Andrea Volpe

Prognostic accuracy of an artificial neural network in patients undergoing radical cystectomy for bladder cancer : a comparison with logistic regression analysis

To compare the prognostic performance of an artificial neural network (ANN) with that of standard logistic regression (LR), in patients undergoing radical cystectomy for bladder cancer.

Calretinin, β-tubulin immunohistochemistry, and submucosal nerve trunks morphology in Hirschsprung disease: possible applications in clinical practice.

Objectives: The aim of this study was to investigate calretinin and &bgr;-tubulin immunohistochemical expression together with submucosal nerve trunks morphology in differently innervated segments of Hirschsprung disease (HD) and total colonic aganglionosis (TCA). Methods: A total of 25 cases (22 HD, 3 TCA) and 18 controls were processed for calretinin and &bgr;-tubulin immunohistochemistry. Sections representative of distal aganglionic, transition, and proximal ganglionic segments were evaluated by a visual grading score; &bgr;-tubulin was evaluated also by image analysis. Submucosal nerve trunks hypertrophy and hyperplasia were measured by citomorphology. The length of proximal segment was correlated to postoperative bowel function. Results: Controls showed intense calretinin and &bgr;-tubulin staining. In HD and TCA, calretinin staining was related to the presence of ganglion cells: negative in distal, faint in transition, intense in proximal segment. &bgr;-Tubulin staining was weak in all of the segments of HD and negative in TCA. Hypertrophic and hyperplastic nerve trunks characterized aganglionic segment, and progressively decreasing nerve size was observed in transition and ganglionic segments. Transient postoperative constipation, soiling, or enterocolitis was present in 59% of patients with HD without clear relation to proximal segment length or presence of hypertrophic nerve trunks. Conclusions: Calretinin is a reliable marker of the presence of ganglion cells, and, together with nerve hypertrophy, it helps to identify the transition zone. Length and nerve size of proximal segment in resected specimen did not affect the postsurgical intestinal function. Reduced &bgr;-tubulin expression along the entire colonic tract, included proximal ganglionic segments, may represent a potential impairing factor for the enteric neural transmission.

Successful conservative management of handlebar hernia in children.

Handlebar hernia (HH), a rare type of acquired traumatic abdominal wall hernias (TAWH), is mostly due to the impact against the abdominal wall of a bicycle handlebar. HH is usually treated surgically. Several reports describe this condition, but it is still debated if, in uncomplicated cases, surgical repair should be performed at diagnosis, delayed or not performed at all. Herein we describe two consecutive cases of HH in children treated conservatively in a large tertiary center. Patient 1, an 8-year-old boy, was admitted to the emergency department for a minor trauma: on the previous day, while riding his bicycle, he fell and hit his abdomen against one handlebar. He presented with a tender swelling to the right lower abdominal region with a hematoma on the skin above. Ultrasound (US) showed a hernia (15 mm) between the rectus and the internal oblique muscles with herniation, during Valsalva manoeuver, of omentum. The patient elected for follow up: US was repeated at 1, 6 and 12 months, showing progressive decrease of the defect (Fig. 1), with the latter scan showing a 3 mm defect without herniation. Patient 2, a 12-year-old boy, was similarly admitted complaining of a painful bulge in the right lower abdominal quadrant, where, the day before, he fell against the brake lever of his bicycle. A defect of 1 cm with bowel herniation was detectable but reducible. The patient was scheduled for follow up: 2 months later, the hernia was no longer palpable and US identified a 3 mm defect without herniation. The parents refused any further follow up due to the lack of symptoms. Several classification systems of TAWH have been previously described. Each system distinguishes TAWH according to location; force of injury and hernia size; mechanism; and type of accident; the classification system used in children differentiates TAWH according to the amount of energy involved with or without the size of the hernia. Type I TAWH includes defects caused by blunt trauma with objects such as a bicycle handlebar. Type II includes defects caused by high-energy trauma (motorbike/motor vehicle accidents without the involvement of seatbelts, or falls from height). Type III includes defects caused by decelerating forces (seatbelt injuries). The mechanism through which HH occurs has already been elucidated: the blunt force is not able to penetrate the skin due to its elastic nature, but the energy is transferred to the fascia and muscles and this, together with the increase of intraabdominal pressure, lead to a disruption of these elements. More frequently the traumatic hernia occurs at anatomic weak points (inguinal region or laterally to the rectus muscle). Handlebar hernia can be diagnosed solely on physical examination. US has been reported as useful, but diagnosis has also been obtained with computed tomography (CT) only. In the present experience, diagnosis was achieved clinically: US was performed to exclude bowel herniation/strangulation and to assess the fascial defect. It would therefore be reasonable to limit the use of CT to critically ill patients or those with associated injuries. A total of 60 cases of TAWH in children have been described, >80% of which were HH, with associated injuries in <10%. Most cases were treated surgically (with open or mini-invasive approach) at the time of diagnosis, or later with delayed repair; the use of prosthetic mesh has been occasionally described.

Accessory‐lobed accessory cardiac bronchus: Presentation and treatment in a pediatric patient

Accessory cardiac bronchus (ACB) is a supernumerary bronchus usually arising from right main or intermediate bronchus. We report the case of a 9‐year‐old male who presented a 6‐month history characterized by two right pneumonia episodes followed by persistent productive cough, recurrent bloody sputum, and chest x‐ray persistence of a segmental thickening of right inferior lobe. Bronchoscopy revealed no abnormalities. Computed tomography documented an accessory‐lobed ACB originating from right lower brochus. Surgical removal of ACB and related parenchyma was approached thoracoscopically and converted to thoracotomy for evidence of a bronchial injury. Two‐year follow‐up showed no recurrent infections or respiratory symptoms.

Anti-Glypican 3, a Novel Ancillary Maker in the Histological Assessment of Hirschsprung's Disease.

Objectives: Hirschsprungs disease (HSCR) results from a malformation of the enteric nervous system. A congenital absence of intrinsic ganglion cells from the distal rectum and a variable length of the contiguous bowel is the required diagnostic feature of Hirschsprungs disease and total colonic aganglionosis (TCA). We evaluated the utility of a monoclonal antibody directed against glypican 3 (GPC-3), a membrane bound protein involved in regulation of the signaling of Wingless-types (WNTs), Hedgehogs (Hh), Fibroblast Growth Factors (FGFs), and Bone Morphogenetic Proteins (BMPs), in the detection of ganglion cells in formalin-fixed, paraffin-embedded tissue sections. Methods: The presence/absence of ganglion cells was evaluated retrospectively by immunohistochemical staining for calretinin and GPC-3 in tissue specimens; a total of 15 patients who underwent colectomy (total or sub-total) for histologically proven aganglionosis (14 HSCR, 1 TCA) and 5 rectal suction biopsies (4HSCR-B, 1 TCA-B) were considered. Of the 20 considered cases, a total of 60 tissue specimens (3 for each patient) were selected. A total of 30 additional normal (N) colonic mucosa biopsy samples were also included. Results: GPC-3 constantly identified ganglion cell bodies in all but 2 normal biopsies (with normal presentation of ganglion cells on hematoxylin and eosin (H&E) stain), and was negative in all 60 aganglionotic biopsies; these results were reflective of calretinin staining pattern. Conclusions: The present study indicates that monoclonal anti-GPC-3 might prove to be useful immunohistochemical marker in the identification of ganglion cells in paraffin-embedded rectal tissue specimens and suction biopsies. Further studies in larger series will contribute to demonstrate its utility as an ancillary marker in the histological assessment of HSCR aganglionosis.

FISH Assay for THE Detection of Bladder Cancer

We evaluated the sensitivity and specificity of fluorescence in situ hybridization (FISH) performed on the urine specimens of patients under follow-up for superficial bladder cancer. Thirty-seven patients were enrolled and underwent cystoscopy, urinary cytology or biopsy and FISH examination. Urinary cytology and FISH were evaluated in exfoliated urothelial cells from bladder washings. A mixture of fluorescent labeled probes to the centromere of chromosomes 3, 7 and 17, and locus 9p21 was used to assess urinary cells for chromosomal abnormalities indicative of malignancy. Nine patients (24.3%) showed an abnormal cystoscopy, but only five patients showed transitional cell carcinoma at histology. Eighteen patients (48.6%) showed an abnormal FISH: one patient (2.7%) had a positive cytology, and three patients (8.1%) showed an atypical cytology. Patients with both positive cystoscopy and histological examination had a positive FISH, while only one patient had a positive cytology. Patients with positive cystoscopy and negative histological examination had a negative FISH. Three patients with negative cystoscopy and suspicious cytology had a positive FISH. Ten patients (27%) with both negative cystoscopy and cytology had a positive FISH. The sensitivity of the FISH assay was 100%, 50% for the cytology and 62% for the cystoscopy. The specificity of the FISH assay, cytology and cystoscopy were 66%, 100% and 86%, respectively. The sensitivity of the FISH assay in detecting non-invasive urothelial tumors is worth further studies.