Diagnostic accuracy of ex vivo fluorescence confocal microscopy in Mohs surgery of basal cell carcinomas: a prospective study on 753 margins.

BACKGROUND: Frozen histological sections are used for intraoperative margin assessment during Mohs surgery. Fluorescence confocal microscopy (FCM) is a new tool that offers a promising and faster alternative to frozen histology. OBJECTIVES: To evaluate prospectively in a clinical setting the accuracy of FCM vs. frozen sections in margin assessment of basal cell carcinoma (BCC). METHODS: Patients with BCC scheduled for Mohs surgery were prospectively enrolled. Freshly excised surgical specimens were examined by FCM and then frozen sections were evaluated. Permanent sections were obtained, in order to validate the sample technique. A blind re-evaluation was also performed for discordant cases. Sensitivity and specificity levels, as well as positive and negative predictive values (PPV and NPV, respectively), were calculated and receiver-operating characteristic curves generated. RESULTS: We enrolled 127 BCCs in as many patients (40·2% females). Seven hundred and fifty-three sections were examined. All BCCs were located in the head and neck area. In evaluating the performance of FCM vs. frozen sections, sensitivity was 79·8%, specificity was 95·8%, PPV was 80·5% and NPV was 95·7% [area under the curve 0·88, 95% confidence interval 0·84-0·92 (P < 0·001)]. Forty-nine discordant cases were re-evaluated; 24 were false positive and 25 false negative. The performance of FCM and frozen sections was also evaluated according to the final histopathological assessment. CONCLUSIONS: We found high levels of accuracy for FCM vs. frozen section evaluation in intraoperative BCC margin assessment during Mohs surgery. Some technical issues prevent the wide use of this technique, but new devices promise to overcome these limitations.

Safety of leucodepleted salvaged blood in oncological surgery: an in vitro model.

Intra-operative blood cell salvage (IOCS) is mainly avoided in onco surgery due to the suspicion that it could increase metastasis' risk. We simulated IOCS followed by leucodepletion: HCT116 (human colorectal cancer) cells were inoculated into packed red blood cells units, and their distribution was evaluated, step-by-step, by flow cytometry and immunohistochemistry. Most of HCT116 cells were lost during washing, and almost completely removed after filtration. IOCS plus leucodepletion could be of great advantage for oncological patients, where allogenic blood transfusion could influence tumour progression.

Impact of 2013 ASCO/CAP guidelines on HER2 determination of invasive breast cancer: A single institution experience using frontline dual-color FISH.

PURPOSE: The new ASCO/CAP guidelines published in 2013 (AC2013) significantly modified the scoring criteria for HER2-FISH, introducing the most controversial change to the HER2-equivocal category. We retrospectively evaluated the impact of AC2013 in a cohort of consecutive invasive breast cancers (IBCs) analyzed with frontline dual-color FISH. METHODS: 2788 consecutive IBCs were reclassified based on the AC2013 guidelines. Clinico-pathological features of equivocal IBCs were compared with HER2-negative and HER2-positive IBCs. FISH HER2-equivocal cases underwent reflex tests: HER2-IHC, RARA-FISH, and SMS-FISH. Overall and disease-free survivals were evaluated in AC2007 HER2-positive patients treated with trastuzumab and in patients that became eligible for target-therapy according to AC2013. RESULTS: Two-hundred HER2-negative cases (7.2%) were classified differently, following AC2013: 0.3% (8/2788) became HER2-positive and 6.9% (192/2788) HER2-equivocal. AC2013, compared with AC2007, significantly increased initial HER2-equivocal cases (6.9%vs1.6%, p < 0.001). AC2013 equivocal-IBCs affected older patients and showed pathological features between HER2-negative and HER2-positive IBCs. After reflex tests, 102 of the 190 equivocal cases (53.7%) were reclassified as HER2-positive, 51 (26.8%) as negative and 37 (19.5%) as equivocal. IHC tested negative in 44.7% of cases, whereas SMS-FISH showed the highest percentage of positive results (45.8%). Clinical outcomes showed no statistically significant differences. CONCLUSION: Overall, 80.5% of FISH-equivocal cases were solved with at least one reflex test and 3.6% of patients became AC2013 HER2-positive, therefore eligible for target-therapy, but showed clinical outcomes similar to HER2-positive patients treated with trastuzumab. Our data belittle the clinical impact of AC2013 HER2-equivocal reclassification; further prospective randomized clinical studies are necessary to support these findings.

Selected mitochondrial DNA landscapes activate the SIRT3 axis of the UPRmt to promote metastasis.

By causing mitochondrial DNA (mtDNA) mutations and oxidation of mitochondrial proteins, reactive oxygen species (ROS) leads to perturbations in mitochondrial proteostasis. Several studies have linked mtDNA mutations to metastasis of cancer cells but the nature of the mtDNA species involved remains unclear. Our data suggests that no common mtDNA mutation identifies metastatic cells; rather the metastatic potential of several ROS-generating mutations is largely determined by their mtDNA genomic landscapes, which can act either as an enhancer or repressor of metastasis. However, mtDNA landscapes of all metastatic cells are characterized by activation of the SIRT/FOXO/SOD2 axis of the mitochondrial unfolded protein response (UPRmt). The UPRmt promotes a complex transcription program ultimately increasing mitochondrial integrity and fitness in response to oxidative proteotoxic stress. Using SOD2 as a surrogate marker of the UPRmt, we found that in primary breast cancers, SOD2 is significantly increased in metastatic lesions. We propose that the ability of selected mtDNA species to activate the UPRmt is a process that is exploited by cancer cells to maintain mitochondrial fitness and facilitate metastasis.

Cadherin-6 promotes EMT and cancer metastasis by restraining autophagy.

The transdifferentiation of epithelial cells toward a mesenchymal condition (EMT) is a complex process that allows tumor cells to migrate to ectopic sites. Cadherins are not just structural proteins, but they act as sensors of the surrounding microenvironment and as signaling centers for cellular pathways. However, the molecular mechanisms underlying these signaling functions remain poorly characterized. Cadherin-6 (CDH6) is a type 2 cadherin, which drives EMT during embryonic development and it is aberrantly re-activated in cancer. We recently showed that CDH6 is a TGFß target and an EMT marker in thyroid cancer, suggesting a role for this protein in the progression of this type of tumor. Papillary thyroid carcinomas (PTCs) are usually indolent lesions. However, metastatic spreading occurs in about 5% of the cases. The identification of molecular markers that could early predict the metastatic potential of these lesions would be strategic to design more tailored approaches and reduce patients overtreatment. In this work, we assessed the role of CDH6 in the metastatic progression of thyroid cancer. We showed that loss of CDH6 expression profoundly changes cellular architecture, alters the inter-cellular interaction modalities and attenuates EMT features in thyroid cancer cells. Using a yeast two-hybrid screening approach, based on a thyroid cancer patients library, we showed that CDH6 directly interacts with GABARAP, BNIP3 and BNIP3L, and that through these interactions CDH6 restrains autophagy and promotes re-organization of mitochondrial network through a DRP1-mediated mechanism. Analysis of the LIR domains suggests that the interaction with the autophagic machinery may be a common feature of many cadherin family members. Finally, the analysis of CDH6 expression in a unique cohort of human PTCs showed that CDH6 expression marks specifically EMT cells. and it is strongly associated with metastatic behavior and worse outcome of PTCs.

Breast granulomatosis with polyangiitis mimicking breast cancer.

Inflammatory lesions of the breast encompass primary reactive processes and local manifestation of systemic diseases. They are very rare and they are generally treated without resort to biopsy. Nevertheless they could be clinically challenge mimicking malignant process and needing surgery to reach a correct diagnosis. Here we describe a rare case of breast granulomatosis with polyangiitis, which presented with radiological and clinical alarming features that immediately raised the suspicious of malignancy leading to breast-conserving surgery.

Thermal acclimation and thyroxine treatment modify the electric organ discharge frequency in an electric fish, Apteronotus leptorhynchus.

In ectotherms, the rate of many neural processes is determined externally, by the influence of the thermal environment on body temperature, and internally, by hormones secreted from the thyroid gland. Through thermal acclimation, animals can buffer the influence of the thermal environment by adjusting their physiology to stabilize certain processes in the face of environmental temperature change. The electric organ discharge (EOD) used by weak electric fish for electrocommunication and electrolocation is highly temperature sensitive. In some temperate species that naturally experience large seasonal fluctuations in environmental temperature, the thermal sensitivity (Q10) of the EOD shifts after long-term temperature change. We examined thermal acclimation of EOD frequency in a tropical electric fish, Apteronotus leptorhynchus that naturally experiences much less temperature change. We transferred fish between thermal environments (25.3 and 27.8 °C) and measured EOD frequency and its thermal sensitivity (Q10) over 11 d. After 6d, fish exhibited thermal acclimation to both warming and cooling, adjusting the thermal dependence of EOD frequency to partially compensate for the small change (2.5 °C) in water temperature. In addition, we evaluated the thyroid influence on EOD frequency by treating fish with thyroxine or the anti-thyroid compound propylthiouricil (PTU) to stimulate or inhibit thyroid activity, respectively. Thyroxine treatment significantly increased EOD frequency, but PTU had no effect. Neither thyroxine nor PTU treatment influenced the thermal sensitivity (Q10) of EOD frequency during acute temperature change. Thus, the EOD of Apteronotus shows significant thermal acclimation and responds to elevated thyroxine.

A rare case of schwannomatosis incidentally detected by 18F-FDG PET/CT during metabolic evaluation of a chest wall tumor / Un caso poco frecuente de schwannomatosis detectado incidentalmente mediante PET/TC con 18F-FDG durante la evaluación metabólica de un tumor de la pared torácica

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PCDD/Fs in the soils in the province of Trento: 10 years of monitoring.

This paper presents a 10-year overview of the dioxins and furans (PCDD/Fs) content in soils in the province of Trento (Italy). The aim was to compare the results found in the Valsugana valley where there is a steel-making plant with other locations within the province. During 2002 and from 2005 to 2010, campaigns were carried out in order to obtain a background reference in terms of micropollutants, in view of the possible construction of a municipal solid waste (MSW) incinerator in Trento. In 2009, a campaign was performed for the environmental characterization of the Valsugana valley, the town of Trento and its surroundings, in order to help assess the impact of the steel-making plant. In 2012, another campaign was carried out by the Department of Civil and Environmental Engineering of Trento, in order to monitor the soils in the area around the steel mill. All the campaigns showed relatively low concentrations of PCDD/Fs, both in protected areas and in the areas close to the industrial plants. No critical situations were identified, as also confirmed by an estimation of the potential daily PCDD/F intake by children subject to accidental ingestion of soil.

Assessment of the local role of a steel making plant by POPs deposition measurements.

Atmospheric depositions of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) and polychlorinated biphenyls (PCBs) were monitored at three sites in the vicinity of a steel making plant, located in an Italian alpine valley. A high variability in the deposition of PCDD/Fs was observed. The influence of the plant was noticeable at two of the sampling sites. However, as the congener profiles demonstrated, wood burning for domestic heating is an additional source of PCDD/Fs for the area under investigation, and this interferes with the characterization of the emissions from the steel plant. The influence of the plant, in terms of PCDD/F deposition, was not noticeable at the most distant site (2km), where an extremely high peak of PCDD/F deposition was measured during the period from 12 January-22 February 2012. The comparison between the congener distribution of PCDD/Fs observed in this sample and the fingerprints of different sources could justify the attribution of this anomalous peak to a possible episode of domestic waste combustion. In order to find a better correlation between the deposition to soil and emissions from the plant, the congener distribution of PCBs was studied. The PCB profiles observed at the three sites well reproduced the average profile found in samples of ash retained by the bag filter of the plant. Thus the monitoring of PCB deposition is an interesting starting point to calibrate dispersion models to assess the impact of steel making activities.

Evaluating ex vivo fluorescence confocal microscopy images of basal cell carcinomas in Mohs excised tissue.

BACKGROUND: Fluorescence confocal microscopy (FCM) is an emerging technology for rapid imaging of excised tissue, without the need for frozen- or fixed-section processing. Basal cell carcinomas (BCCs) can be detected in Mohs excisions although few studies have described the major BCC findings as seen on FCM. OBJECTIVES: To describe the major BCC findings of excised tissue during Mohs surgery and to correlate them with histopathology. METHODS: Freshly excised tumours and frozen-thawed discarded tissue of BCC during Mohs surgery were analysed by means of FCM. A side-by-side correlation between FCM images and histological sections was performed. The FCM features of overlying skin and adnexal structures were also described. RESULTS: Sixty-four BCC cases were analysed. Distinct BCC types appeared unique in terms of shape and size of tumour islands [bigger in nodular (18/25), smaller and rounded in micronodular (7/7) and tiny cords for infiltrative ones (24/30)] and for the presence of clefting, palisading and increased nucleus/cytoplasm ratio. An excellent correlation was found between FCM and histological findings (Cohen's κ statistics = 0·9). In six cases, the presence of sebaceous glands and intense stroma reaction represented possible confounders. CONCLUSIONS: Fluorescence confocal microscopy is a fast and new imaging technique that allows an excellent visualization of skin structures and BCC findings during Mohs surgery.

Accuracy of tympanic and forehead thermometers in private paediatric practice.

AIM: To compare infrared tympanic and infrared contact forehead thermometer measurements with traditional rectal digital thermometers. METHODS: A total of 254 children (137 girls) aged one to 24 months (median 7 months) consulting a private paediatric practice because of fever were prospectively recruited. Body temperature was measured using the three different devices. RESULTS: The median and interquartile range for rectal, tympanic and forehead thermometers were 37.6 (37.1-38.4)°C, 37.5 (37.0-38.1)°C and 37.5 (37.1-37.9)°C, respectively (p < 0.01). The limits of agreement in the Bland-Altman plots were -0.73 to +1.04°C for the tympanic thermometer and -1.18 to +1.64°C for the forehead thermometer. The specificity of both the tympanic and forehead thermometers for detecting fever above 38°C was good, but sensitivity was low. Forehead measurements were susceptible to the use of a radiant warmer. CONCLUSION: Both the tympanic and forehead devices recorded lower temperatures than the rectal thermometers. The limits of agreement were particularly wide for the forehead thermometer and considerable for the tympanic thermometer. In the absence of valid alternatives, because of the ease to use and little degree of discomfort, tympanic thermometers can still be used with some reservations. Forehead thermometers should not be used in paediatric practice.

A proposal for a diet-based local PCDD/F deposition limit.

This study proposes a method to estimate the maximal tolerable value for the atmospheric deposition of dioxins (PCDD/Fs) to soil. The case study for the application of this methodology is an Alpine valley where a steel production plant is present. In order to estimate the limit value for the PCDD/F deposition, consolidated food chain models were applied, but were adapted to be run backwards with respect to their original formulation, by starting from the diet of people living in the region and from the PCDD/F Tolerable Daily Intake value proposed by the World Health Organization. For this case study, the estimated limit value was 2.30 pg WHO-TEQ m(-2) d(-1) when only local diary products were taken into account and 1.91 pg WHO-TEQ m(-2) d(-1) when also the role of local cereals and vegetables was considered. The average PCDD/F deposition measured in the same region during a monitoring campaign was lower than the above limit values (1.40 pg WHO-TEQ m(-2) d(-1)). Indications on how to consider the contribution of meat and fish are provided too. The approach proposed in this paper represents a useful tool to assess the acceptable overall deposition for a specific region.

Development and validation of an enzyme linked immunosorbent assay for palivizumab serum determination.

Palivizumab (Synagis) is a humanized monoclonal antibody (IgG1K) composed of 95 percent human and 5 percent murine sequences. It is directed to an epitope in the A antigenic site of the F protein of respiratory syncytial virus (RSV). Palivizumab is used for prevention of serious lower respiratory tract disease caused by RSV in pediatric patients who are at increased risk of severe disease and is administered intramuscularly (IM) for a total of 5 monthly doses. Herein, we report on the development and validation of a very sensitive enzyme-linked immunosorbent assay (ELISA) to measure serum concentrations of palivizumab by a rabbit polyclonal antibody specifically produced against the murine sequence. The method was developed and validated according to the guidelines "Guidance for Industry" (1998) and has proved suitable for the determination of palivizumab serum levels in the target infant population. The ELISA assay was successfully applied to test the serum samples in an infant population who received palivizumab intramuscularly; thus, the assay could be used to determine serum levels in palivizumab-treated infants to optimize dosing and scheduling and to study the relationship between dose and clinical response.

Web-GIS oriented systems viability for municipal solid waste selective collection optimization in developed and transient economies.

Municipal solid waste management is a multidisciplinary activity that includes generation, source separation, storage, collection, transfer and transport, processing and recovery, and, last but not least, disposal. The optimization of waste collection, through source separation, is compulsory where a landfill based management must be overcome. In this paper, a few aspects related to the implementation of a Web-GIS based system are analyzed. This approach is critically analyzed referring to the experience of two Italian case studies and two additional extra-European case studies. The first case is one of the best examples of selective collection optimization in Italy. The obtained efficiency is very high: 80% of waste is source separated for recycling purposes. In the second reference case, the local administration is going to be faced with the optimization of waste collection through Web-GIS oriented technologies for the first time. The starting scenario is far from an optimized management of municipal solid waste. The last two case studies concern pilot experiences in China and Malaysia. Each step of the Web-GIS oriented strategy is comparatively discussed referring to typical scenarios of developed and transient economies. The main result is that transient economies are ready to move toward Web oriented tools for MSW management, but this opportunity is not yet well exploited in the sector.