Morquio A syndrome due to maternal uniparental isodisomy of the telomeric end of chromosome 16.

Morquio A syndrome (MPS IVA) is a recessive lysosomal storage disorder (LSD) caused by mutations in the GALNS gene leading to the deficiency of lysosomal enzyme N-acetylgalactosamine-6-sulfate sulfatase (GALNS). Patients show a broad spectrum of phenotypes ranging from classical severe type to mild forms. Classical forms are characterized by severe bone dysplasia and usually normal intelligence. So far, more than 170 unique mutations have been identified in the GALNS gene of MPS IVA patients. We report on a Morquio A patient with a classical phenotype who was found to be homozygous for a missense mutation (c.236 G>A; p.Cys79Tyr) in the GALNS gene. This alteration affects the highly conserved p.Cys79 that is transformed into formylglycine, the catalytic residue of the active site. The mutation was present in the proband's mother, but not in the father, whose paternity was confirmed by microsatellite analysis. In order to test the hypothesis of maternal uniparental disomy (UPD), we investigated the segregation of sixteen microsatellite markers from chromosome 16. The results showed a condition of maternal UPD due to an error in meiosis I. Maternal isodisomy of the 16q24 region led to homozygosity for the GALNS mutant allele, causing the patient's disease. These findings allow to add for the first time the LSD Morquio A syndrome to the list of conditions that can be caused by UPD. The possibility of UPD is relevant when giving genetic counseling to couples since the recurrent risk in future pregnancies is dramatically reduced.

Incidence and risk factors of bacterial sepsis and invasive fungal infection in neonates and infants requiring major surgery: an Italian multicentre prospective study.

BACKGROUND: Limited data are currently available on the incidence rates and risk factors for bacterial sepsis and invasive fungal infections (IFIs) among neonates and infants undergoing major surgery. AIM: To assess the incidence of bacterial sepsis and IFI, fungal colonization, risk factors for sepsis, and mortality in neonates and infants aged <3 months undergoing major surgery. METHODS: A multicentre prospective study was conducted involving 13 level-3 neonatal intensive care units in Italy, enrolling all infants aged ≤3 months undergoing major surgery. FINDINGS: From 2018 to 2021, 541 patients were enrolled. During hospitalization, 248 patients had a bacterial infection, and 23 patients had a fungal infection. Eighty-four patients were colonized by fungal strains. Overall, in-hospital mortality was 2.8%, but this was higher in infected than in uninfected infants (P = 0.034). In multivariate analysis, antibiotic exposure before surgery, ultrasound-guided or surgical placement of vascular catheters, vascular catheterization duration, and gestational age ≤28 weeks were all associated with bacterial sepsis. The risk of IFI was markedly higher in colonized infants (odds ratio (OR): 8.20; P < 0.001) and was linearly associated with the duration of vascular catheterization. Fungal colonization in infants with abdominal surgery increased the probability of IFI 11-fold (OR: 11.1; P < 0.001). CONCLUSION: Preventive strategies such as early removal of vascular catheters and the fluconazole prophylaxis should be considered to prevent bacterial and fungal sepsis in infants undergoing abdominal surgery, and even more so in those with fungal colonization.

Reader variability in reporting breast imaging according to BI-RADS assessment categories (the Florence experience).

The inter- and intraobserver agreement (K statistic) in reporting according to BI-RADS assessment categories was tested on 12 dedicated breast radiologists, with little prior working knowledge of BI-RADS, reading a set of 50 lesions (29 malignant, 21 benign). Intraobserver agreement (four categories: R2, R3, R4, R5) was fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80) or almost perfect (>0.80) for one, two, five or four radiologists, or (six categories: R2, R3, R4a, R4b, R4c, R5) fair, moderate, substantial or almost perfect for three, three, three or three radiologists, respectively. Interobserver agreement (four categories) was fair, moderate or substantial for three, six, or three radiologists, or (six categories) slight, fair or moderate for one, six, or five radiologists. Major disagreement occurred for intermediate categories (R3=0.12, R4=0.25, R4a=0.08, R4b=0.07, R4c=0.10). We found insufficient intra- and interobserver consistency of breast radiologists in reporting BI-RADS assessment categories. Although training may improve these results, simpler alternative reporting methods (systems), focused on clinical decision-making, should be explored.

Sphingosine 1-phosphate induces arachidonic acid mobilization in A549 human lung adenocarcinoma cells.

In the present paper, the effect of sphingosine 1-phosphate (Sph-1-P) on arachidonic acid mobilization in A549 human lung adenocarcinoma cells was investigated. Sph-1-P provoked a rapid and relevant release of arachidonic acid which was similar to that elicited by bradykinin, well-known pro-inflammatory agonist. The Sph-1-P-induced release of arachidonic acid involved Ca(2+)-independent phospholipase A(2) (iPLA2) activity, as suggested by the dose-dependent inhibition exerted by the rather specific inhibitor bromoenol lactone. The Sph-1-P-induced release of arachidonic acid was pertussis toxin-sensitive, pointing at a receptor-mediated mechanism, which involves heterotrimeric Gi proteins. The action of Sph-1-P was totally dependent on protein kinase C (PKC) catalytic activity and seemed to involve agonist-stimulated phospholipase D (PLD) activity. This study represents the first evidence for Sph-1-P-induced release of arachidonic acid which occurs through a specific signaling pathway involving Gi protein-coupled receptor(s), PKC, PLD and iPLA2 activities.

Categorizing breast mammographic density: intra- and interobserver reproducibility of BI-RADS density categories.

The inter- and intraobserver agreement (kappa-statistic) in reporting according to Breast Imaging Reporting and Data System (BI-RADS((R))) breast density categories was tested in 12 dedicated breast radiologists reading a digitized set of 100 two-view mammograms. Average intraobserver agreement was substantial (kappa=0.71, range 0.32-0.88) on a four-grade scale (D1/D2/D3/D4) and almost perfect (kappa=0.81, range 0.62-1.00) on a two-grade scale (D1-2/D3-4). Average interobserver agreement was moderate (kappa=0.54, range 0.02-0.77) on a four-grade scale and substantial (kappa=0.71, range 0.31-0.88) on a two-grade scale. Major disagreement was found for intermediate categories (D2=0.25, D3=0.28). Categorization of breast density according to BI-RADS is feasible and consistency is good within readers and reasonable between readers. Interobserver inconsistency does occur, and checking the adoption of proper criteria through a proficiency test and appropriate training might be useful. As inconsistency is probably due to erroneous perception of classification criteria, standard sets of reference images should be made available for training.

Second reading of screening mammograms increases cancer detection and recall rates. Results in the Florence screening programme.

OBJECTIVE: To assess double reading effectiveness in mammography screening. DESIGN: Retrospective study of 177,631 consecutive mammograms double read during 1998-2003. SETTING: The Florence screening programme, involving 11 trained radiologists. Abnormalities reported by at least one reader prompted assessment. RESULTS: The referral rate was 2.89% for the first reader, 3.15% for the second reader, and 3.59% for either reader. Of 713 total cancers detected, 43 were suspected only by the second reader (6.4% relative, 0.024% increase in absolute detection rate) and had a lower stage compared to the first reader (pTis-pT1b = 65.7 versus 52.0%): 41 were reviewed and classified (error type) as "minimal sign" in six, and "screening error" in 35 cases, or as BI-RADS 3 in one, 4a in 20, 4b in 13, and 4c in three cases. The second reading cost was 2.70 per woman examined, or 11,168 per additional cancer detected (versus 11,585 at a single reading). DISCUSSION: Second reading is effective in detecting a limited number of additional cancer cases. Tumour stage (one-third over 1 cm in diameter) and review findings (high rate of "screening errors" and BI-RADS R4b-c categories) suggest that second reading detects small "difficult cases" as well as larger cancers missed due to fatigue or loss of attention. Second reading reduces screening specificity to a minor extent, and since cancer detection at second reading seems cost-effective the procedure is recommendable in routine practice.

The role of arbitration of discordant reports at double reading of screening mammograms.

OBJECTIVE: To asses the effectiveness of arbitration of discordant double readings in mammography screening. DESIGN: A retrospective study of 1217 consecutive arbitrations. SETTING: A subset of discordant double readings from the Florence screening programme underwent arbitration by a third reader. RESULTS: Positive arbitration of 1217 discordant double readings prompted assessment in 476 cases (39.2%), detecting 30 cancers (6.3%). Of 741 negative arbitrations (60.8%), 311 have been followed up thus far, and two cancers (0.64%) occurred in the site previously suspected at one of the two independent readings. Arbitration had a sensitivity of 86.3% and a negative predictive value of 99.3%. Arbitration reduced the overall referral rates from 3.82% to 2.59% (relative decrease 32.1%). Due to false-negative arbitration, cancers detected per 1000 women screened would decrease from 4.58 to 4.50 (relative decrease 1.7%). For every cancer missed due to false-negative arbitration, 151 unnecessary recalls and 21,248 euro would have been saved, whereas the saved cost per screened woman due to arbitration was 1.72 euro. DISCUSSION: Arbitration of discordant double reading would substantially reduce referral rates with a limited reduction in cancer detection rate, and may be recommended as a routine procedure. Greater benefit from arbitration might be expected in the presence of high referral rates at independent double reading, a common scenario in a newly implemented service screening.

Expression of nm23 gene in gastric cancer is associated with a poor 5-year survival.

The nm23 gene is thought to play a role as an inhibitor of metastatic progression in several human cancers and its down-regulation has been associated with increased metastasis and reduced survival in some studies, though not in others. To better investigate the role of nm23 in gastric cancer (GC), the expression and prognostic impact of this gene was examined in 107 radically operated GC patients in a high risk area. The expression of nm23 was determined immunohistochemically by using the rabbit antibody anti-human nm23 protein. The expression of nm23 was detected in 40.2% (n = 43) of 107 gastric tumours and correlated with a poorer clinical outcome. In a survival analysis at 5 years, patients with nm23-positive tumours had significantly worse prognosis than patients (n = 64) with nm23-negative tumours (p < 0.05). The prognostic significance of nm23 expression was confirmed by multivariate analysis including terms for tumour stage and lymph node involvement. Our results suggest that the expression of the nm23 gene in gastric carcinoma is significantly related to tumour progression and poor prognosis at 5 years.

Proficiency test for screening mammography: results for 117 volunteer Italian radiologists.

OBJECTIVE: To analyse the performance of a large sample of Italian radiologists undergoing a proficiency test for screening mammography. DESIGN: Evaluation of performance indicators according to reference standards determined by a panel of experts (sensitivity (reference standard > or = 80%), recall rate (reference standard < or = 15%)). SETTING: 117 Italian radiologists of varying experience (years of practice 0.5-18, average 5.9; mammograms read 500-51,000, average 13,000), all currently reporting clinical mammography and planning to take part in screening in the near future. RESULTS: Eighty four of 117 (72%) radiologists reached the standard for sensitivity, 88 (75%) reached the standard for recall rate, and only 59 (50%) reached both standards and passed the proficiency test. The probability of passing the test was significantly correlated with mammographic practice (p = 0.015), mammograms read (p = 0.024), and mammograms read/year (p = 0.043). DISCUSSION: The performance of a large sample of Italian radiologists currently reporting clinical mammography was disappointing, indicating the need for proper training of at least 50% of the tested subjects. When implementing organised screening the health authority should set up a proper process for training and accrediting radiologists, and a proficiency test should be part of such a process.

Independent double reading of screening mammograms.

OBJECTIVE: To evaluate the cost effectiveness of independent double reading of screening mammograms. SETTING: Prospective study of 18,817 women undergoing first or repeat screening in a population based programme in the Florence district. METHODS: Mammograms were independently double read by experienced radiologists. Subjects with mammographic abnormalities reported by at least one reader were recalled for diagnostic assessment. The mean increase in recall rate, cancer detection rate, and screening costs attributable to double reading was calculated. RESULTS: Eleven of 125 cancers were detected by only one reader. The mean increase in cancer detection rate attributable to double reading compared with single reading was 4.6% (95% confidence interval (CI) 1.1 to 8.9). From a total of 748 cases referred for diagnostic assessment, 196 subjects were referred by one reader only. The mean increase in referral rate attributable to double reading compared with single reading was 15.1% (CI 12.3 to 17.8). Double reading caused a marked increase in the cost for each woman screened -8.5% at the first screening and 6.2% at repeat screening and a more limited increase in the cost for each cancer detected -3.5% at the first screening and 2.7% at repeat screening. Cancers detected by only one screener were at an earlier stage than those detected by both screeners (P = 0.6, not significant). CONCLUSIONS: Independent double reading results in only a modest increase in the detection of cancers and therefore may not be cost effective.

Assessment of lesions detected at mammographic screening: performance at first or repeat screening in the Florence programme.

OBJECTIVE: To evaluate the assessment criteria and the results achieved in the detection of breast lesions at mammographic screening. SETTING: Review of cases assessed in the last screening round of Florence city (FC--first screening round: 29,522 subjects) and Florence district (FD --repeat screening round: 13,268 subjects) programmes. METHODS: Referral and biopsy rates, predictive values, and prevalence of cancers detected by screening were determined, as well as the frequency of the diagnostic procedures used at assessment, and their contribution to the final diagnosis according to the mammographic appearance of the suspected lesion. Assessment costs were estimated. RESULTS: Referral rate (FC 4.2%; FD 1.8%), referral positive predictive value (FC 18.7%; FD 28.3%), surgical biopsy rate (FC 0.96%; FD 0.6%), benign/malignant biopsy ratio (FC 0.20; FD 0.13), and prevalence of cancers detected by screening (FC 0.78%; FD 0.5%) were all within the European Community (EC) recommended standards for screening performance. The benign biopsy rate was considerably lower than that of recommended standards. The cost for each subject assessed was 179,000 Italian lire at the first and 116,000 lire at repeat screening. The cost for each subject screened that was attributable to assessment was 7600 lire at the first or 2100 lire at repeat screening. CONCLUSIONS: Limited referral rates and costs were achieved and the proportion of cancers detected by screening was high. The number of referrals was further reduced at repeat screening, and assessment had a limited impact on total screening costs. Detail or magnification mammography, palpation, sonography, and fine needle aspiration cytology all contributed to the final diagnosis and should be immediately available at the assessment clinic. The observed benign biopsy rate was particularly low and suggests that EC recommended standards should be modified.

The contribution of ultrasonography to the differential diagnosis of breast cancer.

Overall consecutive breast abnormalities (259 carcinomas, 1820 benign) examined with breast ultrasonography (US) are reported. US sensitivity, specificity and positive predictive value were 67.6, 97.7 and 81.0%, resp. (the corresponding values were 57.9, 97.9 and 77.2% for palpation, 79.9, 93.5 and 73.7% for mammography, and 97.6, 92.6 and 87.6% for cytology). US sensitivity was unaffected by age, whereas it was strongly influenced by tumor size (pT1-76.1%; pT2-87.1%) and histologic type (intraductal-7.4%; invasive ductal/lobular-83.4%; invasive special types-64.1%). The features of the lesions at US were significantly associated with cancer (irregular margins, posterior acoustic shadowing) or benign lesions (anechoic structure, lateral shadowing, posterior acoustic enhancement) but had a limited diagnostic accuracy. Overall, US visualized 174 (benign-24, suspicious-150) of 188 palpable, and 32 (benign-7, suspicious-25) of 71 nonpalpable cancers. US contribution was determinant to final diagnosis in 4 of 7 cancers, missed at palpation and mammography, but was at least partially responsible for 8 unnecessary biopsies of benign lesions. A negative/benign US report contributed to avoid unnecessary biopsy in 71 suspicious cases at palpation/mammography. Routine US examination of clinical/mammographic abnormalities is recommended for the advantages of US-guided aspiration and to reduce the frequency of unnecessary biopsies.

Causes of breast cancer misdiagnosis at physical examination.

2740 consecutive breast cancers undergoing physical examination were reviewed. Ninety-two subclinical cancers detected at mammography were excluded from further evaluation and the study focused on palpable false benign cancers. The sensitivity of physical examination varied according to T category (TIS = 0.48, T1 = 0.70, T2 = 0.90, T3 = 0.89, T4 = 0.93), age (20-29 = 0.77, 30-39 = 0.58, 40-49 = 0.75, 50-59 = 0.84, 60-69 = 0.90, greater than 69 = 0.94) and operator (range 0.69-0.89), a significant difference being recorded in favor of more expert operators. Multivariate analysis (Cox) showed that T category, patient's age and operator experience are independent determinants of sensitivity. This study confirms that physical examination is not very sensitive, particularly for small tumors and in younger women and should always be performed by expert operators.

The role of galactography in the detection of breast cancer.

The authors report on a series of 529 consecutive patients examined on physical examination, mammography, nipple discharge cytology and galactography. The criterion for galactography was essentially bloody nipple discharge (73% of cases). Serous nipple discharge was not considered worthy of routine galactography since it is associated with an extremely low incidence of breast cancer. Surgical excision and histologic examination of the discharging duct was performed in 200 cases. Eighteen cases of breast cancer were detected (10 infiltrating, 8 intraductal) of which 9, 6, 7 or 7 were suspected on physical examination, mammography, cytology or galactography, respectively. All combined tests suspected 13 of 18 breast cancers; 3 intraductal breast cancers were biopsied because of evidence of multiple papillomas on galactography, and 2 infiltrating breast cancers were operated because of persistent bloody nipple discharge in the absence of any other sign. No breast cancer was suspected on galactography alone. Galactography is indicated in the presence of bloody nipple discharge, and a biopsy should be performed when breast cancer or multiple papillomas are suspected. The diagnosis and excision of a single papilloma (breast cancer was never misdiagnosed as a single papilloma on galactography) is not worthwhile since a single papilloma is a benign lesion, and the benefit of its excision is still unclear.

[Surgical treatment of thyroid microcarcinoma]. / Trattamento chirurgico dei microcarcinomi tiroidei.

Thyroid microcarcinoma is nowaday defined as a tumor of one centimeter or less in the maximum diameter. It occurs in less than five per cent of all thyroid carcinomas. In personal experience four thyroid microcarcinomas have been found in specimens from 121 thyroidectomies and have been retrospectively reviewed clinical data and the long term follow-up of the patients. Total thyroidectomies nor prophylactic lymphadenectomies were never performed. All patients at present are well. Our purpose was to focus on the current surgical treatment of microcarcinoma. Many hypotheses are done to explain pathogenesis and fairly good prognosis of thyroid microcarcinomas, without univocal conclusions. Almost all authors agree that microcarcinoma of the thyroid gland is a low-aggressive tumor, with good biological behaviour, but the therapeutic strategies are not codified yet. Particularly, doubt still exists about the choice between total thyroidectomy and more conservative procedure, and lymphadenectomy, especially when tumor is found in specimens after surgery for benign disease. In conclusion, in our opinion conservative management is the best choice, provided that the patient is included in a correct long-term follow-up.

[Ileal duplication in adults. A very rare nosological entity]. / La duplicazione ileale dell'adulto. Una rarissima entità nosologica.

The report presents a rare case of intestinal duplication in a 43-year old female. Intestinal duplication is a rare congenital malformation and is extremely exceptional in adults. A lot of etiopathogenic theories have been advanced to explain this malformation that can occur anywhere along the alimentary tract, even if the ileum remains the most common. It may be cystic or tubular. An important aspect of mucosal histology is the possibility of gastric heterotopy, conditioning a particular treatment. The literature shows 14 cases with clinical very different presentations and instrumental exams were rarely helpful for correct diagnosis. Treatment of choice is surgical complete resection of the duplication. When contiguous structures are involved intestinal bypass or Roux-on-Y anastomosis may be necessary with mandatory stripping of the mucosa when heterotopic gastric mucosa is present in order to prevent the risk of gastrointestinal haemorrhage or malignant transformation, an event possible in about 25% of the cases reported in the literature.

Florence-Sydney Breast Biopsy Study: sensitivity of ultrasound-guided versus freehand fine needle biopsy of palpable breast cancer.

BACKGROUND: Fine needle aspiration biopsy (FNAB) is widely used in the diagnosis of breast cancer. It is unknown whether, for palpable cancers, ultrasound-guided FNAB is more accurate than freehand FNAB, and practice varies between physicians, services and countries. METHODS: From consecutive women attending a major cancer centre in Florence, we prospectively recruited subjects who had a definitely palpable lump which was solid on ultrasound and suspicious of malignancy (n = 102). All subjects were investigated using both ultrasound-guided and freehand FNAB (one aspirate with each method). Radiologists skilled in both sampling techniques performed all clinical examinations and aspirations, and for each subject the same radiologist obtained both FNAB samples. Sequence of aspiration method was randomised. Cytological interpretation was blinded to method of sampling. Comparative sensitivity (and insufficiency) for FNAB using the two methods was calculated in all cancers (n = 97). RESULTS: Ultrasound-guided FNAB resulted in 13.6% (5-22%) less insufficient aspirates than freehand FNAB (chi2 = 7.58; p = 0.006). When insufficient aspirates are included and considered as negative, ultrasound-guided FNAB has a 14.6% (5.8-23%) or a 16.5% (7.6-25.4%) significantly better sensitivity than freehand FNAB (for cytology 3-5 positive or cytology 4-5 positive respectively). When insufficient aspirates are excluded from the analysis, ultrasound-guided FNAB has a 1.4% (-1.2 to 3.9%) or a 2.6% (-2.5 to 7.8%) higher sensitivity than freehand FNAB (for cytology 3-5 positive or cytology 4-5 positive respectively) but this difference in the sensitivity of the two methods is not statistically significant. CONCLUSION: Our data suggest that ultrasound-guided FNAB has better sensitivity than freehand FNAB in palpable breast cancer, which is predominantly an effect of a significant reduction in insufficient aspirates, but in part an effect of 'upgrading' cytological classification of cancers.

Breast cancer: reliability of mammographic appearance as a predictor of hormone receptor status.

The association of mammographic appearance with hormone receptor status was investigated in 397 patients with primary breast cancers. The mammographic appearance was classified as type 1, spiculated (n = 159); type 2, structural changes (density) (n = 102); type 3, calcifications (n = 30); type 4, circumscribed opacity (n = 65); and type 5, not visible on mammogram (n = 41). Univariate analysis showed a significant association with estrogen receptor (ER) status for age (less than 50 vs greater than or equal to 50 years), tumor TNM category (those in category 1 vs those in higher categories), and mammographic appearance; with progesterone receptor status, the association was significant only for age. Multivariate analysis adjusted for potential confounders confirmed a significant association between ER status and mammographic appearance (ER status was more likely with type 1 than with the other mammographic types), but the strength of the association was limited. The mammographic appearance of breast cancer is not a reliable method to predict hormone receptor status for clinical purposes.