Maurizio Vertemati

Rapid disappearance of hepatic adenoma after contraceptive withdrawal.

We present the case of a 25-year-old woman who developed a large central liver adenoma after 8 years of continuous oral contraceptive use. The first diagnosis was made by ultrasonography, after a rise in plasmatic gamma-glutamyl-transpeptidase and alkaline phosphatase levels was noted. Withdrawal of the oral contraceptive was followed by shrinkage of the adenoma, with complete disappearance 9 months after the diagnosis. Hepatic adenoma (HA) still presents problems in terms of differential diagnosis and clinical management. There are reports of complete or partial regression of an HA after discontinuation of oral contraceptives, but they are poorly documented. To our knowledge, a patient with such rapid disappearance of a large HA has never been reported.

Is lymphocele in renal transplantation an avoidable complication

BACKGROUND This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx). METHODS A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft. RESULTS Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C. CONCLUSIONS A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.

Analysis of Histological and Immunohistochemical Patterns of the Liver in Posthepatitic and Alcoholic Cirrhosis by Computerized Morphometry

To assess the degree of fibrosis and the structural changes affecting parenchymal and extraparenchymal components in liver cirrhosis, a computerized morphometric model has been applied to liver specimens from patients with posthepatitic and alcoholic cirrhosis. All specimens have been stained with chromotrope-aniline blue method and monoclonal antibodies against cytokeratin 7, CD31, and VIII factor. Volume fractions of parenchymal compartment and fibrosis have been determined stereologically on CAB slices; moreover, volume fractions of portal bile ducts and proliferated bile ductules, hepatocytes with biliary metaplasia, capillary units, and vascular structures have been measured. Volume fraction of fibrosis was higher in alcoholic cirrhosis when compared with the case of posthepatitic cirrhosis. Volume fractions describing parenchymal compartment showed a similar trend in both viral groups. The main differences were related to immunohistochemical stainings. Volume fraction of hepatocytes with biliary metaplasia was higher in hepatitis C virus-related cirrhosis, whereas volume fractions of biliary structures were more prominent in hepatitis B virus-related cirrhosis. Capillary units were more prominent in posthepatitic cirrhosis than in alcoholic cirrhosis. Interestingly, both forms of posthepatitic cirrhosis show similar features when compared with alcoholic cirrhosis. Our computerized morphometric model well describes and quantifies the morphological alterations of the liver, and it could represent an adjunctive tool to evaluate the degree of dysplastic phenomena involving parenchymal and extraparenchymal components.

Liver transplantation in man: morphometric analysis of the parenchymal alterations following cold ischaemia and warm ischaemia/reperfusion

Ischaemia and reperfusion phases represent critical events during liver transplantation. The purpose of this study was to describe morphological alterations of both vascular and parenchymal compartments after ischaemia and reperfusion and to evaluate the possible relationship between morphometric parameters and biochemical/clinical data. Three needle biopsies were drawn from 20 patients who underwent orthotopic liver transplantation. The first biopsy was taken before flushing with preservation solution, and the second and the third to evaluate respectively the effects of cold ischaemia and of warm ischaemia/reperfusion. Biopsies were examined by an image analyser and morphometric parameters related to the liver parenchyma were evaluated. At the second biopsy we observed a decrease of the endothelium volume fraction while the same parameter referred to the sinusoidal lumen achieved a peak value. The hepatocytes showed a lower surface parenchymal/vascular sides ratio. This parameter was reversed at the end of the reperfusion phase; furthermore the third biopsy revealed endothelial swelling and a decreased volume fraction of the sinusoidal lumen. The results quantify the damage to the sinusoidal bed which, as already known, is one of the main targets of cold ischaemia; warm ischaemia and reperfusion accentuate endothelial damage. The end of transplantation is characterised by damage chiefly to parenchymal cells. Hepatocytes show a rearrangement of their surface sides, probably related to the alterations of the sinusoidal bed. In addition, the fluctuations of morphometric parameters during ischaemia/reperfusion correlate positively with biochemical data and clinical course of the patients.

Morphometric analysis of hepatocellular nodular lesions in HCV cirrhosis.

We generated a computerized morphometric model to evaluate and quantify the morphological features in large regenerative nodules (LRN), high-grade dysplastic nodules (HGDN) and hepatocellular carcinoma (HCC). Sixteen LRN, 10 HGDN and 16 HCC in HCV-cirrhotic livers were stained with H&E, smooth muscle actin, CD34, CD31 and reticulin to evaluate volume and surface fractions. On H&E stains, the most discriminatory features between LRN, HGDN and HCC were volume fraction and the number of hepatocyte nuclei in unit volume and hepatocyte nuclear/cytoplasmic ratio. On immunohistochemistry, volume fractions of capillarised sinusoids, capillary units and isolated arteries were significantly different among all groups and highest in HCC; surface fraction of reticulin was markedly decreased in HCC. Our morphometric model is an objective method for quantification of the morphological changes of the nodular lesions, and it could be applied to studies involving histological evaluation of the spectrum of nodular lesions arising in the cirrhotic liver.

In vitro human osteoblast and extracellular matrix changes after transforming growth factor beta 1 treatment

Aims: Normal bone tissue is characterised by a balancing of osteoblast and osteoclast activity. The activity and differentiation of these cells are regulated by vitamins, hormones and cytokines. The action of these factors on bone tissue cells depends on the composition and mineralisation of extracellular bone matrix. In particular, transforming growth factor beta 1 (TGF&bgr;1) acts on collagen fibres, glycosaminoglycan secretion and on the enzymes correlated to the turnover of glycosaminoglycans. The normal functions of bone tissue also depend on its mineralisation, which is highly altered in the process of uraemia. Methods: In this study, we analysed in vitro the effect of transforming growth factor β on osteoblast proliferation, collagen synthesis and glycosaminoglycan secretion with 3H‐thymidine, 3H‐proline or 3H‐glucosamine incorporation, and on enzymes, such as &bgr;‐N‐acetyl‐D‐glucosaminidase and &bgr;‐glucuronidase, involved in extracellular matrix turnover. Moreover, phosphatase alkaline activity and osteocalcin related to mineralisation of extracellular matrix were determined. Results: Our data show that TGF&bgr;1 significantly decreases 3H‐thymidine and 3H‐proline incorporation and increases (p⩽0.01) extracellular sulphated glycosaminoglycan synthesis. It also increases osteocalcin levels, phosphatase alkaline, &bgr;‐N‐acetyl‐D‐glucosaminidase and &bgr;‐glucoronidase activities. Conclusion: TGF&bgr;1 changes the synthesis of extracellular matrix components by osteoblasts. These variations favour the action of cytokine and osteoclasts. Since the TGF&bgr;1 accumulates in bone tissue and increases during uraemia, with due limitations this action leads to an imbalance between synthesis and degradation and could explain bone alterations in uraemic patients.

Morphometric analysis of primary graft non-function in liver transplantation

Aims : Primary graft non‐function (PNF) is a life‐threatening condition that is thought to be the consequence of microcirculation injury. The aim of the present study was to assess, with a computerized morphometric model, the morphological changes at reperfusion in liver biopsy specimens from patients who developed PNF after liver transplantation.

A morphometric model to minimize subjectivity in the histological assessment of hepatocellular carcinoma and its precursors in cirrhosis

Objective: To explore how morphometry can minimize subjectivity in the assessment of liver nodules in cirrhosis using a novel classification tool. Study design: Ten hepatocellular carcinoma (HCC), 6 large regenerative nodules (LRN), and 34 regenerative (cirrhotic) nodules (RN), obtained from cirrhotic explant livers, were analyzed using a Kontron‐Zeiss KS400 image analyzer. We generated a morphometric model based on the analysis of volume fractions occupied by hepatocyte nuclei/cytoplasm, sinusoidal endothelium and lumen, neoplastic acini, fibrosis, centrilobular veins, portal arteries, veins and bile ducts, individual lesional arteries (smooth muscle actin), and capillarized sinusoids (CD34), and on surface fraction occupied by reticulin, and number in unit volume and size distribution of hepatocyte nuclei, and mean hepatocyte nucleus diameter and volume. Results: Volume fraction of capillarized sinusoids and of individual lesional arteries were more prominent in HCC and LRNs, when compared with RN, whereas surface fraction of reticulin was markedly decreased in HCC. The morphometric values of these three features were integrated into our classification tool to construct a hybrid system, which reclassified the nodules in the same categories. Conclusion: Our novel hybrid classification tool may minimize subjectivity in the histological assessment of nodular lesions in cirrhosis. Microsc. Res. Tech., 2008.

Diphenylhydantoin plays a role in gene expression related to cytoskeleton and protein adhesion in human normal palate fibroblasts

Aims: Morphogenetic processes during palate development are related to extracellular matrix composition. The cell–extracellular matrix relation plays a role in cell activity and in gene expression. We studied the effect of diphenylhydantoin, a teratogen known to induce cleft palate in human newborns, on extracellular matrix production. We investigated whether diphenylhydantoin treatment caused any differences in glycosaminoglycans, collagen synthesis and gene expression in human normal palate fibroblasts. Methods: Human palate fibroblasts were maintained for 24 hours in serum‐free 199 medium containing 5 µg/mL 3H‐glucosamine or 3H proline hydrochloride. Collagen and glycosaminoglycan classes were then measured using biochemical methods, gene expression with microarray analysis and cytoskeleton components with immunofluorescent antibodies and computer analysis. Results: In normal fibroblasts diphenylhydantoin reduced collagen and glycosaminoglycan synthesis with a marked effect on sulphated glycosaminoglycans. There were also substantial decreases in tubulin, vimentin and alpha‐actin staining and an increase of vinculin compared to controls. Diphenylhydantoin acted on several genes related to the synthesis of cytoskeleton and adhesion membrane proteins. It inhibited caderin, caveolin, RTK and alpha‐actin, and increased nectin, cytoplasmatic FRG vinculin, ITGA, ITGB extracellular matrix ligand and EDG2 gene expression. DNA binding gene expression, which plays a role in cell growth and senescence, was activated. Conclusions: Since cell activity is dependent on the cell morphology and extracellular matrix composition, these findings indicate that in human normal palate fibroblasts diphenylhydantoin can modify cytoskeletal components and extracellular matrix–cell adhesion, with consequent effects on gene expression. These changes might be related to anomalous palate development.

Endoscopic ultrasound-guided fine-needle aspiration for suspected malignancies adjacent to the gastrointestinal tract.

AIM To investigate the impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in association with a multidisciplinary team evaluation for the detection of gastrointestinal malignancies. METHODS A cohort of 1019 patients with suspected malignant lesions adjacent to the gastrointestinal tract received EUS-FNA after a standardized multidisciplinary team evaluation (MTE) and were divided into 4 groups according to their specific malignant risk score (MRS). Patients with a MRS of 0 (without detectable risk of malignancy) received only EUS without FNA. For patients with a MRS score ranging from 1 (low risk) - through 2 (intermediate risk) - to 3 (high risk), EUS-FNA cytology of the lesion was planned for a different time and was prioritized for those patients at higher risk for cancer. The accuracy, efficiency and quality assessment for the early detection of patients with potentially curable malignant lesions were evaluated for the whole cohort and in the different classes of MRSs. The time to definitive cytological diagnosis (TDCD), accuracy, sensitivity, specificity, positive and negative predictive values, and the rate of inconclusive tests were calculated for all patients and for each MRS group. RESULTS A total of 1019 patients with suspected malignant lesions were evaluated by EUS-FNA. In 515 patients of 616 with true malignant lesions the tumor was diagnosed by EUS-FNA; 421 patients with resectable lesions received early surgical treatment, and 94 patients received chemo-radiotherapy. The overall diagnostic accuracy for the 1019 lesions in which a final diagnosis was obtained by EUS-FNA was 0.95. When patients were stratified by MTE into 4 classes of MRSs, a higher rate of patients in the group with higher cancer risk (MRS-3) received early treatment and EUS-FNA showed the highest level of accuracy (1.0). TDCD was also shorter in the MRS-3 group. The number of patients who received surgical treatment or chemo-radiotherapy was significantly higher in the MRS-3 patient group (36.3% in MRS-3, 10.7% in MRS-2, and 3.5% in MRS-1). CONCLUSION EUS-FNA can effectively detect a curable malignant lesions at an earlier time and at a higher rate in patients with a higher cancer risk that were evaluated using MTE.