Endoscopic pilonidal sinus treatment: a prospective multicentre trial.

BACKGROUND: Pilonidal disease (PD) is a common inflammatory disease of the gluteal fold, resulting in recurrent acute/chronic infection at the level of the natal cleft. In this study, endoscopic pilonidal sinus treatment (EPSiT), a new endoscopic minimally invasive procedure, was evaluated for its effectiveness in treating PD. METHODS: Two hundred and fifty prospective patients with chronic PD were enrolled in a prospective multicentre study conducted at a secondary and tertiary colorectal surgery centre. The primary end-point of this study was wound healing, and the short-/long-term outcomes such as healing time, morbidity rate and recurrence rate were analysed. The secondary end-point of this study was quality of life (QoL). RESULTS: The complete wound healing rate was 94.8%, and the mean complete wound healing time was 26.7 ± 10.4 days. The incomplete healing rate (5.2%) was significantly related to the number of external openings (P = 0.01). There was no difference in the failure rate when EPSiT was performed as the first-line treatment for PD or when it was used after unsuccessful procedures (P = n.s.). Recurrence occurred in 12 cases (5%). The QoL significantly increased from preoperative levels 15 days after the EPSiT procedure (45.3 vs 7.9; P < 0.0001). CONCLUSIONS: The EPSiT procedure is a safe and effective technique for treating PD. It provides better short- and long-term outcomes than various other techniques that are more invasive. EPSiT is a minimally invasive outpatient procedure, which is associated with a quick recovery and a good QoL outcome.

Correlation between coronary microvascular function and angina status in patients with stable microvascular angina.

BACKGROUND: Classical anti-ischemic drugs are the first-line form of treatment in patients with microvascular angina (MVA), but they often fail to achieve a satisfactory control of angina symptoms. It is unknown whether there is any relation between improvement of angina status and changes in microvascular function induced by classical anti-ischemic drugs in MVA patients. AIM: To assess whether, in MVA patients, the effects of classical anti-ischemic drugs on symptoms and quality of life (QoL) are related to changes in coronary microvascular function. PATIENTS AND METHODS: We studied 51 patients (59±10 years; 15 men) with MVA. Coronary blood flow (CBF) response to adenosine (ADO) and to cold pressor test (CPT), Seattle Angina Questionnaire (SAQ) and EuroQoL scale were assessed at baseline, in pharmacological washout, and after 12 months under anti-ischemic therapy. Patients were divided into 2 groups: (1) Group 1 included patients with no improvement of QoL (EuroQoL score change < 10 points); (2) Group 2 included patients with QoL improvement (increase in EuroQoL score ≥ 10 points). RESULTS: At baseline, the 2 groups were similar in age, gender, cardiovascular risk factors, CBF response to ADO and to CPT, SAQ and EuroQoL scores. At follow-up the 2 groups differed only for beta blockers use (27% vs. 88% in group 1 and 2, respectively; p < 0.001). A significant improvement in SAQ score was observed only in group 2. CBF response to both ADO and CPT showed a similar improvement in the 2 groups. No relation was found between changes in coronary microvascular function and in angina status. CONCLUSIONS: In MVA patients beta-blockers are more effective than other anti-ischemic drugs in improving angina symptoms. The improvement of angina status does not seem to be mediated by changes in coronary microvascular function.

[Micronutrient deficiencies in osteoporosis]. / Carenze di micronutrienti nell'osteoporosi

Osteoporosis is a disease characterized by a progressive reduction of bone mass and a simultaneous deterioration of skeletal microarchitecture leading to a loss of bone strength, resulting in bone fracture as consequence of even very low traumas. Osteoporosis has only recently been accorded growing clinical and pathological importance for its impact on health. This disease, thanks to considerable increases in life expectancy, is becoming more visible and is now treated either as a serious public health issue of socio-economic importance, and as a multifactorial disease. In fact, both in women and men, osteoporosis is often associated with e hypogonadism as well as with individual traits such as genetic constitution, cytokines, sex and race, which represent non-modifiable endogenous risk factors. In addition, modifiable exogenous risk factors related to lifestyle (e.g. smoking, alcohol consumption, diet) can lead to an acceleration in the genesis of osteoporosis. This article is intended to contribute to the knowledge of exogenous risk factors in osteoporosis, with special consideration to the role of micronutrient deficiencies.

Safety and short-term effectiveness of EEA stapler vs PPH stapler in the treatment of degree III haemorrhoids: prospective randomized controlled trial.

AIM: Stapled haemorrhoidopexy has gained wide acceptance due to less postoperative pain although postoperative bleeding and prolapse recurrence are among the major drawbacks of this technique compared with the standard Milligan-Morgan hemorrhoidectomy. The aim was to investigate a new stapler device designed to overcome these side effects. METHOD: In all, 135 patients (71 men, mean age 42 years) with degree III haemorrhoids were randomly allotted to stapled haemorrhoidopexy with PPH® staplers (Ethicon EndoSurgery) (63 patients) or with an EEA® stapler (Covidien) (72 patients) in four referral colorectal centres. The number of haemostatic overstitches apposed on the stapled suture, the area of the resected mucosa (in square centimetres) and any postoperative bleeding within 30 days were recorded. RESULTS: The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35.75 ± 17.51 vs 28.05 ± 10.23 cm(2), P = 0.002). The median number of haemostatic stitches apposed in the EEA group was significantly lower than in the PPH groups (median value 1, vs 3, interquartile range 0-2, vs 2-5, P < 0.0001). Intraoperative haemostasis was better in the EEA group compared with the PPH01 and PPH03 groups. Postoperative bleeding occurred only in two PPH patients. CONCLUSION: Data suggest that the EEA stapler has better haemostatic properties than the PPH stapler and allows resection of a larger area of mucosal prolapse with potential benefits over the recurrence rate of haemorrhoid prolapse.

[Selenium deficiency in celiac disease: risk of autoimmune thyroid diseases]. / Carenza di selenio nella malattia celiaca: rischio di tireopatie autoimmuni.

The essential trace mineral selenium is of fundamental importance to human health. It is incorporated in the proteome in the forms of the genetically encoded amino acids selenocysteine and selenomethionine, which are the characteristic components of selenoproteins (SeP) such as glutathione peroxidases (GPx), thioredoxin reductases and iodothyronine deiodinase families. Thyroid is especially sensitive to selenium deficiency, because SeP can modify thyreocytes function by acting as antioxidants and modifying redox status and thyroid hormone metabolism. SeP are also involved in apoptosis, cell growth and modification of the action of cell signalling systems and transcription factors. Some intestinal GPx modulate apoptosis by removing the cells affected by oxidative damage preserving tissue integrity. The malfunctioning of the GPx antioxidant system in intestinal mucosa can trigger a continuous cycle of reactive oxygen species and inflammation. Selenium deficiency is a risk factor, due to the malabsorption, in celiac disease (CD) because the inflammatory damage affects the small intestine; this deficiency can modulate SeP genes expression, with consequent reiteration of inflammation and increase of mucosal damage. In active CD, overexpression of interleukin-15 (IL-15) may increase activation of effector mechanisms of epithelial damage by stimulating T helper 1 cytokine proliferation and production and intraepithelial lymphocytes cytotoxicity by protecting these lymphocytes from apoptosis. Blocking IL-15 has the potential to provide new therapeutic tools to prevent both tissue damage and complication of CD such as autoimmune thyroid diseases (AITD) where IL-15 expression is also increases. In view of the role played by SeP in apoptosis inhibition, the presence of environmental factors such as selenium deficiency can be considered an important direct factor of thyroidal damage in development of AITD.

[Reproduction, endocrine disorders and celiac disease: risk factors of osteoporosis]. / Riproduzione, disordini endocrini e malattia celiaca: fattori di rischio di osteoporosi.

In genetically predisposed individuals, celiac disease (CD) is permanent intolerance to gluten. Besides the overt enteropathy, there are clinical and subclinical forms which appear later in life; target organs include liver, thyroid, skin and reproductive systems. CD interference is related to the different concurrent genetic-environmental factors, showing multifactorial nature. CD induces malabsorption with consequent deficiencies of micronutrients essential for organogenesis, spermatogenesis and bone structure, such as vitamin D and calcium. In fact, among extraintestinal manifestations of CD, osteoporosis deserves attention because it can be a sign of silent CD. In celiac patients' serum, cytochinic imbalance related to bone loss is present; in vitro these sera act on the osteoblastic activity. The IL-1b is also present in celiac patients' relatives, confirming the genetic predisposition to its etiopathogenesis which is also regulated by endocrine-environmental factors. In females, CD acts indirectly on the bone, determining early menopause and amenorrhea. Even frequent pregnancies and long periods of lactation can bring to bone loss; in such periods, silent CD can appear, suggesting the presence of endocrine-immunology factors. In celiac males, osteoporosis presence, besides calcium and vitamin D deficiencies, is associated to growth hormone deficit and hypogonadism, which is related to hyperprolactinemia, endocrine factors which affect the reproduction. Osteoporosis is relevant among the elderly and vitamin D and calcium supplementations are important to people diagnosed with CD later in life. Thus, to prevent damages such as osteoporosis, early CD screening among people with reproductive problems is necessary.

Evolution of clinical behaviour in Crohn's disease: predictive factors of penetrating complications.

BACKGROUND AND AIMS: Crohn's disease is a heterogeneous entity. The Vienna Classification defines three different clinical patterns: 'non-stricturing, non-penetrating', 'stricturing' and 'penetrating'. Aim of this study was to assess the change in clinical behaviour over time and to evaluate whether an evolution towards penetrating complications can be predicted. METHODS: A total of 139 patients with non-penetrating behaviour at the time of diagnosis were included. The mean follow-up was 4.84 years (range 1-23.2 years). The clinical behaviour, according to the Vienna Criteria, was assessed at the diagnosis and at the end of follow up. Statistical analysis was performed by means of the Kaplan-Meier method and standard logistic regression analysis. RESULTS: The cumulative probability of a change in clinical behaviour was 22, 38 and 63% at 3, 6 and 12 years, respectively, and the cumulative probability of developing penetrating complications was 22, 33 and 55% at 3, 6 and 12 years, respectively. Young age at diagnosis (<40 years) and a stricturing behaviour are independent risk factors of developing major penetrating complications (internal fistula, mass or abscess): OR=6.0, 95% CI 1.1-30.5; OR=4.0, 95% CI 1.5-10.9, respectively, but not perianal disease. CONCLUSIONS: The behavioural classification of Crohn's disease is a dynamic model in which each status should be considered as not fixed but evolutive. Perianal disease should be considered a distinct pattern of penetrating behaviour.

[Celiac disease and its endocrine and nutritional implications on male reproduction]. / Malattia celiaca e implicazioni endocrine e nutrizionali nella riproduzione maschile.

The problem of the interference of celiac disease (CD) with the male reproductive system is made evident both by the recognized adverse effects on female reproduction and by the multifactorial nature of the disease. It is important to consider CD as a multifactorial condition since its diverse effects can be modulated, besides gluten, by different concurrent genetic and environmental factors. The male CD patient has a greater risk of infertility and other reproductive disturbances, as well as a greater incidence of hypoandrogenism. In this paper the problems of CD associated to endocrine disorders and to deficiencies of micronutrients are discussed. Affected males show a picture of tissue resistance to androgens. Moreover, attention should be paid to increases of FSH and prolactin; these are not associated to infertility and/or impotence, but they may indicate an imbalance at hypothalamus-pituitary level, with general effects on health: an example is the increased risk of male osteoporosis in CD patients. Hormone alterations are reversible upon start of the gluten-free diet, emphasizing the importance of early diagnosis; this should be performed in the case of clinical suspicion, e.g., unexplained hypoandrogenism. As regards nutritional aspects, the folic acid deficiency of CD can affect rapidly proliferating tissues, such as the embryo and the seminiferous epithelium. More attention should be paid to deficiencies of fat-soluble vitamins, such as A and E, observed in CD. Vitamin A is important for Sertoli cell function as well as for early spermatogenetic phases. Vitamin E supports the correct differentiation and function of epidydimal epithelium, spermatid maturation and secretion of proteins by the prostate. Therefore, CD male patients should be considered as vulnerable subjects; thus, the detection of early biomarkers of andrological or endocrinological dysfunctions should trigger timely strategies for prevention and treatment.

[Possible animal models of endocrine, immune and reproductive complications of celiac disease]. / Possibili modelli animali delle complicanze endocrine, immunologiche e riproduttive della malattia celiaca.

This paper underlines the need of developing animal models to study the diverse complications of celiac disease (CD). CD is a multifactorial condition requiring both an exogenous element (gluten) and complex genetic factors; moreover, CD is associated to several endocrine, immune and reproductive diseases, whose onset may be influenced by other environmental factors as well. In particular, the intestinal absorption of exogenous factors may be important for the outcome of CD as well as of the associated diabetes and/or thyroiditis. Presently, there are no adequate animal models for the systemic complications of CD; in particular, there are no gene knock-out models. However, models are available as regards either gluten enteropathy, such as Irish Setter and Balb/c e BDF1 mouse strains, and endocrine-immune diseases associated with CD, such as BB rats and NOD mice. A deeper exploitation of the available models could provide important information on the factors modulating intestinal permeability, the pathogenesis of extraintestinal alterations and the interactions between gluten and other metabolic, nutritional and environmental factors. The elaboration of in vivo models requires a sound basis of knowledge at molecular level, as well as the modulation of the metabolic alteration through relevant exogenous factors, first of all the dietary assumption of gluten. Therefore, the availability of experimental models may provide significant advances on the prevention and treatment, allowing a complete analysis of affected organisms as well as the use of pharmacological and/or immune stimuli; more information may be also derived on the possible long-term effects of gluten traces in CD-affected subjects, thus reducing the need for lengthy clinical studies.

Plasma and tissue prolactin detection in colon carcinoma.

Serum concentrations of prolactin, a trophic hormone produced by the pituitary gland, have been shown to be raised in certain group of patients with cancer. Prolactin was detected in 0-20% of the colon cancer by immunohistochemistry and in plasma in 6-53% of the patients. These conflicting results do not support the hypothesis of an ectopic prolactin production by colon carcinoma. The aim of this study was to confirm the reported incidence of hyper-prolactinemia in colorectal cancer and to find further evidence for an ectopic prolactin production by the tumor. Thirty consecutive patients with colon carcinoma were studied. Before surgery all the patients underwent blood sample collection to assay plasma prolactin levels. All patients underwent colectomy. All the neoplastic specimens were tested with antiprolactin antibody. In none of the patients were significantly high preoperative levels of plasma prolactin found. Prolactin immunostaining was not identified in any of the tumor specimens. We could not confirm previous reports of frequent hyperprolactinemia in patients with cancer. This is the first report in which the incidence of both hyperprolactinemia and prolactin positive immunostaining was 0%. Our study was unable to demonstrate the synthesis of prolactin by colorectal cancers. The tumor is unlikely to be the source of hormone production. Our results suggest that circulating prolactin levels cannot be used as prognostic marker in patients with colon cancer.

Prognostic impact of CD31 antigen expression in anal canal carcinoma.

BACKGROUND/AIMS: CD31 is a platelet endothelial cell adhesion molecule. Thus CD31 immunostaining of vascular endothelial cells can be used to measure degree of angiogenesis. As angiogenesis is necessary for tumor growth and metastasis, microvessels density could be a predictor of prognosis. The purpose of this study was to examine the relationship between CD31 value and standard pathologic parameters and prognosis of anal canal carcinoma. METHODOLOGY: Twenty-four patients with anal canal carcinoma were evaluated. Five-micron sections of formalin-fixed, paraffin-embedded tissue were tested with monoclonal anti-CD31 antibody. CD31 value is considered positive if more than 185 vessels/mm2 were counted. Pearson's chi 2 test was employed to test for association between CD31 value and clinicopathological variables. RESULTS: We found no correlation between CD31 value and histologic type, lymph node involvement, patients age and neoplastic relapse. Significant correlation was found between CD31 score and depth of parietal invasion. CONCLUSIONS: The relapse type could strengthen the hypothesis that increased vascularity promotes neoplastic dissemination. As angiogenesis could be used as prognostic indicator to determine patients who may be at higher risk for relapse, our results warrant further confirmation. Development of markers of angiogenic activity in anal canal carcinoma must be an integral part of proper clinical trials.

Analysis of a follow-up program for anal canal carcinoma.

The ideal follow-up program for anal canal cancer remains unclear and controversial. We hereby describe an extensive follow-up program for anal canal carcinoma in order to evaluate which examinations and which diagnostic techniques really had impact on survival and management. We evaluated 25 patients with anal canal carcinoma. Local excision (LE) was performed in 5 patients, radiochemotherapy (RCT) in 13, radiochemotherapy and local excision (RCTE) in 7. Mean follow-up time was 6.3 years (range 20 months-11 years). The follow-up program included clinical examination, serum tumor markers evaluation, transrectal ultrasonography (TRUS), anoscopy with either mucosal or by Tru-cut needle multiple biopsies, standard chest X-ray and hepatic-inguinal ultrasonography, endoanal magnetic resonance imaging and in some cases total-body skeletal scintigraphy. A large multicentered randomized and prospective trial is surely lacking and should be undertaken as soon as possible. Our results suggest that an effective local control, rather than a higher survival is the reachable goal at present for anal canal carcinomas. However, further steps should be made to achieve better results. After this experience we propose a more semplified follow-up protocol which consists in performing only rectal examination, endoscopy, Tru-cut needle biopsies and TRUS for local control and inguinal ultrasound and TC to evidence distant metastases.

Duodenal pancreatic heterotopy diagnosed by magnetic resonance cholangiopancreatography: report of a case.

We describe herein the case of a heterotopic pancreas that caused stenosis in the second portion of the duodenum. A 46-year-old man presented with upper abdominal pain and a 12-month history of intermittent vomiting. There was no history of melena, hematochezia, hematemesis, clay-colored stools, jaundice, or hepatitis and he did not describe any food dyscrasias, although fatty foods and alcohol seemed to make the symptoms worse. No specific medication or change in position relieved the pain. An initial diagnosis of chronic pancreatitis with multiple pseudocysts was made on the basis of elevated serum amylase and lipase levels, and abdominal ultrasonography and computed tomography (CT) findings. Medical treatment with octreotide was given for 8 weeks, but without any marked effect. Double-contrast barium examination and esophagogastroduodenoscopy were not diagnostic. Magnetic resonance (MR) cholangiopancreatography revealed findings indicative of cystic dystrophy of a heterotopic pancreas (CDHP), and an endoscopy supported this diagnosis. A pancreatoduodenectomy was performed and pathological examination confirmed a diagnosis of CDHP. In our opinion, MR cholangiopancreatography is the diagnostic tool of choice when CDHP is suspected.

Magnetic resonance imaging using endoanal coil in anal canal tumors after radiochemotherapy or local excision.

The ideal method for evaluation of anal canal tumors after radiochemotherapy and/or local excision remains controversial. Endoanal magnetic resonance imaging (EMRI) is a new, promising technique. The effectiveness of EMRI is reported in a study of 24 patients. Axial SET1-weighted and TSET2-weighted, sagittal and coronal T2-weighted sequences using Fat-suppression were acquired. In 4 cases, the low signal/noise ratio did not allow a diagnosis. In 6 cases, the lesion was not detected. Parietal hypo-intense thickening was detected in 14 patients, but it was not diagnostic for disease recurrence. In this study, EMRI showed 58.3% sensitivity and 41.6% specificity, thus it was not useful in the follow-up of anal tumors.

[Celiac disease. Risk factors for women in reproductive age]. / La malattia celiaca. Fattore di rischio per la donna in età fertile.

In the past coeliac disease, or intolerance to gluten, has been considered a rare disease in infancy, whose most important signs were chronic diarrhea with malabsorption and reduced growth. However, besides this classical form, there are a number of other clinical and subclinical forms which may appear even in the adult life and without any overt intestinal sign. The alterations may affect, e.g., the liver, thyroid, skin and the female and male reproductive system. The overall prevalence of the different forms of coeliac disease in Western Europe is at least 1:300. The aim of the present paper is to describe and evaluate the effects of coeliac disease on female reproduction. Such effects include delayed menarche, amenorrhea, infertility and early menopause. Epidemiological studies show that besides reduced fertility, affected women are at higher risk of reproductive problems such as pregnancy loss, low birthweight of offspring and reduced duration of breastfeeding. There are no adequate studies to evidentiate a possible increase of birth defects; nevertheless, coeliac disease induces malabsorption, with deficiencies of nutritional factors essential to prenatal development such as iron, folic acid and vitamin K. The mechanisms underlying the reproductive alterations are still awaiting clarification; however, an interaction among specific nutritional deficiencies, endocrine imbalances and immune disturbances is suspected. As for the other effects associated to the coeliac disease, the possible prevention or treatment of the reproductive effects is only the lifelong maintenance of a gluten-free diet.

nm23-H1 protein expression in anal canal carcinoma: does it correlate with prognosis?

BACKGROUND AND OBJECTIVES: Anatomic extent is not the sole axis of classification of tumors and of tumor patients relevant to treatment planning and estimation of prognosis. This results in the need to demonstrate an improvement in prognostic assessment and choice of therapy achieved by consideration of factors other than TNM. nm23 protein does prevent tumor from metastasizing and may also play a role in the control of growth and development. The purpose of this study was to elucidate the clinical significance of nm23 expression in human anal canal carcinoma and to evaluate its influence on the outcome of patients after surgery or radiochemotherapy. METHODS: Twenty-two patients affected by anal canal carcinoma were evaluated. Each section was incubated with monoclonal antibody nm23 NDPK-A. Immunostaining was considered positive when at least 10% of the tumor cells were immunostained. RESULTS: nm23 immunoreactivity was detected in 6/22 (27.3%) tumors. No significant association was found between nm23 expression and prognosis. CONCLUSIONS: The mechanisms causing enhanced nm23-H1 expression in anal canal carcinoma are unknown. Although the level and expression were not correlated with prognosis, activation of nm23-H1 gene might be a prerequisite for oncogenesis in this type of tumor, while an alternate possibility is the modification of cellular characteristics in relation to proliferation and/or differentiation as a consequence of oncogenesis.

An unusual late radiotherapy-related complication requiring surgery in anal canal carcinoma.

We herein describe an unusual late radiation-related complication requiring surgery in a 60-year-old male affected by anal epidermoid carcinoma. The patient presented with obstructed defecation and ulcerated perianal lesions. The perianal biopsies were positive for anal squamous carcinoma. Transanal diagnostic investigations could not be performed because of anal stenosis. Computed tomography detected left inguinal lymphadenopathy and a nonhomogeneous presacral mass, infiltrating the rectal wall, the coccyx, and the sacrum. The patient underwent a colostomy, infusion of cisplatin and 5-fluorouracil, and irradiation of the pelvis, perianal region, and inguinal lymph nodes. In June 1997 the patient complained of the onset of continuous pain at the genitalia, and for penis necrosis he underwent penis amputation. The histologic examination was conclusive for postradiotherapy thrombosis. This complication could strengthen the hypothesis of vasculoconnective damage as the origin of long-term effects of radiotherapy. Probably the minimal dose in transit volume could not be achieved. Careful evaluation in choosing the treatment scheme is necessary if different options are available.

[Annular pancreas in adults: diagnostic considerations on a case]. / Il pancreas anulare nell'adulto: considerazioni diagnostiche su di un caso.

Annular Pancreas (AP) is a rare congenital anomaly that usually presents in childhood with symptoms referable to duodenal obstruction; nonetheless, this condition can manifest in adulthood with abdominal pain, pancreatitis, duodenal ulcer, pancreatic head mass. The Authors hereby discuss a case of AP observed in a 63 year-old patient in which EUS played a decisive role in achieving a certain diagnosis.

A risk factor for female fertility and pregnancy: celiac disease.

Celiac disease is a genetically-based intolerance to gluten. In the past, celiac disease has been considered a rare disease of infancy characterized by chronic diarrhea and delayed growth. Besides the overt enteropathy, there are many other forms which appear later in life; target organs are not limited to the gut, but include liver, thyroid, skin and reproductive tract. It is now recognized that celiac disease is a relatively frequent disorder; the overall prevalence is at least 1:300 in Western Europe. Celiac disease may impair the reproductive life of affected women, eliciting delayed puberty, infertility, amenorrhea and precocious menopause. Clinical and epidemiological studies show that female patients with celiac disease are at higher risk of spontaneous abortions, low birth weight of the newborn and reduced duration of lactation. No adequate studies are available on the rate of birth defects in the progeny of affected women; however, celiac disease induces malabsorption and deficiency of factors essential for organogenesis, e.g. iron, folic acid and vitamin K. The overall evidence suggests that celiac disease patients can be a group particularly susceptible to reproductive toxicants; however, the pathogenesis of celiac disease-related reproductive disorders still awaits clarification. At present, like the other pathologies associated with celiac disease, the possible prevention or treatment of reproductive effects can only be achieved through a life-long maintenance of a gluten-free diet.

Immunohistochemical assessment of Ki-67 as prognostic cellular proliferation marker in anal canal carcinoma.

In order to define new prognostic factors useful for therapeutic decision-making, the Authors conducted a study on anal canal carcinomas in which Ki-67 proliferation index is correlated with pathological variables and clinical outcome. The Ki-67-detectable antigen is expressed in all stages of the cells cycle except G0. Thus, Ki-67 index can measure cell proliferation and it could be considered an indicator of prognosis. Thirty-one patients with anal canal carcinoma were evaluated. The specimens were formalin-fixed, paraffin-embedded and used for immunostaining of Ki-67 antigen. We found a significant correlation between Ki-67 score and depth of invasion and lymph node involvement. No correlation was found between high Ki-67 value and neoplastic relapse. These results suggest that Ki-67 positivity carries different significance in different cancers. Additional studies are required to ascertain whether more aggressive therapeutic procedures should be applied in the subset of patients with a high growth fraction.