Endoscopic appearance is not sufficient for a diagnosis of segmental colitis associated with diverticulosis.

Background: It has been recently shown that the prevalence of segmental colitis associated with diverticulosis (SCAD) is about 2% of all patients who have colonic diverticulosis. However, sometimes it can be overdiagnosed if only endoscopic criteria are applied. We have recognized endoscopic signs of SCAD (lesions of the interdiverticular mucosa with diverticular and rectal sparing) in patients with a variety of conditions other than SCAD. Method: We reviewed clinical, endoscopic and histologic data from selected patients with endoscopically visualized signs of SCAD. Results: Five patients with endoscopic signs of SCAD were included in this study. SCAD was excluded by the lack of specific biopsy findings, combined with laboratory exams. Final diagnoses were iatrogenic colitis due to immunotherapy (n=1), eosinophilic colitis (n=1), Salmonella typhi (n=1), undetermined inflammatory bowel disease (n=1), and Crohn's disease (n=1). Conclusions: Lesions of the interdiverticular mucosa with diverticular and rectal sparing are not specific for SCAD, but rather a predictor of disease. In consequence, histology and, if necessary, laboratory analyses are mandatory to support a correct SCAD diagnosis.

Sporadic Spinal Hamartoma in Adults: A Rare Pathologic Entity.

BACKGROUND: Sporadic spinal hamartomas in adults are extremely rare tumor-like lesions, without defined guidelines of treatment. The aim of this study is to investigate the peculiar features of this pathologic entity to support a more accurate diagnosis and management. METHODS: A comprehensive and detailed literature review of sporadic spinal hamartomas in adults, including a personal case, was performed. Demographic (sex and age), clinical (presenting symptoms), radiologic and pathologic (size, localization, dural and spinal cord relationship of lesion) features, as well as treatment (time to surgery, extent of resection, perioperative and postoperative complications) and outcome (clinical) data were analyzed. RESULTS: Seven studies, including 7 patients, were eligible for the review. A personal case was also added. Sporadic adult spinal hamartomas equally affect males and females, in a range of age from 18 to 75 years; sensory radicular deficits were detected in all patients at clinical onset; thoracic segment (4/8) of the spine and intradural compartment (6/8) were most involved. All patients underwent surgery and just one experimented postoperative complication; gross total resection was achieved in only 3 patients, mainly in an extradural localization; clinical improvement at last follow-up was reported in all but 1 patient. CONCLUSIONS: Spinal hamartomas in adults may sometimes account for progressive worsening of neurologic symptoms and lead to potentially irreversible neurologic deficit; therefore, prompt and adequate diagnosis and treatment are mandatory. Surgical resection represents the only curative treatment and is indicated for symptomatic lesions to achieve neurologic symptoms restoration or arrest/prevent their progressive deterioration.

Ulcerative Colitis After Complicated Diverticulitis.

It has been recently shown that inflammatory bowel disease may follow an episode of acute complicated diverticulitis. We report 3 cases of ulcerative colitis after acute complicated diverticulitis that required surgery. All cases occurred in elderly patients with moderate-to-severe disease and 1 individual who also received treatment with biologics. These cases highlight the need for older patients to be strictly monitored after an episode of perforated diverticulitis requiring surgery because of the risk of developing ulcerative colitis.

COVID-19 as a Trigger for De Novo Crohn's Disease.

A 47-year-old woman developed a de novo occurrence of Crohn's disease after coronavirus disease 2019. This is an unusual occurrence and suggests that severe acute respiratory syndrome coronavirus 2 could trigger inflammatory bowel disease in predisposed people.

Histological Remission in Ulcerative Colitis in Deep Remission under Treatment with Adalimumab.

BACKGROUND AND AIMS: Histological remission (HR) has been recently demonstrated as the last therapeutic goal in ulcerative colitis (UC), but it is unknown whether and how it may occur. Our aim was to assess the histology during the follow-up of an UC population in deep remission under treatment with adalimumab (ADA). METHODS: We performed a retrospective study on 22 UC patients who were in deep remission and followed-up while receiving therapy with ADA. Colonoscopy in those patients was performed every year. Four-quadrant biopsies every 10 cm were obtained during each colonoscopy and assessed by hematoxylin and eosin stain. Histological activity was classified using the Geboes scale. RESULTS: A total of 22 patients were enrolled in the study. The mean follow-up of those patients was 28±7 months, and 2,592 biopsy specimens in total were taken during 108 colonoscopies performed during the follow-up. At the beginning of the follow-up, histological inflammation was found in 15/22 (68.2%) of patients in deep remissio while receiving maintenance ADA therapy, 8/22 (36.4%) of them with Geboes score ≥3.1. At the end of the follow-up, when patients were still in deep remission while receiving maintenance ADA therapy, only 4 patients (18.2%) had at least one biopsy specimen with evidence of any histological inflammation during the follow-up; only two patients (9.1%) had Geboes score ≥3.1. CONCLUSIONS: Our study shows for the first time that UC patients in deep remission under ADA may reach HR, but it seems slower than other clinical or endoscopic goals.

Metaplastic breast cancer: an old histotype but a current therapeutic problem.

Metaplastic breast cancer (MPBC) is a rare and aggressive tumor type in great need of satisfactory therapies. Although most cases of MPBC are 'triple negative', they are nonetheless related to worse outcomes compared with other triple-negative invasive tumors. MPBC presents high levels of genetic and molecular heterogeneity, suggesting that novel targeted therapies can be exploited. Overexpression of PD-L1 and high levels of tumor-infiltrating lymphocytes have also been observed in these tumors, suggesting a role for immunotherapy. We present an updated literature revision on clinical, histopathological and molecular features of MPBC and their significance to prognosis and therapy options. We discuss emerging efforts to improve and personalize prognostic and therapeutic approaches, exploiting the molecular signature of MPBC with targeted therapies and immunotherapies.

Histological inflammation in ulcerative colitis in deep remission under treatment with infliximab.

BACKGROUND AND OBJECTIVE: There are few data on how histological signs of inflammation develop under treatment with infliximab (IFX). We investigated the patterns of histological features of inflammation in patients with UC in sustained clinical and endoscopic remission under IFX. METHODS: We performed a retrospective study on 47 patients with UC in clinical and endoscopic remission and undergoing surveillance colonoscopy with biopsies while receiving maintenance therapy with IFX. Each colonic segment was evaluated based on the Mayo endoscopic subscore and the Geboes histology score (range 0-5.4). RESULTS: Globally, 6110 biopsy specimens were collected from 235 colonoscopies. At the beginning of the follow-up, histological features of inflammation were found in 48.9% of patients receiving maintenance IFX therapy; 25.9% of them had at least moderate inflammation based on histology scores. At the end of the follow-up, when patients were still under endoscopic and clinical remission, 40.4% of patients had at least one biopsy specimen with evidence of any histological inflammation during the follow-up, and 19.1% had biopsy specimens that met the Geboes criteria for histological inflammation and architectural alteration. In none of the different disease locations (pancolitis, left-sided colitis, distal colitis) histological inflammation improved significantly during the follow-up. CONCLUSIONS: Patients in clinical and endoscopic remission from UC under IFX still frequently have histological features of inflammation.

Lung ultrasonography may provide an indirect estimation of lung porosity and airspace geometry.

BACKGROUND: Echographic vertical artifacts (B-lines) in chest ultrasonography have often been associated with pathological patterns. A scientifically sound explanation of these artifacts has not yet been proposed. OBJECTIVES: The 'spongy' nature of the lung in its liquid and solid components and the changes that take place in peripheral airspace (PAS) geometry might be the key point to understanding these phenomena. METHODS: Six excised right rabbit lungs were obtained. Each lung underwent direct ultrasound evaluation in two different conditions: at complete tissue elastic recoil volume and at pulmonary expansion volume achieved by applying a constant positive pressure of 12 cm H2O. Lung volumes and densities were reported in both conditions. Histological examination was performed on three naturally collapsed lungs and on three lungs under positive pressure inflation after having been fixed in formalin solution. RESULTS: Mean volumes of naturally collapsed lungs and fixed expanded lungs were 11.2 ± 0.36 and 44.83 ± 3.03 ml, respectively. Mean densities were 0.622 ± 0.016 and 0.155 ± 0.007 g/ml, respectively. Ultrasound evaluation of collapsed lungs showed dense vertical artifacts and a 'white lung' pattern, while the evaluation of expanded lungs showed hyperechoic line and horizontal artifacts of reflection. Histological evaluation showed a different PAS geometry in collapsed lungs caused by alveolar size reduction and shape changes with unfolded and closed units modifying the peripheral porosity of the frothy nature of the lung. CONCLUSIONS: Airspace geometry, frothy nature and porosity are the determinants of the different behavior of ultrasound interacting with the subpleural lung parenchyma. Chest ultrasound may thus be interpreted as an indirect 'estimator' of lung porosity.

Mucosal expression of basic fibroblastic growth factor, syndecan 1 and tumour necrosis factor-α in Crohn's disease in deep remission under treatment with anti-TNFα antibodies.

BACKGROUND AND AIMS: Both inflammation and fibrosis may be detected in Crohn's disease (CD). The molecular pattern of Basic Fibroblastic Growth Factor (bFGF) and Syndecan-1 (SD1) expression is altered in stenosing CD, but we do not know what the behaviour of this teamwork factor is in CD in deep remission under treatment with anti-TNFα antibodies. Our aim was to compare the expression of bFGF, SD1 and TNF-α in patients with CD in deep remission under treatment with Infliximab (IFX) or Adalimumab (ADA) and a control group of patients with active CD. METHODS: We assessed the expression of bFGF, SD1 and TNF-α in 10 patients with active CD and in 28 patients with CD in sustained deep remission for at least 6 months. All patients underwent surveillance colonoscopy with biopsies, while receiving maintenance therapy with IFX or ADA. Analysis was conducted by real-time reverse transcriptase PCR (RT-PCR) in biopsy samples. RESULTS: We found that bFGF, SD1 and TNF-α were significantly reduced under treatment with anti-TNFα versus controls (p=0.000). bFGF and SD1 expression were similar between IFX and ADA patients (p=0.335 and p=0.289, respectively), while TNF-α was significantly under-expressed in ADA patients (p=0.008). CONCLUSIONS: bFGF, SD1 and TNF-α are significantly reduced in CD patients in deep remission under treatment with anti-TNFα, likely as an expression of optimal control of inflammation. The significance of the TNF-α under-expression in patients under treatment with ADA with respect to those under treatment with IFX should be elucidated in further studies.

Detection of endoscopic and histological inflammation after an attack of colonic diverticulitis is associated with higher diverticulitis recurrence.

BACKGROUND & AIMS: Colonic diverticulitis shows a high recurrence rate, but the factors associated with such recurrence are still unknown. The aim of our study was to investigate the role of endoscopic and histological inflammation as predictors for the recurrence of diverticulitis. METHODS: One hundred and thirty patients suffering from Acute Uncomplicated Diverticulitis (AUD) (81 males, 49 females, mean age 64.71 years, range 40-85) were prospectively assessed. All patients had AUD confirmed by computerized tomography (CT) and endoscopy. Clinical, endoscopic and histological follow-up was performed after 6, 12 and thereafter 24 months after diagnosis of AUD. RESULTS: Sixteen patients were lost to follow-up. Diverticulitis recurred in 18 patients (13.84%): 15 (13.15%) patients showed recurrence of AUD, whilst 3 (2.63%) showed recurrence of complicated diverticulitis. At the end of the follow-up period, endoscopic inflammation was still detected in 31 (27.67%) patients, and active histological inflammation in 41 patients (36.6 %). Only detection of endoscopic and of histological inflammation during the follow-up was a predictor of diverticulitis recurrence (Log rank test, p = 0.0004). CONCLUSIONS: Detection of endoscopic and histological inflammation after attack of AUD was identified as a predictor of diverticulitis recurrence.

Ex vivo lung sonography: morphologic-ultrasound relationship.

Ultrasound (US) interstitial syndrome is a sonographic lung pattern characterized by the presence of acoustic artifacts (B-lines and white lung). The purpose of this study was to demonstrate how interstitial syndrome is determined by acoustic interactions in lungs of variable density and in healthy organs deflated to a nonphysiologic level of density. Normal rabbit lungs were studied ex vivo by US at varying known degrees of inflation, and their histologic appearances were described. In this experimental setting, US interstitial syndrome recognizes a mechanism related to tissue density or porosity. Artifacts (B-lines and white lung) appear in the normal rabbit lung through air-dependent increases in density. As in pathologic conditions, US interstitial syndrome can be reproduced in histologically normal lungs that are deflated to a critical level (>0.45 g/mL) of density, which is not achievable under physiologic conditions.

Torsion of a neoplastic intrascrotal testis: when the torsion reveals the mass. A case report and review.

Cases of torsion of the spermatic cord are rare in men over 30-years-old. Testicular tumors manifest themselves rarely with symptoms of acute scrotum. We report the case of a 38-years-old patient who presented for a suspected left testis torsion. On examination, the testicle was markedly increased in size and painful. The manual derotation made pain dramatically disappear. He came to our attention after about a month asking for an orchidopexy. During the surgery a biopsy was performed. The diagnosis was a Yolk Sac Tumor. A radical inguinal orchiectomy was performed with left hemiscrotal excision, "in block". He performed four cycles of chemotherapy and with no recurrence after 12 months of follow-up. In literature only seven cases of torsion of an intrascrotal testicle with cancer are reported. Our case is the eighth one.

Segmental colitis associated with diverticulosis: a 5-year follow-up.

BACKGROUND AND AIMS: Literature data about the outcome of segmental colitis associated with diverticulosis (SCAD) are scarce. Our aim was to assess the clinical outcome of SCAD according to the type of disease. PATIENTS/METHODS: Twenty-seven SCAD patients underwent a 5-year follow-up (13 males, 14 females; mean age, 63.71 years; range, 50-85 years). Eleven patients were affected by type A, eight by type B, four by type C and four by type D SCAD. During the follow-up, all type B, C, and D patients were under continuous medical treatment. Five type A patients refused any maintaining treatment, but accepted to undergo the clinical, endoscopic, and histological follow-up. RESULTS/FINDINGS: Five type A patients taking therapy (83.33%), two type A not taking therapy (50%), all type C patients (100%), five type B patients (62.5%) and none of type D (0%) were under continuous remission at the end of the follow-up. All type D patients required further steroid course to obtain remission, and two patients required azathioprine to maintain remission. INTERPRETATIONS/CONCLUSIONS: SCAD B and D patients fail to maintain long-term remission, often requiring immunosuppressive treatment. SCAD A and C patients show a more benign course; however, long-term treatment guarantees longer remission also in those patients.

Tumour necrosis factor-alpha expression in segmental colitis associated with diverticulosis down-regulates after treatment.

BACKGROUND AND AIMS: Tumour necrosis factor-α (TNF-α) expression may be increased in segmental colitis associated with diverticulosis (SCAD). Our aim was to assess TNF-α expression in SCAD in relationship to the treatment. METHODS: 10 patients affected by severe (type B and D) SCAD were studied (6 males, 4 females, mean age 60.54 years, range 43-85 years). All patients were treated with beclomethasone dipropionate 10 mg/day plus a probiotic preparation VSL#3 for 8 weeks. At that time, clinical, endoscopic and histological reassessment was performed. Controls were 5 patients with active ulcerative colitis (UC). RESULTS: After treatment, all SCAD B and no SCAD D patients were in remission. The TNF-α expression dropped from 42.7% (+/-7.58) to 15.7% (+/-2.6) in SCAD B patients (p=0.001), and from 40% (+/-5.9) to 28.6% (+/-5.3) in SCAD D patients (p=0.005). In UC patients, the TNF-α expression dropped from 45.5% (+/-5.09) to 22.5% (+/-2.5) (p=0.001). Neither SCAD B nor SCAD D patients showed a significant difference in TNF-α expression compared to UC after treatment. Finally, TNF-α was significantly overexpressed in SCAD D than in SCAD B at the end of treatment (p=0.048). CONCLUSIONS: TNF-α expression in SCAD down regulates after treatment, and seems to be related to the clinical response to therapy. This behaviour, similar to that of Inflammatory Bowel Diseases (IBD), confirms that this disease should be considered as a subtype of IBD.

Tumour necrosis factor-alpha expression in segmental colitis associated with diverticulosis is related to the severity of the endoscopic damage.

BACKGROUND: Tumour necrosis factor-α expression may be increased in segmental colitis associated with diverticulosis. AIMS: To assess tumour necrosis factor-α expression in segmental colitis associated with diverticulosis in relation with the severity of the endoscopic damage. METHODS: 21 patients affected by segmental colitis associated with diverticulosis were studied (15 M, 6 F, mean age 58.87 years, range 43-85 years). Segmental colitis associated with diverticulosis was graduated as mild-moderate (patterns A and C) and severe (patterns B and D). Ten patients with moderate-to-severe ulcerative colitis, 10 patients with moderate-to-severe Crohn's disease, and 10 patients with irritable bowel syndrome served as control groups. RESULTS: Tumour necrosis factor-α expression was significantly higher in segmental colitis associated with diverticulosis B (42.7%) and segmental colitis associated with diverticulosis D (40%) than in segmental colitis associated with diverticulosis A (19.1%) and segmental colitis associated with diverticulosis C (21.1%).Tumour necrosis factor-α expression was lower in segmental colitis associated with diverticulosis A and C than in ulcerative colitis and Crohn's disease, whilst no different tumour necrosis factor-α expression was found between segmental colitis associated with diverticulosis B and D and both ulcerative colitis and Crohn's disease.Finally, tumour necrosis factor-α expression was significantly lower in irritable bowel syndrome (8%±4) than in every type of segmental colitis associated with diverticulosis. CONCLUSIONS: Tumour necrosis factor-α expression in segmental colitis associated with diverticulosis seems to be related to the severity of the endoscopic damage. This behaviour, similar to that of the inflammatory bowel diseases (IBD), confirms that this disease should be considered as a subtype of IBD.

Hydrocele with surprise. Case report and review of literature.

INTRODUCTION: Hydrocele is a fluid collection between tunica vaginalis and testis. Approximately 10% of testicular cancers occurs with a reactive hydrocele. CASE REPORT: A 64 year old male presented with a 30 year history of left hydrocele, progressively increasing. Physical examination demonstrated a left large hydrocele, transilluminable, not under pressure. Ultrasonography showed a "corpusculated hydrocele with vaginal hypertrophy jutting out near the head of the epididymis, perhaps caused by an inflammatory reaction [...]" As the patient showed only a minimal discomfort due to the groin swelling, without pain, surgical excision was planned without priority (Class C < 180 days). RESULTS: The surgical exploration showed a paratesticular papillary neoplasm of 3 cm. Intraoperative pathologic examination of a frozen sample demonstrated a "borderline papillary cystadenoma". The Left orchifunicolectomy was performed. The definitive histological examination showed a "left paratesticular Papillary Serous Tumor of Low Malignant Potential (PSTLMP) with morfoimmunoistochemical features of Mullerian origin of neoplasm". Computed tomography (CT) was negative for lymph nodes and metastasis. In agreement with the oncologist we decide for atchful waiting. DISCUSSION: Despite of rich personal experience of resections and eversions of the vaginal tunic, an urologist rarely observes a case of paratesticular cancer. A PubMed search found 28 citations between 1985 and 2010 with 42 reported cases of paratesticolar neoplasm, including 27 with malignancy features. Rhabdomyosarcoma is the most common, followed by mesothelioma, adenocarcinoma and neuroblastoma. This case report consists of a "borderline" neoplasm for which in the literature, after orchiectomy, it is reported no case of recurrence or metastasis (with a follow up of up to 18 years). CONCLUSION: The banality of the disease never must underestimate the possibility of an undetected cancer.