Molecular Tumor Board as a Clinical Tool for Converting Molecular Data Into Real-World Patient Care.

PURPOSE: The investigation of multiple molecular targets with next-generation sequencing (NGS) has entered clinical practice in oncology, yielding to a paradigm shift from the histology-centric approach to the mutational model for personalized treatment. Accordingly, most of the drugs recently approved in oncology are coupled to specific biomarkers. One potential tool for implementing the mutational model of precision oncology in daily practice is represented by the Molecular Tumor Board (MTB), a multidisciplinary team whereby molecular pathologists, biologists, bioinformaticians, geneticists, medical oncologists, and pharmacists cooperate to generate, interpret, and match molecular data with personalized treatments. PATIENTS AND METHODS: Since May 2020, the institutional MTB set at Fondazione IRCCS Istituto Nazionale Tumori of Milan met weekly via teleconference to discuss molecular data and potential therapeutic options for patients with advanced/metastatic solid tumors. RESULTS: Up to October 2021, among 1,996 patients evaluated, we identified >10,000 variants, 43.2% of which were functionally relevant (pathogenic or likely pathogenic). On the basis of functionally relevant variants, 711 patients (35.6%) were potentially eligible to targeted therapy according to European Society of Medical Oncology Scale for Clinical Actionability of Molecular Targets tiers, and 9.4% received a personalized treatment. Overall, larger NGS panels (containing >50 genes) significantly outperformed small panels (up to 50 genes) in detecting actionable gene targets across different tumor types. CONCLUSION: Our real-world data provide evidence that MTB is a valuable tool for matching NGS data with targeted treatments, eventually implementing precision oncology in clinical practice.

A2AR Expression and Immunosuppressive Environment Independent of KRAS and GNAS Mutations in Pseudomyxoma Peritonei.

In pseudomyxoma peritonei (PMP), KRAS and GNAS mutations are frequent. We hypothesized that these mutations may contribute to the suppression of antitumor immunity: KRAS may induce GMCSF expression, while GNAS may enhance the expression of cyclic adenosine monophosphate and A2AR signaling. This study aimed to explore possible mechanisms facilitated by KRAS and GNAS mutations for escaping immune surveillance. Additionally, we looked for new potential therapeutic and prognostic targets in this rare disease which is poorly characterized at the molecular level. GM-CSF, A2AR, CD73, CD39, and PD-L1 expression was investigated by immunohistochemistry in 40 PMPs characterized for GNAS and KRAS mutational status. Immune cell populations were studied by immunohistochemistry and nanostring nCounter®. Following the criteria of a prognostic nomogram reported for PMP, we stratified the patients into two different risk groups, with 28 "low-risk" and 12 "high-risk" patients. We observed the expression of GM-CSF (74%); CD39 (37%); CD73 (53%); A2AR (74%); and PD-L1 (16%) which was unrelated to GNAS or KRAS status. The tumor microenvironment showed the presence of CD4+ T cells (86%); CD8+ T cells (27%); CD20+ B (67%); CD15+ cells (86%); and CD163+ M2 macrophages (67%), while CD56+ NK cells were absent. CD163 expression (27%) in PMP tumor cells was associated with poor prognosis. GNAS mutation and A2AR expression were not associated with a specific immune transcriptional signature. However, the expression assay revealed 21 genes associated with prognosis. The "high-risk" patients exhibited worse progression-free survival (HR = 2.3, CI 95%: 1.1-5.1, p = 0.034) and significant downregulation of MET, IL8, PPARG, DTX4, HMGA1, ZIC2, WNT5B, and CCRL2. In conclusion, we documented the presence of immunosuppressive factors such as GM-CSF, A2AR, and PD-L1 in PMP. These factors were not associated with GNAS and KRAS status and could be explored as therapeutic molecular targets. Additionally, a set of potential prognostic biomarkers, including CD163 expression in tumor cells, deserve further investigation.

Prevalence of BRCA homopolymeric indels in an ION Torrent-based tumour-to-germline testing workflow in high-grade ovarian carcinoma.

Tumour DNA sequencing is essential for precision medicine since it guides therapeutic decisions but also fosters the identification of patients who may benefit from germline testing. Notwithstanding, the tumour-to-germline testing workflow presents a few caveats. The low sensitivity for indels at loci with sequences of identical bases (homopolymers) of ion semiconductor-based sequencing techniques represents a well-known limitation, but the prevalence of indels overlooked by these techniques in high-risk populations has not been investigated. In our study, we addressed this issue at the homopolymeric regions of BRCA1/2 in a retrospectively selected cohort of 157 patients affected with high-grade ovarian cancer and negative at tumour testing by ION Torrent sequencing. Variant allele frequency (VAF) of indels at each of the 29 investigated homopolymers was systematically revised with the IGV software. Thresholds to discriminate putative germline variants were defined by scaling the VAF to a normal distribution and calculating the outliers that exceeded the mean + 3 median-adjusted deviations of a control population. Sanger sequencing of the outliers confirmed the occurrence of only one of the five putative indels in both tumour and blood from a patient with a family history of breast cancer. Our results indicated that the prevalence of homopolymeric indels overlooked by ion semiconductor techniques is seemingly low. A careful evaluation of clinical and family history data would further help minimise this technique-bound limitation, highlighting cases in which a deeper look at these regions would be recommended.

Management of pregnancy and childbirth in a patient with glutaric aciduria type II: a case report and literature review.

Glutaric aciduria type II (GA II) is a genetic disorder that interferes with the body's ability to break down proteins and fats in order to produce energy. Signs and symptoms vary greatly depending on the age of onset and severity of the condition. Pregnancy may be a high risk period in women affected by metabolic disorders, because the mother has to guarantee wellness for both her and fetus. A 37-years-old primigravida woman affected by a mild form of GA II presented to our high risk department. During pregnancy a dietician strictly controlled her diet and nutritional intake. The fetal growth was regular but around the 38th week a polyhydramnios was diagnosed. A modification in carbohydrate intake led to a normal amniotic fluid. Considering the high risk of metabolic decompensation during labor, an elective cesarean section was programmed. The rare disease geneticist gave some indications to follow before, during and after delivery to reduce the risk for the mother. No complications occurred and the patient with her baby was discharged on the third postoperative day. We present a case report and a review of literature. In pregnant women affected by GA II periodical nutritional and obstetrical evaluations are important to monitor maternal condition and fetal growth. Adequate nutrient intake is fundamental to preserve mother and fetus from complications. Elective caesarean section is preferred to reduce metabolic distress during delivery and to avoid the risk of metabolic crisis. Pregnant women with metabolic diseases are increasing, consequently guidelines may be necessary for a better management.

Uterine rupture during pregnancy: The URIDA (uterine rupture international data acquisition) study.

OBJECTIVE: To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients. METHODS: Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR. RESULTS: Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy. CONCLUSION: Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies.

Genital Brucella suis Biovar 2 Infection of Wild Boar (Sus scrofa) Hunted in Tuscany (Italy).

Brucellosis is a zoonosis caused by different Brucella species. Wild boar (Sus scrofa) could be infected by some species and represents an important reservoir, especially for B. suis biovar 2. This study aimed to investigate the prevalence of Brucella spp. by serological and molecular assays in wild boar hunted in Tuscany (Italy) during two hunting seasons. From 287 animals, sera, lymph nodes, livers, spleens, and reproductive system organs were collected. Within sera, 16 (5.74%) were positive to both rose bengal test (RBT) and complement fixation test (CFT), with titres ranging from 1:4 to 1:16 (corresponding to 20 and 80 ICFTU/mL, respectively). Brucella spp. DNA was detected in four lymph nodes (1.40%), five epididymides (1.74%), and one fetus pool (2.22%). All positive PCR samples belonged to Brucella suis biovar 2. The results of this investigation confirmed that wild boar represents a host for B.suis biovar. 2 and plays an important role in the epidemiology of brucellosis in central Italy. Additionally, epididymis localization confirms the possible venereal transmission.

Leptospira Survey in Wild Boar (Sus scrofa) Hunted in Tuscany, Central Italy.

Leptospirosis is a re-emerging, worldwide zoonosis, and wild boar (Sus scrofa) are involved in its epidemiology as the reservoir. The aim of this study was to investigate the prevalence of Leptospira with serological, bacteriological, and molecular assays in wild boar hunted in Tuscany (Italy) during two hunting seasons. In total, 287 specimens of sera, kidneys, and liver were collected to perform microscopic agglutination tests (MATs), isolation, and RealTime PCR to detect pathogenic (lipL32 gene), intermediate (16S rRNA gene), and saprophytic (23S rRNA gene) Leptospira. Within sera, 39 (13.59%) were positive to the MAT, and Australis was the most represented serogroup (4.88%), followed by Pomona (4.18%), and Tarassovi (3.14%). Moreover, four Leptospira cultures were positive, and once isolates were identified, one was identified as L. borgpetersenii serovar Tarassovi, and three as L. interrogans serovar Bratislava. Pathogenic Leptospira DNA were detected in 32 wild boar kidneys (11.15%). The characterization through the amplification of the rrs2 gene highlighted their belonging to L. interrogans (23 kidneys), L. borgpetersenii (four), and L. kirschneri (one), while nine kidneys (3.14%) were positive for intermediate Leptospira, all belonging to L. fainei. The results of this study confirmed the importance of wild boar in the epidemiology of leptospirosis among wildlife in Central Italy.

Laparoscopic transperitoneal left adrenalectomy and wandering spleen risk.

BACKGROUND AND OBJECTIVES: Laparoscopic transperitoneal left adrenalectomy (LTLA) has become the standard treatment for adrenal masses<6 cm. LTLA involves the dissection of splenic suspensory ligaments, which replicates their congenital absence or weakening, present in cases of wandering spleen (WS). WS is a rare condition in which the spleen migrates from the left upper quadrant to a more caudal location in the abdomen. A unique case of WS after LTLA was described by Corcione et al. In this prospective study, we investigated the possibility of WS as a consequence of LTLA. METHODS: Twenty-four patients, 8 men and 16 women, who underwent LTLA with the dissection of splenoparietal and splenorenal ligaments were selected. RESULTS: Clinical and ultrasonographic follow-up showed no evidence of postoperative WS. CONCLUSIONS: In the literature, WS is not commonly reported as a postoperative complication of LTLA. In effect, especially in the case of small adrenal masses, the spleen's repositioning in its seat is autonomous. However, the alarming possibility of WS should not be ignored, especially in the case of extensive dissection of the left colic flexure. It would be useful for other authors to signal this complication, so that different approaches and consequent results may be compared.

Conservative Treatment of Stage IA1 Adenocarcinoma of the Uterine Cervix during Pregnancy: Case Report and Review of the Literature.

Microinvasive adenocarcinoma (MIAC) of the uterine cervix is rare in pregnancy. Published data on conservative treatment of MIAC both in pregnant and nonpregnant women are scarce. A conservatively treated case of MIAC in a 13-week-pregnant woman after a diagnosis of atypical glandular cells (AGC) on pap smear at the 6th week of pregnancy is presented. The problems of suspected adenocarcinoma in situ (AIS) on biopsy and MIAC on cone biopsy in pregnancy, as well as the risks and benefits of a conservative treatment are discussed. After colposcopic guide laser cervical conization and expression of informed consent the patient underwent followup and vaginal delivery at 40 weeks plus 3 days of gestation. In this case, no obstetric complication has been recorded after the cervical conization, and after a followup of 18 months the patient was alive and free of disease, with negative results as far as pap smear, colposcopy, HPV status, and cervical curettage are concerned. In a stage Ia1 disease of endocervical type, with clear margins and without lymph-vascular space invasion, cervical conization performed during the second trimester may be considered a definitive and safe treatment, at least up to delivery, after expression of informed consent by the woman.

Puerperal ovarian vein thrombosis: two case reports.

Ovarian vein thrombosis (OVT) is an uncommon but potentially serious complication in the early postpartum. Two case studies seem to prove the point: Case 1 A 24-year-old woman was transferred to our hospital with the chief complaint of abdominal pain radiating to the right thigh, vomit, diarrhea, and a slight pyrexia (37.6 °C rectal). Five days earlier, she had a spontaneous vaginal delivery after labor induction. The woman appeared slightly distressed because of pain; vital signs were found to be normal and the CRP elevated (129.9 mg/L). Abdominal examination was remarkable for tenderness by palpation in the right lower quadrant with no rebound tenderness or guarding. Pelvic examination was remarkable for mild right adnexal tenderness. Abdominal-pelvic computer tomography with contrast medium revealed a 2.5-cm OVT having extended into the inferior vena cava for 14 cm with a slight peripheral edema. The patient was treated with nadroparin 0.6 cc (5700 IU) bid and warfarin 5 mg since the attainment of the therapeutic INR range. Case 2 A 31-year-old twin-pregnant woman had an emergency cesarean section at 35 gestational weeks because of hypertension complicated by increased liver enzymes, diuresis contraction, and continuous lower back pain bilaterally radiating to the groins. One day after delivery, CT scan that was performed because of onward anemia showed a pelvic, perihepatic, and perisplenic blood effusion, and a 1-cm right OVT extended to the inferior vena cava below renal veins for 28 mm. She underwent exploratory laparotomy and blood transfusion, and because of respiratory insufficiency she was transferred to a second level center with ICU facility, where she was placed under a suprarenal inferior vena cava filter, and AngioJet Rheolytic Thrombectomy for acute pulmonary embolism was performed.

Robotics in general surgery: personal experience in a large community hospital.

HYPOTHESIS: Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting. DESIGN: The study describes the clinical experience of the Department of General Surgery, Misericordia Hospital, Grosseto, Italy, in robot-assisted surgery using the da Vinci Surgical System. RESULTS: Between October 2000 and November 2002, 193 patients underwent a minimally invasive robotic procedure (74 men and 119 women; mean age, 55.9 years [range, 16-91 years]). A total of 207 robotic surgical operations, including abdominal, thoracic and vascular procedures, were performed; 179 were single procedures, and 14 were double (2 operations on the same patient). There were 4 conversions to open surgery and 3 to conventional laparoscopy (conversion rate, 3.6%; 7 of 193 patients). The perioperative morbidity rate was 9.3% (18 of 193 patients), and 6 patients (3.1%) required a reoperation. The postoperative mortality rate was 1.5% (3 of 193 patients). CONCLUSIONS: Our preliminary experience at a large community hospital suggests that robotic surgery is feasible in a clinical setting. Its daily use is safe and easily managed, and it expands the applications of minimally invasive surgery. However, the best indications still have to be defined, and the cost-benefit ratio must be evaluated. This report could serve as a basis for a future prospective, randomized trial.