Vittorio Perrone

High-Throughput MicroRNA (miRNAs) Arrays Unravel the Prognostic Role of MiR-211 in Pancreatic Cancer

Background Only a subset of radically resected pancreatic ductal adenocarcinoma (PDAC) patients benefit from chemotherapy, and identification of prognostic factors is warranted. Recently miRNAs emerged as diagnostic biomarkers and innovative therapeutic targets, while high-throughput arrays are opening new opportunities to evaluate whether they can predict clinical outcome. The present study evaluated whether comprehensive miRNA expression profiling correlated with overall survival (OS) in resected PDAC patients. Methodology/Principal Findings High-resolution miRNA profiles were obtained with the Torays 3D-Gene™-miRNA-chip, detecting more than 1200 human miRNAs. RNA was successfully isolated from paraffin-embedded primary tumors of 19 out of 26 stage-pT3N1 homogeneously treated patients (adjuvant gemcitabine 1000 mg/m2/day, days-1/8/15, every 28days), carefully selected according to their outcome (OS<12 (N = 13) vs. OS>30 months (N = 6), i.e. short/long-OS). Highly stringent statistics included t-test, distance matrix with Spearman-ranked correlation, and iterative approaches. Unsupervised hierarchical analysis revealed that PDACs clustered according to their short/long-OS classification, while the feature selection algorithm RELIEF identified the top 4 discriminating miRNAs between the two groups. These miRNAs target more than 1500 transcripts, including 169 targeted by two or more. MiR-211 emerged as the best discriminating miRNA, with significantly higher expression in long- vs. short-OS patients. The expression of this miRNA was subsequently assessed by quantitative-PCR in an independent cohort of laser-microdissected PDACs from 60 resected patients treated with the same gemcitabine regimen. Patients with low miR-211 expression according to median value had a significantly shorter median OS (14.8, 95%CI = 13.1–16.5, vs. 25.7 months, 95%CI = 16.2–35.1, log-rank-P = 0.004). Multivariate analysis demonstrated that low miR-211 expression was an independent factor of poor prognosis (hazard ratio 2.3, P = 0.03) after adjusting for all the factors influencing outcome. Conclusions/Significance Through comprehensive microarray analysis and PCR validation we identified miR-211 as a prognostic factor in resected PDAC. These results prompt further prospective studies and research on the biological role of miR-211 in PDAC.

Renal cell carcinoma with caval involvement: Contemporary strategies of surgical treatment

OBJECTIVES We retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition. MATERIALS AND METHODS From 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration. RESULTS Two patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6-90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxons test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418). CONCLUSIONS Despite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.

Incidence, Diagnosis, and Treatment of Chylous Leakage After Laparoscopic Live Donor Nephrectomy

Background. Chylous leakage (CL) is a rare complication of laparoscopic live donor nephrectomy (LLDN). It may lead to malnutrition and immunological deficits because of protein and lymphocyte depletion. Methods. Data from 208 consecutive LLDN performed at two institutions, between April 2000 and September 2010, were reviewed to identify the anatomical basis behind CL along with its diagnostic and therapeutic options. Results. CL developed in eight donors (3.8%), as determined by high-volume drainage (range 540–800 mL/24 hr) of triglyceride-rich fluid. All donors were managed conservatively. Seven were put on total parenteral nutrition plus octreotide. One received low-fat diet, medium-chain triglyceride supplementation, and octreotide. Chylous fistulas resolved in 5 to 16 days (mean time 12.3 days). Drains were removed before hospital discharge, and no donor was readmitted and/or needed outpatient care. Conclusions. CL is a potentially insidious and perhaps misdiagnosed complication after LLDN. It occurs in nearly 4% of LLDN and it seems to be uniquely associated to left-sided kidney recovery because of distinctive lymphatics distribution around the periaortic area of dissection. Conservative therapy is effective in most donors and should be initially attempted. Surgical ligatures or fibrin sealants may be indicated in case of refractory CL before the arising of malnutrition and/or relevant immunodeficiency.

Update on pancreatic transplantation on the management of diabetes

Pancreas transplantation is the only therapy that can restore insulin independence in beta-cell penic diabetic recipients. Because of the need for life-long immunosuppression and the intial surgical risk associated with the transplant procedure, Pancreas transplantation is a therapeutic option only in selected diabetic patients. Based on renal function, three main populations of diabetic recipients of a pancreas transplant can be identified: uremic patients, posturemic patients (following successful kidney transplantation), and non-uremic patients. Uremic patients are best treated by simultaneous kidney-pancreas transplantation with grafts obtained from the same deceased donor. Posturemic patients can receive a pancreas after kidney transplantation, if the previous renal graft has a good functional reserve. Non-uremic patients can receive a pancreas alone transplant if their diabetes is poorly controlled, despite optimal insulin therapy, suffer from unawareness hypoglycemia events and/or develop progressive chronic complications of diabetes. The results of pancreas transplantation have improved over the years and are currently not inferior to those of renal transplantation in non-diabetic recipients. A functioning pancreatic graft can prolong the life of diabetic recipients, improves their quality of life, and can halt, or reverse, the progression of chronic complications of diabetes. Unfortunately, because of ageing of donor population and lack of timely referral of potential recipients, the annual volume of pancreas transplants is declining. Considering that the results of pancreas transplantation depend on center volume, and that adequate center volume is required also for training of newer generations of transplant physcians and surgeons, centralization of pancreas transplantation activity should be considered.

The odd case of a small and mucinous-like acinar cell cystoadenocarcinoma of the pancreas

Improvement of imaging has made the incidental diagnosis of pancreatic cysts very common. Interpretation of diagnostic information, however, is not always straightforward. We report on one of such patients, initially thought to have a mucinous cystic tumor of the pancreas, and eventually diagnosed with a higher grade acinar cell cystoadenocarcinoma (ACC). In April 2009, a 63-year old woman underwent total gastrectomy because of gastric cancer (undetermined tumor type, T2bN0M0–G1; 48 examined lymph nodes). During preoperative work-up contrast enhanced computed tomography (CT) showed a uniloculated cystic lesion in the head of the pancreas. During gastrectomy the cyst was aspirated. Cytology revealed protein rich fluid without evidence of epithelial cells. The patient underwent a 4 month course of multi-agent adjuvant chemotherapy, based on FOLFIRI (irinotecan, 5-fluoracil, and folinic acid), platinum and taxotere. During the follow-up CT showed progressive increase of the size of the cyst up to 30 mm, and the patient was referred to our center. Magnetic resonance cholangiopancreatography and CT (Fig. 1) demonstrated no communication between the cyst and the main pancreatic duct (MPD). Although the more likely preoperative diagnosis was mucinous cystadenoma, we preferred to proceed with pancreaticoduodenectomy mostly because of the growth of the cystic lesion, despite the patient was receiving multi-agent chemotherapy. We also considered that the digestive changes associated with total gastrectomy could have blurred the interpretation of developing complaints. Finally, concerns on pursuing major surgery in a patient recently operated because of gastric cancer were, at least in part, addressed by favorable tumor staging. Frozen section histology suggested side branch intraductal papillary mucinous neoplasm with normal MPD. On gross examination, the cyst measured 3 2 cm, communicated with the MPD, and was filled with milky content. Final pathology disclosed ACC (Fig. 2). Resection margins were negative and no metastasis was discovered in 30 regional lymph nodes. Post-operative course was uneventful and the patient was discharged on post-operative day 9. She received gemcitabine-based adjuvant chemotherapy for 5 months. One year after pancreaticoduodenectomy the patient is alive and disease-free. Acinar cell carcinoma of the pancreas is a rare solid epithelial exocrine tumor (1–2% of all exocrine pancreatic tumors) [1–5]. It is defined as a carcinoma exhibiting exocrine differentiation and lacking significant (<25%) ductal or endocrine differentiation [2,3].

Influence of videogames and musical instruments on performances at a simulator for robotic surgery

Abstract Objective: To assess if exposure to videogames, musical instrument playing, or both influence the psychomotor skills level, assessed by a virtual reality simulator for robot-assisted surgery (RAS). Materials and methods: A cohort of 57 medical students were recruited: playing musical instruments (group 1), videogames (group 2), both (group 3), and no activity (group 4); all students executed four exercises on a virtual simulator for RAS. Results: Subjects from group 3 achieved the best performances on overall score: 527.09 ± 130.54 vs. 493.73 ± 108.88 (group 2), 472.72 ± 85.31 (group 1), and 403.13 ± 99.83 (group 4). Statistically significant differences (p < .05) between group 3 and group 4 were found for overall score (p = .009) and for time of completion (p = .044). As regards experience with the piano, subjects from group 3 outperformed those from group 1 on overall score (496.98 ± 122.71 vs. 470.25 ± 92.31), but without statistically significant difference (p = .646). Conclusions: The present study suggests that the level of psychomotor skills in subjects exposed to both musical instrument playing and videogames is higher than that in those practicing either one alone. The effect of videogames appears negligible in individuals playing the piano.

Total Robotic Pancreaticoduodenectomy

Context The “da Vinci” surgical system reintroduces much of the operative dexterity lost during laparoscopic operations and offers the unique opportunity to verify if pancreaticoduodenectomy (PD) can be safely performed through a minimally invasive approach. Objective We report our technique for total robotic PD employed in 39 consecutive patients. This experience was earned at a high-volume center of pancreatic surgery, having extensive experience in advanced laparoscopy and robotic surgery. Methods Our technique for total robotic PD is unique in several respects: pure laparoscopy is not used at any stage; only the right colonic flexure is mobilized; a total of five ports are used; the camera port is placed along the right pararectal line to allow optimal view of the uncinate process (UP); the third robotic arm is placed on the patient’s left side and it is used to “hang” the duodenum during dissection of the UP; the gallbladder is used to retract the liver; the first jejunal loop is fully mobilized but it is not sectioned until the specimen is ready for removal, to facilitate jejunal rotation behind the mesenteric vessels. Results No PD was converted to open surgery or laparoscopy, despite 3 patients required segmental resection of the mesenteric vein and reconstruction by a jump graft. Mean operative time was 597 minutes (range: 420-960 minutes). Thirty-day operative mortality was nil. No pseudoaneurysm of the gastroduodenal artery was noted. Only 4 patients developed grade B pancreatic fistulas and none grade C fistulas. Mean hospital-stay was 23 days (range: 10-86 days). Malignant tumors were diagnosed in 51% of the patients. Overall, the mean number of lymph nodes retrieved was 32 (range 15-76). None of the margins was positive. Conclusions In selected patients total robotic PD is feasible. As compared to hybrid techniques, coupling laparoscopic dissection with robotic reconstruction, a total robotic procedure spares unnecessary dissections and allows optimal control of large peripancreatic vessels permitting segmental vein resection and tailored reconstruction. Technology refinements and improvement of surgical technique could make robotic PD an appealing alternative to open PD in selected patients.

Analysis of Instrument Traffic During Laparoscopic Robot-Assisted Pancreaticoduodenectomy

Context Robotic surgery entails specific issues that are not present, or are not equally relevant, in open surgery or conventional laparoscopy. Instrument traffic (IT) is one of such issues. IT is the time during which surgery is paused because the surgeon at the console is waiting for the action of the surgeon the table (e.g., instrument change, camera cleaning, introduction/withdrawal of needles). Objective We provide the first objective evaluation of IT during robotic pancreaticoduodenectomy (PD). Methods The operative videos of 12 robot-assisted PDs were reviewed to define IT. The analysis included: crude IT time (CITT), relative IT time (RITT) (defined as the percentage of operative time spent for IT), number of robotic instruments changes (RIC), time spent for RIC (TRIC), number of pure laparoscopic actions (PLA), and time spent for PLA (TPLA). Figures were estimated for the entire operation as well as for dissection and reconstruction phases. Details on pancreaticojejunostomy (PJ) or hepaticojejunostomy (HJ) were related to IT to define their relative impact on operative time. Results Mean operative time was 517 min (range 420-600 min). Mean CITT was 3,681.6 sec (RITT 11.89%). Mean RIC or PLA was 315.7. Each RIC or PLA paused surgery for 11.8 sec. Mean RIC was 184.4 (TRIC 2,633.8 sec). Mean PLA was 131.4 (TPLA 1,039.5 sec). Mean dissection time was 326.9 min. Mean CITT was 2,095.1 sec (RITT 10.68%). Mean RIC was 105.8 (TRIC 1,645.2 sec). Mean PLA was 35.7 (TPLA 382.5 sec). Each RIC or PLA paused surgery for 14.4 sec. PJ was made by invaginating technique or duct-to-mucosa. The last one required fewer stitches, but did not reduced CITT or RIC. HJ was performed using either 4 half running sutures or interrupted external stitches plus inner half running sutures. Despite similar CITT the former technique was associated with fewer RIC. Conclusions Some 12% of operative time of laparoscopic robot-assisted PD is wasted because of IT. Since in this series operative time of robotic PD averaged 517 minutes, IT prolonged surgery of more than one hour. Technology improvements and/or refinements in surgical technique are expected to reduce IT during robotic PD.

Kidney Transplant Recipient Surgery

The first successful kidney transplantation between identical twins, performed in Boston in 1954, opened the clinical transplant era. Ever since, kidney transplantation has become one of the milestones of the recent history of medicine, whilst saving millions of lives. Although the nature of this extraordinary accomplishment is multifactorial, the successful outcome of a renal transplant begins with an impeccable surgery. This chapter will illustrate the state of the art of kidney transplant surgery in the recipient.

The New Automated Algorithm to Evaluate Ki67 in pNET. The Five “W” law: Who, When, Where, What, and Why

Context Ki67 index (Ki67-I), is the percentage Ki67 immunoreactive cells, expressing tumor proliferation, with important clinical relevance in pancreatic neuroendocrine tumors (pNET) and to standardize its evaluation is extremely important. The pNET guideline indicate to evaluate at list 2 mm 2 of tissue or 2,000 tumor cells. However, this type of evaluation is currently done by subjective opinion of pathologist concerning the area of interest (AI). Objective We elaborated a new algorithm of analysis able to catch all tumor cells present in the selected area according to the pathologist’s criteria. Methods The program (D-Sight, 2.0, Menarini, Florence, Italy) catch all color intensity on the tissue surface, to understand whether which type of sensitivity to immunohistochemistry could match with the Ki67-I. The system returns automatically the number of both total and stained cells. Results The first attempts made on the samples previously evaluated (15 cases with the oldest algorithm) showed an improvement of two important parameters: 1) a better evaluation of total tumor cells present in AI; and 2) a good evaluation of nuclei aggregation. These two data showed a better Ki67-I in pNET, very close to the pathologist’s interpretation. Conclusion The possibility to standardize a fully automated methodology to evaluate Ki67 value can improve both pathological evaluation (i.e., grading of the tumor) and clinical management of pancreatic neuroendocrine patients. This application could open also the new analytical evaluations of other protein markers involved in clinical outcome of oncologic patients.