Metastatic renal cell carcinoma invading liver, duodenum and ivc, surgical treatment and literature review. A case report

Renal Cell Carcinoma has a biologic predisposition for direct vascular invasion: intravascular tumor thrombus is found in 5% to 20% of the cases inside the renal vein or the inferior vena cava. Despite new and effective conservative therapy such as targeted therapy and immunotherapy, cytoreductive nephrectomy and palliative nephrectomy continues to have an important role in T4 patient. The patient selection for cytoreductive nephrectomy should be done carefully. This report present an unique case of metastatic RCC with invasion of the duodenum, liver and retrohepatic IVC, the adopted surgical approach and a review of the literature. Complete surgical extirpation is possible in cases of RCC invading other organs such as pancreas, duodenum, liver, retroperitoneum and IVC. In this scenario, to narrow the possible intraoperative complication, a multidisciplinary approach and equipe is recommended

A rare case of primary gastric Burkitt's lymphoma associated with malignant pleural mesothelioma

Il linfoma di Burkitt (BL) e il mesotelioma pleurico maligno (MPM) sono tumori rari con prognosi infausta e nella maggior parte dei pazienti è indicato solo il trattamento palliativo. Il ruolo dell'infezione da HIV e da EBV nell'eziologia del BL sono stati confermati, mentre resta controversa l’associazione del BL a localizzazione gastrica con l’Helicobacter pylori. Il BL è endemico in Africa e sporadico nel resto del mondo, la localizzazione primitiva nello stomaco (PG BL) è estremamente rara, fino al 2017 erano stati descritti solo 53 casi, ed è altamente aggressiva con una frazione di crescita tra le più alte tra i tumori maligni. La sintomatologia di esordio è costituita da vomito, dolore post-prandiale, sanguinamento acuto o cronico. L'MPM è solitamente associato all'esposizione all'amianto e la dispnea dovuta a versamento pleurico è la manifestazione clinica tipica. Finora in Letteratura non sono stati descritti casi caratterizzati dall’associazione del mesotelioma pleurico maligno con il linfoma gastrico primitivo di Burkitt. Qui riportiamo il caso di un maschio caucasico di 80 anni, negativo per i comprovati fattori di rischio per LB e MPM, che si presentava alla nostra attenzione per un quadro di insufficienza respiratoria acuta da versamento pleurico massivo nell’emitorace sinistro, con sbandieramento mediastinico controlaterale. La tomografia computerizzata con mdc (CE-CT) mostrava una grossa massa causa di ispessimento circonferenziale del fondo gastrico, infiltrante la cupola diaframmatica sinistra e il pilatro omolaterale. All'esame endoscopico, il fondo gastrico appariva completamente occupato da una grossa massa ulcerata sporgente nel lume gastrico. L'esame istopatologico ed immunoistochimico dei campioni bioptici prelevati durante l'EGDS e la toracoscopia ha permesso di formulare la diagnosi di PG BL e MPM. Il paziente è stato sottoposto prima a posizionamento di drenaggio toracico per il versamento pleurico e poi a talcaggio pleurico toracoscopico nell'emitorace sinistro. Per la rapida crescita e l'elevato rischio di sanguinamento veniva programmato il trattamento chirurgico della lesione gastrica, ma il paziente è deceduto a causa di un'aritmia cardiaca fatale, prima di sottoporsi all’intervento chirurgico addominale. Questo case report mette in evidenza la vera sfida per i medici che è quella di identificare il MPM e il PG BL nella loro fase iniziale, specialmente nei pazienti senza i fattori di rischio comprovati. I sintomi di esordio ne fanno un caso molto singolare, caratterizzato da grave dispnea fino all'insufficienza respiratoria, per versamento pleurico massivo sinistro e sbanderiamento mediastinico controlaterale, senza sanguinamento attivo dalla massa gastrica, mentre i reperti CE-TC erano invece negativi per ispessimento pleurico e positivo per ispessimento circonferenziale del fondo gastrico.Background: Primary gastric Burkitt lymphoma (PG BL) and malignant pleural mesothelioma (MPM) are rare and aggressive tumors with poor prognosis. HIV and EBV infection have a link in the aetiology of PG BL, while MPM is usually associated with asbestos exposure. Endoluminal bleeding from massive solid tumor, and dyspnea usually due to pleural effusion, are the typical clinical manifestations respectively of PG BL and MPM. In most patients just palliative treatment is indicated. Case report: A caucasian elderly male, negative for the proven risk factors, presenting respiratory failure due to massive left pleural effusion with severe mediastinal shift. Contrast enhanced - Computed Tomography (CE-CT) showed a large mass causing circumferential thickening of the gastric fundus, infiltrating the left diaphragmatic dome and the ipsilateral crus. Macroscopically, on endoscopy the gastric fundus appeared completely occupied by an ulcerated large mass protunding in the gastric lumen. Histopathological examination from biopsy specimens taken during esophagogastroduodenoscopy and thoracoscopy allowed to make diagnosis of PG BL and MPM. The patient first underwent a placement of a chest tube drainage for the pleural effusion and then a thoracoscopic talc insufflation (TTI) in the left hemithorax. A surgical treatment of the gastric lesion was planned, due to the rapid growth and the high risk of bleeding. The patient died because of fatal cardiac arrhythmia, before undergoig abdominal surgery. Conclusions: This report presents an unique case of PG BL associated with MPM and highlights the real challenge for the physicians to identify them in early stage, especially in patients without the proved risk factors. The onset symptoms make it a very singular case, characterized by severe dyspnea up to respiratory failure, due to massive left pleural effusion and contralateral mediastinal fluttering, without an active bleeding from the gastric mass, while CE-CT findings were instead negative for pleural thickening and positive for circumferential thickening of the gastric fundus. Key words: Burkitt Lymphoma, Case Report, Gastric, Pleural Mesothelioma, Pleural Effusion, Respiratory Failure

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Single Molecule Force Spectroscopy study of the coordination bond between a histidine tag and the nickel-nitrilotriacetate group.

Nowadays several methods used for the purification of recombinant proteins are based on the formation of a coordination bond between the nickel(II)-nitrilotriacetate (NTA) group present on a chromatographic matrix and a stretch of six consecutive histidine residues (6XHis-tag) appended to the primary sequence of the protein [1]. Measuring the force anchoring the His-tagged proteins on the Ni2+-NTA functionalized matrices at the single molecule level can provide an insight in the chemical details of the bond, which could then be used to design possible improvement strategies. This approach has been already explored by different groups which measured the force of the Ni2+-NTA-(His)6 bond obtaining highly variable results [2,3,4]. Probably, these differences derived from the different experimental setups used. We faced such a problem by using an internal force gauge constituted by a dsDNA linker tethering the nitrilotriacetate (NTA) group to the surface. The mechanical properties of dsDNA have been in fact thoroughly investigated by different groups at the single molecule level [5,6]. We constructed a DNA molecule presenting a Ni2+-NTA group at one end and a thiol group, for the binding onto a gold surface, at the other end. Force-distance curves between the AFM tip, previously functionalised with a CG6H6 peptide, and the DNA bound to the surface were collected. The formation of the desired coordination bond leads to a force curve with 3 phases: (1) entropic stretching of the DNA linker; (2) overstretching transition of the linker, generating a plateau whose length is equal to 70% of that of the employed DNA; (3) detachment of the probe, which corresponds to the breaking of the coordination bond. Preliminary results show the overstretching plateau at 50 pN, a value close to the earlier reported ones, followed by the two possible rupture force profiles: either a single entropic stretching represented by classical Worm Like Chain (WLC) or a more complex profile which seems to be the combination of two WLC. This means that there are two possible scenarios in our experiments. In the first case, after the overstretch, the DNA linker (in the S-DNA form) is extended till the force reaches the value of the rupture of the Ni2+-NTA-(His)6 bond; in the second case the stretching of the S-DNA is followed by a melting process leading to the partial separation of the DNA strands. A description of the experiments and the values of the forces measured for the Ni2+-NTA-(His)6 bonds, which seems in agreement with the one measured by the Hinterdorfer group [3], will be presented. [1] Hochuli E et al. (1987) J. Chromatogr., 411: 177. [2] Conti M et al. (2000) Angew. Chem. Int. Ed., 39: 215. [3] Kienberger F. et al (2000) Single Mol., 1: 59. [4] Schmitt L. et al. (2000) Biophys J., 78: 3275. [5] Smith, S. B. et al. (1996) Science. 271: 795. [6] Rief, M. et al. (1999) Nature Struct. Biol. 6: 346

Post-traumatic multifocal abdominal splenosis. The role of the clinical history. Case report and review of literature

Splenosis is a benign clinical condition caused by the heterotopic autotransplantation of spleen's tissue tipically occurring after spleen rupture. Splenosis may be asymptomatic and found accidentally. When signs and symptoms occur they are due to mass effect or bleeding of the splenic nodules.INTRODUZIONE: La splenosi è una condizione clinica benigna di non comune riscontro. È caratterizzata dall’autotrapianto eterotopico di tessuto splenico dopo trauma addominale con rottura della milza. Nella maggior parte dei casi i pazienti sono asintomatici o paucisintomatici e i noduli splenici sono reperti accidentali. Più raramente, a causa dell’accrescimento intramurale o della compressione estrinseca, i noduli splenici possono essere causa di sanguinamento o di ostruzione intestinale. Essi costituiscono un vero dilemma diagnostico poiché simulano una lesione neoplastica metastatica e solo l’esame istopatologico può confermare la diagnosi di splenosi addominale. CASO CLINICO: Uomo di 74 anni, con anamnesi positiva per splenectomia post-traumatica all’età di 18 anni, si presenta alla nostra attenzione per subocclusione intestinale. La TC addominale con mdc mostra la presenza di multiple lesioni solide con intenso enhancement post-contrastografico in sede sottodiaframmatica. Le lesioni appaiono localizzate nel fegato, nel grembiule omentale, sul mesentere dell’intestino tenue e nel peritoneo parietale dell’emiscavo pelvico destro; si associa evidenza di stenosi di un’ansa ileale dello scavo pelvico con dilatazione e stasi fecale sovra-stenotica. Sulla base dei risultati radiologici si avanza sospetto diagnostico di carcinomatosi peritoneale da tumore primitivo a sede occulta. Tenuto conto del reperto TC di stenosi di ansa ileale, in paziente con quadro clinico di subocclusione intestinale, la procedura chirurgica è stata ritenuta il trattamento di scelta. All’apertura della cavità peritoneale si evidenziavano nel fegato, grande omento e mesentere lesioni multifocali di diametro variabile, colore blu rossastro, sessili, lobulate, di consistenza parenchimatosa e tenacemente adese al peritoneo viscerale. La stenosi dell’ansa ileale, causa della dilatazione sovrastenotica, era determinata da un impianto extraparietale delle suddette lesioni della lunghezza di circa 8 cm. È stata eseguita l’omentectomia e sono stati rimossi, con manovra delicata, tre gettoni solidi tenacemente adesi alla sierosa dell’intestino tenue substenotico. L’esame istopatologico dei campioni chirurgici mostrava trattarsi di tessuto splenico con polpa rossa. CONCLUSIONE: Nonostante la disponibilità delle tecnologie di imaging, la splenosi resta di difficile identificazione strumentale, inducendo erroneamente alla diagnosi di una malattia neoplastica metastatica da tumore primitivo occulto. Alla luce dei limiti diagnostici della TC, una storia clinica di trauma splenico o splenectomia, positiva in tutti i casi riportati in letteratura, rappresenta l’elemento più importante per avanzare il sospetto di splenosi addominale. La corretta gestione diagnostica e terapeutica di questa rara entità clinica dovrebbe essere il più possibile conservativa. Nei casi di splenosi addominale l’approccio chirurgico, open o laparoscopico, va riservato ai soli pazienti sintomatici per dolore addominale, subocclusione intestinale e sanguinamento, limitandosi quando possibile all’esecuzione di un semplice prelievo bioptico della lesione necessario per una diagnosi di natura. Si consiglia di non procedere alla rimozione di tutti gli impianti splenici che compensano, almeno in parte, l’immunodepressione tipica dell’asplenia

Incidental papillary thyroid microcarcinoma in consecutive patients undergoing thyroid surgery for benign disease. A single center experience

Background: There has recently been an increase in the incidental histological diagnosis of papillary thyroid microcarcinoma (I-PTMC), that varies from 3.5% in autopsies studies, to 5.2% in thyroid specimens from thyroid surgery, up to 9.4% in patients from areas of endemic goiter. Aim: To evaluate the incidence and the histological characteristics of I-PTMC in patients undergoing thyroidectomy for benign thyroid diseases, and to evaluate sex, age, toxic and non-toxic goiter, Hashimoto's thyroiditis as potential risk factors. Materials and methods: Prospective observational study on 124 patients, median age 56.3±13.25sd range 24-80 years, 93(75%)F, 31(25%)M, with surgical indications for toxic and non-toxic uni/multinodular goiters, in pharmacological euthyroidism. An accurate histological examination (HE) of entirely embedding thyroid samples was performed to identify microscopic foci of I-PTCM. Logistic regression analysis of the abovementioned parameters was performed to identify the risk factors. Results: Total incidence of I-PTMC was 15.3%(19/124), with F/M ratio 2:1. All I-PTMCs were intraparenchymal with an intact thyroid capsule; 68.5% were bilateral-multifocal, 21% unilateral-unifocal, 10.5% unilateral-multifocal; maximum diameter was <5mm in 57.9% and ≥5mm in 42.1%; 63.1% were follicular variant, 36.9% classical variant; intra-thyroid lymphatic invasion and lymph node infiltration of the central compartment and para-tracheal was found in the only patient with "tall-cell" classical variant. No risk factors was found. Conclusions: The incidence higher than that reported in the literature, is probably due to the accurate HE of entirely embedding thyroid samples, which is the most important tool to identify microscopic foci of I-PTCM. The highest reported rate of bilateral multifocality of the neoplasm recommend the total thyroidectomy as surgical treatment of choice, also in patients undergoing thyroid surgery for "presumptive" benign diseases. Key words: Benign Thyroid Disease, Incidental Papillary Thyroid Microcarcinoma, I-PTCM, Thyroid Surgery.SCOPO: Recentemente è stato riscontrato un aumento della diagnosi istologica incidentale del microcarcinoma papillare della tiroide (I-PTMC). L'incidenza istologica varia dal 3.5% negli studi autoptici, al 5.2% negli esami dei campioni operatori da chirurgia tiroidea, fino al 9.4% nei pazienti provenienti da aree di gozzo endemico. Lo scopo principale di questo studio è stato quello di valutare l'incidenza e le caratteristiche istologiche dell’I-PTMC nei pazienti con indicazione alla chirurgia tiroidea per patologia benigna della tiroide. Obiettivo secondario è stato quello di valutare le caratteristiche demografiche, cliniche e istopatologiche (sesso, età, gozzo tossico e non tossico, tiroidite di Hashimoto) quali potenziali fattori di rischio di I-PTCM. PAZIENTI E METODI: Studio prospettico osservazionale eseguito su 124 pazienti, 93(75%) F, 31(25%) M, con età mediana 56.3±13.25sd, range 24-80 anni, sottoposti a chirurgia tiroidea tra Gennaio 2018 – Febbraio 2021, con indicazione posta dagli specialisti endocrinologi per patologia benigna, quale gozzo uni/multinodulare, non tossico e tossico, in eutiroidismo farmacologico. Per ciascun paziente è stato eseguito un accurato esame istologico di tutta la tiroide, aumentando i campionamenti al fine di identificare i focolai microscopici di I-PTCM. È stata eseguita l'analisi di regressione logistica dei suddetti parametri demografici, clinici e istopatologici, allo scopo di identificarli quali eventuali fattori di rischio. RISULTATI: L'incidenza totale di I-PTMC è stata del 15.3% (19/124), con rapporto F/M 2:1. Tutti gli I-PTMC erano intra parenchimali con capsula tiroidea intatta; il 68.5% era bilaterale-multifocale, il 21% unilaterale-unifocale, il 10.5% unilaterale-multifocale; il diametro massimo era <5mm nel 57.9% e ≥5 mm nel 42.1%; il 63.1% era una variante follicolare, il 36.9% una variante papillare classica; l’invasione linfatica intra-tiroidea e l’infiltrazione linfonodale del comparto centrale e para-tracheale è stata riscontrata nell'unico paziente con variante classica " tall-cell ". Sesso, età, gozzo tossico e non tossico, tiroidite di Hashimoto non si sono configurati come fattori di rischio. CONCLUSIONI: Nel nostro studio l’incidenza di I-PTCM significativamente superiore a quella riportata in letteratura, è probabilmente dovuta all'accurato esame istopatologico eseguito includendo tutta la tiroide e aumentando il numero dei campionamenti, che è lo strumento più importante per identificare i focolai microscopici di I-PTCM. Il più alto tasso di multifocalità bilaterale della neoplasia, riscontrato nella nostra esperienza, raccomanda la tiroidectomia totale come trattamento chirurgico di scelta, anche nei pazienti sottoposti a chirurgia tiroidea per patologia “presunta” benigna

Kounis Syndrome as First Manifestation of Allergic Sensitization

Mast cells are abundant in the heart, among myocardial fibers, around coronary arteries, within arterial intima and intramural vessels, and in atherosclerotic plaques. Their mediators can be released during anaphylaxis and be responsible for acute coronary syndrome. This condition has been described as Kounis syndrome (KS). We report three cases of acute myocardial ischemia, which fulfill the definition for KS. In Cases 1 and 2, the association of intense chest pain with acute urticaria after an allergenic contact (wasp sting and betalactam antibiotic administration, respectively) was suspected to be an attack of angina related to an allergic reaction. No signs of an allergic reaction were observed in Case 3, but only the history of a wasp sting suggested its relationship to loss of consciousness and heart ischemia when hypersensitivity to venom was ascertained. These cases strongly recommend measurement of anaphylactic biomarkers, such as tryptase, during acute coronary syndromes to detect the possible involvement of an allergic reaction. Conversely, measurement of cardiac biomarkers during anaphylaxis, even without obvious signs of myocardial ischemia, might identify patients at risk of myocardial injury