Antonella Bianchi

Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure?

OBJECTIVE To determine whether the stripping technique by laparoscopy is a tissue-sparing procedure. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Forty-two women, 21 to 35 years of age, who had a unilateral ovarian cyst (26 endometriomas, 7 serous, 6 dermoid, and 3 mucinous cysts). INTERVENTION(S) Laparoscopic excision of ovarian cysts by using the stripping technique. MAIN OUTCOME MEASURE(S) Histologic analysis of the excised specimens was done to evaluate the presence and nature of ovarian tissue adjacent to the cyst wall. RESULT(S) Recognizable ovarian tissue adjacent to the cyst wall was present in 15 of 42 excised specimens (36%). A significant difference was present for endometriomas versus non-endometriosis cysts (ovarian tissue was present in 14 of 26 specimens [54%] vs. 1 of 16 specimens [6%]; P<.005). No specimen showed the normal follicular pattern observed in healthy ovaries. CONCLUSION(S) The stripping technique appears to be a tissue-sparing procedure. In 36% of the cysts, ovarian tissue is excised together with the cyst wall, but this tissue does not show the morphologic characteristics observed in normal ovarian tissue.

Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: Does the surgeon matter?

OBJECTIVE To evaluate whether the amount of ovarian tissue inadvertently removed along with the endometrioma cyst wall at laparoscopy differs in relation to the operating surgeons level of expertise. DESIGN Multicenter, prospective trial. SETTING Four tertiary care university hospitals. PATIENT(S) Fifty patients, aged 25 to 40 years, with monolateral ovarian endometriomas who underwent laparoscopic excision. INTERVENTION(S) Operation with the stripping technique by surgeons with specific expertise in endometriosis surgery in four centers (groups A, B, C, and D) and by residents with average training in laparoscopic surgery (group E). MAIN OUTCOME MEASURE(S) Histologic examination for the evaluation of the mean thickness of the cyst wall from each specimen, and the mean thickness and morphologic characteristics of any ovarian tissue removed. RESULT(S) No statistically significant differences were present in the rate of presence of ovarian tissue in the endometrioma wall specimens from the different groups (44%, 45%, 55%, 56%, and 60% in groups A, B, C, D, and E, respectively). For groups A+B+C+D versus group E, a statistically significant difference was found in the mean thickness of the tissue specimens (1.51 mm vs. 1.91 mm, respectively) and in the mean thickness of ovarian tissue inadvertently excised (0.49 mm vs. 0.97 mm, respectively). CONCLUSION(S) Level of expertise in endometriosis surgery is inversely correlated with inadvertent removal of healthy ovarian tissue along with the endometrioma capsule.

High density of CD68+/CD163+ tumour‐associated macrophages (M2‐TAM) at diagnosis is significantly correlated to unfavorable prognostic factors and to poor clinical outcomes in patients with diffuse large B‐cell lymphoma

To the Editor Tumour-Associated Macrophages (TAM) may have both anti-tumoural and tumour-promoting functions, depending on their acquired immunophenotype (M1 or M2). Recent studies have shown that TAM expression was related with prognosis in hematologic malignancies, particularly in Hodgkin’s lymphoma [1]. However, the role of microenvironment in diffuse large B-cell lymphoma (DLBCL) has been less studied in the last years, and contrasting results about the role of TAM concentration on prognosis were obtained. Hasselblom et al. demonstrated that it is not possible to predict worse clinical outcomes in terms of disease-free survival (DFS) and overall survival (OS) in DLBCL patients just evaluating CD68+ TAM concentration [2], whereas other studies showed that high TAM density was significantly related to poor prognosis [3] and worse therapy-response [4]. More recently, Nam et al. suggested that an increase ofM2-TAM predicts poor outcome in DBLCL patients treated with R-CHOP regimen [5]. The aim of this study is to quantify TAM concentration making use of a double immunofluorescence in DLBCL patients at diagnosis and to evaluate the presence of a significant correlation between the prevalent subtype of macrophages, clinical and biological disease features and clinical outcomes in terms of therapy response, DFS and OS. Sixty-one patients diagnosed with de novo DLBCL were enrolled in our study. Fifty-seven patients were treated with R-CHOP regimen (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone), whereas the remaining four received R-CHOP-like regimens (with liposomal Doxorubicin). Every patient gave an informed written consent to authorize sensitive data processing for scientific purposes; this study has been approved by a local Ethical Committee. Treatment responses were evaluated according to Cheson’s criteria [6]. Different subtypes of macrophage infiltration were identified by a double indirect immunofluorescence for CD68/CD163 (M2) and CD68/HLA-DR (M1). Antibodies against CD68 were used as primary antibodies to recognise CD68+ cells. Then we used a secondary antibody (Ab) binding the Fc fragment of the primary Ab. The secondary Ab was marked with Alexa Fluor 488 fluorochrome (Life

Rituximab as Single Agent in Primary MALT Lymphoma of the Ocular Adnexa

Ocular Adnexal Lymphomas are the first cause of primary ocular malignancies, and among them the most common are MALT Ocular Adnexal Lymphomas. Recently systemic immunotherapy with anti-CD20 monoclonal antibody has been investigated as first-line treatment; however, the optimal management for MALT Ocular Adnexal Lymphomas is still unknown. The present study evaluated retrospectively the outcome of seven consecutive patients with primary MALT Ocular Adnexal Lymphomas, of whom six were treated with single agent Rituximab. All patients received 6 cycles of Rituximab 375 mg/mq every 3 weeks intravenously. The overall response rate was 100%; four patients (67%) achieved a Complete Remission, and two (33%) achieved a partial response. In four patients an additional Rituximab maintenance every 2-3 months was given for two years. After a median follow-up of 29 months (range 8–34), no recurrences were observed, without of therapy- or disease-related severe adverse events. None of the patients needed additional radiotherapy or other treatments. Rituximab as a single agent is highly effective and tolerable in first-line treatment of primary MALT Ocular adnexal Lymphomas. Furthermore, durable responses are achievable with the same-agent maintenance. Rituximab can be considered the agent of choice in the management of an indolent disease in whom the “quality of life” matter is of primary importance.

PD-1/PD-L1 expression in extra-medullary lesions of multiple myeloma.

Multiple myeloma patients may develop extraosseous involvement in the course of the disease making prognosis very poor and new drugs clearly needed. The PD-1/PD-L1 axis has emerged as a master immune checkpoint in antitumor responses and recent studies investigated the role of PD-L1 in multiple myeloma cells; no data however are still available about PD-L1 expression in extramedullary localizations. We demonstrate PD-L1 expression in 4/12 cases of extraosseous myeloma suggesting that these lesions represent a specialized microenvironment. We found presence of PD-1+ infiltrating lymphocytes in all observed cases supporting the relevance of PD-1/PD-L1 checkpoint in extramedullary myeloma. We also investigated the correlation in PD1/PD-L1 staining between marrow staining and EMP lesions.

PD-1 /PD-L1 checkpoint in hematological malignancies

Programmed cell death protein 1 (PD-1), is a cell surface receptor with an important role in down-regulating the immune system and promoting self-tolerance by suppressing T cell inflammatory activity. PD-1/PDL1 axis represents a checkpoint to control immune responses and it is often used as a mechanism of immune escaping by cancers and infectious diseases. Many data demonstrate its important role in solid tumors and report emerging evidences in lymphoproliferative disorders. In this review, we summarized the available data on the role of PD-1/PD-L1 checkpoint in lymphoproliferative diseases and the therapeutics use of monoclonal blocking antibodies.

Intravascular Lymphoma: Look for the Less Obvious!

Intravascular large B cell lymphoma (IVBCL) is a rare subtype of extranodal large B-cell lymphoma with a distinct presentation. Anatomically the disease is characterized by the proliferation of clonal lymphocytes within small vessels with relative sparing of the surrounding tissue. The clinical symptoms of the disease are dependent on the specific organ involvement, which often includes the central nervous system and skin. Because of the various modes of presentation and the rarity of IVBCL, the diagnosis is challenging and made post-mortem in most cases. The tumor is often disseminated at the time of diagnosis and prognosis is poor, even with aggressive chemotherapy. The spectrum of neurological presentations of IVBCL can be heterogeneous. We report a case of intravascular lymphoma diagnosed on autopsy.

PD-L1/PD-1 Check Point in Anaplastic Large Cell Lymphoma, ALK+: A Case Report with Immunohistochemical and Molecular Study

Anaplastic large cell lymphoma, ALK+ (ALK+ ALCL) is a T-cell lymphoma consisting of large and pleomorphic lymphoid cells, often with horseshoe-shaped nuclei, with a chromosomal translocation involving the ALK gene and expression of ALK protein and CD30. ALK+ ALCL must be distinguished from primary cutaneous ALCL and from other subtype of T-cell or B-cell lymphoma with anaplastic features and/or CD30 expression. PD-L1/PD-1 check point physiologically plays a key role in induction and maintenance of immune tolerance to self-antigens and limits normal immune response against microorganisms. PD-L1 has been demonstrated in the whole spectrum of normal hematopoietic and non-hematopoietic cells, as well as in a large variety of epithelial cells. Moreover, it is also very commonly expressed by a large number of malignant cell types of epithelial and hematopoietic cell origin, and its activation is one of the major mechanisms exerted by neoplastic cells to evade elimination by the host immune system. Here we report a case of an ALK+ ALCL, with confirmed FISH rearrangement of ALK gene, PD-L1-positive and discuss the molecular mechanism involved in its immunohistochemical profile.

Composite Mantle-Cell Lymphoma and Classical Hodgkin Lymphoma in a Very Old Adult

because of atypical presentation, limited history, and presence of multiple pathologies. Abdominal pain and hematuria are typical symptoms of EC, but they are present in only 80% and 50% of cases, respectively. The symptoms are not uncommon in elderly adults, but they are often treated for uncomplicated UTIs. Plain abdominal radiograph is highly sensitive (90%), and computed tomography is the most sensitive and specific diagnostic tool. Abdominal radiographs are not routinely performed in elderly adults with UTI. The mechanism of gas formation is not exactly known. Given its prevalence in individuals with diabetes mellitus and those with urinary retention, several theories have suggested fermentation of glucose or albumin in urine as plausible mechanism for the gas formation within the affected tissue. Escherichia coli and Klebsiella pneumoniae have been the commonest pathogens associated. EC is usually treatable with medical therapy alone, but bladder irrigation may be needed if blood clots are present, as in the woman described herein. Rarely, bladder debridement and partial or total cystectomy are required. Overall mortality is 9%. In conclusion, UTI and cystitis are common diagnoses in elderly adults, and plain abdominal X-ray is not routinely ordered unless there is suspicion of renal calculi. This woman with diabetes mellitus presented with typical symptoms of EC, namely abdominal pain and hematuria, but diagnosis of EC was incidentally revealed on plain film ordered to look for renal calculus. Geriatricians and internists should consider this rare condition, and with early imaging, timely diagnosis and treatment will lower morbidity and mortality.

Desmoid tumor occurrence in female siblings not associated with familial adenomatous polyposis: genetic or sporadic form?

Sir, Desmoid tumors (DTs) are rare tumors which belong to heterogenous group of soft tissue tumors. Affected patients usually fall within the age range of 10–40 years, with a higher prevalence among women during their fertile period [1]. Desmoids may occur either sporadically or as an extra-colonic manifestation of familial adenomatous polyposis (FAP). This association was first discovered by Nichols in 1923 [2] and confirmed by McAdam and Goligher in 1970 [3]. Genetic factors involved in DTs are not completely known, although mutations of APC or β-catenin genes are probably to be the main factors for tumor development, especially in FAP-associated forms [4]. Nonetheless, causes of DTs are still uncertain. Besides specific mutations in the APC gene, risk factors for the development of DTs include even previous surgical procedures, pregnancy, and female sex. Trauma in the tumor site may elicit DTs. It seems that the increased risk after surgery may be due to the activation of fibroblasts, normally involved in repairing tissue damage [5]. Sporadic DTs are more common in female than in male patients. This can be explained by the regulatory role which estrogens play. Indeed, fibroblasts have been demonstrated to exhibit a proliferative response to estrogens; on the other hand, there are evidences of regression of tumors by estrogens blockade and their occasional disappearance after menopause [6]. About 50 % of DTs recur in anterior abdominal wall and arise from musculoaponeurotic structures, especially the rectus and internal oblique muscles and their fascial coverings, and occasionally from the external oblique muscle and the transversalis muscle or fascia [7]. We describe the case of two female siblings who developed abdominal wall desmoids within 5 months apart from each other. They had no family history of FAP and colorectal diseases, but both had previous surgery. A 34-year-old woman was admitted to our hospital for the presence of a palpable, painless lesion in the sovrapubic area, fixed to the abdominal wall. The M. Langella :A. L. Pendolino (*) : P. F. Delle Femmine : P. Persichetti Plastic and Reconstructive Surgery Unit, Università Campus Bio-Medico di Roma, 00128 Rome, Italy e-mail: lucapendolino@msn.com