Middle ear metastasis from dormant breast cancer as the initial sign of disseminated disease 20 years after quadrantectomy.

We describe an unusual case of breast cancer metastatic to the middle ear in a 71-year-old woman. The metastasis was the initial sign of disseminated disease 20 years after the patient had undergone a quadrantectomy for her primary disease. Computed tomography (CT) demonstrated the presence of an intratympanic mass with a soft-tissue density that was suggestive of chronic inflammation. The patient underwent a canal-wall-down tympanoplasty. When a brownish mass was found around the ossicles, a mastoidectomy with posterior tympanotomy was carried out. However, exposure of the tumor was insufficient, and therefore the posterior wall of the ear canal had to be removed en bloc. Some tumor was left on the round window membrane so that we would not leave the patient with a total hearing loss. Our case highlights the limitations of CT and magnetic resonance imaging in differentiating inflammatory and neoplastic lesions

Surgical treatment of gastrointestinal stromal tumors of the duodenum. A literature review

Background: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4–5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment. Methods: An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST. Results: Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections). Conclusions: dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1–2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided

Neuroimaging, Networking and Systems Biology: The New Way to Investigate Pathologies with Neurological System Implications. The example of Tourette Syndrome as a Pilot Study

Purpose: Recently, many academic research groups have focused their attention on changes in human brain networks related to several kinds of pathologies and diseases, generating the new discipline termed “Network Medicine”. Purpose of this paper is to investigate the ability of the Network Medicine to give deeper insights in the functionality of brain activity. Material and Methods: In the proposed study of Tourette syndrome, we have investigated with the functional magnetic resonance imaging the possibility that the mechanisms associated with the monitoring and internal control of movements were compromised in individuals with Tourette syndrome; we enrolled 20 Tourette Syndrome patients in comparison with a healthy Controls group of 15 subjects matching for age and sex distribution. We proposed, for the fMRI analysis, a novel task based on the execution of switching between complex movements on demand. Results: The elementary activation model found that the effort related to the task in comparing Tourettic vs Controls mainly concerns the areas of the Gyrus of the Cingulum, the precuneus and the thalamic area of the ventral-lateral nucleus. In particular, the BA11 plays an essential role in the Tourette Patients related to the continue tentative to correct the TIC. Considering the status of the pilot study of this work, we remark the power of proposed methods to investigate the complex interaction of the brain networks. Conclusion: Alteration in brain activity for a population of Tourette Syndrome patients is evaluable by the use of complex indexes, results confirm the literature about this pathology and these medical physics methods can be applied to all neurological diseases investigation by opportune task-driven experiments or by resting state fc-MRI experiments

Occurrence of Fatal and Nonfatal Adverse Outcomes after Heart Transplantation in Patients with Pretransplant Noncytotoxic HLA Antibodies

HLA antibodies (HLA ab) in transplant candidates have been associated with poor outcome. However, clinical relevance of noncytotoxic antibodies after heart transplant (HT) is controversial. By using a Luminex-based HLA screening, we retested pretransplant sera from HT recipients testing negative for cytotoxic HLA ab and for prospective crossmatch. Out of the 173 consecutive patients assayed (52±13y; 16% females; 47% ischemic etiology), 32 (18%) showed pretransplant HLA ab, and 12 (7%) tested positive against both class I and class II HLA. Recipients with any HLA ab had poorer survival than those without (65±9 versus 82±3%; P=0.02), accounting for a doubled independent mortality risk (P=0.04). In addition, HLA-ab detection was associated with increased prevalence of early graft failure (35 versus 15%; P=0.05) and late cellular rejection (29 versus 11%; P=0.03). Of the subgroup of 37 patients suspected for antibody mediated rejection (AMR), the 9 with pretransplant HLA ab were more likely to display pathological AMR grade 2 (P=0.04). By an inexpensive, luminex-based, HLA-screening assay, we were able to detect non-cytotoxic HLA ab predicting fatal and nonfatal adverse outcomes after heart transplant. Allocation strategies and desensitization protocols need to be developed and prospectively tested in these patients

Increase in 20–50 Hz (gamma frequencies) power spectrum and synchronization after chronic vagal nerve stimulation

Objective: Though vagus nerve stimulation (VNS) is an important option in pharmacoresistant epilepsy, its mechanism of action remains unclear. The observation that VNS desynchronised the EEG activity in animals suggested that this mechanism could be involved in VNS antiepileptic effects in humans. Indeed VNS decreases spiking bursts, whereas its effects on the EEG background remain uncertain. The objective of the present study is to investigate how VNS affects local and inter regional syncronization in different frequencies in pharmacoresistent partial epilepsy. Methods: Digital recordings acquired in 11 epileptic subjects 1 year and 1 week before VNS surgery were compared with that obtained 1 month and 1 year after VNS activation. Power spectrum and synchronization were then analyzed and compared with an epileptic group of 10 patients treated with AEDs only and with 9 non-epileptic patients. Results: VNS decreases the synchronization of theta frequencies (P!0.01), whereas it increases gamma power spectrum and synchronization (!0.001 and 0.01, respectively). Conclusions: The reduction of theta frequencies and the increase in power spectrum and synchronization of gamma bands can be related to VNS anticonvulsant mechanism. In addition, gamma modulation could also play a seizure-independent role in improving attentional performances. Significance: These results suggest that some antiepileptic mechanisms affected by VNS can be modulated by or be the reflection of EEG changes.2026-2036Pubblicat

Metabolomics As a Tool for the Characterization of Drug-Resistant Epilepsy.

PURPOSE: Drug resistance is a critical issue in the treatment of epilepsy, contributing to clinical emergencies and increasing both serious social and economic burdens on the health system. The wide variety of potential drug combinations followed by often failed consecutive attempts to match drugs to an individual patient may mean that this treatment stage may last for years with suboptimal benefit to the patient. Given these challenges, it is valuable to explore the availability of new methodologies able to shorten the period of determining a rationale pharmacologic treatment. Metabolomics could provide such a tool to investigate possible markers of drug resistance in subjects with epilepsy. METHODS: Blood samples were collected from (1) controls (C) (n = 35), (2) patients with epilepsy "responder" (R) (n = 18), and (3) patients with epilepsy "non-responder" (NR) (n = 17) to the drug therapy. The samples were analyzed using nuclear magnetic resonance spectroscopy, followed by multivariate statistical analysis. KEY FINDINGS: A different metabolic profile based on metabolomics analysis of the serum was observed between C and patients with epilepsy and also between R and NR patients. It was possible to identify the discriminant metabolites for the three classes under investigation. Serum from patients with epilepsy were characterized by increased levels of 3-OH-butyrate, 2-OH-valerate, 2-OH-butyrate, acetoacetate, acetone, acetate, choline, alanine, glutamate, scyllo-inositol (C  R > NR). SIGNIFICANCE: In conclusion, metabolomics may represent an important tool for discovery of differences between subjects affected by epilepsy responding or resistant to therapies and for the study of its pathophysiology, optimizing the therapeutic resources and the quality of life of patients

Primary breast lymphomas: a multicentric experience

Background: The Primary Breast Lymphomas (PBL) represent 0,38-0,70% of all non-Hodgkin lymphomas (NHL), 1,7-2,2% of all extranodal NHL and only 0,04-0,5% of all breast cancer. Most frequent PBLs are the diffuse large B cell lymphomas; in any case-reports MALT lymphomas lack or are a rare occurrence. Their incidence is growing. From 1880 (first breast resection for "lymphadenoid sarcoma" carried out by Gross) to the recent past the gold standard treatment for such diseases was surgery. At present such role has lost some of its importance, and it is matter of debate. Methods: Twenty-three women affected by PBL underwent surgery. Average age was 63 years (range: 39-83). Seven suffered of hypothyroidism secondary to autoimmune thyroiditis. Fourteen patients underwent mastectomy, nine patients received quadrantectomy (average neoplasm diameter: 1,85 cm, range: 1,1-2,6 cm). In 10 cases axillary dissection was carried out. Pathologic examination revealed 16 diffuse large B cell lymphomas and 7 MALT lymphomas. Results: Seven patients in the mastectomy group had a recurrence (50%), and all of them with diffuse large B cell lymphomas at stage II. Two of these had not received chemotherapy. No patient undergoing quadrantectomy had recurrence. In the mastectomy group disease free survival (DFS) at 5 and 10 years was 57 and 50%. Overall survival (OS) at 5 and 10 years was 71.4% and 57.1% respectively. All recurrences were systemic. DFS and OS at 5 and 10 years was 100% in the quadrantectomy group. In the patients with recurrence mortality was 85.7%. For stage IE DFS and OS at 5 and 10 years were 100%. For stage II DFS at 10 years was 62.5% and 56.2% respectively; OS at 5 and 10 years was 75% and 62.5% respectively. For MALT lymphomas DFS and OS at 5 and 10 years were 100%. For diffuse large B cell lymphomas DFS at 5 and 10 years was 62.5% and 56.2% respectively; OS at 5 and 10 years was 75% and 62,5% respectively. Conclusions: The role of surgery in this disease should be limited to get a definitive diagnosis while for the staging and the treatment CT scan and chemio/radioterapy are repectively mandatory. MALT PBLs have a definitely better prognosis compared to large B cell lymphomas. The surgical treatment must always be oncologically radical (R0); mastectomy must not be carried out as a rule, but only when tissue sparing procedures are not feasible. Axillary dissection must always be performed for staging purposes, so avoiding the risk of under-staging II o IE, due to the possibility of clinically silent axillary node involvement

Value of split-bolus multidetector-row CT technique in the quantitative assessment of pancreatic enhancement [Pankreatik tutulumun kantitatif değerlendirilmesinde bölünmüş-bolus multidetektör-dizi BT tekniğinin değeri]

The aim of this study is to quantitatively assess radiation comma, and pancreatic enhancement by split-bolus intravenous injection of contrast material using 64-slice CT. Single-pass split-bolus MDCT of the chest and abdomen was performed in 37 patients (female: 18, male: 9; mean age, 66.1±14.2 years; range 17-80 years) without pancreatic disease. Regions of interest in the pancreatic head, body and tail were drawn, and mean attenuation values for pancreatic parenchymal phase (PPP) of the standard MDCT protocol and split-bolus were calculated. P<0.05 was considered statistically significant. Mean effective dose by split-bolus was measured. In all MDCT examinations split-bolus protocol allowed acquisition of optimal images. Mean pancreatic enhancement was higher by split-bolus with respect to PPP of standard triphasic MDCT (131.35 HU±20.63 vs 126.1 HU±20.01). Reduction of dose using MDCT split-bolus was approximately 17%. In conclusion MDCT split-bolus protocol provides an optimal pancreatic enhancement, significantly greater than the enhancement of standard MDCT on PPP which confers an advantage for the detection and staging of pancreatic tumors

Urinary gas chromatography mass spectrometry metabolomics in asphyxiated newborns undergoing hypothermia: from the birth to the first month of life.

BACKGROUND: Perinatal asphyxia is a severe clinical condition affecting around four million newborns worldwide. It consists of an impaired gas exchange leading to three biochemical components: hypoxemia, hypercapnia and metabolic acidosis. METHODS: The aim of this longitudinal experimental study was to identify the urine metabolome of newborns with perinatal asphyxia and to follow changes in urine metabolic profile over time. Twelve babies with perinatal asphyxia were included in this study; three babies died on the eighth day of life. Total-body cooling for 72 hours was carried out in all the newborns. Urine samples were collected in each baby at birth, after 48 hours during hypothermia, after the end of the therapeutic treatment (72 hours), after 1 week of life, and finally after 1 month of life. Urine metabolome at birth was considered the reference against which to compare metabolic profiles in subsequent samples. Quantitative metabolic profiling in urine samples was measured by gas chromatography mass spectrometry (GC-MS). The statistical approach was conducted by using the multivariate analysis by means of principal component analysis (PCA) and orthogonal partial least square discriminant analysis (OPLS-DA). Pathway analysis was also performed. RESULTS: The most important metabolites depicting each time collection point were identified and compared each other. At birth before starting therapeutic hypothermia (TH), urine metabolic profiles of the three babies died after 7 days of life were closely comparable each other and significantly different from those in survivors. CONCLUSIONS: In conclusion, a plethora of data have been extracted by comparing the urine metabolome at birth with those observed at each time point collection. The modifications over time in metabolites composition and concentration, mainly originated from the depletion of cellular energy and homeostasis, seems to constitute a fingerprint of perinatal asphyxia

The lymphatic drain of below-knee malignant melanoma. Is the popliteal fossa a ghost station?

Sentinel lymph node biopsy is fundamental in the staging of primary cutaneous melanoma (PCL), but reported lymphoscintigraphic patterns are very heterogeneous. In this systematic review, we evaluated the role of the popliteal station in below-knee PCL. A systematic search of literature through was conducted on the electronic databases PubMed, SCOPUS and Web of Science (WOS) to identify eligible studies. A total of 22 studies (n=5,673 patients) were included. The average Breslow thickness of PCL was 2.86 mm. During the analysis of the included articles, it was not possible to classify patients into the 3 Menes popliteal drainage pattern, obtained by lymphoscintigraphy. The analysis of lymphatic drainage in patients undergoing lymphoscintigraphy for melanoma of the lower extremities below the knee was reported in 5,637 patients and the lymphatic popliteal drainage was reported only in 5.64% (320 patients). The rate of popliteal lymph nodes melanoma metastases was 1.48%: they were located exclusively at the popliteal level in 0.60%, at the popliteal and inguinal levels in 0.39%, at the popliteal and iliac level in 0.02% and at the groin level in 0.48%. In conclusion, the most common lymphoscintigraphic pattern is represented by popliteal nodes in-transit or interval nodes, so metastases from below-knee melanomas commonly transit through popliteal nodes stations and arrive to inguinal nodes stations. The popliteal nodes are the primary station in about 5.64% of cases. Larger studies are needed to corroborate these findings