Clampless Laparoscopic Tumor Enucleation for Exophytic Masses Greater Than 4 cm: Is Renorrhaphy Necessary?

Objective: To demonstrate the safety of clampless 3D laparoscopic tumor enucleation (cLTE) for exophytic T1b kidney masses, avoiding suture to achieve hemostasis. Methods: Between January 2010 and January 2021, 241 consecutive patients with an exophytic renal tumor underwent sutureless cLTE. Patients with predominantly endophytic growth or tumors 4 mm closer to the collecting system less were excluded. In all cases, an attempt was made to accomplish surgery without suturing kidney parenchyma. Data were obtained from a retrospective review of history and physical examinations, operative and pathology reports, anesthesia records during the hospital stay, and follow-up visits. Results: Among 241 patients who underwent cLTE, 148 had cT1a and 93 had cT1b renal tumor. The median tumor size was 32 mm, and the median R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) score was 6. Renorrhaphy was necessary in 5 cases. The median operative time (OT) was 100 minutes, and the estimated blood loss (EBL) was 150 mL. The median 24-hour decrease in hemoglobin was 1.8 g/dL. The median length of stay was 4 days. Nineteen patients had postoperative complications: 3 cases had Clavien-Dindo (CD) 3a or more, 6 had CD2, and 10 had CD1. Comparing the T1a and T1b groups, except for the median OT and the EBL, no significant differences were observed in all the other variables analyzed. In both groups, renal function was preserved after 1 year from surgery. Conclusion: Our experience showed that sutureless cLTE is safe and feasible for T1b tumors leading to radical oncological outcomes and preserving renal function.

The Role of Intraoperative Ultrasonography Associated with Clampless Technique in Three-Dimensional Retroperitoneoscopic Laparoscopic Enucleation of Completely Endophytic Renal Tumors.

Objectives: To evaluate perioperative and functional outcomes of clampless laparoscopic tumor enucleation for completely endophytic renal tumors with the guide of intraoperative ultrasonography. Methods: We analyzed patients with clinically completely endophytic tumors, renal tumors, who underwent clampless three-dimensional (3D) retroperitoneoscopic laparoscopic tumor enucleation between January 2012 and January 2021. Patients with exophytic tumors were excluded. Intraoperative ultrasonography was used to map out the mass in all surgeries. Results: Overall, 57 patients underwent clampless 3D retroperitoneoscopic laparoscopic tumor enucleation. Mean surgical time was 131 minutes, and mean estimated blood loss was 202 mL. Mean hospital stay was 4.7 days. Major and minor postoperative complications occurred, respectively, in 3 and 10 cases. Only a patient had a positive surgical margin. One-year renal function did not differ from baseline. Conclusion: Our study showed that clampless laparoscopic enucleation guided by laparoscopic ultrasonography ensured satisfactory outcomes for completely intrarenal tumors, with excellent renal function preservation 1 year after surgery.

Survey on COVID-19-related mortality associated with occupational infection during the first phase of the pandemic: A systematic review.

According to the Centre for Disease Control and Prevention in 2020, a cluster of pneumonia cases of unknown etiology caused by the severe acute respiratory syndrome (SARS)-coronavirus 2 was reported in Wuhan, China. The present review examined the literature to reveal the incidence of novel coronavirus-2019 disease (COVID-19) infections, underlying comorbidities, workplace infections and case fatality rates. A review was performed to identify the relevant publications available up to May 15, 2020. Since the early stages of the COVID-19 outbreak, the case fatality rate among healthcare workers (HCWs) has stood at 0.69% worldwide and 0.4% in Italy. Based on the current information, most patients have exhibited good prognoses in terms of after-effects or sequelae and low mortality rate. Patients that became critically ill were primarily in the elderly population or had chronic underlying diseases, including diabetes and hypertension. Among all working sectors, HCWs, since they are front-line caregivers for patients with COVID-19, are considered to be in the high-risk population. Increased age and a number of comorbidity factors have been associated with increased risk of mortality in patients with COVID-19. The most frequent complications of COVID-19 reported that can cause fatality in patients were SARS, cardiac arrest, secondary infections and septic shock, in addition to acute kidney failure and liver failure. Overcoming the COVID-19 pandemic is an ongoing challenge, which poses a threat to global health that requires close surveillance and prompt diagnosis, in coordination with research efforts to understand this pathogen and develop effective countermeasures.

Laparoscopic single port radical prostatectomy in the 2020: Why not? Our experience.

OBJECTIVES: To analyze the feasibility, safety and advantages of Laparo-Endoscopic Single-site Surgery radical prostatectomy (LESS-RP) based on our personal experience. PATIENTS AND METHODS: Details of 520 patients were retrospectively analyzed, from 2009 to 2019. Extraperitoneal approach, with only two accesses (2.5 cm and 5 mm respectively) was used to perform radical prostatectomy. Perioperative characteristics and postoperative oncologic and functional outcomes are reported. RESULTS: The mean age was 66.6 ± 5.6 years. Mean PSA level was 9 ± 3.5 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 116 (22.4%), 275 (52.8%), and 129 (24.8%) respectively. Mean operative time was 156 ± 43 min. Mean estimated blood loss was 214 ± 93 ml. Positive surgical margins (PSMs) were detected in 110 (21.2%) patients. PSM rates in pT2 and pT3 stages were 20.1% and 22.9%, respectively. The overall complication rate was 9.2%, based on the modified Clavien classification. The 12 months continence and potency rates were 90.9% and 49.1%, respectively. The biochemical recurrence rate was 6.8%, at the median follow-up time of 26.7 months (IQR 12-32). CONCLUSIONS: Our analyses show that LESS-RP is a safe procedure, if performed by surgeons with adequate experience and skills. Unlike the classic laparoscopic prostatectomy, this technique allows better aesthetic and psychological results, reduced postoperative pain, and a faster return to normal daily activity with the same functional and oncological results.

Assessment of Comfort Variation among Different Types of Driving Agricultural Tractors: Traditional, Satellite-Assisted and Semi-Automatic.

Over the past years, in the agricultural field, geo-localization has been introduced in order to develop specific farming processes, optimize resources, and reduce environmental pollution. Researchers have found alternative driving methods to traditional ones, such as assisted and semi-automatic driving. The aim of this study was to monitor the musculoskeletal efforts necessary to carry out different kinds of driving. The muscular strain was assessed using surface electromyographic devices, the distribution of the pressure exerted by the operator's body on the seat was observed by using two barometric pads applied on the seat back and on the seat, respectively, while the body movements and postures were analyzed through a Microsoft Kinect Camera 3D acquisition system. Results showed a significantly greater muscular activation during manual and assisted driving conditions. The pressure exerted by the operator on the barometric pads was significantly higher in manual and semi-automatic driving modes than in the assisted one. A remarkable increase in the average swinging speed of examined joints was also detected, as well as the distances run by the joints in semi-automatic driving. From our study, assisted driving seems to be the best driving mode both in terms of joint economy and from the efficiency of agricultural processes.

Laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A combined retroperitoneal and transperitoneal approach.

Renal cell carcinoma with inferior cava thrombus indicates biologically aggressive cancer, so the complete surgical resection remains standard of care with best long-term outcomes. Laparoscopic radical nephrectomy with vena cava thrombectomy represents nowadays a mini-invasive surgical alternative to the classic open nephrectomy. We present the case of a patient with incidental diagnosis of a right renal mass with level II inferior cava thrombus completely managed with both retroperitoneal and transperitoneal approaches. The use of a double access was planned to ensure a safe and complete vascular control. In our opinion, optimal patient selection, extensive laparoscopic experience, and knowledge of both transperitoneal and retroperitoneal approaches are critical elements for the safe application of this technique, although this procedure remains challenging and technically demanding.

Fibulin-3 as biomarker of malignant mesothelioma.

Many malignant diseases are associated with past asbestos exposure; the most lethal and strictly related to previous fiber exposure being malignant mesothelioma (MM). Effective preventive protocols may include sensitive and specific biomarkers. The role of Fb-3 has been recently investigated for MM early detection, but its role is still under debate. After an independent search for scientific literature, nine studies were included for a systematic review. Human Fb-3 levels seem to be able to separate healthy people with previous exposure to asbestiform fibers from MM patients. Fb-3 blood levels can distinguish MM effusions from other malignant and benign effusions. Furthers investigations on more significant groups of patients are desirable to validate and assess the validity of combining Fb-3 with other biomarkers.

Tuberculosis screening among healthcare workers in Sicily, Italy.

Tuberculosis (TB) is a diffuse communicable disease; and healthcare workers (HCWs) are among the at-risk populations for the disease. This study reports the result of TB surveillance in HCWs operating in three hospitals: one classified as 'low' risk for TB and two as 'medium' risk. A total of 2228 HCWs underwent TB screening using the standard Mantoux technique (also known as the tuberculin sensitivity test [TST]). Interferon-γ release assay (IGRA) was carried out in TST-positive subjects. Results showed an overall positivity of 21% to TST and 2% to IGRA test. TST and IGRA results were statistically associated with HCWs born after 1981. This result is due to university policies that highly recommend TB immunization. Data support the use of IGRA assay in TST-positive HCWs, in order to identify latent TB infection from vaccination.

The risk of HCV infection among health-care workers and its association with extrahepatic manifestations (Review).

Health care workers (HCWs) are frequently exposed to different biological agents during their activities and are frequently monitored. Among these infectious agents, human hepatitis C (HCV) can infect HCWs. In this review article, the risk of HCV infection among HCWs is discussed along with extrahepatic HCV-related malignancies, such as non­Hodgkin lymphoma. Accidental contamination, represented by percutaneous and mucocutaneous infections is the main risk factor for such infection. The compliance of the protection procedures, included in the current regulation for HCWs, is the most important issue to reduce the risk of pathogen infections that in turn may produce reduction of infection­associated malignancies.

Epigenetic alterations and occupational exposure to benzene, fibers, and heavy metals associated with tumor development (Review).

The chronic occupational exposure to contaminants and carcinogens leads to the development of cancer. Over the past decades, many carcinogens have been found in the occupational environment and their presence is often associated with an increased incidence of cancer. According to the International Agency for Research on Cancer (IARC), the majority of carcinogens are classified as 'probable' and 'possible' human carcinogens, while, direct evidence of carcinogenicity is provided in epidemiological and experimental studies. Additionally, accumulating evidence suggests that epigenetic alterations may be early indicators of genotoxic and non-genotoxic carcinogen exposure. In the present review, the relationship between exposures to benzene, mineral fibers, metals and epigenetic alterations are discussed as the most important cancer risk factors during work activities.

Absence of t(14;18) chromosome translocation in agricultural workers after short-term exposure to pesticides.

Exposure to pesticides represents a potential health risk for the general population and for agricultural workers in particular. Some researchers observed that occupational exposure to pesticides is associated with risk of non­Hodgkin's lymphoma (NHL). The chromosomal translocation t(14;18)(q32;q21) is one of the most common chromosomal abnormalities in NHL. The aim of this study was to detect the effects of pesticides on t(14;18) chromosome translocation in agricultural workers after short-term exposure. Fifty-two workers occupationally exposed to pesticides (fungicides and insecticides) and 52 non-exposed were recruited. The farm workers were on average exposed to pesticides for ~3.7 h a day for 5 years. The frequency of BCL2-IGH t(14;18) translocation in workers occupationally exposed to pesticides was 10% (5 of 52) vs. 8% (4 of 52) in the control group. Overall, these data suggest that no significant association between occupational exposure to pesticides and an increased frequency of the chromosomal translocation BCL2-IGH t(14;18) in farmers was observed. However, further studies with a higher number of subjects exposed to pesticides are necessary to confirm this observation.

Non­infective occupational risk factors for hepatocellular carcinoma: A review (Review).

Liver cancer is the second leading worldwide cause of cancer­associated mortalities. Hepatocellular carcinoma, which accounts for the majority of liver tumors, ranks fifth among types of human cancer. Well­established risk factors for liver cancer include the hepatitis B and C viruses, aflatoxins, alcohol consumption, and oral contraceptives. Tobacco smoking, androgenic steroids, and diabetes mellitus are suspected risk factors. Current knowledge regarding non­infective occupational risk factors for liver cancer is inconclusive. The relevance of liver disorders to occupational medicine lies in the fact that the majority of chemicals are metabolized in the liver, and toxic metabolites generated via metabolism are the predominant cause of liver damage. However, their non­specific clinical manifestations that are similar in a number of liver diseases make diagnosis difficult. Furthermore, concomitant conditions, such as viral hepatitis and alcohol or drug abuse, may mask liver disorders that result from occupational hepatotoxic agents and block the demonstration of an occupational cause. The identification of environmental agents that result in human cancer is a long and often difficult process. The purpose of the present review is to summarize current knowledge regarding the association of non­infective occupational risk exposure and HCC, to encourage further research and draw attention to this global occupational public health problem.

Fluoro-edenite induces fibulin-3 overexpression in non-malignant human mesothelial cells.

Exposure to asbestos is associated with the development of mesothelioma. In addition to asbestos, other fibers have been identified as risk factors for malignant and non-malignant diseases of the lungs. Among these, fluoro-edenite (FE) was found in patients from Biancavilla (Sicily, Italy) with pleural and lung disease, suggesting its role for tumor expansion. In this context, the identification of early biomarkers useful for the diagnosis of cancer is mandatory. Fibulin-3 represents an important marker for the diagnosis of mesothelioma. However, it remains to be determined whether it is directly associated with exposure to asbestos-like fibers. In the present study, peripheral blood levels of fibulin-3 from 40 asbestos-exposed workers were compared with those detected in 27 street cleaners from Biancavilla. Intriguingly, the results showed that fibulin-3 levels were higher in the group of street cleaners compared with those of the asbestos-exposed workers, suggesting that these workers used the personal protective equipment according to the current regulations. These data suggest that subjects exposed to FE should be monitored for the risk of mesothelioma. FE and volcanic particulates are probably contained within dust inhaled by street cleaners from Biancavilla during their work activities. Based on these criteria, in this study, such fibers were used to treat mesothelial cells (MeT5A) in order to verify whether fibulin-3 levels are affected by these treatments. The results showed that only treatment with FE was associated with fibulin-3 overexpression at both the transcript and protein levels. It was previously demonstrated that mesothelial cells exhibited low levels of p27 following treatment with FE. Notably, p27 downregulation is associated with stathmin upregulation in cancer, conferring an aggressive phenotype of tumor cells. This observation prompted us to perform a computational evaluation demonstrating the activation of stathmin in lung cancer in patients exposed to asbestos. Overall, it can be speculated that both fibulin-3 and stathmin overexpression may be associated with the malignant transformation of mesothelial cells following exposure to asbestos-like fibers.

Occupational exposure to carcinogens: Benzene, pesticides and fibers (Review).

It is well known that the occupational exposure to contaminants and carcinogens leads to the development of cancer in exposed workers. In the 18th century, Percivall Pott was the first to hypothesize that chronic exposure to dust in the London chimney sweeps was associated with an increased risk of developing cancer. Subsequently a growing body of evidence indicated that other physical factors were also responsible for oncogenic mutations. Over the past decades, many carcinogens have been found in the occupational environment and their presence is often associated with an increased incidence of cancer. Occupational exposure involves several factors and the association between carcinogens, occupational exposure and cancer is still unclear. Only a fraction of factors is recognized as occupational carcinogens and for each factor, there is an increased risk of cancer development associated with a specific work activity. According to the International Agency for Research on Cancer (IARC), the majority of carcinogens are classified as 'probable' and 'possible' human carcinogens, while, direct evidence of carcinogenicity is provided in epidemiological and experimental studies. In the present review, exposures to benzene, pesticides and mineral fibers are discussed as the most important cancer risk factors during work activities.

Fluoro-edenite and carbon nanotubes: The health impact of 'asbestos-like' fibres.

Several decades have passed since Wagner et al demonstrated a causal link between asbestos fibre inhalation and the development of pleural mesothelioma in 1960. It was later suggested that pleural plaques are a benign consequence of exposure to these fibres. Most recently, a significant association between exposure to asbestos and cancer diagnosed at various sites, such as the peritoneum, stomach, pharynx, colon and ovaries has been demonstrated. The great concerns about public health that arose from the scientific evidence presented above have led to the banning of asbestos in several countries. Over the years, the suspicion that particles with a high aspect ratio may have asbestos-like pathogenicity has been supported by increasing evidence. Natural occurring minerals, as well as man-made fibres, have proven capable of inducing either chronic inflammation of serous membranes, or, in some cases, the development of peritoneal and pleural mesothelioma. The pathogenic role of both fluoro-edenite and carbon nanotubes, two 'asbestos-like' fibres is summarized and discussed in this review. The data presented herein support the notion that occupational exposure to these two types of fibre contributes to the development of different types of cancer.

FBLN-3 as a biomarker of pleural plaques in workers occupationally exposed to carcinogenic fibers: a pilot study.

FBLN-3 has recently been proposed as a biomarker for malignant mesothelioma. A significantly increased standardized mortality rate from malignant mesothelioma has been reported in Biancavilla, Italy. Its cause has been identified in environmental exposure to fluoro-edenite. The aim of this study was to seek a correlation between plasma FBLN-3 concentration and pleural plaques in subjects exposed to fluoro-edenite and in a nonexposed control group. Pleural plaques was never detected in the control group, whereas it was found in 52% of exposed subjects. Median FBLN-3 concentrations were 12.96 and 5.29 ng/ml in the exposed and the control group, respectively (p < 0.001). FBLN-3 plasma levels exhibited a high predictive value for the presence of pleural plaques.

Detection of pleural plaques in workers exposed to inhalation of natural fluoro-edenite fibres.

Fluoro-edenite is a natural mineral species initially isolated in Biancavilla, Sicily. The fibres are similar in size and morphology to certain amphibolic asbestos fibres, the inhalation of which may cause chronic inflammation and cancer. Occupational asbestos exposure is known to be associated with pleural and lung diseases, including pleural plaques. The aim of this study was to report the pleural and lung parenchymal lesions detected by high-resolution computed tomography (HRCT) in a group of construction workers exposed to fluoro-edenite. Information regarding life habits and occupational history was collected from 43 workers enrolled into the study. The participants underwent physical examination, blood analysis, search for uncoated fibres and ferruginous bodies in the sputum, pulmonary function tests, including diffusion capacity for carbon monoxide (TLCO), and HRCT chest imaging. A general descriptive outcome analysis was also conducted; a prevalence ratio (PR) with 95% confidence interval and a two-tailed test P-value were calculated for pleural plaques using log-binomial regression, measuring plaque size and thickness, and cumulative exposure index (CEI). The mean values of the functional respiratory tests were within the normal range for all participants. A restrictive ventilatory defect was identified in two (5%) subjects and an obstructive ventilatory defect in three (7%) subjects. TLCO was reduced in two additional participants. Fibres were detected in 19 (44%) of subjects. Pleural involvement was documented in 39 (91%) workers, of whom 31 (72%) had bilateral plaques. Calcifications were detected in 25 (58%) of these participants. PR indicated a progressive increase in the risk of developing pleural lesions with rising CEI, i.e. length of exposure. The present findings demonstrate for the first time the presence of pleural plaques in the lungs of subjects exposed to fluoro-edenite fibres, and not to asbestos, through residing in Biancavilla and through their occupation.

Analysis of the B-RafV600E mutation in cutaneous melanoma patients with occupational sun exposure.

Sun-exposure is one of the risk factors associated with the development of a cutaneous neoplasm. In melanoma, the Ras-Raf-MEK-ERK (MAPK) signaling pathway is constitutively activated through multiple mechanisms, including B-Raf mutation. It has been hypothesized that B-Raf mutations in melanocytic lesions arise from DNA damage induced by ultraviolet (UV) radiation. However, it is still discussed if B-Raf mutations are associated with melanoma patients exposed to the sun. Therefore, in the present study, the known B-RafV600E mutation was analysed in melanoma samples from 30 indoor and 38 outdoor workers. B-RafV600E mutation was detected in 52 and 73% of outdoor workers and indoor workers, respectively. Of note, this mutation was identified in 12 of 14 (85%) melanoma of the trunk diagnosed in indoor workers and in 9 of 19 (47%) samples from outdoor workers (p=0.03). By analyzing melanomas of other body sites, no statistical difference in the frequency of B-RafV600E mutation was identified between the groups of workers. It appears that the mutation detected among indoor workers may be associated with a recreational or intermittent exposure to the sun, as usually the trunk is a sun-protected body site. Overall, these data indicate that the B-RafV600E mutation detected in melanoma is not associated with a chronic exposure to the sun. Mutations detected in other genes may also contribute to melanoma development in the subset of patients exposed to UV radiation.

A tailored health surveillance program unveils a case of MALT lymphoma in an HCV-positive health-care worker.

Non-Hodgkin lymphoma (NHL) may occur among hepatitis C virus (HCV)-infected individuals. HCV is one of the most common blood-borne pathogens transmitted from patients to health-care workers (HCWs). The development of NHL among HCV-infected HCWs has recently been shown. To investigate this issue further a tailored health surveillance program was applied to 3,138 HCWs from four Medical Institutions. To this aim, all employees were screened for both anti-HCV antibodies and HCV-related extrahepatic manifestations. The HCV prevalence rate, similar among all the HCW subgroups, was 7.3%. The occurrence of a gastric mucosa-associated lymphoma tissue (MALT) lymphoma, diagnosed in a physician following a long history of HCV chronic infection, was observed. Molecular characterization of MALT tissue indicated that immunoglobuline gene combinations were those usually found among HCV-associated lymphomas. Furthermore, B-cell expansion exhibited t(14;18) translocation, as a genetic abnormality associated with the development of MALT lymphomas from HCV-positive patients. Overall, these findings support the hypothesis that HCV viral infection potentially affects the pathway of transformation and progression of lymphoma cells. The occurrence of B-cell NHL, among HCV-positive HCWs, is an additional reason to apply the standard precautions to reduce the risk of blood-borne pathogen transmission.

Correlation of the risk of breast cancer and disruption of the circadian rhythm (Review).

Breast cancer is the worldwide leading cause of cancer incidence among women. Night shift work exposure has been recently considered one of the significant breast cancer risk factors in industrialized countries. The mechanisms by which this work exposure may be responsible for cancer development is still discussed. In the last 15 years, many authors have paid attention to the relationship between night shift work and breast cancer risk. In the current study, eight case-control studies and four prospective epidemiological studies describing such relationship are discussed. A positive correlation between night shift work and breast cancer risk was described in 8 out of 12 studies. However, different reasons suggest that some of these studies have an Achilles heel according to the International Agency of Cancer (IARC) indications. Both the circadian system alteration and the melatonin output reduction, related to the exposure to light-at-night during night shift work, remain the most valid hypotheses on the causal relation of shift work and breast cancer. Overall, the results of the present study suggest that there is an association between night shift work and breast cancer development in western countries. However, further studies are needed to confirm such association and to understand which biomolecular mechanisms may be involved in the pathogenesis of cancer diagnosed in patients with night shift work exposure.