A unique presentation of a renal clear cell carcinoma with atypical metastases.

INTRODUCTION: Renal cancer is a relatively common neoplasia with renal clear cell carcinoma being the most frequent histological type. This tumor has a strong tendency to metastasize virtually to all organs. Today, new diagnostic tools allow physicians to distinguish between those patients with "incidental findings" and those with advanced metastatic disease. PRESENTATION OF CASE: A 70-year-old male with multiple indolent subcutaneous masses underwent colonoscopy after a positive fecal screening test for colorectal carcinoma. A rectal lesion was discovered but biopsy was negative. CT scan revealed advanced renal cancer involving the peritoneal cavity, retroperitoneum and lung. Biopsy of subcutaneous masses confirmed the suspected metastases. The patient underwent surgery (an open left nephrectomy with rectosigmoid resection and metastases debulking) because of a high risk of bowel obstruction and increasing anemia. After three years of multi-targeted therapy and follow-up, the patient is still asymptomatic and in good general condition. DISCUSSION: Treatment of metastatic renal cancer is still controversial even if more than 30% of patients have metastasis at the time of diagnosis. Recently introduced targeted therapies are encouraging but still present problems with side effects and an unlimited period of efficacy. Although there is no consensus, several studies and guidelines consider metastasectomy to be a valid option. CONCLUSION: Recent series highlight surgery as a key-point in the management of advanced renal clear cell carcinoma. Our case demonstrates the validity of a surgical strategy supported by a multidisciplinary approach.

Organ sharing in the management of acute liver failure.

BACKGROUND: Liver transplantation (OLT) for acute liver failure (ALF) is associated with high morbidity and mortality rates in the early posttransplant course. An efficient organ-sharing organization may grant favorable results. METHODS: This is a retrospective analysis of prospectively collected data on patients wait listed for ALF at a single center. Patients were listed for OLT when matching King's College Criteria. Based on patients' clinical status, ABO-incompatible grafts were used. RESULTS: From January 2001 to December 2010, 37 patients were wait listed for ALF. Two patients were de-listed (5.4%) for improvement of their clinical conditions; two patients (5.4%) died on the list and 33 (89.2%) underwent OLT. Among these latter, 21 (63.6%) were Italian and 12 (36.4%) were foreign citizens, with four referred from their home country on the basis of international agreements on ALF management. Donors were procured in our region in 10 cases (30.3%), nationally in 22 (66.6%), and outside Italy in 1 (3.1%). Mean time from wait listing to OLT was 1 day (range 0-6), and seven patients received an ABO-incompatible graft. Graft and patient survivals at 1 month, 1 year, and 3 years were 78.8%, 72.7%, 66.5%, and 81.8%, 75.8%, and 72.7%, respectively. Five patients underwent retransplantation: two on postoperative day (POD) 2 for primary nonfunction of the liver graft, two on POD 8 and 95 for hepatic artery thrombosis, and one at 18 months for nonanastomotic biliary stenosis. CONCLUSIONS: Prompt referral to a OLT center and efficient organ-sharing system play a fundamental role in optimizing the outcome of the patient with ALF. Development of international organ exchange programs might further improve the results for this category of patients. In very selected cases, ABO-incompatible grafts may be a valuable resource.

Raw milk for sale in Pisa province: biosecurity of dairy farms and hygienic evaluation of milk.

Selling raw milk by automatic dispenser on the farm is a good way to increase income. The aim of the present research is to evaluate both the biosecurity of dairy farms in the Pisa province and the hygienic quality of raw milk. Two farms, chosen because of previously analyzed results carried out on animals and milk, were monitored for 9 months according to the regional law DGR 381/2007. The results obtained showed that these farms presented good cattle health status. The raw milk tested was of a satisfactory hygienic quality, with great variability among milk samples in certain parameters, such as somatic cell count. This study confirmed the importance of consistent, ongoing control of safety conditions on dairy farms.

Changes in Cytokine levels related to the Immunopathogenesis of Helicobacter pylori disease. Immunological and histological effects of triple treatment (omeprazol, azytromycin, and amoxycillin)

Las enfermedades gastroduodenales causadas por H. pylori son consecuencia de una inapropiada respuesta inmunitaria del huésped. Los objetivos del presente estudio han sido evaluar: 1) niveles séricos de citocinas en pacientes infectados o no con H. pylori y la relación de los primeros con la inmunopatogénesis de las lesiones en la mucosa gástrica y duodenal causada por este agente; 2) cambios en los niveles de citocinas posteriores al tratamiento y relacionados con algunas alteraciones histológicas.Se estudiaron 40 pacientes ambulatorios (edad media 68.7 años; 59-80 años),de ambos sexos, con diagnóstico clínico y endoscópico de úlcera gástrica,úlcera duodenal y gastritis erosiva y/o lesiones duodenales. Se diagnosticó H. pylori en muestras de tejido gástricas y duodenales por el Test de la Ureasa rápido, exámenes histológicos y cultivo de tejido. La sensibilidad antibiótica se determinó por la Técnica Elipsométrica, para evaluar la concentración inhibitoria mínima (CIM) en g.ml–1 de azytromycina y amoxycilina. Se evaluaron los niveles séricos de IL-2, IL-4, IL-10, IFN-γ y TGF-β antes y después del tratamiento. Los pacientes con diagnóstico confirmado de infección por H. pylori fueron tratados con omeprazol, amoxycilinay azitromycina. Aquellos no infectados con H. pylori sólo recibieron omeprazol.Se detectó una diferencia significativa en los niveles de todas las citocinas entre los pacientes H. pylori (+) y H. pylori (-) (p<0.01). Se determinaronniveles significativamente menores de IL-2 (p<0.05) e IFN-γ ymayores de IL-4, IL-10 y TGFβ en pacientes H.pylori (+) comparados conlos de pacientes H. pylori (-)(p<0.01). También las diferencias fueron significativas entre las determinaciones pre y post tratamiento de los pacientes H.pylori (+) (p<0.01). La eficacia del tratamiento empleado se evidenció tanto por los valores de las citocinas evaluadas así como en la reversión las alteraciones histológicos observadas antes de la terapia (AU)

Gastroduodenal diseases caused by Helicobacter pylori are a consequence of an inappropriate host's immune response This study aims to evaluate: 1) cytokine serum levels in H. pylori infected patients and its relationship with the immunopathogenesis of the gastric and duodenalmucosa lesions caused by this agent; 2) the immunological changes that could be detected after treatment and linked to some histological alterations Forty ambulatory patients (mean age 68.7 years; 59-80 years), both sexes with clinical and endoscopical diagnosis of gastric ulcer, duodenalulcer or erosive gastric and/or duodenal lesions, were studied. H. pyloriwas diagnosed in gastric and duodenal tissue samples by urease rapidtest, histological examination and tissue culture. Antibiotic sensitivitytests by the ellipsometric technique was performed to determine the minimalinhibitory concentration (MIC) in g.ml–1 of azytromycin, and amoxycillin.The serum levels of IL-2, IL-4, IL-10, IFN-γ and TGF-β were assessed before and after treatment. Patients with confirmed diagnosis of H.pylori infection were treated with omeprazol, amoxycillin and azitromycin.H. pylori non infected patients only received omeprazol. A significant difference was detected in cytokine levels between H. pylori (+) (n=24)and H. pylori (-) (n=16) patients (p<0.01) In H. pylori (+) patients IL-2(p<0.05) and IFNγ levels were lower and IL-4, IL-10 and TGF-β were higher when compared with H. pylori (-) subjects (p<0.01). Pre and post treatment assessments were also significantly different (p<0.01). The employed treatment efficiency was expressed not only on cytokine values but also on the reversion of the histological c (AU)

Changes in Cytokine levels related to the Immunopathogenesis of Helicobacter pylori disease. Immunological and histological effects of triple treatment (omeprazol, azytromycin, and amoxycillin)

Las enfermedades gastroduodenales causadas por H. pylori son consecuenciade una inapropiada respuesta inmunitaria del huésped. Los objetivosdel presente estudio han sido evaluar: 1) niveles séricos de citocinasen pacientes infectados o no con H. pylori y la relación de los primeroscon la inmunopatogénesis de las lesiones en la mucosa gástrica y duodenalcausada por este agente; 2) cambios en los niveles de citocinas posterioresal tratamiento y relacionados con algunas alteraciones histológicas.Se estudiaron 40 pacientes ambulatorios (edad media 68.7 años; 59-80 años),de ambos sexos, con diagnóstico clínico y endoscópico de úlcera gástrica,úlcera duodenal y gastritis erosiva y/o lesiones duodenales. Se diagnosticóH. pylori en muestras de tejido gástricas y duodenales por el Test de laUreasa rápido, exámenes histológicos y cultivo de tejido. La sensibilidadantibiótica se determinó por la Técnica Elipsométrica, para evaluar la concentracióninhibitoria mínima (CIM) en g.ml–1 de azytromycina y amoxycilina.Se evaluaron los niveles séricos de IL-2, IL-4, IL-10, IFN-γ y TGF-βantes y después del tratamiento. Los pacientes con diagnóstico confirmadode infección por H. pylori fueron tratados con omeprazol, amoxycilinay azitromycina. Aquellos no infectados con H. pylori sólo recibieron omeprazol.Se detectó una diferencia significativa en los niveles de todas lascitocinas entre los pacientes H. pylori (+) y H. pylori (-) (p<0.01). Se determinaronniveles significativamente menores de IL-2 (p<0.05) e IFN-γ ymayores de IL-4, IL-10 y TGFβ en pacientes H.pylori (+) comparados conlos de pacientes H. pylori (-)(p<0.01). También las diferencias fueron significativasentre las determinaciones pre y post tratamiento de los pacientesH.pylori (+) (p<0.01). La eficacia del tratamiento empleado se evidenciótanto por los valores de las citocinas evaluadas así como en la reversión lasalteraciones histológicos observadas antes de la terapia

Gastroduodenal diseases caused by Helicobacter pylori are a consequenceof an inappropriate host's immune response This study aims toevaluate: 1) cytokine serum levels in H. pylori infected patients and itsrelationship with the immunopathogenesis of the gastric and duodenalmucosa lesions caused by this agent; 2) the immunological changes thatcould be detected after treatment and linked to some histological alterationsForty ambulatory patients (mean age 68.7 years; 59-80 years), bothsexes with clinical and endoscopical diagnosis of gastric ulcer, duodenalulcer or erosive gastric and/or duodenal lesions, were studied. H. pyloriwas diagnosed in gastric and duodenal tissue samples by urease rapidtest, histological examination and tissue culture. Antibiotic sensitivitytests by the ellipsometric technique was performed to determine the minimalinhibitory concentration (MIC) in g.ml–1 of azytromycin, and amoxycillin.The serum levels of IL-2, IL-4, IL-10, IFN-γ and TGF-β were assessedbefore and after treatment. Patients with confirmed diagnosis of H.pylori infection were treated with omeprazol, amoxycillin and azitromycin.H. pylori non infected patients only received omeprazol. A significantdifference was detected in cytokine levels between H. pylori (+) (n=24)and H. pylori (-) (n=16) patients (p<0.01) In H. pylori (+) patients IL-2(p<0.05) and IFNγ levels were lower and IL-4, IL-10 and TGF-β were higherwhen compared with H. pylori (-) subjects (p<0.01). Pre and post treatmentassessments were also significantly different (p<0.01). The employedtreatment efficiency was expressed not only on cytokine values butalso on the reversion of the histological changes

Influence of disease severity on nitrite and cytokine production by peripheral blood mononuclear cells (PBMC) from patients with pulmonary tuberculosis (TB).

Earlier studies in patients with pulmonary TB have revealed a higher production of Th1 cell type cytokines in moderate TB, with predominant Th2-like responses in advanced disease. Given the influence of IL-12 in T cell differentiation, as well as the roles of transforming growth factor-beta (TGF-beta), nitric oxide and tumour necrosis factor-alpha (TNF-alpha) in the immune response against intracellular pathogens, we decided to analyse the interferon-gamma (IFN-gamma), IL-4, IL-12, TGF-beta, TNF-alpha and nitrite concentrations in culture supernatants of PBMC from TB patients showing different degrees of lung involvement. The sample population comprised 18 untreated TB patients with either moderate (n = 9) or advanced (n = 9) disease and 12 age- and sex-matched healthy controls (total population (patients and controls) 12 women, 18 men, aged 37 +/- 13 years (mean +/- s.d.)). PBMC were stimulated with whole sonicate from Mycobacterium tuberculosis and the supernatants were collected on day 4 for measurement of cytokine and nitrite levels. Antigen-stimulated IFN-gamma, TGF-beta and TNF-alpha production was found to be significantly increased in TB patients, both moderate and advanced, compared with the controls. Levels of IFN-gamma were significantly higher in moderate disease than advanced cases, whereas advanced cases showed significantly higher IL-12, TGF-beta and TNF-alpha concentrations when compared with cases of moderate TB. Nitrite levels were also increased in TB patients and the increase was statistically significant when advanced cases were compared with controls. These findings may contribute to a clearer picture of the net effect of cytokine interactions in TB, essential for a better understanding of the immunopathological mechanisms underlying the distinct clinical forms of the disease.

[Hürthle-cell thyroid neoplasms: a clinical enigma]. / Le neoplasie tiroidee a cellule di Hürthle: un enigma clinico.

Hürthle cell neoplasms represent a pathological entity whose diagnosis and therapy are still not defined. These neoplasms constitute from 1.5% to 10% of all thyroid tumors. Hürthle cell nodule is clinically indistinguishable from other nodular thyroid diseases and histologic features of the tumors do not always allow us to distinguish benign nodules from malignant ones. The authors, analyzing a segment of their own experience (335 surgical thyroid diseases), observed nine cases of Hürthle cell adenomas (0.03%). Because of concomitant presence of heterolobar thyroid disease, seven cases were treated with a total thyroidectomy, and two cases were treated with a lobo-isthmectomy. In a long-term follow-up study, there were not signs of Hürthle cells neoplastic disease. The authors suggest that the treatment of choice for patients with "surely benign" Hürthle cell nodule is lobo-isthmectomy. For malignant Hürthle cell tumors, total thyroidectomy is the most rational treatment associated with cervical lymphadenectomy in presence of metastatic nodes. In all cases, a long-term periodical check-up proves to be the best solution, also for patients treated for benign pathological Hürthle cell.

Myocardial infarction caused by compression of anomalous circumflex coronary artery after mitral valve replacement.

We report a case of myocardial infarction after mitral valve replacement occurring in a patient with the left cyrcumflex coronary artery arising from the right one. The patient underwent mitral valve replacement with a size 27 Carbomedics prosthesis and a tricuspidal annuloplasty was performed according to the De Vega technique. Patient died on the 20th postoperative day.

[Anaplastic carcinoma of the thyroid: long-term survival]. / Il carcinoma anaplastico della tiroide: sopravvivenza a distanza.

Anaplastic carcinoma of the thyroid is a highly aggressive neoplasm with quickly total course. It is characterized by an average survival of 4-12 months. It infiltrates precociously into the windpipe, oesophagus, vessels of the neck and gives distant metastases in 10-48% of cases. In 30.8 to 80% of cases, this carcinoma originates in an old multinodular goiter. The hypothesis has been also advanced that this neoplasm could derive from a pre-existent well-differentiated carcinoma. The improvement in diagnostic techniques (especially immunohistochemistry) allows a more correct definition of this neoplasm, permitting a differential diagnosis with other tumours (lymphoma, medullary carcinoma, hemangioblastoma) with which in the past it has been erroneously identified. The results reported in the literature are controversial as regards long-term survival, but usually it is less than one year. Longer survival must lead to the suspicion of wrong diagnosis. A relatively better prognosis is observable in intraglandular forms, "minimi" neoplastic focus and young patients. The presence of regional metastatic lymph nodes doesn't seem to modify the prognosis. Instead, a factor which can condition the prognosis is the type of therapy. Now a days the most efficacious curative treatment is the multinodal one (surgery, radio- and chemotherapy). The best results about survival and quality of life have been obtained using chemo-radiotherapy before operation and chemotherapy after it.

Inmunocomplejos en la psoriasis / Immunocomplexes in psoriasis

Se estudió el suero de 80 enfermos con psoriasis, de diversas formas clínicas (60 en placas, 13 en gotas y 7 atropáticas). Para ello se aplicó la técnica de microconsumo de complemento, que permitió identificar a los inmunocomplejos que contenían IgG. Los resultados obtenidos demostraron un 56,25% de positividad estadísticamente significativa, poniendo en evidencia su participación en la patogenia de esta enfermedad. Los inmunocomplejos hallados, no guardan relación con la evolución clínica de la enfermedad (AU)

Inmunocomplejos en la psoriasis / Immunocomplexes in psoriasis

Se estudió el suero de 80 enfermos con psoriasis, de diversas formas clínicas (60 en placas, 13 en gotas y 7 atropáticas). Para ello se aplicó la técnica de microconsumo de complemento, que permitió identificar a los inmunocomplejos que contenían IgG. Los resultados obtenidos demostraron un 56,25% de positividad estadísticamente significativa, poniendo en evidencia su participación en la patogenia de esta enfermedad. Los inmunocomplejos hallados, no guardan relación con la evolución clínica de la enfermedad

Evaluation of circulating immune complexes in cutaneous diseases associated with immune disorders.

Several skin diseases associated with immune disorders may be related to the formation of circulating immune complexes (CIC) and their skin deposition. Sera from 20 controls and 108 patients, including: 23 psoriasis, 10 lichen planus, 30 atopic eczemas, 32 cases of leprosy, 10 vasculitis and 3 pyoderma gangrenosum were evaluated for the presence of IgG-containing CIC by the microconsumption complement test (MCT). Additionally, the presence of IgE-containing CIC by means of a polyethylene glycol precipitation and radioimmunoassay technique was evaluated in 10 patients with atopic eczema. It was found that 56.5% of psoriatic patients show moderate CIC concentrations, as well as 34% of leprosy patients, with increased levels when bacillus were detected in skin lesions, and in 90% of leukocytoclastic vasculitis. A close relationship between CIC levels and the clinical evolution of skin lesions was demonstrated in patients with pyoderma gangrenosum and lichen planus. IgG-CIC were detected in 33% and IgE-CIC in 30% of patients with atopic eczema, with the presence of both types of CIC in 2 out of 3 cases. The systematic research on CIC presence in some selected skin diseases shows that immune complexes take part, with different degrees of relevance, in the pathogenesis of all the entities.