO/CAP guidelines published in 2013 (AC2013) significantly modified the scoring criteria for HER2-FISH, introducing the most controversial change to the HER2-equivocal category. We retrospectively evaluated the impact of AC2013 in a cohort of consecutive invasive breast cancers (IBCs) analyzed with frontline dual-color FISH. METHODS: 2788 consecutive IBCs were reclassified based on the AC2013 guidelines. Clinico-pathological features of equivocal IBCs were compared with HER2-negative and HER2-positive IBCs. FISH HER2-equivocal cases underwent reflex tests: HER2-IHC, RARA-FISH, and SMS-FISH. Overall and disease-free survivals were evaluated in AC2007 HER2-positive patients treated with trastuzumab and in patients that became eligible for target-therapy according to AC2013. RESULTS: Two-hundred HER2-negative cases (7.2%) were classified differently, following AC2013: 0.3% (8/2788) became HER2-positive and 6.9% (192/2788) HER2-equivocal. AC2013, compared with AC2007, significantly increased initial HER2-equivocal cases (6.9%vs1.6%, p < 0.001). AC2013 equivocal-IBCs affected older patients and showed pathological features between HER2-negative and HER2-positive IBCs. After reflex tests, 102 of the 190 equivocal cases (53.7%) were reclassified as HER2-positive, 51 (26.8%) as negative and 37 (19.5%) as equivocal. IHC tested negative in 44.7% of cases, whereas SMS-FISH showed the highest percentage of positive results (45.8%). Clinical outcomes showed no statistically significant differences. CONCLUSION: Overall, 80.5% of FISH-equivocal cases were solved with at least one reflex test and 3.6% of patients became AC2013 HER2-positive, therefore eligible for target-therapy, but showed clinical outcomes similar to HER2-positive patients treated with trastuzumab. Our data belittle the clinical impact of AC2013 HER2-equivocal reclassification; further prospective randomized clinical studies are necessary to support these findings.

Selected mitochondrial DNA landscapes activate the SIRT3 axis of the UPRmt to promote metastasis.

By causing mitochondrial DNA (mtDNA) mutations and oxidation of mitochondrial proteins, reactive oxygen species (ROS) leads to perturbations in mitochondrial proteostasis. Several studies have linked mtDNA mutations to metastasis of cancer cells but the nature of the mtDNA species involved remains unclear. Our data suggests that no common mtDNA mutation identifies metastatic cells; rather the metastatic potential of several ROS-generating mutations is largely determined by their mtDNA genomic landscapes, which can act either as an enhancer or repressor of metastasis. However, mtDNA landscapes of all metastatic cells are characterized by activation of the SIRT/FOXO/SOD2 axis of the mitochondrial unfolded protein response (UPRmt). The UPRmt promotes a complex transcription program ultimately increasing mitochondrial integrity and fitness in response to oxidative proteotoxic stress. Using SOD2 as a surrogate marker of the UPRmt, we found that in primary breast cancers, SOD2 is significantly increased in metastatic lesions. We propose that the ability of selected mtDNA species to activate the UPRmt is a process that is exploited by cancer cells to maintain mitochondrial fitness and facilitate metastasis.

The role of bio-mechanical treatments of waste in the dioxin emission inventories.

PCDD/Fs are one of the most studied molecules in the world because of their toxicity. In the last years the toxicity of these compounds has been analyzed in details. For years PCDD/F inventories have pointed out the significant role of municipal solid waste (MSW) incinerators in the overall balance. Recently, thanks to new regulations on PCDD/F emissions, in a few countries this scenario is changing: it can be demonstrated that modern MSW incinerators can play a secondary role even if the percentage of MSW sent to combustion has increased. In the latest inventories an unconventional source of PCDD/F has appeared: in nineties some biogas characterizations have demonstrated that there is a release of PCDD/F from MSW sanitary landfills. In addition, the combustion of collected biogas can generate not negligible amounts of PCDD/F. A new question can be put: does the MSW contribute with other management options to the overall balance of PCDD/F? The present work points out that a detailed inventory should take into account also the PCDD/F release from bio-mechanical treatment plants (both composting and bio-drying/bio-stabilization plants). However the contribution from this option is secondary when it is compared with the one from old MSW incinerators.