Short bowel disease after emergency surgery for massive intestinal infarction. A case report and review of the literature.

Mesenteric ischemia is an infrequent diagnosis, although it carries substantial morbidity and mortality. In adults, the massive resection of small bowel leaving less than 150 cm of intestine results in malabsorption and diarrhoea and defines the short bowel syndrome (SBS). In this report, we present a case of emergency surgery with a near total enterectomy due to superior mesenteric ischemia with a long time of survival. KEY WORDS: Case report, General surgery, Mesenteric ischemia, Small intestine.

Chemotherapy-Induced Neurotoxicity: Evidence of a Protective Role of CC Homozygosis in the Interleukin-1ß Gene-511 C>T Polymorphism.

We hypothesized that the IL-1ß-511 C>T polymorphism could be associated with the development of neurotoxicity and that it could be a possible biomarker to rate the risk of occurrence of neurotoxicity in cancer patients. Genomic DNA was extracted from 85 cancer patients: 49 received systemic chemotherapeutic treatment (CHT) and 36 patients did not receive it (No-CHT). All subjects were genotyped for the functionally active polymorphisms of IL-1ß-511 C>T. We estimated neurotoxicity with the evaluation of neurological deficits. CHT patients showed erythrocytopenia, neurological deficit and a slight lowering of cognitive performance. The subgroup of patients carrying the CC genotype of the IL-1ß-511 C>T gene showed lesser neurological deficits. In the context of cancer treatment, we suggested the potential value of IL-1ß-511 C>T as genetic biomarkers to identify patients with higher risk to develop neurological deficits.

Using PET-CT in the restaging of primitive mediastinal B-cell lymphoma (PMBCL) after chemotherapy: which criteria should we use?

AIM: Primitive mediastinal B-cell lymphoma (PMBCL) is a relatively rare form of non-Hodgkin lymphoma (NHL), typically concerning the youngster, with an aggressive course and poor prognosis. The therapy generally consists of high dose chemotherapy followed by radiotherapy. PET-CT is used at staging, restaging after chemotherapy and after radiotherapy, or when relapse is suspected. Aim of the study was to compare different criteria in the evaluation of response to chemotherapy in this setting. METHODS: Thirty-eight patients with PMBCL (15 M, 23 F, median age 33 yrs [range 18-79]), all treated with chemo-immunotherapy and radiotherapy, who had undergone baseline (b-PET) and end of chemotherapy (f-CHT-PET) 18F-FDG-PET-CT scans at our institution between July 2004 and September 2014 were retrospectively re-evaluated; the median follow-up was 42 months (range 4-109), at which 4/38 (11%) had died, 5/38 (13%) were in partial response (PR) and 29/38 (76%) were in complete response (CR). The primary endpoint was progression-free survival (PFS), while the secondary one was overall survival (OS), according to the Cheson criteria. SUV max of the mediastinal disease mass at staging, of the residual mass at CT after chemo-immunotherapy, SUV max of the liver and of the mediastinal blood pool (MBP) were calculated for all patients. RESULTS: In our population, we observed that: 1) visual criteria performs better when positivity-negativity threshold is set at point 3 of the 5-point scale (5-PS); 2) semiquantitative approach by use of Δ SUV max performs better when the threshold is set at 66% decrease: in fact, at Δ SUV max analysis with 66% decrease, 9 patients resulted positive at the test (Δ SUV max ≤66%), 29 negative (Δ SUV max >66%). CONCLUSION: In our population Δ SUV max could be working well in these patients because the baseline values are very high and very homogeneous. Our data, though limited in numerosity of patients and events, suggests that in this particular setting the use of the 5-PS reporting system could not be the best tool available; on the other hand, Δ SUV max could prove to be reliable in the evaluation of response to chemotherapy.

The Neurobiological Basis of the Distress Thermometer: A PET Study in Cancer Patients.

The objective of this study was to investigate the possible associations between the Distress Thermometer (DT) scores and the brain metabolism of structures involved in stress response. Twenty-one cancer patients were assessed using the DT, Problem Checklist and Hospital Anxiety and Depression Scale (HADS). The psychological measures were correlated with [18 F]PET-FDG brain glucose metabolism. Multiple and linear regression and binary logistic regression were run to analyse data. The DT and HADS scores illustrated that 48% of patients were distressed, 19% were depressed and 48% were anxious. Results showed that some subcortical areas activity, such as part of midbrain and of hypothalamus, was correlated with the DT scores. The Problem Checklist scores correlated with the activity of the same areas and included more regions in the limbic forebrain and brainstem. Compared with the DT and Problem Checklist, HADS-Depression scores showed a more extensive pattern of correlation with brain activity, including limbic and cortical areas. The results highlighted that the DT scores correlated with the activity of brain areas typically involved in stress response. Indeed, hypothalamus metabolism was found to be the best predictor of distressed patients.

The chemotherapy long-term effect on cognitive functions and brain metabolism in lymphoma patients.

AIM: A growing number of neuropsychological studies reported that chemotherapy may impair brain functions, inducing persistent cognitive changes in a subset of cancer survivors. The aim of this paper was to investigate the neural basis of the chemotherapy induced neurobehavioral changes by means of metabolic imaging and neuropsychological testing. METHODS: We studied the resting brain [¹8F]FDG-PET/CT images of 50 adult cancer patients with diagnosis of lymphoma: 18 patients were studied prior and 32 after to chemotherapy. All patients underwent to a neuropsychological examination assessing cognitive impairment (tests for shifting attention, verbal memory, phonemic fluency), depression, anxiety and distress. RESULTS: Compared to no chemotherapy patients, the treated group showed significant bilateral lower rate of glucose metabolism in prefrontal cortices, cerebellum, medial cortices and limbic brain areas. The metabolism of these regions negatively correlated with number of cycles and positively with post-chemotherapy time. The treated group showed a poorer performance in many frontal functions, but similar level of depression, anxiety and distress. CONCLUSIONS: Chemotherapy induced significant long-term changes in metabolism of multiple regions with a prevailing involvement of the prefrontal cortex. The observed cognitive dysfunctions could be explained by these changes. The recovery from chemotherapy is probably affected by treatment duration and by the time elapsed after its end. We speculated that the mechanism could be an accelerating ageing / oxidative stress that, in some patients at risk, could result in an early and persistent cognitive impairment.

Bone marrow disease detection with FDG-PET/CT and bone marrow biopsy during the staging of malignant lymphoma: results from a large multicentre study.

AIM: To compare the accuracy of bone marrow biopsy (BMb) and positron emission tomography (PET) in bone marrow disease (BMD) detection, in a large multicentre population of patients with new diagnosis of malignant lymphoma. METHODS: PET and BMb were performed to complete disease staging in 337 consecutive patients: 130 Hodgkin's disease (HD), 207 aggressive non Hodgkin's lymphoma (NHL). Sensitivity, specificity and accuracy of both techniques in BMD detection were evaluated and compared. RESULTS: 87 patients with BMD (25 positives at both exams, 27 only at the BMb and 35 only at the PET study). PET vs. BMb were reordered: sensitivity: 69% vs. 59.8%; specificity: 99.2% vs. 100%; accuracy: 91.4% vs. 89.6%; positive predictive value: 96.8% vs. 100%; negative predictive value: 90.2% vs. 87.7%. CONCLUSION: The sensitivity of PET and BMb is similar (69% and 60%, respectively), PET and BMb are complementary: in fact out of 87 patients with confirmed BMD only 25 are positive at both exams, while 27 only at the BMb and 35 only at the PET exam; the integration of PET findings with BMb ones increases the diagnostic accuracy. Consequentially PET is essential during the staging of malignant lymphomas.

Decreased [99mTc]Sestamibi uptake with dobutamine versus dipyridamole stress.

AIM: Animal studies suggest an interference of dobutamine on [99mTc]sestamibi uptake. In this study dobutamine was compared to dipyridamole rest-stress [99mTc]sestamibi uptake ratio (UR). METHODS: Twenty-five patients with suspect coronary artery disease (CAD) underwent rest, dobutamine, and dipyridamole [99mTc]sestamibi SPECT at 24-h intervals and coronary angiography. UR was calculated separately for each coronary territory considering injected dose and acquisition delay. RESULTS: There were 38 CAD territories in 20 patients. On a patient basis, dipyridamole SPECT sensitivity was 85%, versus 70% for dobutamine. On a territory basis, sensitivity was 66% versus 42% (P<0.05), and specificity 92% versus 86%, respectively for dipyridamole versus dobutamine. In the 38 CAD territories, dipyridamole UR was -4.1+/-29.4%, and dobutamine UR was -13.1+/-19.9% (P<0.05). In the 37 no-CAD territories, UR was 34+/-23.6% for dipyridamole and -0.4+/-17.8% for dobutamine (P<0.0001). UR difference between CAD versus no-CAD territories was larger using dipyridamole (P<0.0001) than dobutamine (P<0.005). CONCLUSIONS: The UR comparison confirms that [99mTc]sestamibi uptake underestimates the blood flow heterogeneity induced by dobutamine more than that produced by dipyridamole.

Role of whole-body [18F] fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and conventional techniques in the staging of patients with Hodgkin and aggressive non Hodgkin lymphoma.

PURPOSE: The aim of this study was to evaluate the role of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the staging of Hodgkin's and aggressive non-Hodgkin's lymphoma (HL and NHL), comparing it with conventional diagnostic methods, i.e. contrast-enhanced CT and bone marrow biopsy. MATERIALS AND METHODS: Sixty-five consecutive patients (30 HL and 35 NHL) who underwent conventional disease staging and FDG-PET/CT were included. Concordance between conventional methods and PET was established when both procedures identified the same disease stage. Discordant findings were investigated further by using other diagnostic techniques (ultrasonography or magnetic resonance imaging) and/or clinical follow-up. RESULTS: PET correctly staged 93.8% of enrolled patients (61/65), whereas conventional techniques correctly staged 89.2% (58/65; p=NS, Chi(2) test). There was complete concordance in 54/65 patients (83.1%); among the remaining 11 cases, PET upstaged eight patients (seven true positive and one false positive), and downstaged three (all false negative). In 5/65 patients, chemotherapy treatment was modified on the basis of PET findings. CONCLUSIONS: Our data confirm the high accuracy of FDG-PET/CT in staging HL and NHL. FDG-PET/CT should therefore be used routinely in the initial evaluation of both patient subgroups.

FDG-PET in the detection of bone marrow disease in Hodgkin's disease and aggressive non-Hodgkin's lymphoma and its impact on clinical management.

AIM: Identification of bone marrow disease (BMD) is a crucial step in the diagnostic work-up of patients with lymphoma. In lymphoma staging, bone marrow biopsy (BMb) is considered as the gold standard, despite its limitations. The aim of this study was to compare the usefulness of 2-deoxy-2-[(18)F]fluoro-D-glucose positron emission tomography (FDG-PET) vs BMb in the detection of BMD in patients with Hodgkin's disease (HL) or aggressive non-Hodgkin's lymphoma (NHL) and its impact on therapy. METHODS: A total of 194 consecutive patients with malignant lymphoma were referred for staging. The clinical stage was defined according to the Ann Arbor classification by means of contrast enhanced computed tomography (CT), BMb and whole body FDG-PET/CT scan. Sensitivity, specificity, accuracy in BMD evaluation were calculated for PET and BMb. RESULTS: FDG-PET vs BMb: sensitivity 65.3% vs 55.1%; specificity 98.6% vs 100%; accuracy 90.2% vs 88.7%; positive and negative predictive value 94.1% and 89.3% vs 100% and 86.8%, respectively. Although PET and BMb had similar sensitivity and accuracy, BMD was identified by both methods in only 10 out of 49 patients. There were no significant differences in PET and BMb accuracy between the HL and the NHL patients. Moreover, treatment regimen was changed in 12 patients on the basis of FDG-PET findings. CONCLUSION: Our study demonstrates that BMb and FDG-PET are complementary in the evaluation of BMD. FDG-PET improves the sensitivity of BMb, especially in the presence of focal BMD. Performing FDG-PET before BMb is advised for optimal biopsy site targeting.

Role of whole body positron emission tomography/computed tomography scan with 18F-fluorodeoxyglucose in patients with biopsy proven tumor metastases from unknown primary site.

AIM: The aim of this study was to evaluate the role of whole body PET/CT scan with (18)F-fluorodeoxyglucose (FDG) in the detection of the primary tumor in patients with metastatic cancer from unknown primary origin (CUP syndrome). METHODS: Sixty-eight consecutive patients, with CUP syndrome (39 lymph nodes, 29 visceral biopsy proven tumor metastases), underwent a whole-body FDG-PET/CT study. All enrolled patients were unsuccessfully studied, within the previous month, with physical examination, laboratory tests and conventional diagnostic procedures. All the pathological findings identified at PET/CT scan and suspected for primaries, were further investigated. After PET study, the minimum follow-up period for the inclusion in the studied population was 3 months. RESULTS: The primary tumor site was correctly identified by FDG-PET/CT in 24 patients (24/68, 35.3%): lung (n=9), rino/oro-pharynx (n=6), pancreas (n=5), colon (n=2), uterus (n=2). In 5 cases, FDG-PET scan did not identify a primary pathological focus, which was subsequently detected by other diagnostic methods within 3 months. In 39 patients (39/68, 57.4%), the primary tumor site was not localized. However, in 9 of them, FDG-PET/CT scan identified further unexpected metastases, modifying the stage of disease. Overall, the following oncological treatment was influenced by the PET scan, in a total of 33 patients (33/68, 48.5%). CONCLUSIONS: Our data strongly support the diagnostic contribution of whole body FDG-PET/CT scan in the evaluation of patients with CUP syndrome and suggest its use in an early phase of the diagnostic iter to optimize patient management.

[Lymphoscintigraphic localization of sentinel lymph nodes in colorectal carcinoma in early stage: results of a single center study and proposal of a multicenter protocol]. / Localizzazione linfoscintigrafica del linfonodo sentinella nel carcinoma del colon-retto in stadio precoce risultati di uno studio monocentrico e proposta di un protocollo multicentrico.

In colorectal cancer the sentinel node dissection may help to identify any unusual mesenteric lymphatic drainage pattern from the primary tumor site (ex/skip metastases); assuming that accurate pathological staging is critical for therapeutic decisions we are conducing a study to evaluate the feasibility of the sentinel node technique in colorectal neoplasms and its overall accuracy in predicting regional lymph nodes metastases for appropriate staging. From February 2001 to September 2004 we included in this study 30 patients with rectal lesions or degenerate colonic polyps not radically excised by endoscopy. Lymphatic mapping was performed with low molecular weight albumin colloid labelled with 500Mci of 99mTc in a 2 ml volume and injected submucosally by an endoscopic route at the four cardinal points around the tumor, the afternoon before the surgical procedure, both in case of colonic or rectal lesions. Scintigraphic images were obtained with a gamma camera fitted with a general purpose collimator. The day of the intervention, a hand held gamma detecting probe (Scintiprobe m100, Pol-Hi-Tech, Italy) was employed to detect the "hot" nodes, in vivo and ex vivo. These lymph nodes were tagged with a stitch in vivo; the specimen was removed by a standard resection and SLN were dissected ex vivo and sent separately for pathological examination. In case of rectal lesions, the sentinel nodes were searched ex vivo into mesorectal fat in case. All lymph nodes, including blue or hot ones, were embedded separately for preparation of paraffin sections and haematoxylin and eosin staining. Sentinel lymph node were submitted to multi-seriate sections in order to look for micrometastases. Using the radioactive tracer, sentinel lymph nodes were successfully identified in 27 out of 30 patients. Concordance between SLNs and nodal status was observed in 23 out of 27 cases (85%); two patients (7.4%) were upstaged, as SLN was the only site of metastases. In another two cases we observed no concordance between negative sentinel node and non sentinel nodes (false negative rate, 7.4%). Starting from this experience we are proposing a multicentric trial concerning the value of sentinel node technique in rectal cancer and in early colorectal cancers detected by screening programs.

Pre-operative lymphatic mapping and intra-operative sentinel lymph node detection in early stage endometrial cancer.

Lymphatic mapping and sentinel lymph node (SLN) biopsy are becoming increasingly useful for the identification of tumour lymphatic spread in a wide variety of neoplasms, such as breast cancer and melanoma, reducing unnecessary radical lymph node resection. The aim of our study was to determine the feasibility of lymphatic mapping with both labelled colloid and patent blue violet in patients with early stage endometrial cancer. Sixteen consecutive patients with endometrial cancer, stage International Federation of Gynecology and Obstetrics (FIGO Ib), were included in the study. Lymphoscintigraphy and laparoscopically assisted intra-operative SLN detection were performed in all patients. In addition, to verify the prognostic role of this method, 12 of 16 patients were followed up for a period of at least 1 year. In 15 of 16 patients, 24 SLNs (all internal iliac lymph nodes) were detected at lymphoscintigraphy (six monolateral and nine bilateral). At histological analysis, three of the 24 were positive for micrometastases, whereas the remaining 21 were negative. No other surgically dissected lymph nodes presented metastases. At 1 year of follow-up, none of the 12 patients presented relapse of their disease. In conclusion, in endometrial cancer, both pre-operative lymphoscintigraphy and intra-operative gamma-probe detection of SLNs represent promising tools for the visualization of SLNs. The status of the latter may yield a correct representation of pelvic lymph node involvement, providing important information for further treatment.

Lymphatic mapping in early stage breast cancer: comparison between periareolar and subdermal injection.

The combination of preoperative lymphatic mapping with intra-operative probe detection is becoming the standard procedure for identifying tumour lymphatic spread at the time of initial treatment in breast cancer. There are a number of identification techniques for sentinel lymph nodes, but the concordance of the results of a sentinel lymph node biopsy with axillary lymph node dissection did not vary significantly among them. Periareolar (p.a.) injection of tracer is a new procedure specifically studied to overcome some limitations of other techniques; in two groups of patients with early breast cancer we compared the periareolar with the subdermal technique. One hundred and fifty biopsy proven breast cancer patients were consecutively enrolled in this study. This population was divided into two groups: (1) group A, including 100 cancers; lymphatic mapping was performed by s.d. injection of both blue dye and radiotracer; and (2) group B, including 50 cancers; lymphatic mapping was performed with a combination of blue dye injected p.a. and radiotracer injected s.d. For group A, with both techniques we identified one or more SLNs in 100/100 tumours; blue dye detected the SLNs in 99/100 cancers (99%), lymphoscintigraphy in 93/100 cancers (93%). The concordance rate was 92%. For group B, with both techniques we identified one or more SLNs in 49/50 cancers (98%); blue dye detected the SLNs in 48/50, lymphoscintigraphy in 46/50 cancers (92%). The concordance rate was 92%. In the present study p.a. and s.d. injection of blue dye give similar and comparable results. The periareolar technique is simpler and has several advantages over the subdermal technique.

One year temporal pattern of neurohumoral factors and natriuretic peptides compared with clinical variables in patients with dilated cardiomyopathy.

BACKGROUND: Elevated levels of neuroendocrine peptides and hormones are some of the compensatory mechanisms activated in patients with congestive heart failure. The aim of this study was to describe their time related variability in clinically stable patients and to compare hormones and peptides levels to clinical variables. METHODS: Nineteen patients with history of congestive heart failure due to dilated cardiomyopathy and in sinus rhythm were recruited. At baseline, after 3 months, and at 1 year they underwent 6-min walk test, Minnesota Living with Heart Failure Questionnaire, and blood measurements of ANP, BNP, plasma renin activity, aldosterone, norepinephrine and epinephrine. RESULTS: After 1 year, 17 patients remained clinically stable, and did not change their therapy and functional class. Also echocardiographic data and neurohormonal parameters did not change significantly except for epinephrine that decreased significantly after 3 months and returned to a value similar to the basal one at 1 year. Two outliner values were observed for norepinephrine belonging to the only 2 patients that spontaneously withdrew the ace-inhibitor therapy during the follow-up. CONCLUSIONS: This study indicates that plasma concentration of neurohormones and peptides were fairly stable over 1 year interval in stable patients with mild-moderate heart failure due to dilated cardiomyopathy and that norepinephrine could be considered as the most sensible parameters to monitor therapy compliance.

Sentinel node detection in breast carcinoma.

AIMS AND BACKGROUND: The standard procedure for the evaluation of axillary nodal involvement in patients with breast cancer is still complete lymph node dissection. However, about 70% of patients are found to be free of metastatic disease while axillary node dissection may cause significant morbidity. Lymphatic mapping and sentinel lymph node (SLN) biopsy are changing this situation. METHODS AND STUDY DESIGN: In a period of 18 months we studied 201 patients with breast cancer, excluding patients with palpable axillary nodes, tumors > 2.5 cm in diameter, multifocal or multicentric cancer, pregnant patients and patients over 80 years of age. Before surgery 99mTc-labeled colloid and vital blue dye were injected into the breast to identify the SLN. In lymph nodes dissected during surgery the metastatic status was examined by sections at reduced intervals. Only patients with SLNs that were histologically positive for metastases underwent axillary dissection. RESULTS: We localized one or more SLNs in 194 of 201 (96.5%) patients; when both techniques were utilized the success rate was 100%. Histologically, 21% of patient showed SLN metastases (7.8% micrometastases) and 68% of these had metastases also in other axillary nodes. None of the patients with negative SLNs developed metastases during follow-up. CONCLUSIONS: At present there is no definite evidence that negative SLN biopsy is invariably correlated with negative axillary status; however, our study and those of others demonstrate that SLN biopsy is an accurate method of axillary staging.

Radiolabeled localization of the sentinel lymph node: dosimetric evaluation in personnel involved in the procedure.

AIMS AND BACKGROUND: Peritumoral injection of 99mTc-labeled colloids for lymphoscintigraphy and radioguided surgery does not entail any relevant radiation burden to the patients. The real issue about radiation protection concerns the personnel involved in the procedure besides the nuclear medicine personnel. The aim of our study was to evaluate the cumulative doses to personnel involved during the injection of radiolabeled compounds, under ultrasound or stereotactic guidance and the radiation burden to the personnel involved in the surgical incision of the tumor 24 hours after the administration of 99mTc-labeled colloids. METHODS AND STUDY DESIGN: We performed environmental contamination tests (SMEAR TEST) and exposure evaluation in the operating room. RESULTS: In the operating room the removed activity in the analyzed samples was less than 0.5 Bq/g and exposure to the personnel was less than 6 micro Sv/h. The evaluations made during ultrasound guidance demonstrated an equivalent and effective dose less than 20 microSv. CONCLUSIONS: Our results show that during ultrasound or stereotactic administration of radiolabeled compounds the radiation burden to the personnel involved in the procedure is virtually negligible. The surgeons too are exposed to a negligible radiation dose.