Leiomyosarcoma of the rectum: A systematic review of recent literature.

Leiomyosarcomas (LMSs) are rare tumors originating from the muscular layer. We performed a literature review of cases of confirmed rectal leiomyosarcomas (rLMSs) to clarify the history of such an infrequent tumor arising at such an uncommon location. In this research local recurrence was related to poorly differentiated rLMS and no other association between recurrence and any criteria was found. Concerning overall survival (OS), rLMS patients developing recurrence presented shorter longevity compared with the group without.

Mitochondria Transplantation Mitigates Damage in an In Vitro Model of Renal Tubular Injury and in an Ex Vivo Model of DCD Renal Transplantation.

OBJECTIVES: To test whether mitochondrial transplantation (MITO) mitigates damage in 2 models of acute kidney injury (AKI). BACKGROUND: MITO is a process where exogenous isolated mitochondria are taken up by cells. As virtually any morbid clinical condition is characterized by mitochondrial distress, MITO may find a role as a treatment modality in numerous clinical scenarios including AKI. METHODS: For the in vitro experiments, human proximal tubular cells were damaged and then treated with mitochondria or placebo. For the ex vivo experiments, we developed a non-survival ex vivo porcine model mimicking the donation after cardiac death renal transplantation scenario. One kidney was treated with mitochondria, although the mate organ received placebo, before being perfused at room temperature for 24 hours. Perfusate samples were collected at different time points and analyzed with Raman spectroscopy. Biopsies taken at baseline and 24 hours were analyzed with standard pathology, immunohistochemistry, and RNA sequencing analysis. RESULTS: In vitro, cells treated with MITO showed higher proliferative capacity and adenosine 5'-triphosphate production, preservation of physiological polarization of the organelles and lower toxicity and reactive oxygen species production. Ex vivo, kidneys treated with MITO shed fewer molecular species, indicating stability. In these kidneys, pathology showed less damage whereas RNAseq analysis showed modulation of genes and pathways most consistent with mitochondrial biogenesis and energy metabolism and downregulation of genes involved in neutrophil recruitment, including IL1A, CXCL8, and PIK3R1. CONCLUSIONS: MITO mitigates AKI both in vitro and ex vivo.

Local excision of T1 colorectal cancer: good differentiation, absence of lymphovascular invasion, and limited tumor radial infiltration (≤4.25 mm) may allow avoiding radical surgery.

BACKGROUND: Early colorectal cancer (ECC) is defined as T1NXM0 colorectal cancer (CRC). Although a non-negligible number of T1-CRCs presents metastatic lymph-nodes, local excision is increasingly proposed as alternative to radical resection. Several criteria have been suggested to identify low-risk T1-CRC, but recommendations on this topic are still heterogeneous. This study aims to identify criteria associated with N+ T1-CRC, to select patients to undergo (or not) local excision. METHODS: A retrospective analysis of demographic, clinical, and histology criteria of 122 consecutive T1-CRC patients undergoing radical resection at Parma University Hospital between 2000 and 2018 has been performed. RESULTS: Lymph-node metastasis (LNM) was observed in 15/122 patients (12.3%). No LNM was observed among well-differentiated (G1) tumors (0/37), while 10/65 (15.4%) G2 cases as well as 5/20 (25%) G3 patients presented LNM. G1 was associated with absence of LNM (p = 0.013). After excluding G1 patients, the rate of N + T1-CRC was 17.6% (15/85). LNM was observed in 4/8 (50%) patients with lymphovascular invasion (LVI) and in 11/77 (14.2%) without LVI. LVI resulted being associated with LNM (p < 0.042). LNM was reported in 28.3% of cases with a tumor infiltration >4.25 mm (13/46), compared to 5.1% in cases with an infiltration ≤4.25 mm (2/39) (p = 0.012). In Cox regression analysis, the higher hazard ratio (HR) was reported for the LVI + and infiltration >4.25 mm (HR 24.849). CONCLUSIONS: In patients with ECC (pT1NXM0), good differentiation (G1), absence of lymphovascular invasion (LVI-), and tumor radial infiltration ≤4.25 mm may allow performing local resection and avoiding radical surgery.

Open Technique.

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Open surgical cholecystostomy under local anaesthesia as salvage therapy of acute cholecystitis during the 4th COVID-19 wave in Northern Italy: experience from a rural hospital.

The COVID-19 pandemic outbreak delayed interventions of elective surgery worldwide. In Italy, the first western country to be affected, 410000 operations formerly planned were cancelled with the beginning of the first wave. Symptomatic cholelithiasis represents one of the most common, benign medical conditions in the world leading the affected patients to general surgeons'attention; in 0.5% of cases gallstones (symptomatic or not) can complicate with acute lithiasic cholecystitis (ALC) whose universally acknowledged treatment of choice is laparoscopic cholecystectomy. Delaying in surgery of ALC can increase the rate of complications like severe ALC, acute cholangitis and sepsis. The 4th wave of COVID 19 in Northern Italy induced further stress on the healthcare system. In fact, the occurrence of difficult communication and delays in ALC patients transfer between first and second level hospitals lead to the re-emergence of obsolete surgical procedures. In our rural hospital, in fact, a 92 years old patient affected with ALC and several comorbidities was treated with a successful emergency surgical procedure of transperitoneal cholecistostomy in lieu of a radiological transperitoneal approach. Such a choice was dictated by the absence of an interventional radiology unit in our hospital as well as the unavailability of patient transfer to our central referral hub (the hospital of Parma) due to hospital overcrowding secondary to the 4th wave of COVID 19 pandemic.

Tonsillectomy as Prevention of Tonsil and Base of Tongue Cancer: Systematic Review and Meta-analysis on the Immuno-Oncological Effect of One Among the Most Common Surgeries in the World.

Otorhinolaryngology tradition is that tonsillectomy (TE) is conducted among children and adolescents for obstructive sleep apnea secondary to adenotonsillar hypertrophy and in adults for chronic disease of the tonsils and adenoids (recurrent tonsillitis). Nevertheless, over the last 50 years, we have observed a decline in TE worldwide. As a result, there is an emerging concern of a correlated possible increased risk of tonsil cancer (TC) and other subtypes of oropharyngeal squamous cell carcinoma. Since the available data on such topics are limited and controversial, our aim was to elucidate the impact of TE on the incidence mainly of TC through a systematic review of the literature and a meta-analysis of the studies. After a thorough search, 7 retrospective studies were considered eligible for review and meta-analysis (MA). At MA, patients with a history of TE seem to show a reduced risk of TC but a higher predisposition for base of tongue (BOT) cancer (p<0.001): however, the elevated heterogeneity of the studies hampers drawing firm and convincing conclusions (statistical inconsistency >95%). In future, randomized control trials will be welcome to elucidate the prophylactic role of TE against TC and its real impact on BOT cancer.

The double challenge (preoperative diagnosis and surgical approach) of primary leiomyosarcoma of the sigmoid colon.

BACKGROUND AND AIM: Primary colonic leiomyosarcoma (cLMS) is a rare malignancy of muscularis mucosae or muscularis propria showing highly aggressive behaviour and poor prognosis. To date, making a preoperative diagnosis and performing the most appropriate treatment represent laborious tasks for the clinicians. On the one hand, in fact, cLMS diagnosis is often difficult to achieve preoperatively because of the low specificity of clinical, radiological and bioptical features: for these motives, the diagnosis is usually obtained at postoperative histology/immune-histochemistry. On the other hand, although surgery represents the mainstay of multi-modal treatment, in the current era of minimally invasive surgery the optimal approach to cLMS is debated: in the absence of a standardized and unanimous algorithm, in fact, laparoscopy is usually proposed for small tumors, whereas laparotomy for masses exceeding 4 cm in diameter. Our aim was to elucidate such two aspects by reporting our experience. METHODS: We present the case of a 51-year-old man affected with a 6-cm LMS of the sigmoid colon. RESULTS: Preoperative diagnosis was achieved through a preoperative echo-endoscopic biopsy. The lesion was successfully and safely managed by laparoscopic surgery. CONCLUSIONS: Our case suggests that a preoperative diagnosis of cLMS is possible in an appropriate setting. Moreover, laparoscopy seems to be a safe and successful approach to resect cancers even larger than the common 4 centimetres proposed by the current literature.

Hypothermic Machine Perfusion and Spontaneous Kidney Allograft Rupture: Causation or Correlation? A Case Report and Review of Pertinent Literature.

BACKGROUND: Spontaneous kidney allograft rupture (KAR) is a severe complication of kidney transplant. KAR occurs when no identifiable injuries noted at the time of the organ retrieval are present. KAR is associated with acute rejection, renal vein thrombosis, severe acute tubular necrosis, or trauma. In recent years, the introduction of hypothermic machine perfusion (HMP) has provided an excellent option for kidney allograft preservation reducing the incidence of delayed graft function. On the other hand, HMP can also represent a potentially traumatic event for a fragile graft, especially one belonging to expanded criteria donor. CASE PRESENTATION: Here, to our knowledge, we report the first case of KAR after the use of HMP, which occurred in 60-year-old women undergoing a single kidney transplant from a donation after brain death donor belonging to the expanded criteria donor category. The allograft was perfused for 240 minutes with HMP with passive oxygenation. The post-transplant course was unremarkable with early graft function, but on post operatory day 14 the patient complained of severe pain over the transplant site. A computed tomography scan showed a massive fluid collection in the perigraft region. Immediate surgical exploration showed 2 lacerations of 10 cm and 5 cm length at the upper and midpole of the kidney, requiring transplantectomy. Histologically, the graft did not show features of acute rejection. CONCLUSIONS: In the presented case, the repair and salvage of the kidney allograft was not possible. However, the review of the pertinent literature does not report another case linking HMP to KAR.

Amyand's hernia: which oncologic risk can be hidden in the sac?

Amyand's hernia (AH) is a rare condition in which the appendix is found in the sac of an inguinal hernia. It occurs in only 1% of adult inguinal hernias. The herniated appendix can occasionally range varying degrees of acute inflammation up to neoplastic transformation. An appendiceal tumor can be rarely described inside the AH sac. We describe a case of gangrenous appendicitis in AH and offer a review of the literature on AH when presenting with appendicitis associated with appendiceal cancer. As of 2022, only nine cases of AH presenting with appendicitis associated with appendiceal cancer have been reported by the pertinent literature. In order of decreasing frequency, AH, AH-related appendicitis and AH-related appendicitis associated with appendiceal cancer are three rare conditions. Particular attention should be kept in each situation as diagnosis is achieved postoperatively most of the times.

Intussusception of the bowel in adult women due to bulky inflammatory fibroid polyp treated in emergency. A case report.

Introduction: Intussusception represents a rare form of bowel obstruction in the adult, which is defined as the telescoping of a proximal segment of the gastrointestinal tract into the lumen of the adjacent distal segment of the GI tract Case Report: We report the case of a 50-year-old woman was admitted in our hospital with acute bowel obstruction. CT showed intestinal occlusion secondary to intussusception. the patient underwent emergency surgery. Surgery confirmed intussusception at the level of the distal ileum (about 30 cm from the ileocecal valve) due to a 3-4 oval mass of hard consistency that appeared to be suspicious for GIST. Was performed a resection of the ileal segment involved associated with oncologically radical lymphadenectomy. The histological examination reported benign ileal mesenchymal neoformation compatible with inflammatory fibroid polyp. Patient had a regular course Discussion: In adults, 90% of invaginations manifest as a result of an organic lesion caused by benign or malignant tumors. The clinical presentation in adults is generally chronic or nonspecific. The emergence of acute symptoms due to complete intestinal obstruction occours in fewer than 20% of patients. Abdominal computed tomography (CT) is the most sensitive radiologic method to confirm intussusception. As many cases are secondary to organic pathologies with malignant potential, surgical resection of the affected bowel segment with oncological procedures is the primary method of treatment Conclusion: Due to the fact that adult intussusception is often frequently associated with organic lesions, surgical intervention is necessary. Treatment usually requires formal resection of the involved bowel segment. (www.actabiomedica.it).

Omental torsion at the time of COVID-19 in Northern Italy: a case report of conservative management with a review of the pertinent literature.

BACKGROUND AND AIM: In middle-aged men, omental torsion (OT) can be a cause of acute abdomen.The right side of the omentum is longer, heavier and more mobile than the left one and, as a consequence, it can twist more easily on its vascular axis. Consequently, OT localization in the lower right quadrant is more frequent, and therefore it can mimic acute appendicitis clinical onset.In most cases, OT is defined as "primary" in the absence of any other underlying pathologies, or,  rarely, "secondary", when caused by other intra-abdominal diseases such as inguinal hernia, tumors, cysts or post-surgical scarring. To date, clinical diagnosis of OT still remains a challenging one in a preoperative setting and most cases are diagnosed intraoperatively. If diagnosis is correctly achieved preoperatively by adequate imaging examinations, most patients presenting with OT do not undergo surgery anymore. Such considerations gain importance at the time of COVID 19 pandemic, where a conservative management and an early discharge may be preferred owing to in-hospital morbidity after abdominal surgery whenever surgery may be avoided. METHODS AND RESULTS: We present a case of an OT successfully treated in a non-operative manner during COVID-19 outbreak in Norhern Italy and offer a review of the literature that supports such a clinical attitude.  Conclusions:  OT preoperative diagnosis is challenging and is usually achieved by abdominal CT-scan. The suggested OT initial management is conservative, leaving a surgical approach, preferably by laparoscopy, for the 15% of cases not improving with a non-surgical approach.

Exosomal Functional Cargoes from Liquid Biopsy of Gastric Cancer: A Systematic Review of Studies With Potential Clinical Relevance.

BACKGROUND/AIM: Liquid biopsy (LB) is a promising non-invasive tool to detect cancer. Over the last few years, exosomes recruited from LB have attracted the attention of researchers for their involvement in cancer. We focused on the role of LB exosomes in gastric cancer (GC). MATERIALS AND METHODS: We investigated the world literature on exosome-encapsulated functional biomarkers (non-coding RNAs and DNAs) taken from GC patients' LBs. Only the studies exploring serum, intraperitoneal fluid or gastric lavage were included. RESULTS: As of 2022, fifty articles with an overall count of 3552 GC patients were investigated. Given the statistically significant associations with the clinicopathological categories of tumor depth, lymph node metastasis, staging class and tumor size, most exosome-mediated microRNAs, long non-coding RNAs and circular RNAs proved to exert a potentially important bioclinical role in terms of diagnosis, screening, prognosis and therapeutic targets. CONCLUSION: In the future, resorting to exosomal biomarkers taken from LB of affected patients could revolutionize the non-invasive fight against GC.

Regenerative medicine technologies applied to transplant medicine. An update.

Regenerative medicine (RM) is changing how we think and practice transplant medicine. In regenerative medicine, the aim is to develop and employ methods to regenerate, restore or replace damaged/diseased tissues or organs. Regenerative medicine investigates using tools such as novel technologies or techniques, extracellular vesicles, cell-based therapies, and tissue-engineered constructs to design effective patient-specific treatments. This review illustrates current advancements in regenerative medicine that may pertain to transplant medicine. We highlight progress made and various tools designed and employed specifically for each tissue or organ, such as the kidney, heart, liver, lung, vasculature, gastrointestinal tract, and pancreas. By combing both fields of transplant and regenerative medicine, we can harbor a successful collaboration that would be beneficial and efficacious for the repair and design of de novo engineered whole organs for transplantations.

Transplant Renal Artery Stenosis: A Case Report of Functional Recovery Six Months After Angioplasty.

Transplant renal artery stenosis (TRAS) is a common vascular complication after kidney transplantation, leading to worsening or refractory hypertension, deterioration in renal function, and possible cause of graft loss. Early diagnosis and an appropriate treatment are crucial for organ preservation. Endovascular treatment, including percutaneous transluminal angioplasty and stent implantation, is considered the first-line therapy for TRAS. Here we report the case of a 69-year-old woman with end-stage renal disease for chronic kidney disease not biopsy proven, who underwent a kidney transplant from expanded criteria donors on December 2018. Postoperative course was characterized by delayed graft function. Doppler ultrasonography (US) showed an increase of peak systolic velocity at the origin of the renal artery, and parvus-tardus waveform in periferic graft arteries and an abdominal computed tomography scan confirmed a stenosis at the origin of the main renal artery (TRAS). The patient underwent a percutaneous transluminal angioplasty. It was not possible to place a stent at the particular location of the stenosis at the anastomosis. Despite the improvement of the graft's perfusion, monitored with Doppler US, the patient showed a very poor improvement in renal function and remained on hemodialysis for months. A percutaneous needle biopsy reported a normal renal parenchyma and excluded acute rejection. During this period, the patient received immunosuppressive therapy. About 6 months after the transplant, the patient had an unexpected and slow renal function recovery until she was weaned completely from hemodialysis.

Laparoscopic Partial Splenectomy: A Critical Appraisal of an Emerging Technique. A Review of the First 457 Published Cases.

Background: Laparoscopic partial splenectomy (LPS) may allow avoiding total splenectomy (TS) complications and maximizing the advantages of mini-invasive approach. The objective of this review is to assess feasibility and safety of LPS, to compare this approach with alternative options. Materials and Methods: A literature review of articles reporting LPS is performed. Several parameters, including age, indication, surgical technique, devices used for splenic section/hemostasis, adverse outcomes, including morbidity/mortality, conversions to open surgery, conversions to TS, operative time (OT), and hospital stay (HS), are analyzed. Articles comparing LPS' results with those of open partial splenectomy and laparoscopic TS are also analyzed. Results: Fifty-nine articles reporting 457 LPS were included. Patients' characteristics varied widely, concerning age and indications, including hematological disease (hereditary spherocytosis, drepanocytosis), splenic focal masses, and trauma. Several technical options are reported. Mean OT and HS are 128 ± 43.7 minutes and 4.9 ± 3.8 days, respectively. No mortality and 5.7% morbidity are reported. Conversion rates to open surgery and to TS are 3.9% and 3.7%, respectively. Conclusions: In conclusion LPS is feasible and safe, with no mortality, low morbidity, and low conversion rates to laparotomy and to TS. LPS may be accomplished by various techniques and tools. Major complications are sporadically reported, thus potential risks should not be underestimated.

Inguinal GIST: A Systematic Literature Review of Primary and Metastatic Cases.

BACKGROUND/AIM: Gastrointestinal stromal tumor (GIST) has a wide spectrum of clinical manifestations. Involvement of the groin region can cause interesting presentations but, as of 2020, has rarely been investigated. Our aim was to assess the clinicopathological and prognostic features of GIST appearing in this specific part of the body. MATERIALS AND METHODS: We investigated the world literature dealing with primary or metastatic GIST appearing in the inguinal region (IGIST). A case of metastatic IGIST from our clinical records was also included. RESULTS: We found only six cases of primary and nine of metastatic IGIST. All were of male gender, and most aged 60 years or more (10 cases). Inguinal hernia (11 cases) was the patient type most frequently affected. The association between metastatic IGIST and inguinal lymphadenopathy was statistically significant (p=0.049). CONCLUSION: IGIST is a rare entity with particular clinical manifestations. Inguinal hernia and inguinal lymphadenopathy should be carefully investigated in patients with a history of GIST.

MRI and correlation between TNM and CEA, CA19.9, AFP in rectal cancer Experience of a single academic surgical center.

In our study we examined 75 patients treated for rectal cancer in the period between 01/01/2011 and 31/12/2014. Out of these 75 patients, we considered those 36 staged through MRI. We then compared the TNM stage obtained through MRI with the one emerged from histological examination. The correlation between the two TNM stages was assessed considering all patients staged through MRI and dividing the cases according to the submission or not to a neoadjuvant treatment. Finally, we analyzed serum levels of tumor markers CEA, CA 19.9 and AFP, relating them with the final disease stage. Data analysis showed a statistically significant correlation in the T stages, especially in the population not subjected to neoadjuvant treatment. Instead, for N, we found no statistically significant correlation. Similarly, none of the tumor markers presented a statistically significant correlation with disease stage. However, according to the positivity of tumor markers, we associated the following score: 0, (no positive marker)1 (only one marker positive) 2 (two markers positive) 3 (three markers positive). In presence of three markers positive, meaning the highest score, we found a statistically significant correlation with N + staging of the disease, obtained by postoperative pathologic examination. The conclusion is that MRI is certainly effective in T stage evaluation. Probably, for limph node involvement evaluation, more reliable parameters for establishing possible lymph node malignancy need to be found. The role of the tumor markers CEA, CA 19.9, AFP during preoperative evaluation of rectal tumors remains undefined. KEY WORDS: MRI, Rectal cancer, Tumor markes, Tumor regression, T stage.

Early-Isolated V Lesion in Kidney Allograft: Acute Rejection or Ischemic Injury? A Case Report of Primary Nonfunction and Graft Loss.

Intimal arteritis (v-lesion) is a negative prognostic factor for kidney allograft survival. Early isolated v-lesions do not always represent a pathologic marker of acute T cell- or antibody-mediated rejection. In particular, in the case of transplant negative for C4d and donor-specific antibodies, such a finding can suggest an ischemic-reperfusion injury. There is an intense debate in the literature concerning the origin of this histologic feature. In the present study, we analyze how this argument can have a clinical relevance. Here we report a case of a 61-year-old woman with end-stage renal disease due to autosomal dominant polycystic kidney disease. The patient underwent kidney transplant from expanded criteria donor. Organs from expanded criteria donors are more prone to ischemic-reperfusion injury. Postoperative course was characterized by primary nonfunction of the graft. A first biopsy showed early isolated v-lesion in otherwise normal renal parenchymal. Simultaneously, a computed tomography scan revealed stenosis of the main renal artery. An endovascular stent was placed. Despite improved vascularization of the graft, no clinical response was observed and the patient remained anuric. A second biopsy was performed, showing T-cell mediated rejection (Banff Classification 1A). Despite pulse steroid, the patient lost the graft.

Retrospective survival analysis of stage II-III rectal cancer: tumour regression grade, grading and lymphovascular invasion are the only predictors.

BACKGROUND: Tumour regression grade is gaining interest as a prognostic factor of patients undergoing neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer. METHODS: A series of 68 consecutive patients with locally advanced rectal cancer treated by neoadjuvant chemoradiotherapy and surgery between 2010 and 2016 was retrospectively studied. The impact on disease-free survival (DFS) and overall survival (OS) of several criteria was analysed. Univariate analysis was performed through Kaplan-Meier statistics. Multivariate analysis was performed through Cox regression model. Using criteria found to be related to long-term outcomes, a predictive model of patient's OS was calculated. RESULTS: Poor tumour regression grade - TRG3 (P = 0.010), poor grading - G3 (P = 0.001) and lymphovascular invasion (LVI; P = 0.030) were associated with short OS at univariate analysis. OS was associated with TRG3 and G3 at multivariate analysis (P = 0.016 and P = 0.027, respectively). DFS was associated with LVI (P = 0.001), G3 tumours (P = 0.046) and TRG3 (P = 0.045) at univariate analysis. At multivariate analysis, only LVI was associated with DFS (P = 0.041). A score, pondering the impact of three parameters (2 points for TRG3, 2 for G3 and 1 for LVI), was created and resulted to predict patient OS (P = 0.008), ranging from 94.5 months (score = 0-1) to 32 months (score = 3-5). CONCLUSION: TRG3 and G3 were associated with poor OS, and LVI was the most significant predictor of DFS. An easy-to-use score may allow for a more accurate prediction of OS.