A Standardized Evaluation Method for FOXP3+ Tregs and CD8+ T-cells in Breast Carcinoma: Association With Breast Carcinoma Subtypes, Stage and Prognosis.

BACKGROUND/AIM: The role of FOXP3+ Tregs and CD8+ T-cells in different stages and subtypes of breast carcinoma (BC) is yet to be fully defined, mainly because of methodological variations between studies. The aim of this study was to assess FOXP3+ and CD8+ intratumoral stromal TILs (sTILs) by a standardized method, in order to discern differences between the histological subtypes and BC stage and evaluate the applicability of the method. PATIENTS AND METHODS: FOXP3+ and CD8+ sTILs were studied immunohistochemically in 207 BCs and counted on digital images, amounting to a standard stromal area of a 10×10 grid on ×40 magnification. The results were correlated with clinicopathological features and outcomes. RESULTS: Tregs and CD8+ TILs were more abundant in HER2+ BCs (p=0.02, p=0.007, respectively), estrogen receptor (ER)-BCs (p<0.001, for both cell types), and triple-negative BCs (TNBCs) (p=0.01, p=0.006, respectively). Tregs and CD8+ TILs were associated with high grade (p<0.001 and p=0.002, respectively) and high Ki67 index (p<0.001, for both cell types). Lower CD8/FOXP3 ratio was associated with node metastases (p=0.007). Node metastases and advanced stage paralleled with decreased CD8+ sTILs (p=0.023, p=0.019, respectively). In the entire group and in ER- BCs, CD8+ TILs were associated with favorable distant metastasis-free survival (p=0.021, p<0.001, respectively), disease-free survival (p=0.022, p<0.001, respectively) and breast cancer specific survival (BCSS) (p=0.022, p=0.005). In ER-BCs, Tregs were associated with favorable BCSS (p=0.02). CONCLUSION: Tregs and CD8+ TILs are higher in early-stage TNBCs and HER2+ BCs and diminish with progression to advanced stages. The findings provide support for immunotherapeutic manipulation of TILs, particularly in early stages of these BC subtypes. The evaluation methodology can be easily implemented for standardization of immunohistochemically-detected TILs.

A standardized protocol for the treatment of severe pneumonia in kidney transplant recipients.

Although the incidence of pneumonia after kidney transplantation is the lowest among all solid organ transplants, it is associated with high mortality rate (40-50%). We evaluated the efficacy of a protocol consisting of bronco-alveolar-lavage (BAL) for early microbiological diagnosis, reduction of the immunosuppressive therapy, and prompt administration of standardized antibiotic regimen in renal transplant recipients with severe pneumonia. Between 6/1989 and 5/1999, 40 kidney transplant recipients developed 46 episodes of severe pneumonia (hypoxia and/or infiltrate on the chest X-ray). According to protocol, in all these cases, a BAL was immediately performed and empirical antibiotic therapy was initiated with erythromycin and trimethoprim-sulfamethoxazole i.v. Furthermore, the immunosuppressive therapy was drastically reduced. Analyses of BAL fluid included cell differential count, cytopathologic examination and cultures for bacteria, fungi and viruses. Within 48 h, the therapy was switched to proper i.v. antibiotics, if necessary, according to the results of sensitivity testing of BAL specimens. The mortality rate was 12.5% (5 of 40). Mechanical ventilation was required in 20 cases (34.5%) and four of the patients that required intubation died. BAL alone established a diagnosis in 67.4% (31 of 46) of the patients. Bacteria were responsible for 61% of the episodes, with fungi responsible for 29% and viruses for 10%. Seven cases of Pneumocystis carinii pneumonia were treated with the prolongation of the initial therapy. We conclude that a combination of early detection of the responsible pathogen by BAL, aggressive reduction of the immunosuppressive therapy and the immediate empirical administration of erythromycin and trimethoprim-sulfamethoxazole is an effective strategy to treat pneumonia kidney transplantation (KTX) recipients.

Significance of bile leaks complicating conservative surgery for liver hydatidosis.

Hepatic hydatidosis presents a challenge in liver surgery, and there is still controversy regarding the appropriate surgical technique. A high incidence of postoperative bile leaks is reported as a significant disadvantage of conservative surgical procedures. The purpose of this study was to examine the incidence and clinical importance of bile leakage in patients being treated exclusively by a conservative surgical technique. From January 1985 to November 2000 a total of 187 patients were operated on at our department for hepatic hydatidosis. They were subjected to the standard conservative surgical technique (wide unroofing and cyst drainage). A total of 18 complications were related to bile leakage (10%), 3 of them bile abscesses (1 drained surgically and 2 percutaneously), 1 case of bile peritonitis due to an accessory bile duct in the gallbladder bed (treated surgically), and 14 fistulas (1 bronchobiliary and 13 biliocutaneous). Five of the fistulas, including the bronchobiliary one, were treated successfully by endoscopy; and the remaining nine healed after conservative treatment. Bile leakage, representing a significant complication following conservative operations for hepatic hydatidosis, can be effectively treated conservatively or endoscopically, not justifying more aggressive surgical approaches.