Search

Immunosuppressive cells have been reported to play an important role in tumor progression mainly because of their capability to promote immune-escape, angiogenesis and metastasis. Among them, myeloid derived suppressor cells (MDSCs) have been recently identified as immature myeloid cells, induced by tumor-associated inflammation, able to impair both innate and adaptive immunity. While murine MDSCs are usually identified by the expression of CD11b and Gr-1, human MDSCs represent a more heterogeneous population characterized by the expression of CD33 and CD11b, low or no HLA-DR and variable CD14 and CD15. In particular, the last two may alternatively identify monocyte-like or granulocyte-like MDSC subsets with different immunosuppressive properties. Recently, a substantial increase of MDSCs has been found in peripheral blood and bone marrow (BM) of multiple myeloma (MM) patients with a role in disease progression and/or drug resistance. Preclinical models recapitulating the complexity of the MM-related BM microenvironment (BMM) are major tools for the study of the interactions between MM cells and cells of the BMM (including MDSCs) and for the development of new agents targeting MM-associated immune suppressive cells.This review will focus on current strategies for human MDSCs generation and investigation of their immunosuppressive function in vitro and in vivo, taking into account the relevant relationship occurring within the MM-BMM. We will then provide trends in MDSC-associated research and suggest potential application for the treatment of MM.

The era of real-time radiotherapy is upon us. Robotic and gimbaled linac tracking are clinically established technologies with the clinical realization of couch tracking in development. Multileaf collimators (MLCs) are a standard equipment for most cancer radiotherapy systems, and therefore MLC tracking is a potentially widely available technology. MLC tracking has been the subject of theoretical and experimental research for decades and was first implemented for patient treatments in 2013. The AAPM Task Group 264 Safe Clinical Implementation of MLC Tracking in Radiotherapy Report was charged to proactively provide the broader radiation oncology community with (a) clinical implementation guidelines including hardware, software, and clinical indications for use, (b) commissioning and quality assurance recommendations based on early user experience, as well as guidelines on Failure Mode and Effects Analysis, and (c) a discussion of potential future developments. The deliverables from this report include: an explanation of MLC tracking and its historical development; terms and definitions relevant to MLC tracking; the clinical benefit of, clinical experience with and clinical implementation guidelines for MLC tracking; quality assurance guidelines, including example quality assurance worksheets; a clinical decision pathway, future outlook and overall recommendations., (© 2020 American Association of Physicists in Medicine.)

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines: Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances. Approved by AAPM Professional Council 3-31-2017 and Executive Committee 4-4-2017., (© 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.)

Small bowel tumours are rare, representing 0.3% of all cancers. The main problem with these tumours is that they induce vague, non-specific symptoms, causing a delay in diagnosis, which is often reached in cases of acute complications such as intestinal obstruction. Moreover, the small bowel is often involved secondarily by tumours that actually start from adjacent organs or by processes of peritoneal carcinomatosis, conditions which are responsible for a distinct worsening of the prognosis (up to 70% mortality). The aim of the study was to define the indications and the most appropriate surgical treatment modalities depending on the presentation of the small bowel tumour. At the Emergency Surgery Unit of the Vittorio Emanuele, Ferrarotto and S. Bambino Hospital in Catania 21 cases of intestinal obstruction caused by small bowel tumours were observed out of a total of 335 patients affected by intestinal occlusion (1.6%). Thirteen patients (62%) had already undergone abdominal surgery for a malignant neoplasm. All patients underwent plain abdominal X-ray which showed air-fluid levels; 14 (66%) were additionally studied by CT scans. Thirteen patients were operated on immediately on the day of admission, while the other 8 were initially treated conservatively. The small bowel was the primary site of the neoplasm only in 3 cases; in the other 10 it was secondarily involved by tumours originating from adjacent organs or by peritoneal carcinomatosis. In 8 cases an intestinal resection was accomplished together with removal of the involved organs, while in the 5 cases of carcinomatosis simple diverting procedures were carried out. Of the 8 patients initially treated conservatively, 6 were subsequently submitted to diverting operations because of persistence of the occlusive status. Nine patients had postoperative complications (47%) and another 3 died (14%). In conclusion, intestinal obstruction is a frequent complication of small bowel tumours, especially if they are in the final stages. Intestinal resection offers a good chance of recovery in cases--unfortunately rare--of confined tumours; in the other instances it is preferable to perform diverting procedures and subsequently refer the patient to the oncologist in order to plan adjuvant therapy, if possible.

Severe secondary peritonitis is diagnosed in only 20-30% of all patients, but studies to date have persisted in using a standard fixed duration of antibiotic therapy. This prospective, double-blind, multicenter, randomized clinical study compared the clinical and bacteriological efficacy and tolerability of ertapenem (1 g/day) 3 days (group I) vs >or=5 days (group II) in 111 patients with localized peritonitis (appendicitis vs non-appendicitis) of mild to moderate severity, requiring surgical intervention. In evaluable patients, the clinical response as primary efficacy outcome were assessed at the test-of-cure 2 and 4 weeks after discontinuation of antibacterial therapy. Ninety patients were evaluable. In groups I and II, 92.9 and 89.6% of patients were cured, respectively; 95.3% in group I and 93.7% in group II showed eradication. These differences were not statistically significant. The most frequent bacteria recovered were Escherichia coli and Bacteroides fragilis. A wound infection developed in seven patients (7.7%) and an intraabdominal infection in one patient (1.1%). There was a low frequency of drug-related clinical or laboratory adverse effects in both groups. Our study demonstrated that, in patients with localized community-acquired intraabdominal infection, a 3-day course of ertapenem had the same clinical and bacteriological efficacy as a standard duration.

The Authors report on a case of a 69 years old woman with an acute peritonitis secondary to a perforated jejunal diverticulum, treated by laparotomy and intestinal resection with end-to-end anastomosis in one layer. The patient was dismissed after seven days, in good general conditions. Jejunal diverticula occur in around 1% of general population. They are usually asymptomatic; sometimes they give origin to dyspepsia or acute manifestations. These are due to complications at the site of the diverticulum like bleeding, occlusion and acute infection with perforation and peritonitis, as occurred in our patient. The main risk in diverticular complications is to prolong the interval between admission of the patient and surgical treatment, favouring the initiation of hypovolemic or septic shock. For these reasons, in most recent years, C.T. and, in case of bleeding, capsule endoscopy, were used in the diagnostic pre-operative work-up. The surgical technique is jejunal resection with direct anastomosis, leaving percutaneous drainage only for patients with an abscess, in poor general conditions for a narcosis.

Objective: Diaphraghmatic injuries are rare (5-7%), usually secondary to blunt, or more rarely penetrating, thoracic or abdominal trauma. The most frequent site of trauma is the left postero-lateral region. We'll try to review this pathology in all its aspects., Materials and Method: We report our personal experience from January 2002 to December 2004 on 280 thoraco-abdominal trauma, 262 (93.5%) blunt and 18 (6.5%) penetrating, of which 5 (3.7%) interested the diaphragm. 4 following a blunt trauma and 1 an open trauma (gunshot) Each trauma was evaluated for possible associated injuries and for the type of symptoms at the admission and during the hospitalization. Preoperative diagnosis has been obtained only in 3 patients, haemodynamically stable. In the other 2 cases an emergency laparotomy was carried out because of their critic conditions and the diaphragmatic injuries were recognized during the procedure. Two patients died., Conclusions: We remark as during the acute phase the diaphragmatic rupture may be missed because of shock, respiratory insufficiency or coma of the patient; however, it's mandatory that the right diagnosis is reached as soon as possible in order that mortality is mostly influenced by the time elapsing between trauma and diagnosis.

Background: Aim of the study is to work out diagnostic and therapeutic guidelines in blunt abdominal trauma, considering our modern diagnostic tools and actual international propensity for non-operative treatment., Methods: Seventy five patients observed during the last three years at Emergency Surgery Unit of "Vittorio Emanuele" Hospital in Catania, Italy. All patient underwent, after blood tests, abdominal ultrasound and/or CT showing one or more abdominal lesions in 52 (69.3%) of them. Out of these 52 patients with organ injuries, 29 (55.8%) underwent surgery, while 23 (44.2%) non-operative treatment: the most injured organs were spleen (34 cases), liver (18 cases) and kidneys (4 cases). On the basis of haemodynamic conditions of the patients and of the results of abdominal ultrasound and/or CT the Authors decided between surgical or non-surgical treatment, working out in the meantime their diagnostic-therapeutic guidelines. In Authors' experience, while for splenic injuries the majority of patients was operated (splenectomy), for hepatic injuries non-operative treatment was preferred, as well as for all renal injuries., Results: Two patients (2.6%) died because of hypovolemic shock secondary to an high-grade hepatic trauma associated with d.i.c.; both patients reported other major lesions of, respectively, chest and brain. Other 4 patients developed postoperative complications: 1 patient a pleuritis and 3 patients a wound infection. All these patients recovered with antibiotics and, where necessary, repeated change of medical dressing. The other 69 patients recovered completely, without any significant complication., Conclusions: The study of personal experience of the last three years on abdominal blunt trauma (75 patients) has allowed the Authors to work out diagnostic-therapeutic guidelines, which are based mainly on patients' haemodynamic conditions and on sonographic and CT results. The applications of this protocol has allowed the Authors during last 12 months to practice more frequently the non-operative treatment, avoiding unnecessary surgical operations, sparing the patient organic deficit and possible intra and post-operative complications.

After a brief review of acute postoperative acalculous cholecystitis, the Authors report their experience over the past 10 years consisting of 9 out of 520 cases (1.73%) of acute cholecystitis operated on in their department. They describe the surgical procedures after which acute cholecystitis developed, the diagnostic tools used, the laboratory test results and the types of cholecystitis encountered. Morbidity was 50% (4 cases) and mortality 11.1% (1 case). Acute postoperative acalculous cholecystitis obliges the surgeon to make an early diagnosis and intervene equally rapidly with treatment.

Introduction: Adrenal cysts are usually asymptomatic; they are usually identified occasionally during ultrasound or C.T. scans (incidentaloma). Among adrenal cysts the most common types are epithelial cysts and pseudocysts. Intracystic haemorrhage is one of the possible complications of adrenal pseudocysts., Case Report: We report a case of a young woman with right superior abdominal pain, fever and acute anemia. A C.T. scan showed a 10 cm. mass between the liver and the right kidney. To be sure of the nature of this mass also M.R., urography and C.T.-guided biopsy were carried out. This latter only let us make the final diagnosis of hemorrhagic adrenal pseudocyst. Thereafter, a laparotomic right adrenalectomy was performed, with full recovery of the patient., Discussion: Adrenal cysts may cause differential diagnostic problems with masses of contiguous organs like kidney, liver and gallbladder. For this reason, ultrasound and C.T. scans may not be sufficient and must be completed by M.R., urography and/or C.T.-guided biopsy. Intracystic hamorrhage, spontaneous or post-traumatic, may cause to the patient acute anemia which, as soon as the diagnosis is confirmed, indicates surgery. The operation usually is a laparotomic adrenalectomy, since the laparoscopic approach is not sufficient to control large masses with active bleeding inside.

Despite advances in diagnosis, surgical treatment, antimicrobial therapy and intensive care support, severe secondary peritonitis remains a potentially fatal affliction. The purpose of this study is to present our experience of postoperative mortality in 255 patients with secondary acute peritonitis between 1998 to 2002. The Mannhein Peritonitis Index score (MPI) was calculated for each patient to predict the peritonitis related in-hospital death. Both literature reviews and our results show a strong correlation between some etiopathogenetic elements (age, origin of sepsis, organ failure, ...) and prognosis. Our patients were classified in three groups according to MPI, one with a score less than 21, another with a score between 21 and 29 and the third one with a score greater than 29. There was no mortality in the first group and there was significantly less mortality in the second group than the third one (P<0.001). While prognosis is influenced by many factors, the intervention time was the same, greater than 24 hours, for all the patients regardless of MPI score. This study suggests that intervention time may be considered the main determinant of mortality in patients with peritonitis. This observation is especially relevant since intervention time is a modifiable prognostic factor whilst many other factors are not.

Aim of this study was to compare, taking into consideration data from the literature, the various diagnostic examinations and therapeutic modalities nowadays available to manage patients affected by pancreatic pseudocysts. Personal experience regarding three patients with post-necrotic pancreatic pseudocysts is reported; these patients complained of epigastric pain with nausea and tenderness in the upper abdominal quadrants. Diagnosis was made by CT. In one case a progressive decrease of the pseudocyst was observed; the second patient was treated by a pseudocyst-jejunostomy; the last patient initially underwent a trans-gastric percutaneous drainage for infection of the pseudocyst and afterwards an open pseudocyst-gastrostomy. All patients were cured, even if the second patient during the postoperative course developed a pleuric effusion, which was treated by thoracentesis. Pancreatic pseudocysts in 20% of cases resolve spontaneously, as observed in one of our patients. In other cases, a surgical operation is needed, now feasible through an endoscopic, percutaneous, laparotomic or laparoscopic approach. The endoscopic and percutaneous approach are indicated only in selected cases, so that the "gold standard" treatment is still the laparotomic one, especially by a pseudocyst-jejunostomy, which also in our experience has given the best result. Very promising also, according to the latest data from the literature, seems the laparoscopic approach, by which a wide communication between the stomach and the pseudocyst is obtained.

The authors report a case of a ruptured splenic artery aneurysm. The case was diagnosed during emergency surgery for haemoperitoneum. Aetiopathogenetic and clinical findings are considered. Surgery is regarded as the logical conclusion of the diagnosis in order to avoid the much feared complication of rupture of the aneurysm, which still presents a high mortality rate.

The observation of a case of intestinal intussusception caused by lipoma of the colon prompted the authors to review the literature on the subject and to examine the main characteristics of lipoma of the colon which represent the most frequent benign neoplasia of the large intestine after adenomatous polyps. Lipomas of the colon are localised in 90% of cases at the submucous level, are usually solitary, of varying size and may be sessile or pedunculated. They are almost always asymptomatic; only when they are of a reasonable size do they become manifest following alterations of the alveus, rectorrhagia, abdominal pain or the occupation of the colic lumen by the mass, or intestinal intussusception caused by the progression of the pedunculated lipoma. This difficult diagnosis may be aided by colonscopy with biopsy and dual contrast opaque enema. The prognosis of the disease depends on the presence or absence of complications and, in the case of the former, on early diagnosis and treatment. Lipoma of the colon of less than 2 cm may be electively removed endoscopically, those greater than 2 cm by laparotomy or laparoscopy. In emergency cases, it is advisable to perform a more or less extensive resection of the colon depending on the size of the tumour. In the case reported by the authors, an intussusception manouevre was first performed followed by left segmentary colectomy.

A valid program of follow-up has always been a crucial point in the overall therapy of the colon-cancer. In this retrospective study, the authors have used as specimen 74 patients put under observation between the years 1987 and 1992. The patient have been followed throughout the diagnostic period with various methods. It has been the will of the authors, who have presented their protocol of reference, to put under comparison the various controlling methods in order to visualize their reliability, specificity and the indication of each one of them. The CEA is the most sensible haemanalysis for lifting the doubt of recidivation. As for the TAC and ultrasound it has been reserved the job of formulating a correct diagnosis; the results of both diagnostics through imagery have been more or less the same. However, the ultrasound examination have shown more false positives than the TAC. The research of the blood occult in the stool is a rapid and economic detection in the case of intramural recidivations, even if we cannot disregard the share of false positives. A high specificity for the study of intramural recidivations has been offered by the endoscopic scan particularly when associated by a brushing and biopsy.

The sexual activity was studied in 28 males and 18 females, one year after abdominoperineal resection for low rectal carcinoma, using a questionnaire. Sexual desire, potentia coeundi and ejaculation, capacity for orgasm and sexual satisfaction in the male, and sexual desire, possibility of vaginal coitus, dyspareunia, orgasm capacity and sexual satisfaction in the female were analyzed. Among the female patients (18 cases), sexual desire was judged to be decreased in 77.77% (15 cases) and decreased capacity for orgasm occurred in 5.5% (1 case). Loss of sexual satisfaction and dyspareunia were present in 44.4% (8 cases) and 33.6% (6 cases) respectively. Among the male patients (28 cases), sexual desire decreased in 75% (21 cases), incomplete erection but sufficient for copulation occurred in 17.85% (5 cases), such as retrograde ejaculation in 10.71% (3 cases) and no ejaculation in 7.14% (2 cases) and impotentia coeundi in 25% (7 cases). In couples that reported a satisfying sexual activity, the first coitus occurred 6 months after surgery (range: 4 to 15 months). In no case was there separation of the couple after surgery.

Acute cholecystitis is a non-rare disease, the incidence of which was increasing in the last years parallel to biliary lithiasis, which in 90% of cases is the first cause of such pathology. From the anatomopathological standpoint, we distinguish three types of acute cholecystitis: catarrhal, suppurative and gangrenous. The most frequently remarked symptom is ache at right hypochondrium. Only in 30% of cases cholecyst can be palpated, in form of ovoid mass; typical is the positiveness of Murphy's manoeuvre; constant is fever, but not subicterus. The introduction of new methods of ascertainment, exempt from any risks, simple to be performed and remarkably careful, made the diagnostics of acute cholecystites easier: parietal cholecystotomography, hepato-biliary scintigraphy, echotomography (first approach investigation), computerized axial tomography and laparoscopy almost always succeed in dispelling doubts. By using more than one of these investigations, a diagnostic accuracy, touching on 100%, can be reached. The differential diagnosis should be placed with: peptic ulcer, acute pancreatitis, acute appendicitis, gonococcus perihepatitis, virus hepatitis, acute pyelonephritis, right basal pneumonia. The complications an acute cholecystitis can occur are: perforation (localized, in free peritoneum or in a hollow organ), choleperitonaeum, necrosis of hepatic parenchyma, acute pancreatitis. Due to the possible arising of such complications, the mortality unfortunately is not indifferent (5%), especially in patients already weakened by other chronic diseases. Still discussed is the question as to when performing operation. In fact, there are three trends: intervention in immediate emergency, in postponed emergency, or in remote time (preceded by a medical treatment). The Authors prefer the intervention in postponed emergency, as, in their experience, they remarked the poor effectiveness of the delay medical treatment, also involving a greater difficulty in the technical execution of the intervention and a longer stay in hospital. From 1973 up to 1983, 241 cases of acute cholecystitis (158 women and 83 men) were hospitalized at the First Aid Surgical Centre of the Catania University. Eight patients refused the surgical intervention. The remaining 233 underwent, depending upon the seriousness of the affection, the associated diseases and the different reactiveness to the medical treatment, operation: in immediate emergency (26.1%); in postponed emergency (67.8%; in remote time (6.1%). The mortality was 2.2%, with the lowest percentage in the second group.

Esophagitis is caused by a gastro-esophageal reflux sometimes reflecting anatomical inadequacy of structures that secure the relationships between the cardia and the diaphragm, fundus of the stomach, and other surrounding viscera, but more often due to functional deficiency of lower esophageal sphincter (LES), this representing the main factor for maintenance of the mechanism of cardial continence. Manometric studies of intraluminal pressures in the esophagus have revealed the presence of a high-pressure segment in the distal esophagus, where a mean pressure of 12-13 mm Hg obtains over a length of 3 or 4 cm. In the first two weeks of extrauterine life the LES is between 0.5 and 1 cm long, with a pressure of 3 mm Hg; pressure values in the LES equal adult values at about one month of age, showing that neuromuscular control of the sphincter has been achieved. Gastro-esophageal reflux, however, is very common in the newborn and not enough by itself to cause peptic disease of the esophagus; this requires the concomitance of morphological defects of the esophageal mucosa and/or dynamic-functional disturbances. This, according to the authors, is why esophagitis actually occurs in only about 60% of patients with radiologically and pHmetrically demonstrated gastro-esophageal reflux.

16 patients suffering from acute pancreatitis were treated by intramuscular or intravenous administration of glucagon, with control of the amylasemia and amylasuria values at the start of treatment, the 12th hour and the 36th hour. By the 12th hour from the start of therapy they already observed a reduction in amylasemia and amylasuria to normal values, with disappearance of the symptomatology (pains, vomiting, shock) and complete cure of the patients in 94% of cases. On the basis of their own and others' experience, the Authors therefore believe that glucagon can advantageously be used in this disease, which is characterised by much higher mortality if treated with the traditional therapeutic means.

In consideration of the well-known difficulties associated with the precise diagnosis of hemoperitoneum, the authors offer their personal experience in support of laparoscopy as a diagnostic aid in such dramatic events. They review 23 cases of emergency laparoscopy performed in the First Institute of Clinical Surgery of the University of Catania between January 1978 and January 1979. Recalling that the procedure was applied to patients as young as 3 and as old as 80, they confirm the opinion expressed from other quarters, namely that laparoscopy is an essentially harmless and rapid procedure conducive to very accurate diagnosis in view of appropriate planning of therapeutic treatment.

After a brief review of the history of laparoscopy starting from the first endoscope, the authors remark on the great usefulness, ease, and essential harmlessness of the procedure. They list all the possible uses of laparoscopy in general and emergency surgery, exemplifying their claims with the illustration of personal cases and recommending widespread use of the method in surgery.

A problem of some complexity is the management of pathological gastro-esophageal reflux due to the presence of cardio-hiatal malformation, malposition of the cardia and gastric tuberosity, a congenitally short esophagus, and the like. Sometimes, however, there is no demonstrable morphological aleration and the condition, characterized by primitive hypotonia of the LES, goes under the name of infant chalasia of the esophagus. The general policy is to try first a conservative treatment consisting of dietary and postural measures and the administration of metoclopramide and d;ugs that protect the esophageal mucosa; this stage, however, should not be prolonged beyond 6 weeks. The presence of gastro-esophageal reflux associated with hiatal hernia; the presence of severe esophagitis or peptic stenosis of the esophagus and the persistence of symptoms after an adequate period of conservative therapy constitute as many indications for surgical correction. Good results can be obtained by restoring or strengthening the failing function of the LES, as is done quite successfully with funduplication after Nissen or with method of Belsey-Mark IV.

The authors describe one case of massive penetration of barium and air through the splenic vein into the portal system during administration of a radiopaque enema to a woman suffering from hemorrhagic proctitis in the florid phase. They provide a detailed description of this rare clinical case and discuss the possible etiology and pathophysiology of the observed event.

The authors review several existing classifications of traumatic events affecting the peripheral blood vessels; after discussing the symptoms of such events and diagnostic guidelines, they outline therapeutic approaches and emphasize above all the need for prompt surgery with the least possible delay after the injury. They review of cases of their own observation, and conclude by highlighting the basic concepts of modern surgery in this field of pathology.

The authors offer a review of their ten-year (1968-1978) experiences at the First Institute of Clinical Surgery, University of Catania. In particular, they report on the low morbidity (12.9%) and mortality (4.5%) observed in a series of 240 patients with gastric or duodenal perforation due to peptic ulcers treated surgically by simple suture of the perforation.

After reviewing all the various procedures for surgical treatment of pseudocysts of the pancreas, the Authors, analysing the advantages and disadvantages of each method, present a set of nineteen personal cases treated by simple cystogastrostomy, simple cystojejunostomy and cystojejunostomy combined with entero-entero-anastomosis according to Braun, or cystojejunostomy on defunctionalised loop according to Roux. After stading the overall criteria for selection of the technique to be applied individually, the Authors conclude by stressing the advantages that cystojejunostomy on defunctionalised loop according to Roux offers as compared with all the other procedures.

A case of ampicillin-associated colitis is described. The authors stress the importance of emergency colonoscopy for the correct diagnosis and treatment of severe diarrhea and hemorrhage occurring during treatment with antibiotics.