CXCL11 in bronchoalveolar lavage fluid and pulmonary function decline in systemic sclerosis.

OBJECTIVES: Several studies have focused on the antifibrotic potential of the Th1 cytokine IFN-γ-1b through suppression of Th2 fibrogenic functions. It has been reported that IFN-γ induces the production of CXCL11 in the lung and plasma of patients with lung-fibrosis. The aim of the present study was to determine whether the levels of CXCL11 in the bronchoalveolar lavage fluid (BALF) of SSc patients might be a predictor of clinically significant fibrotic lung involvement. METHODS: In a retrospective longitudinal study we analysed BALF samples from 16 SSc patients with interstitial lung disease (ILD) and 16 matched control patient without ILD. Patients were eligible if they did not have evidence of ILD at the time of BAL as shown by HRCT. A standard morphological and immunological analysis of BALF cellular components was performed. CXCL11 was measured in BALF by specific ELISA assay. RESULTS: BALF CXCL11 concentrations were significantly elevated in the samples taken from patients who did not developed ILD as compared to those who developed ILD (p<0.001). Stepwise logistic regression analysis revealed that BALF CXCL11 levels predicted clinically significant ILD (p<0.001). CONCLUSIONS: The presence of elevated BALF concentrations of CXCL11 in SSc patients who do not developed lung fibrosis suggest that determination of CXCL11 in BALF could serve as a prognostic factor for pulmonary function decline.

Abdominal aortic aneurysm with coexistent horseshoe kidney.

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.

Tracheoinnominate fistula in a Duchenne muscular dystrophy patient: successful management with an endovascular stent.

Tracheoinnominate fistula is a rare but often fatal complication occurring in Duchenne Muscular Dystrophy (DMD) patients with long-term tracheostomy. We report a 16-year-old boy with DMD who developed a fistula causing massive haemorrhage 26 months after tracheostomy. Due to the high risk of perioperative complications, a minimally invasive technique with placement of an endovascular stent grafting the innominate artery was performed. The patient was successfully managed and recovered uneventfully. We believe that endovascular repair of tracheoinnominate fistula by stent grafting may be the treatment of choice in severely compromised patients and that clinicians who treat tracheostomised DMD patients should be familiar with this management strategy.

Hypoxic antiblastic stop-flow limb perfusion: clinical outcome and pharmacokinetic findings of a novel treatment for in transit melanoma metastases.

Hypoxic antiblastic stop-flow perfusion (SFP) has recently been proposed as a therapeutic option for patients with locally advanced tumors. We report on the clinical and pharmacological results of our prospective study of limb SFP for the treatment of in transit melanoma metastases. Twenty-three patients with limb-sited melanoma metastases were treated with melphalan (10 mg/l) based pelvic (n=11, group A) or femoral (n=12, group B) SFP under hypoxic conditions. Systemic and locoregional toxicity, tumor response rate, and local progression-free survival were analyzed. Melphalan concentrations were measured in the perfusate and systemic circulation during SFP, and after 30-min hemofiltration. Perfusate-to-plasma leakage was assessed using a scintigraphic method. No postoperative deaths occurred. Mild locoregional toxicity was observed in 5 patients (18%), and systemic toxicity was mild to severe in 8 patients (30%), the incidence being higher in group A. Tumor response rate (complete + partial response) and time to local disease progression were significantly different in group A and B (9% vs 58% and 7 vs 13 months, respectively). The pharmacokinetic study showed that pelvic SFP was associated with a higher leakage rate and a lower area under the curve ratio than femoral SFP (44% vs 31% and 5.6 vs 9.8, respectively). Limb SFP is a feasible and relatively simple procedure. Toxicity and tumor response rates strictly depend upon drug leakage control. Further efforts should be made to exploit the potential anti-tumor activity of this novel locoregional drug delivery system.

High-sensitivity power Doppler imaging of normal superficial lymph nodes.

PURPOSE: This study was conducted to describe the various patterns of vascularity of the normal superficial lymph nodes detected using high-sensitivity power Doppler imaging according to the dimension and anatomic location of the nodes. SUBJECTS AND METHODS: A total of 712 lymph nodes (416 in the neck, 205 in the groin, and 91 in the axilla) were studied in 118 patients with high-sensitivity Power doppler. Three categories of vascularity were defined: absence of vascularity (type 1), hilar and perihilar vascularity (type 2), and vascularity in the entire node (type 3). The 3 types of vascularity were correlated with the anatomic location and the dimension (maximum transverse diameter) of the nodes. RESULTS: Type 3 vascularity was found in all lymph nodes with a maximum transverse diameter > 6 mm, in the 67.9% (133/196) of lymph nodes between 4 and 6 mm in diameter, and in 45.7% (42/92) of lymph nodes between 2 and 4 mm in diameter. In lymph nodes with transverse diameters of 2-6 mm, type 3 vascularity was detected in 80.7% (46/57) of the axillary nodes, in 69.0% (87/126) of the inguinal nodes, and in 40.0% (42/105) of the cervical nodes. Type 2 vascularity was seen in 14.2% (101/712) of all examined lymph nodes. The absence of vascularity (type 1) was noted in only 1.9% (8/416) of cervical and 2.0% (4/205) of inguinal nodes. CONCLUSIONS: State-of-the-art power Doppler equipment can demonstrate type 3 vascularity in a high percentage of normal superficial lymph nodes. This pattern of intense, extensive-but harmonious-vascularity must be considered as an indicator of benignity.

Morphological and functional modifications of the aneurysm-endograft complex following endoluminal exclusion in 30 consecutive cases.

Data from 30 consecutive excluded abdominal aortic aneurysms (AAA) have been analysed, to verify whether important morphological changes take place after exclusion, and whether these can be considered as risk factors for functional (leaks, flow alterations) and clinical complications (rupture, obstruction). All AAAs have been initially successfully excluded and patients have been followed up by clinical examinations and ct scan controls post-operatively, at the third and sixth month, then yearly. At a mean follow-up of 17 months, dimension of the proximal neck increased significantly (> 2 mm in diameter) in five pts and graft was distally dislodged in two. Maximum aneurysm diameter reduced significantly (at east 10% than originally) in half of the case and more than 25% in 10% of cases. Four AAAs presented an initial increase, that reduced only in two. Calculation of length of the AAA was unreliable due to tortuosity. Two secondary type II leaks and one secondary type III leak were observed associated to stable or slightly increased AAA diameter (the latter patient suddenly died probably for miocardial infarction, but a rupture could not be formally excluded). Marked tortuosity of the graft was seen in five patients, all associated with frank shrinkage of the aneurysmal sac. Parietal thrombosis without explanation was observed in five, and in one progressed to obstruction of an iliac branch. Two pts needed anticoagulation. These data indicate that endoluminal aneurysm exclusion can not be considered as a definitive solution, for long-term outcome is unforeseeable in a number of patients.