Cardiovascular Risk Score and Pulmonary Gas Exchange in COVID-19 Patients Show No Correlation.

BACKGROUND: COVID-19 induces robust systemic inflammation. Patients with cardiovascular disease (CVD) are at an increased risk of death. However, much effort is being spent to identify possible predictors of negative outcomes in order to have a more specific clinical setting. CVD scores are a useful tool in evaluating risk of cardiovascular events. AIM: We evaluated oxygenation and characteristics in COVID-19 patients according to cardiovascular risk stratification performed using the Framingham risk score (FRS) for cardiovascular disease. MATERIALS AND METHODS: We evaluated 155 COVID-19 patients (110 males and 45 females, aged 67.43 ± 14.72 years). All patients underwent a complete physical examination, chest imaging, laboratory tests and blood gas analysis at the time of diagnosis. Seventeen patients died (10 males and 7 females, aged 74.71 ± 7.23 years) while the remaining 138 patients (100 males and 38 females, aged 66.07 ± 15.16 years) were alive at discharge. RESULTS: Deceased patients have an increased FRS compared to those that survived (27.37 ± 5.03 vs. 21.33 ± 9.49, p < 0.05). Compared to survivors, the deceased group presents with a significant increase in white blood cells (p < 0.05) and D-dimers (p < 0.05). There was no difference in pCO2, SO2, and in alveolar arteriolar oxygen difference (A-aDO2). On the contrary, in deceased patients there was an increased pO2 (p < 0.05) and a decreased ratio between oxygen inspired and pO2 (P/F; p < 0.05). FRS shows a negative correlation to P/F (r = 0.42, p < 0.05) in the deceased while no correlation was found in the survivors. No other correlation has been found with blood gas parameters or in the inflammation parameters evaluated in the two groups. DISCUSSION: CVD may be considered as a major risk factor for death in COVID-19 patients. The increased risk relates to a reduced lung capacity but it is not related to blood gas values. Similarly, CV risk score results are independent from the inflammatory status of the patients.

What's new in mesothelioma.

Malignant pleural mesothelioma is a neoplasm characterized by a very poor prognosis and medico-legal implications. Diagnosis, prognosis and therapy are often challenging and include several issues. Cytological diagnosis is frequently the first step of the diagnostic process, and although its sensitivity may be somewhat lower, diagnostic criteria should be taken into account. When effusion cytology is inconclusive for the diagnosis, tissue biopsies should be taken. Even if the morphologic criteria for deciding whether a mesothelial proliferation is a benign or a malignant process have been defined, the separation of benign from malignant mesothelial proliferation is often a difficult problem for the pathologist, particularly on small biopsies. Thirdly, when the diagnosis is made, despite many efforts have been made to identify possible new biomarkers for early diagnosis, prognostic stratification and also predictive tools should be defined. Nowadays, the main prognostic parameter is still represented by the histological subtype, having the epithelioid MPM a better outcome than the sarcomatoid or biphasic MPM. A nuclear grading system have been also proposed to stratify patient outcome. Reliable predictive biomarkers are still lacking in MPM and a personalized therapeutic concept is eagerly needed. Mesothelioma occurs mostly as sporadic cancer and the main risk factor is asbestos exposure, but it also occurs among blood relatives suggesting possible increased genetic susceptibility besides shared exposures. Recently the study of genetic predisposition syndrome raised new aspect in the occurrence of mesothelioma cases.This review summarize these most important issues.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and multiple pulmonary epithelioid hemangioendothelioma (PEH): a case report.

We report a case of a 76-year-old female with multiple lung nodules (Fig. 1 Rx). Pathologic evaluation of the lower left video-assisted thoracoscopic surgery (VATS) lobectomy VATS-lobectomy showed four nodules that were described as pulmonary epithelioid hemangio-endothelioma (PEH); the immunohistochemical stains showed that the neoplastic cells expressed CD31, a variable expression for factor VIII and a low expression of CD34. In the remaining parenchyma of the lobe, multiple nests of neuroendocrine cells were observed with immunohistochemical confirmation, and the diagnosis was diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH). To our knowledge, the association between PEH and DIPNECH has never been described in the literature.

Large fraction radiotherapy plus misonidazole for treatment of advanced lung cancer: report of a phase I/II trial.

From August 1978 through December 1979, 51 patients with advanced non-oat cell carcinoma of the lung were enrolled in a Phase I/II trial sponsored by the Radiation Therapy Oncology Group (RTOG) employing misonidazole (a 2-nitroimidazole) as a hypoxic cell sensitizer and radiation. The purpose of this study was to test drug and radiation tolerance and to assess the short term efficacy of this unconventional treatment. Tumor doses of 600 rad wer given twice weekly for three weeks for a total of 3600 rad, preceded four to six hours by misonidazole in a dose of 2 gm/m2 or 1.75 gm/m2, administered orally. Forty-nine patients were evaluable. Serious toxicity from this treatment was rare. Grade 2 or 3 peripheral neuro-toxicity occurred in eight of 24 patients (33%) with drug doses of 2 gm/m2 and in four of 26 patients (15%) who received 1.75 gm/m2. Grade 3 or 4 central nervous system toxicity occurred in two patients. Two patients developed serious late radiation complications: one patient had a transverse myelitis that appeared one year following delivery of 3600 rad to the spinal cord; a second patient developed a tracheoesophageal fistula and pericarditis eight months following treatment. Objective responses were reported in 67% of patients (complete in 18%); 70% of the patients died with a median survival time of nine months. Of 32 patients eligible for 12 month follow-up, 34% survived more than one year. Patterns of relapse after initial treatment and comparison with results from other RTOG trials using conventional fractionation are discussed.

Immunohistochemical panels for differentiating epithelial malignant mesothelioma from lung adenocarcinoma: a study with logistic regression analysis.

Immunohistochemistry provides an important indicator for differential diagnosis between pleural malignant mesothelioma and lung adenocarcinoma, which have complex therapeutic and medicolegal implications. To pinpoint a reliable, restricted panel of markers, the authors evaluated the efficacy of select commercial antibodies in a series of patients with confirmed clinicopathologic diagnosis of mesothelioma or lung adenocarcinoma with the aid of multiple logistic classification tables. Specimens of 46 mesotheliomas and 20 lung adenocarcinomas were examined with calretinin, thrombomodulin, cytokeratins (CKs) 5/6, and high-molecular weight CKs (indicators of mesothelioma), alongside MOC 31, Ber-EP4, and carcinoembryonic antigen (CEA; indicators of lung adenocarcinoma). Of the mesotheliomas, 40 of 46 (87%) were positive with calretinin, 29 of 46 (63%) with thrombomodulin, 40 of 46 (87%) with CKs 5/6, and 41 of 46 (89%) with high-weight CKs; five of 46 mesotheliomas (11%) were focally reactive with MOC 31, four of 46 (9%) with Ber-EP4, and two of 46 (4%) with CEA. Of the lung adenocarcinomas, 18 of 20 (90%) were positive with MOC 31, 20 of 20 (100%) with Ber-EP4, and 17 of 20 (85%) with CEA; and two of 20 (10%) were focally reactive with calretinin, one of 20 (5%) with thrombomodulin, none of 20 (0%) with CKs 5/6, and five of 20 (25%) with high-weight CKs. Multiple logistic modeling indicated two batteries of three antibodies permitting more than 98% overall accuracy: Ber-EP4 plus CKs 5/6 plus calretinin, and Ber-EP4 plus CKs 5/6 plus CEA.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome.

BACKGROUND: The impact of myocardial revascularization without cardiopulmonary bypass (CPB) was evaluated in a series of consecutive patients with multivessel disease. METHODS: From May 21, 1997 to November 30, 2000, 1,843 consecutive patients underwent isolated myocardial revascularization. From this total, 919 patients were done without CPB (group A, 49.9%) and 924 patients were done with CPB (group B, 50.1%). Patients that converted from without CPB to with CPB were included in group A. Thirty-three variables were evaluated with univariate and multivariate analysis to identify the independent variables predictive of higher incidence of early mortality, acute myocardial infarction, cerebrovascular accident, and early major events. RESULTS: Early mortality was 2.2% (group A, 1.4%; group B, 3.0%; p = 0.016), acute myocardial infarction incidence was 1.8% (group A, 1.1%; group B, 2.6%; p = 0.027), cerebrovascular accident incidence was 0.9% (group A, 0.8%; group B, 1.0%; p = not significant), and early major events incidence was 6.7% (group A, 5.3%; group B, 8.2%; p < 0.001). Stepwise logistic regression analysis showed that CPB was an independent risk factor for higher mortality (odds ratio, 2.2; p = 0.0217), higher incidence of acute myocardial infarction (odds ratio, 2.5; p = 0.0185), and higher incidence of early major events (odds ratio, 1.8, p = 0.0034). CONCLUSIONS: When CPB was not used, patients experienced lower early mortality and incidences of acute myocardial infarction were less complicated, both at univariate analysis and stepwise logistic regression analysis.

Modern radiotherapy for malignant epitheliomas.

There are exceptional cases of malignant epitheliomas in which radiotherapy is at once or eventually becomes a treatment of last resort. We recount the clinical facts, histologic findings, radiotherapeutic techniques, and results of treatment of seven such cases.

Role of radiation therapy in the management of meningioma.

Surgery is the accepted form of treatment of meningioma; the role of radiotherapy has not been clearly established. With this in mind, we have reviewed our experience with radiation therapy in the management of meningiomas at New York University Medical Center. Sixty-eight patients fell into three groups. Forty-three (Group A) underwent operation followed by radiation therapy, 14 patients (Group B) had radiation for recurrence after operation, and 11 patients (Group C) had radiation therapy as the primary treatment. In Group A, 41 of 43 are alive. During a follow-up of 1 to 10 years, only 2 have deteriorated. Five of 14 Group B patients showed neurological improvement and 7 showed deterioration, including 5 who died of tumor. All 11 patients in Group C are alive with follow-up periods of 3 to 6 years; 9 of these show improvement in neurological function. Eleven patients had malignant meningioma, of whom 8 are alive and stable. We present 4 case reports, including computed tomographic scans that show evidence of tumor necrosis after radiation therapy. Pathological verification of tumor necrosis is presented in 1 case. We believe that radiation therapy has an established role in the treatment of incompletely excised, recurrent, or malignant meningiomas and, in some cases, as the initial management of meningiomas. Indications for treatment and guidelines are presented.

Radiotherapy for bronchogenic carcinoma.

Treatment of carcinoma of the lung to cure or even to prolong survival time to a satisfactory degree is not yet a reality. For squamous cell carcinoma confined to the lung, radical surgery offers the best possibility of cure. When surgery is not feasible in such a case for other than technical reasons (eg, poor general condition of the patient), radical (megavoltage) radiotherapy offers a good possibility of cure. For anaplastic or oat cell carcinoma confined to the lung, cure by surgery or radiotherapy is less likely and there is little advantage of one or the other of these modalities. Once metastasis has occurred, surgery is largely precluded and radiotherapy becomes a measure of last resort that offers a good possibility of relief of distressing symptoms and some hope of prolonging worthwhile life.

Small airways diseases.

The histopathology of the small airways is frequently quite subtle, even in cases with clinically severe disease. In the present paper, we will demonstrate some recognizable straightforward pathological changes in the small airways, and also provide a list of clinico-pathological conditions that should be considered when each is encountered. In the second part of the paper, we will briefly overview some general histological patterns of lesions and specific diseases that may involve the small airways. The basic lesions will be subdivided into inflammatory (acute, chronic, granulomatous, with or without necrosis), proliferative (epithelial or mesenchymal), and remodeling reactions. Inflammatory and proliferative reactions may lead to a the third category of remodeling reactions, characterized by a variety of distortions of normal bronchiolar architecture, including occlusion, constriction, dilatation (with or without mucostasis), tortuosity and nodularity. In addition to this schematic distinction, it is important to recognize that these lesions are frequently combined together and evolve with one another. Each of the 3 reaction patterns may be exquisitely bronchiolar, or may extend in the surrounding parenchyma. In this case, it is important to distinguish between lesions that extend from the bronchiole to the parenchyma or vice versa (such as in organizing pneumonia patterns, where the main lesion is in the parenchyma). As most of these lesions are part of a dynamic process, it is important to recognize that a single causative agent may produce distinct pathologic features at different times in the natural history of the disease. In addition, the same clinical disease may result in a variety of pathologic lesions. Accordingly, there may be not always be an unequivocal relationship between the clinical disease/condition and specific histopathologic lesions in the small airways.

Radiotherapy of intracerebral metastatic malignant melanoma.

The results of 35 courses of palliative irradiation in 30 patients with intracerebral metastatic malignant melanoma are reviewed. Marked improvement in neurologic status occurred in approximately 35%. Slight to moderate improvement was evident in an additional 35%. Palliative whole-brain irradiation is the treatment of choice for patients with cerebral metastases from malignant melanoma despite the commonly held impression that this tumor is radioinsensitive.

Blue nevus of the lymph node capsule. Report of a case.

A case of blue nevus in the lymph node capsule is described. It's not a common pathology and only few cases have been reported so far. Nevus-cell aggregates in the same location are more frequent and difference between the two entities is described. So for histogenesis of these lesions, a melanocyte migration arrest is favoured rather than the hypothesis of a 'benign metastasis' from a cutaneous primitive site.

Radiotherapy for aggressive and destructive keratoacanthomas.

An experience of treating five cases of aggressive and destructive keratoacanthomas by radiotherapy is recounted. The results were satisfactory in every instance.

Value of radiation therapy in the management of patients with cerebral metastases from malignant melanoma: Radiation Therapy Oncology Group Brain Metastases Study I and II.

Sixty patients from two Radiation Therapy Oncology Group (RTOG) studies with cerebral metastases from malignant melanoma were analyzed to determine the response to whole brain irradiation. General performance status, neurologic function, and specific neurologic symptoms were evaluated for rate and duration of improvement. Also analyzed was the influence of chemotherapy and steroids, although neither was a controlled factor. Results indicate a significant benefit from radiation therapy in terms of symptomatic and neurologic function improvement. Symptomatic improvement was observed in 76%, with 31% completely improved. Of the four most frequent symptoms, complete or partial improvement was observed as follows: headache--27 of 37 patients (73%); motor loss--14 of 23 patients (61%); impaired mentation--13 of 24 patients (62%); and convulsions--10 of 12 patients (83%). Improvement in neurologic function class was observed in 18 of 44 patients (41%). Median survival for Study 1 patients was 10 weeks (range 1-200) and that of Study II patients 14 weeks (range 1-76). These results are comparable to those found in radiation therapy of brain metastases from all other primary tumors.

[Solitary necrotic nodule of the liver simulating a metastasis]. / Nodulo solitario necrotico del fegato (N.S.N.F.) simulante una metastasi.

Solitary necrotic nodule of the liver is a uncommon benign lesion reported in old patients. The patients often had previous history of malignant lesions. The clinical aspects of S.N.N.L. suggest a metastatic lesion. The characteristic histological appearances are represented by a necrotic core (eosinophilic) surrounded by a hyalinised fibrotic tissue. We describe a case of S.N.N.L. identified in a 69 old woman previously resected for a colonic carcinoma.

Small liver masses in cirrhotic patients. A pathological clue for the morphogenesis of human hepatocellular carcinoma.

Eleven small primary liver lesions detected in four cirrhotic patients are reported in detail. Some lesions showed the histopathological features of macroregenerative nodules (MRN) containing foci of cellular and structural atypia or of hepatocellular carcinoma (HCC). Other lesions showed the histological abnormalities of the early developmental stage of HCC without a background of MRN. Finally one lesion is described with an equivocal background between benign and malignant, containing a focus of carcinoma. All lesions presented suggest the presence of different pathways in the morphogenesis of human HCC.