Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence.

Background. R0 minor parenchyma-sparing hepatectomy (PSH) is feasible for colorectal liver metastases (CRLM) in contact with hepatic veins (HV) at hepatocaval confluence since HV can be reconstructed, but in the case of contact with the first-order glissonean pedicle (GP), major hepatectomy is mandatory. To pursue an R0 parenchyma-sparing policy, we proposed vessel-guided mesohepatectomy for liver partition (MLP) and eventually combination with liver augmentation techniques for staged major PSH. Methods. We analyzed 15 consecutive vessel-guided MLPs for CRLM at the hepatocaval confluence. Patients had a median of 11 (range: 0-67) lesions with a median diameter of 3.5 cm (range: 0.0-8.0), bilateral in 73% of cases. Results. Grade IIIb or more complications occurred in 13%, median hospital stay was 14 (range: 6-62) days, 90-day mortality was 0%. After a median follow-up of 17.5 months, 1-year OS and RFS were 92% and 62%. In nine (64%) patients, MLP was combined with portal vein embolization (PVE) or ALPPS to perform staged R0 major PSH. Future liver remnant (FLR) volume increased from a median of 15% (range: 7-20%) up to 41% (range: 37-69%). Super-selective PVE was performed in three (33%) patients and enhanced ALPPS (e-ALPPS) in six (66%). In two e-ALPPS an intermediate stage of deportalized liver PSH was necessary to achieve adequate FLR volume. Conclusions. Vessel-guided MLP may transform the liver in a paired organ. In selected cases of multiple bilobar CRLM, to guarantee oncological radicality (R0), major PSH is feasible combining advanced surgical parenchyma sparing with liver augmentation techniques when FLR volume is insufficient.

Intestinal histomorphological and molecular alterations in patients with Parkinson's disease.

BACKGROUND AND PURPOSE: Changes in gut microbiota composition, enteric inflammation, impairments of the intestinal epithelial barrier and neuroplastic changes in the enteric nervous system have been reported in Parkinson's disease (PD) patients and could contribute to the onset of both neurological and gastrointestinal symptoms. However, their mutual interplay has rarely been investigated. This study evaluated, in an integrated manner, changes in faecal microbiota composition, morphofunctional alterations of colonic mucosal barrier and changes of inflammatory markers in blood and stools of PD patients. METHODS: Nineteen PD patients and nineteen asymptomatic subjects were enrolled. Blood lipopolysaccharide binding protein (LBP, marker of altered intestinal permeability) and interleukin-1ß (IL-1ß) levels, as well as stool IL-1ß and tumour necrosis factor (TNF) levels, were evaluated. Gut microbiota analysis was performed. Epithelial mucins, collagen fibres, claudin-1 and S100-positive glial cells as markers of an impairment of the intestinal barrier, mucosal remodelling and enteric glial activation were evaluated on colonic mucosal specimens collected during colonoscopy. RESULTS: Faecal microbiota analysis revealed a significant difference in the α-diversity in PD patients compared to controls, while no differences were found in the ß-diversity. Compared to controls, PD patients showed significant chenags in plasma LBP levels, as well as faecal TNF and IL-1ß levels. The histological analysis showed a decrease in epithelial neutral mucins and claudin-1 expression and an increased expression of acidic mucins, collagen fibres and S100-positive glial cells. CONCLUSIONS: Parkinson's disease patients are characterized by enteric inflammation and increased intestinal epithelial barrier permeability, as well as colonic mucosal barrier remodelling, associated with changes in gut microbiota composition.

Pre-embedding of small biopsies using a Paraform gel system in a high throughput pathology laboratory.

In histology, the correct handling and orientation of small/thin biopsies is often crucial for diagnosis. Automation is progressively growing and modifying the routine work in the histopathology laboratories, providing new chances for quality improvement and workload optimization. We have tested the use of Paraform orientation gels together with an automated embedding system for processing small/thin biopsies, first skin, but also other tissue/organ biopsies. The study aimed to assess the benefits and challenges of routinely using orientation gels in a high throughput pathology laboratory. Gel introduction required a short training of the pathologists, including trainees, at grossing; it did not cause significant delay at grossing, interference with embedding, or microtome steps, whereas re-do inclusions and re-cut slides were significantly reduced. In conclusion, orientation gel and automatic embedding constituted an efficient system for small/thin biopsies that had to be correctly placed and orientated, allowing the re-modeling of technicians' workflow and very safe handling of small/thin biopsies that were not manipulated further after grossing.

Total area of inflammatory infiltrate and percentage of inflammatory infiltrate identify different clinical-serological subsets of primary Sjögren's syndrome better than traditional histopathological parameters.

OBJECTIVES: Recently, the total area of the inflammatory infiltrate and the percentage of inflammatory infiltrate have been proposed as novel histopathological parameters to improve the stratification of patients with Sjögren's syndrome (SS) in clinical trials. Both these parameters provide a more accurate assessment of the extent of the infiltrate in minor salivary gland biopsies (MSGBs) and may overcome the bias related to the Focus score (FS). To date, however, only few studies have investigated their clinical value and feasibility. In this study we revised consecutive MSGBs obtained routinely in a real-life clinical setting and correlated the total area of the inflammatory infiltrate and the percentage of inflammatory infiltrate both with the other MSGB histopathological parameters and with patients' clinical features in order to explore their usefulness in SS diagnostic work-up. METHODS: We assessed the area of the inflammatory infiltrate and the percentage of the inflammatory infiltrate in consecutive MSGBs and correlated these parameters with the number of foci, the FS and the presence of ectopic lymphoid structures (ELS). We also correlated these additional parameters with patients' clinical and biological data. RESULTS: We revised 69 MSGB samples: 46 from patients with a diagnosis of SS and 23 from subjects with no SS. The total area of inflammatory infiltrate and the percentage of inflammatory infiltrate appeared significantly higher in patients fulfilling the ACR/EULAR classification criteria for SS and correlated significantly with both the number of foci (p<0.001) and the FS (p<0.001). Particularly, they correlated better with the ELS in MSGBs than the number of foci and the FS. When we limited the analysis to the 32/69 patients with a FS<1, both the total area of the inflammatory infiltrate (p=0.02) and the percentage of the inflammatory infiltrate (p=0.03), but not the number of foci (p=0.12) remained significantly higher in the 10/32 anti-Ro/SSA positive patients fulfilling the ACR/EULAR classification criteria. Finally, the total area of inflammatory infiltrate and the percentage of inflammatory infiltrate correlated significantly with several biological and haematological SS-related abnormalities including hypergammaglobulinaemia, C4 levels, total number of white blood cells and the number of circulating lymphocytes. CONCLUSIONS: The total area of the inflammatory infiltrate and the percentage of the inflammatory infiltrate in SS referral centres, and particularly for selected cases, may maximise the information on disease activity at tissue level, ultimately improving SS patients' assessment.

EGFR and AKT1 overexpression are mutually exclusive and associated with a poor survival in resected gastric adenocarcinomas.

PURPOSE: The evaluation of molecular targets in gastric cancer has demonstrated the predictive role of HER2 amplification for trastuzumab treatment in metastatic gastric cancer. Besides HER2, other molecular targets are under evaluation in metastatic gastric tumors. However, very little is known about their role in resected tumors. We evaluated the expression of HER2, EGFR, MET, AKT1 and phospho-mTOR in resected stage II-III adenocarcinomas. METHODS: Ninety-two patients with resected stomach (63%) or gastro-esophageal adenocarcinomas (27%) were evaluated. Antibodies anti-HER2, EGFR, MET, AKT1 and phospho-mTOR were used for immunostaining of formalin-fixed paraffin-embedded slides. Using FISH, HER2 amplification was evaluated in cases with an intermediate (+2) staining. RESULTS: EGFR overexpression (11%) was a poor prognostic factor for overall survival (3-year OS: 47% vs 77%; Log-Rank p= 0.033). MET overexpression (36%) was associated with a trend for a worse survival (3-year OS: 65% vs 77%; Log-Rank p= 0.084). HER2 amplification/overexpression and mTOR hyper-phosphorylation were observed in 13% and 48% of tumors, respectively. AKT1 overexpression (8%) was not a prognostic factor by itself (p= 0.234). AKT1 and EGFR overexpression was mutually exclusive and patients with EGFR or AKT1 overexpression experienced a poor prognosis (3-year OS: 52% vs. 79%, Log-Rank p= 0.005). CONCLUSIONS: EGFR is confirmed a poor prognostic factor in resected gastric cancers. We firstly describe a mutually exclusive overexpression of EGFR and AKT1 with potential prognostic implications, suggesting the relevance of this pathway for the growth of gastric cancers.

Genomic instability and cellular stress in organ biopsies and peripheral blood lymphocytes from patients with colorectal cancer and predisposing pathologies.

Inflammatory bowel disease (IBD) and polyps, are common colorectal pathologies in western society and are risk factors for development of colorectal cancer (CRC). Genomic instability is a cancer hallmark and is connected to changes in chromosomal structure, often caused by double strand break formation (DSB), and aneuploidy. Cellular stress, may contribute to genomic instability. In colorectal biopsies and peripheral blood lymphocytes of patients with IBD, polyps and CRC, we evaluated 1) genomic instability using the γH2AX assay as marker of DSB and micronuclei in mononuclear lymphocytes kept under cytodieresis inhibition, and 2) cellular stress through expression and cellular localization of glutathione-S-transferase omega 1 (GSTO1). Colon biopsies showed γH2AX increase starting from polyps, while lymphocytes already from IBD. Micronuclei frequency began to rise in lymphocytes of subjects with polyps, suggesting a systemic genomic instability condition. Colorectal tissues lost GSTO1 expression but increased nuclear localization with pathology progression. Lymphocytes did not change GSTO1 expression and localization until CRC formation, where enzyme expression was increased. We propose that the growing genomic instability found in our patients is connected with the alteration of cellular environment. Evaluation of genomic damage and cellular stress in colorectal pathologies may facilitate prevention and management of CRC.

Drug addiction during pregnancy: correlations between the placental health and the newborn's outcome - elaboration of a predictive score.

During pregnancy, drug addiction represents one of the most dangerous situations. Each drug can badly affect the fetal development and, when the pregnancy is over, the negative influence continues in the newborn which is exposed to many risks, in particular the withdrawal syndrome. Since it is difficult to predict the newborn's outcome only on the basis of the kind of drug assumed by the mother during pregnancy, we propose the idea of a score based on the placenta's state of health. The aim of the study is to correlate the placental score to the withdrawal symptoms graveness. Our retrospective study includes 35 newborns exposed in uterus to illegal and legal drugs. We used the Finnegan's scoring system to quantify withdrawal symptoms and the placental score, based on the anatomopathological analysis, to assess the placenta's health. The newborns included in our study have been divided into two groups depending on the result of the placental score (< or =2 or > or =3). We found a significant statistical difference between the newborns whose placental score was low (< or =2) and those whose score was high (> or =3): the second group showed severe withdrawal symptoms for a longer time during the hospital stay (p = 0.014).

Large needle percutaneous aspiration biopsy of the testicle in men with nonobstructive azoospermia: technical performance.

The aim of this study was to relate retrospectively in 215 percutaneous large needle aspiration biopsy (LNAB) of the testicles the number of seminiferous tubules (ST) per testicular biopsy, from differently sized testicles, to the size of the needle used in order to obtain information useful for selecting the needle size according to the testicular size. Clinical, ultrasonographic and pathologic data of 134 patients with nonobstructive azoospermia examined with LNAB were retrospectively analyzed. One hundred and sixty-three testicles with volume>or=10 ml, 39<10 ml and>or=6 ml, 13<6 ml underwent 215 LNABs. In the larger testicle group the prevalence of adequate biopsies (ST>/=20) varied from 83% to 50% with a statistically significant difference among the needle groups (P=0.028) and being 83% in the biopsies with the 18 gauge (g.) needle. The mean number of ST obtained with the 18 g. needle was significantly higher than that obtained with the other needles (P=0.000). In the medium volume testicle group the adequate biopsy incidence varied from 20% to 83.3% with statistical significance among the various needle groups (P=0.042) being 83.3% in the biopsies with the 22 g. needle. In the smaller testicle group the mean number of ST obtained with the 22 g. needle was significantly higher than with the 20 g. needle (71 versus 25, P=0.011). In the patients with nonobstructive azoospermia, the 18 g. needle seemed to offer the best performance in the larger testicles, while in the medium and lower sized testicles the smaller 22 g. needle gave results comparable to or slightly better than the other larger needles.

Large-needle percutaneous aspiration biopsy of the testicle in men with nonobstructive azoospermia.

Two hundred thirteen testicular specimens of men with nonobstructive azoospermia were obtained by large-needle percutaneous aspiration biopsy. The mean values of the number of seminiferous tubules per histologic section, dimension, weight, and the fraction of biopsies with spermatogenetic cells (53, 0.2 x 0.3 x 0.62 cm, 385 mg, and 63%, respectively) were similar to those obtained by open or other surgical biopsy techniques that were used for assisted fertilization in the same type of patients.

Fine-needle and large-needle percutaneous aspiration biopsy of testicles in men with nonobstructive azoospermia: safety and diagnostic performance.

OBJECTIVE: To assess by ultrasonography the safety of the association fine-needle aspiration (FNA) plus a new percutaneous large-needle aspiration biopsy technique (LNAB), and to compare the results obtained with the two techniques in the same testicle and with FNA in the two testicles of the same patient. DESIGN: Retrospective analysis of clinical, ultrasonographic, and pathologic data. SETTING: Clinical and academic research environment. PATIENT(S): Three hundred and eighty-seven testicles of 233 patients (ages 19 to 57 years) with nonobstructive azoospermia were consecutively examined with FNA (154) or FNA + LNAB (233); 54 patients (89 testicles) examined with FNA + LNAB underwent a second ultrasonography up to 63 days after. INTERVENTION(S): Ultrasonography, FNA, LNAB. MAIN OUTCOME MEASURE(S): Hypoechoic area at ultrasonography; cytologic picture at FNA or LNAB of only Sertoli cells (category 1), spermatogenetic cells different from elongated spermatids or spermatozoa (category 2), and elongated spermatids and/or spermatozoa (category 3). RESULT(S): Among the 54 patients monitored by ultrasonography 48 (88.9%) showed no difference and 6 (11.1%) showed an hypoechoic area < or =1 cm in the second image. Category 1 occurred at FNA or LNAB in a very similar number of testicles (36% vs. 36.9%). Categories 2 and 3 were more frequent at LNAB (29.9% vs. 9.8%) and at FNA (54.2% vs. 33.2%), respectively. One hundred and sixty-six patients had both testicles examined by FNA; 147 pair of testicles were concordant for the presence or the absence of spermatozoa or elongated spermatids. In the remaining 19 patients (11.4%), these spermatogenetic cells were shown only in the specimen from one of the two testicles. These 19 patients accounted for 20.0% of 93 patients with spermatogenetic cells in at least one of the two testicles. CONCLUSION(S): The combination of FNA and LNAB did not produce clinically or subclinically relevant complications. No important differences in the identification of category 1 with FNA or LNAB were found. Fine-needle aspiration was more adequate in identifying category 3, which was particularly relevant in 20% of the men who had these cells in at least one of the two testicles.

Feline cutaneous neuroendocrine carcinoma (Merkel cell tumour): clinical and pathological findings.

A case of a feline Merkel cell tumour is described. An 8-year-old, female cat developed a round, alopecic, reddish mass on the nose. Wide excisional surgery was performed with cartilage resection. Histologically the mass was composed of solid islands of mostly basophilic densely packed cells with a scant cytoplasm, which was suggestive of a neuroendocrine origin. Results of immunohistochemical studies using antibodies against neurone-specific enolase, chromogranin, synaptophysin and pan-cytokeratin allowed classification of the lesion as a Merkel cell tumour. Ultrastructurally, dense core granules were identified in the cytoplasm. In a 2-year follow-up no relapses or metastases were observed. The clinical course recorded is in contrast with the malignant nature of a Merkel cell tumour recently described in a cat and of the human Merkel cell tumour, but is similar to the course of the canine Merkel cell tumour which is often benign. Early diagnosis along with the use of wide surgical excision might be considered an important factor in preventing relapse of this tumour.

Chemotherapy with epirubicin and paclitaxel for breast cancer during pregnancy: case report and review of the literature.

BACKGROUND: Breast cancer diagnosed during pregnancy is a challenging clinical situation. Little data are currently available about chemotherapy in pregnant women with this malignancy. CASE REPORT: We report the case of a 36-year-old pregnant woman with a T2N1M0 breast cancer who received sequential chemotherapy including epirubicin (120 mg/m2 every three weeks for four cycles) and paclitaxel (175 mg/m2 every three weeks for three cycles) from the 14th to the 32nd week of gestation. The patient delivered a normal female baby by caesarean section at the 36th week. The immunohistochemical examination of the placenta showed a diffuse, strong P-glycoprotein expression. Thirty-six months after the delivery, the mother was disease-free and the infant showed normal development and growth. DISCUSSION: Sequential chemotherapy including epirubicin and paclitaxel should be taken into consideration as adjuvant treatment for pregnant women with high-risk breast cancer. The strong placental expression of P-glycoprotein may play a major role in limiting fetal exposure to anthracyclines and taxanes.

Spermatogenesis in azoospermic, formerly cryptorchid men. Use of needle aspiration techniques.

OBJECTIVE: To assess the use of testicular needle aspiration techniques to evaluate fertility potential in azoospermic, formerly cryptorchid men. STUDY DESIGN: Fifteen consecutive adult azoospermic, formerly cryptorchid patients (eight unilateral and seven bilateral) were examined by needle aspiration techniques, fine (FNA) and large needle (LNAB) testicular aspiration biopsy, for cytologic and histologic analysis. Five of the 15 subsequently underwent surgical biopsy for attempted assisted fertilization. RESULTS: Spermatozoa or spermatids were detected by FNA cytology or LNAB histology in one or both testicles in 87.5% of the unilateral and 28.6% of the bilaterally affected, formerly cryptorchid patients (P = .041, Fisher's exact test). The addition of LNAB to FNA identified spermatids in one patient with unilateral cryptorchidism and only Sertoli cells on FNA cytology. Furthermore, LNAB differentiated testicles with the cytologic finding of only Sertoli cells into those with or without diffuse fibrosis. In the five patients in whom assisted fertilization was attempted, the needle aspiration techniques predicted the presence or absence of spermatozoa in the subsequent surgical biopsy. CONCLUSION: The two needle aspiration techniques can be used to assess the fertility potential of azoospermic, formerly cryptorchid men and to select patients for assisted fertilization.