Barrett's oesophagus: long-term follow-up after complete ablation with argon plasma coagulation and the factors that determine its recurrence.

BACKGROUND: Argon plasma coagulation seems to be a promising technique for ablation of Barrett's oesophagus, yet few long-term efficacy data are available. AIM: To report on a long-term follow-up and the factors that determine the recurrence of intestinal metaplasia in a cohort of patients with non dysplastic, intestinal type Barrett's oesophagus, after complete ablation of the metaplastic mucosa with argon plasma coagulation. METHODS: Ninety-six patients underwent endoscopic argon plasma coagulation with adequate acid suppression obtained through a continuous omeprazole therapy (50 patients) or through laparoscopic fundoplication (46 patients). Complete ablation was achieved in 94 patients who underwent follow-up. Endoscopic and histological examinations were performed every 12 months. RESULTS: The median follow-up of the patients was 36 months (range 18-98). A recurrence of intestinal metaplasia was found in 17 patients (18%), with an annual recurrence rate of 6.1%. Neither dysplasia, nor adenocarcinoma were found during the follow-up. Through the use of logistic regression analysis, previous laparoscopic fundoplication was associated with a reduced recurrence rate of intestinal metaplasia (odds ratio 0.30, 95% confidence interval 0.10-0.93). CONCLUSIONS: The long-term recurrence of intestinal type Barrett's oesophagus was low after complete ablation with argon plasma coagulation. The control of oesophageal acidity acid exposure with laparoscopic fundoplication seems to reduce the recurrence rate.

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication.

BACKGROUND: Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described. METHODS: From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months). RESULTS: Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up. CONCLUSION: The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.

Gastric carcinoma risk index, type III intestinal metaplasia and Helicobacter pylori status on antrum and body biopsies in a prospective general population study.

BACKGROUND: To evaluate the utility of 2 biopsies of antrum and gastric body on routinary endoscopy for the assessment of type III intestinal metaplasia (IM-3) and Helicobacter pylori (Hp) status, 1750 patients (pts) (895 males and 855 females, mean age 60.2) were considered from June 1998 to June 2000. METHODS: Specimens were graded 0 to 3 for atrophy, IM-3 and Hp status. 620 pts treated previously with antibiotics or not eligible for biopsy were excluded from initial 2360 pts. RESULTS: IM-3 (score >0), was found in 118 pts (6.7%), 86 pts (4.9%) only in the antrum. Ten of 355 pts (2.8%) with normal endoscopy findings and 47 of 702 (6.6%) with non erosive endoscopic gastritis resulted IM-3 positive in the antrum. 709 pts (40.5%) were found positive for Hp in antrum or/and corpus. The presence of Hp and IM-3 in the antrum was not correlated (p=0.99; spearman test). A positive correlation (p=0.000) between duodenal ulcer and Hp was found when antral Hp positivity was taken into account. Gastric carcinoma risk index (GCRI) was found in 358 pts (20.4%); in this group 131 pts (36.6%) were Hp positive, 82 pts (23%) have IM-3, 184 pts (51.4%) have atrophy. CONCLUSIONS: The incidence of IM-3 is low (6.7%) in routinary endoscopy. Normal endoscopy does not exclude the presence of IM-3. The biopsy is necessary to discover IM-3 in the antrum in 5.3% of pts with normal or aspecific endoscopic gastritis. Application of the GCRI might be useful to identify a group of patients carrying a higher risk for gastric carcinoma.

Detection of breast cancer cell contamination in leukapheresis product by real-time quantitative polymerase chain reaction.

Identification of sensitive techniques for breast cancer cell detection might be relevant for high-dose chemotherapy programs with autologous stem cell transplantation. We investigated the feasibility of Maspin, Mammaglobin and c-ErbB-2 amplification by real-time quantitative polymerase chain reaction (RQ-PCR) for the detection of breast cancer cells in leukaphereses. Expression of the three markers was determined in primary breast cancers and cell lines. Peripheral blood (PB), bone marrow (BM), and leukapheresis samples from patients with malignancies other than breast cancer were used as controls. Sensitivity was evaluated by dilution of primary tumors and cell lines with mononuclear blood cells. We found expression of the three markers in all primary tumors and most cell lines. No blood specimen from control patients had the Maspin transcript, while only one was positive for Mammaglobin. Weak c-ErbB-2 expression was detectable in most PB, all BM and all leukapheresis samples from controls. We observed a low sensitivity of Maspin RQ-PCR and a sensitivity of Mammaglobin RQ-PCR up to one tumor cell in 10(6) mononuclear cells. One out of 18 leukaphereses from breast cancer patients screened for the presence of Mammaglobin mRNA was positive. We conclude that Mammaglobin RQ-PCR might be a useful tool for detection of leukapheresis contamination.

Oncocytic and oncocytoid tumors of the exocrine pancreas, liver, and gastrointestinal tract.

Tumors having typical oncocytic features very rarely affect the gastrointestinal (GI) tract, liver, and pancreas, although several tumors with prominent "pink" (eosinophilic) cytoplasm are recognizable in the digestive tract. From a practical point of view, interest in the former lesions is limited to the differential diagnosis of a primary neoplasm versus metastatic deposits of malignant oncocytic tumors from other sites. This article briefly reviews the diagnostic features and clinical significance of the currently known tumors of the alimentary tract displaying a prominent oxyphilic character.

Biliary bile acid composition in gastric cancer.

Bile reflux into the stomach has been considered carcinogenic. Secondary bile acids, and in particular deoxycholic acid, have been shown to act experimentally as co-carcinogens in the colon and are increased in patients with colorectal adenocarcinoma. No information is available with respect to biliary bile acid composition in patients with gastric cancer. We studied biliary bile acid composition in 11 patients with gastric cancer and 23 healthy controls. Bile acids were measured using high-performance liquid chromatography. The site of gastric cancer was the antrum in 6 patients and body in 5. There were 6 intestinal-type and 5 diffuse adenocarcinomas. Only 2 patients had Helicobacter pylori infection. Deoxycholic acid constituted 24% +/- 2% of biliary bile acid in gastric cancer patients versus 22% +/- 2% in healthy controls (NS). Similarly, no differences were found between the two groups for all other bile acids. Deoxycholic acid constituted 23% +/- 3% of biliary bile acid (NS vs. controls) in patients with antral adenocarcinoma and 25% +/- 2% (NS vs. controls) in patients with intestinal-type gastric adenocarcinoma. Gastric adenocarcinoma is not associated with an increase in the more-toxic secondary bile acids, and deoxycholic acid in particular. This reduces the importance of bile acid composition as a promotor in gastric carcinogenesis.

Pre-treatment levels of anti-HCV core IgM antibodies are closely associated with response to alpha interferon therapy in chronic hepatitis C patients.

OBJECTIVES: To investigate the relationship between pre-treatment levels of anti-hepatitis C virus (HCV) immunoglobulin M (IgM) antibodies and the outcome of interferon therapy, and also the relationship with genotypes and quantitative viraemia. PATIENTS: One hundred and four patients with biopsy-proven chronic hepatitis C without cirrhosis, consecutively enrolled in three general hospitals in Turin, Italy, and treated according to the same interferon schedule (3 MU of recombinant alpha-2b interferon three times a week for 6 months). Anti-HCV IgM were measured by a second-generation enzyme-linked immunoassay and results expressed as sample-cutoff ratio. In 30 patients, determination of viraemia by branched DNA (bDNA) and genotyping were performed and the correlation with anti-HCV IgM ratios was assessed. RESULTS: According to univariate analysis, anti-HCV IgM ratios, age, serum gamma-glutamyltranspeptidase (gamma-GT) and ferritin levels were significantly associated with sustained response to therapy. A log-linear model, testing the effect of these variables on response to therapy, showed that anti-HCV IgM ratio was the only independently associated variable (P=0.00057). Anti-HCV IgM were associated with viraemia levels (r=0.57), but not with genotype distribution. Patients with anti-HCV IgM ratio less than 1 were sustained responders to the 'standard therapy' in 65% of cases. By contrast, among patients with a ratio greater than 3, sustained response was achieved in only one patient (3%), while 73% were non-responders; the majority of relapsers were found among patients with a ratio between 1 and 3. CONCLUSION: Anti-HCV IgM antibodies provide an easily accessible and cheap serological marker of active viral replication, and are significantly related to the outcome of interferon therapy in patients with chronic hepatitis C.

Relationship between hepatocyte proliferation and hepatitis delta virus replication in neoplastic and non-neoplastic liver tissues.

We studied the relationship between hepatocyte proliferation and hepatitis delta virus (HDV) replication at the single cell level. The proliferating cell nuclear antigen (PCNA) (by immunohistochemistry) and the HDV RNA (by in situ hybridization) were stained in neoplastic and non-neoplastic liver tissues of 19 patients with chronic HDV infection, including four cases of cirrhosis with superimposed hepatocellular carcinoma (HCC). As controls, we assessed the hepatocyte proliferation of liver tissues from 16 patients with chronic hepatitis B and on three normal livers. The hepatocyte PCNA labelling index of HDV-infected tissues was comparable with that seen in chronic hepatitis B-infected livers but was significantly higher than that observed in normal livers. Although cirrhotic tissues had lower hepatocyte proliferating fractions than non-cirrhotic tissues, the difference was not statistically significant. The hepatocyte proliferation rate did not correlate with the level of intrahepatic HDV replication or with the histological activity. In double-labelling experiments, PCNA and HDV RNA staining did not co-localize, with the exception of two of three cirrhotic tissues associated with HCC, where the association between the two markers was statistically significant. This co-localization was not observed, however, in the adjacent tumorous tissues. In patients with chronic HDV infection the hepatocyte proliferation was increased with respect to normal liver tissue, but was comparable with that observed in patients with chronic hepatitis B virus infection and did not correlate with the level of HDV replication or the histological activity. In the cirrhotic tissue of patients with HCC (but not in the tumour counterpart), HDV RNA may occasionally co-localize with the marker of hepatocyte proliferation. Whether this association between viral replication and cell division is related to liver carcinogenesis remains to be established.

Thyroid cancer histotype changes as observed in a major general hospital in a 21-year period.

The existing registries of thyroid carcinoma are seldom comparable as far as epidemiological data, diagnostic criteria and histopatological description are concerned. Epidemiological studies report a progressive increase in the incidence of thyroid carcinoma in the last twenty years and in both sexes this increase of incidence has been referred to papillary histotype. Data collected from surgical series show a rate of thyroid carcinomas from 7 to 20% of total thyroid surgeries. The present study was designed in order to obtain a retrospective review of the distribution of thyroid carcinoma's different histotypes in the last 21 years in a major General Hospital. Detailed analysis of patients with histologically confirmed thyroid carcinoma admitted between 1974 and 1994 to the Surgery Department of Mauriziano Hospital of Torino, Italy showed an overall 11.8% prevalence of thyroid cancer out of the total thyroid surgeries. The rate of papillary carcinoma was the highest (54.3%) followed by follicular carcinoma (27.6%), anaplastic carcinoma (11.1%), medullary carcinoma (4.6%) and others (2.4%). The papillary-to-follicular ratio varied from 0.60 in 1974-76 to 6.88 in 1992-94. Female to male ratio of all thyroid carcinoma histotypes was 2.0 or more; papillary and follicular histotypes had the highest ratio. The variations of the histotype rate observed may be consequence of the silent increase of daily iodine intake throughout the subsequent years, while improved diagnostic tools available and increased experience of the medical staff have probably increased the number on thyroid ablations performed. Our data confirm the changing epidemiology of thyroid carcinoma, reported by international literature.

Flow cytometric DNA analysis of cirrhotic liver cells in patients with hepatocellular carcinoma can provide a new prognostic factor.

BACKGROUND: DNA flow cytometry of hepatocellular carcinoma (HCC) cells has been investigated in many studies, but, to the best of our knowledge, there are no data on DNA analysis of cirrhotic parenchyma around the HCC. In this study, cell kinetics and ploidy of parenchymal cells around HCC were performed to ascertain if this would predict the possibility of recurrence in the cirrhotic areas. METHODS: The DNA content of 93 cases of HCC and of cirrhotic liver around the tumor nodules was analyzed by flow cytometry. Ploidy and proliferative index of HCC and cirrhotic liver were compared with macroscopic, histologic, and clinical features of each case and linked with the behavior of these tumors. Survival curves were assessed according to the Kaplan-Meier method. A multivariate analysis based on Cox proportional hazards regression model was performed on cases of diploid cirrhosis cells in which the S-phase fraction was evaluable. RESULTS: The univariate analysis of survival suggested significant roles for age, number of intrahepatic nodules, Edmondson-Steiner's classification, portal invasion, vascular invasion, presence of necrosis, hepatitis B surface antigen, alpha-feto-protein, Child's score, ploidy, and S-phase fraction of HCC cells. The DNA analysis of the cirrhotic cells showed that polyploidy was dramatically reduced in patients with HCC, compared with normal hepatocytes, and aneuploid clones were present among diploid cells. High S-phase fraction of cirrhotic cells and Child-Pugh classification were the strongest independent parameters affecting the tumor behavior in this study. CONCLUSIONS: The results of this study suggest that S-phase fraction of cirrhotic liver parenchyma may be employed as a new parameter in the prognostic evaluation of HCC patients.

[A case of Leydig cell tumor of the testis]. / Su di un caso di tumore del testicolo a cellule di Leydig.

Leydig cell tumors represent about 3% of all testicular neoplasms. Actually no specific pathologic criteria has really distinguished the benign from the malignant tumors which represent about 11% of the cases. The presence of metastases is the only unequivocal criteria of malignancy. Authors present a rare Leydigoma case with gynecomastia. Clinical, diagnostical and most of all therapeutical aspects are discussed reconfirming the role of the orchifuniculectomy in T1 N0 M0 stage.

[Metastasis of thyroid carcinoma. A rare case of secondary renal tumor]. / Metastasi da carcinoma tiroideo. Un raro caso di tumore secondario del rene.

Secondary tumours of the kidney are becoming an increasingly frequent pathology due to the accurate follow-up and longer survival of cancer patients. The paper reports a rare case of renal metastasis from a thyroid carcinoma, which started as a Hürthle cell adenoma and was transformed into a carcinoma with a follicular appearance after 26 years. The suspicion of a secondary site was based on the high serum levels of HTG (human thyroglobulin); metastasis was identified following scintigraphic tests using a dual marker (99mTC, 201TL) and renal scintigraphy with 123I Hippuran. The definitive diagnosis was obtained following histological tests; conservative surgery was performed to treat the metastasis (tumorectomy with removal of healthy pericapsular tissue).

[Palliative embolic treatment of synchronous bilateral renal carcinoma with metastasis]. / Trattamento embolizzante palliativo nel carcinoma renale bilaterale sincrono con metastasi.

The paper reports the use of embolic treatment in a case of synchronous bilateral renal carcinoma with caval thrombosis extending to the right atrium. Embolic treatment was also used for a large metastatic mass in the right iliac wing. The problems associated to palliative embolic treatment are discussed together with the relative histopathological aspects and the use of intrarterial IFN.

[Dermatitis caused by Cheyletiella. Description of 8 cases and review of the literature]. / Dermatite da Cheyletiella. Descrizione di otto casi e revisione della letteratura.

The Authors report eight cases of Cheyletiella dermatitis, parasite mite of domestic animals but also known as pathogenic for man. This animal parasitosis mentioned many times in other countries, seems to be very diffused in Italy, too. Nevertheless, the literature tells that normally, in our country, Cheyletiella dermatitis is a pathology completely underestimated and almost unknown. The Authors, because of the aspecificity of the clinical and histopathological data, lay special stress on the differential diagnosis problems concerning this infestation.

Hepatocellular carcinoma in cirrhotic liver in Trieste.

One hundred consecutive cases of hepatocellular carcinoma (HCC) in cirrhosis observed at autopsy were studied and their pathological aspects were compared with those reported in the literature. The results, which are representative of HCC epidemiology in a geographical area where cirrhosis is mostly due to alcohol abuse, show that similarities in the architectural pattern of HCC and weight of the liver exist between our material and samples with different aetiology and epidemiology. A relationship between the histological grade of HCC and its propensity to metastasize was demonstrated. The reported better prognosis of clear cells per se could not be confirmed, although clear cell HCC occurred exclusively in grade 2. It was also demonstrated that the relationship between grading and staging was strongly influenced by the association of HCC with cirrhosis, which is a fact that is usually overlooked by the common staging (and grading) methods.

[Benign multilocular cystic nephroma. Description of 1 case]. / Nefroma cistico multiloculare benigno. Descrizione di un caso.

The case of a multiple kidney cyst in an adult patient is described. The cyst had caused parenchymal atrophy by blocking the excretory ways. The pathological anatomy of the lesion is described and the aetiopathogenic hypotheses found in the literature are reported.