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In recent years, battery technology has been greatly improved and some types of battery chainsaws are currently comparable with light-type petrol machines, suggesting their possible introduction into forest operations. In this context, the aim of this study was to test and compare the performance, in a Douglas-fir thinning, of two chainsaws similar in terms of weight and power, the Stihl MS 220 CB battery-powered saw and the Stihl MS 201 CM petrol-powered saw, measuring the working times and calculating the productivities. The results showed that, within a working day (about 6 h gross time), an average of 15 trees of 0.56 m3 was felled in each area. No statistically significant differences between the two chainsaws were found in terms of gross and net productivity; and the same result was obtained when focusing the analysis only on operations conducted using the chainsaws. Moreover, the average battery charge duration was 1.04 h, while the full tank duration for the petrol model was 1.12 h. In conclusion, our study demonstrates that, on the basis of their performance, battery chainsaws can be introduced into thinning operations, but a solution is needed to manage batteries in the forest, since the actual need is for 7–8 charges per workday.

Information and Communication Technologies (ICT) play a key role for improving the implementation of sustainable forest management at local, regional, and global level. The ICT potential to easily exploit a wider and more up-to-date set of information on the economic, environmental, and so- cial value of forests is of relevant help for the daily work of technicians, land owners, and companies in boosting the efficiency and effectiveness of forest management. The concept of “Precision Forestry” (PF) was developed from the early 2000s, as a branch of precision farming or precision agriculture. PF includes the use of ICT, remote and proximal sensing technologies, and other devices to coordinate and control several processes on a spatial scale (“Precision”) for monitoring, planning, and managing forest resources (“Forestry”). The aim of this monography is to collect and describe some of the most important PF experiences applied or potential- ly useful for the Italian forestry sector. It may represent a reference guide for the stakeholders, such as forest owners, professional technicians, public administrators, and policy makers. The book includes eleven chapters reviewing the main tech- nological tools available in the Italian context and the most recent advances of ICT in forestry, also focusing on the strengths and weaknesses of their practical implementation. The opportunities and challenges of implementing PF meth- ods, practices and technologies are also discussed. In the first two chapters the precision forestry concept and its historical development are introduced. In the third chap- ter some basic elements of ICT, GIS, Global Navigation Satellite Systems (GNSS), remote/proximal sensing, and related technologies which are essential for a better compre- hension of PF applications are recalled. In chapter 4 recent advances in large scale forest inventories with a focus on mapping and on the spatial estimation of forest variables integrating field surveys and multisource re- motely sensed data are described. Current advancements in the acquisition of field information including Terrestrial La- ser Scanning (TLS), new digital dendrometers, tree-talkers, terrestrial cameras, and APP for portable devices such as smartphones or tablets for dendrometric tree measures and new citizen science applications to support quantitative and qualitative spatial estimation of forest variables over large areas (i.e., forest health, fuel types) are also presented. The chapter ends up with the description of some experiences in the implementation of Forest Information Systems in Italy to provide a simple open-access to such new generation of spatial forest information. In chapter 5 PF tools, instruments, and technologies to sup- port sustainable forest management are illustrated. APPs developed to acquire field plots data to simulate manage- ment operations, the application of photogrammetric tech- nologies from Unmanned Aerial Vehicles and TLS data for monitoring with high-spatial scale forest monitoring and for acquiring indicators at single tree level are presented. A de- tailed description of new user-friendly tools for forest roadplanning, design and construction, as well as forest opera- tion planning is also included. Precision forest tree farming (with particular reference to poplar cultivation), useful to promote and increase the prof- itability and sustainability of forest plantations within the Italian context is described in chapter 6. The innovation and enhancement within the supply chain of wood plantations (from planting to harvesting, including monitoring and identification of stress) by soil proximal sensing techniques, Early Warning Systems, and specific software are highlight- ed. Considering the even higher market demands, promoted by the large-scale planting programs for climate changes mit- igation and the demands for propagation material for en- vironmental recovery, innovative techniques and methods supported by ICT in the forest nursery sector are described in chapter 7. In chapter 8 available technologies related to precision har- vesting are analyzed and described taking into consideration the wood chain efficiency, by means of improved commu- nications between the owner/buyer and operators as well as among machineries used in forest operations, health and safety of forest operators, environmental impacts mitigation and recovery, and operators training. Advanced communi- cation systems and sensors for the exchange of data and information between machines, machine-equipments and/or machine-operators, teleoperations and automation are also described. Chapters 9 and 10 are related to wood products traceabil- ity, timber quality assessment as well as the technologies for the optimization of wood transformation processes. The concepts of wood product traceability and tracing, togeth- er with latest digital technologies for the identification and tracking of the logs (i.e., fingerprinting and RFID), are de- tailly reported. Chapter 11 is finally dedicated to the relationship between the EU policy framework and the digitalization process in both agricultural and forestry sectors. The book summarizes, under a proactive and homogeneous framework, PF methods, tools and technologies in relation with the digital transition of the Italian forestry sectors. The authors hope this book will be useful for improving the implementation of sustainable forest management practic- es at all levels in Italy, providing a comprehensive review useful for policy makers, technicians, forestry owners and students.

The recent technological development of batteries has allowed the production of powerful tools that are also used in forestry operations. For this reason, this study aimed to compare the performance of two latest chainsaw models in a conifer clear-cut. The examined chainsaws, the battery-powered Stihl MSA 300 and the petrol-powered MS 261 C-M, have comparable power and weight. The overall working times were recorded and then gross, net and felling/processing productivities were quantified. Our findings reported that in a working day (7.4 h gross time), each chainsaw felled and processed an average of 20 trees of 0.64 m3 with an average diameter at breast height of 28 cm. Considering the net productivity, no statistically significant differences were recorded between the two chainsaws. Investigating the productivities on operations conducted using the chainsaws, the battery chainsaw showed a lower average tree-processing productivity than that recorded for the petrol chainsaw. On average, the battery duration was 0.88 h, while the petrol tank duration was 0.97 h. Our study shows that battery chainsaws have great potential in forestry operations; however, considering the actual need for 8 charges per standard workday, optimizing battery management is an important objective for future work.

Even at a well-managed harvesting site, vehicle trafficking occurs on at least 12% of the area and might cause ruts and compaction. The use of drones for inventory and mapping in forestry is still ...

Advanced age is associated with comorbidities and immune system impairment, which may influence the efficacy and tolerability of immune checkpoint inhibitors. There is evidence that anti-PD1 antibodies in advanced melanoma are equally effective in patients65 years. However, data on patients75 years are lacking as co-morbidities and logistics often exclude them from clinical trials.We retrospectively reviewed the clinical records of older patients with advanced melanoma undergoing any-line treatment with an anti-PD1 (nivolumab/pembrolizumab) to investigate its clinical effectiveness and toxicity in a real-life setting. Clinical response was assessed using RECIST criteria and toxicity was evaluated according to CTCAE 4.0. Progression-free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method and the Cox model was used to assess potential prognostic factors.174 patients were considered; 59.2% males, median age 79 years (range 75-93). The majority had a performance status of 0 and normal lactate dehydrogenase (LDH) levels (55.2% and 52.4%, respectively). 69.1% had multiple co-morbidities. 56.9% received nivolumab. 36.7% of cases showed an objective response and the disease control rate was 56.3%. Median OS was 17.2 months [95% CI: 8.87-not reached] and a better prognosis was observed for patients with normal LDH (p .001) and lower performance status (p .001). Treatment was well tolerated, only 11 patients experiencing severe (grade 3/4) toxicity. There were no treatment-related deaths. Adverse events were managed with corticosteroids and additional immunosuppressive agents were unnecessary.Anti-PD1 antibodies appear effective and well tolerated in older patients with advanced melanoma.

Chainsaw operators are exposed to many hazards that can lead to health problems. The two most frequently documented ergonomics threats in the use of chainsaws are noise and vibration exposure. Since the use of battery chainsaws is increasing due to the growing improvements in battery life and power, the study aims to compare the difference in terms of noise emission and vibration levels of the following two new models of chainsaws: the battery-powered Stihl MSA 300 and the petrol-powered Stihl MS 261 C-M. Black pine and European beech logs were cross-cut in order to evaluate both noise and vibration exposure. The results show that the use of battery-powered chainsaws, in comparison to the petrol one, can reduce the daily vibration exposure by more than 51% and the noise dose by 11%. The daily vibration exposure of 1.60 ms−2 and 1.67 ms−2 measured for the battery-powered chainsaw on Black pine and on European beech, respectively, is far from the daily exposure action value set by the EU directives for health and safety requirements (2.5 ms−2). On the contrary, the daily noise exposure for the battery chainsaw was 93 dB(A), exceeding the upper exposure action value of 85 dB(A).

Intensive forestry operations may cause soil compaction, plastic soil disturbances and rutting, which are responsible for undesirable effects on soils, vegetation and water bodies. Despite the numerous studies aimed to identify the main factors affecting soil damages, it still remains unclear whether wood extraction methods and driving direction (uphill or downhill) may affect the impacts of forest machines. This research analyses soil compaction and soil penetration resistance as well as rutting from forwarding and skidding using the same farm tractor in up- and downhill wood extraction. Rutting was estimated by 3D soil reconstruction derived by portable laser scanning (PLS) and close-range photogrammetry using structure for motion (SfM). Our findings showed that the direction of extraction did not affect soil damage severity during forwarding on a 25% slope. On the contrary, in order to reduce soil compaction, downhill skidding is preferable to uphill skidding. The results showed that the pressure on the ground caused by vehicles can be distributed horizontally, thus affecting also the soil between the wheel tracks. The soil bulk density inside the tracks after 10 forwarding passes increased by 40% and with 23% between the wheel tracks. The soil displacement in skidding trails (7.36 m3 per 100 m of trail) was significantly higher than in forwarding (1.68 m3 per 100 m of trail). The rutting estimation showed no significant difference between the PLS and SfM methods, even comparing the two digital surface models (DSMs) obtained, even if photogrammetry was preferred for technical and practical reasons.

The use of battery tools is very common in many fields of work. In fact, the electric engine and batteries have several advantages over traditional endothermic engines, including low emissions, in terms of pollutants, vibration and noise. In this context, the chainsaw market started producing electric models powered by batteries. These machines can be useful in forestry, but information on their performance is scarce. The aim of this work was to compare the performance, in terms of cutting times, of three Stihl chainsaw models: the MS 220C-B (battery powered), and the MS 201 C-M and MS 261 C-M (both petrol powered). The study was carried out on five different wood species, also taking into consideration the presence/absence of wood defects in the cutting. More than 800 cuts on 15 m × 15 cm wood beams were video recorded, and the cutting times were later obtained to a resolution of 4/100 of a sec, using video-editing software. The results showed a poorer performance of the battery chainsaw than the petrol chainsaws, especially on certain wood species. However, this difference has been reduced when compared with older models. In conclusion, battery chainsaws need some additional improvements to be introduced into forestry, but their high potential is evident.

One of the most serious complications of advanced melanoma is the diffusion of cancer cells to the central nervous system. The diagnosis of leptomeningeal metastasis (LMM) is notoriously challenging and requires a combination of consistent MRI and cerebrospinal fluid (CSF) cytology. In ambiguous cases, mutations like BRAF V600E in CSF-cell-free (cf)DNA may help to clarify diagnosis of LMM. Here we present the case of a young woman who developed isolated LMM after the diagnosis of a node-positive primary melanoma with normal LDH. The CSF was negative for tumour cells by cytology but positive for cfDNA BRAF V600E mutation, thus allowing us to diagnose LMM. To our knowledge, this is the first case where CSF sampling for the detection of BRAF mutation was used to identify leptomeningeal disease in the presence of negative MRI and without involvement of any other distant sites.

Wildfires can affect agroforest-ecosystems generating several cascade effects on the soil-water continuum, among which erosion is one of the most important. Even so, few field studies analyse post-fire soil erosion at watershed scale, especially in the Mediterranean Basin, although here wildfires are particularly frequent.The present work analyses the impact of the first rain events following one severe wildfire in the Pisan Mountains, Tuscany region, Italy, with the aim to quantify and characterize the post-fire impact in terms of soil erosion and sediment yield at watershed scale.The study site is characterized by olive groves, maquis, maritime pine and chestnut forest, depending on the elevation. The area was affected by a fire involving an area of about 1000 ha in September 2018. Fire severity was assessed by remote sensing imagery, while fire impact on soil properties and sediment yield was assessed by field experiments, and sampling and lab analysis. Finally, a hydrological model was implemented in HEC-HMS environment for exploring the relationship between the erosion-deposition events monitored in a sample watershed, and the hydrological processes induced by the rainfall events.Experimental analysis revealed that the organic fraction of topsoil dramatically declined after the wildfire, together with the saturated hydraulic conductivity. Fire occurrence also generated a shift in the soil water repellency. The analysis of sediment deposited at the outlet of the catchment revealed that the first two rainfall-induced erosion-deposition events transported a larger amount of non-organic sediments, probably already close to the riverbed before the fire, while the other four events analyzed corresponded to deposited material much richer in organic matter, produced by the fire event. Overall, at watershed scale, soil erosion amounted to 7.85 t/ha, a relatively moderate rate considering the large fire impact on soil. This could be partly explained by the shallow soil depth of the study area (around 50 cm on average) and the high stoniness of soil, which would lead to preferential infiltration pathways for water, reducing runoff and erosion.

The incidence of melanoma is rising worldwide thus underlining the need to implement primary prevention strategies. Early diagnosis is based on the clinical and dermoscopic features and is a cornerstone of the management of melanoma. Indeed, thin melanomas show a good prognosis whereas thick melanomas are associated with a significant risk of spread and high mortality rates.

Aim: A survival benefit was demonstrated by dabrafenib + trametinib for metastatic BRAF-mutated melanoma patients. Best response is a strong prognostic marker for survival. Patients & methods: The specific features associated with complete response (CR) were evaluated. Results: A total of 15/66 patients achieved CR. Median size of lesions was 3 cm (range: 0.5–10). Using that value as cut-off, the CR rate was 39.3% in patients with smaller lesions and 10.5% in patients with bigger size (p = 0.006). The clinical features associated with CR were the number of metastatic sites and the largest diameter of the biggest metastatic site. Conclusion: The number of the metastases and the diameter of the largest metastatic site are associated with a higher CR rate.

Compaction and rutting on forest soils are consequences of harvesting operations. The traditional methods used to investigate these consequences are time consuming and unable to represent the entire longitudinal profile for a forest trail. New methods based on photogrammetry have been developed. The overall objective was to compare photogrammetry and traditional methods (e.g. cone penetrometer, manual rut depth measurements, bulk density and porosity) used for the evaluation of soil compaction and rutting (i.e. depth and rut volume) after multiple passes of a loaded forwarder using two different tyre pressure levels. The comparison of photogrammetric versus manually measured profiles resulted in R2 0.93. Both tyre inflation pressure and number of passes had effect on soil disturbance. The rut volumes on 100 m long trails after 60 passes were 8.48 and 5.74 m3 for tire pressures of 300 and 150 kPa, respectively. Increased rut volume correlated positively with increased soil compaction and decreased ...

Simple Summary COVID-19 is a highly contagious infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In March 2020, the World Health Organization (WHO) declared that COVID-19 had become a pandemic; since then, several elective clinical and surgical activities have been postponed to reduce the risk of nosocomial infection. This has influenced the diagnosis and management of many diseases, including melanoma. The aim of our literature review was to evaluate whether the management of melanoma has been changed by the outbreak of COVID-19, and if so, what the consequences of these changes are. The main topics in this literature review are the screening of suspicious lesions, diagnosis of primary melanoma, and the management of early-stage and advanced melanomas in the COVID-19 era. We also reported the experience of our dermatological clinic in Turin, one of the most affected areas in Italy. Abstract Background: The current COVID-19 pandemic has influenced the modus operandi of all fields of medicine, significantly impacting patients with oncological diseases and multiple comorbidities. Thus, in recent months, the establishment of melanoma management during the emergency has become a major area of interest. In addition to original articles, case reports and specific guidelines for the period have been developed. Purpose: This article aims to evaluate whether melanoma management has been changed by the outbreak of COVID-19, and if so, what the consequences are. We summarized the main issues concerning the screening of suspicious lesions, the diagnosis of primary melanoma, and the management of early-stage and advanced melanomas during the pandemic. Additionally, we report on the experience of our dermatological clinic in northern Italy. Methods: We performed a literature review evaluating articles on melanomas and COVID-19 published in the last two years on PubMed, as well as considering publications by major healthcare organizations. Concerning oncological practice in our center, we collected data on surgical and therapeutic procedures in patients with a melanoma performed during the first months of the pandemic. Conclusions: During the emergency period, the evaluation of suspicious skin lesions was ensured as much as possible. However, the reduced level of access to medical care led to a documented delay in the diagnosis of new melanomas. When detected, the management of early-stage and advanced melanomas was fully guaranteed, whereas the follow-up visits of disease-free patients have been postponed or replaced with a teleconsultation when possible.

// Riccardo Marconcini 1 , Francesco Spagnolo 2 , Luigia Stefania Stucci 3 , Simone Ribero 4 , Elena Marra 4 , Francesco De Rosa 5 , Virginia Picasso 2 , Lorenza Di Guardo 6 , Carolina Cimminiello 6 , Stefano Cavalieri 6 , Laura Orgiano 7 , Enrica Tanda 2 , Laura Spano 2 , Alfredo Falcone 1 and Paola Queirolo 2 for the Italian Melanoma Intergroup (IMI) 1 Unit of Medical Oncology 2, Azienda Ospedaliera-Universitaria Pisana, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy 2 Department of Medical Oncology, IRCCS AOU San Martino-Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy 3 Medical Oncology Unit, Department of Biomedical Sciences and Clinical Oncology, University of Bari, Bari, Italy 4 Dermatologic Clinic, Department of Medical Sciences, University of Turin, Turin, Italy 5 Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST IRCCS, Meldola, Italy 6 Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy 7 AOU Cagliari, Department of Medical Oncology, University of Cagliari, Cagliari, Italy Correspondence to: Riccardo Marconcini, email: marconcini.riccardo@gmail.com Keywords: melanoma; immunotherapy; ipilimumab; pembrolizumab; nivolumab Received: April 23, 2017 Accepted: November 03, 2017 Published: January 03, 2018 ABSTRACT Metastatic melanoma was the first malignancy in which immune checkpoint inhibitors demonstrated their successful efficacy. Currently, the knowledge on the interaction between the immune system and malignant disease is steadily increasing and new drugs and therapeutic strategies are overlooking in the clinical scenario. To provide a comprehensive overview of immune modulating drugs currently available in the treatment of melanoma as well as to discuss of possible future strategies in the metastatic melanoma setting, the present review aims at analyzing controversial aspects about the optimal immunomodulating treatment sequences, the search for biomarkers of efficacy of immunocheckpoint inhibitors, and innovative combinations of drugs currently under investigation.

Metastatic melanoma is an aggressive and rapidly progressive disease. Heart metastases were shown in over 50% of autopsy. However, these metastases are usually clinically silent and reported in less than 2% of living patients1.2. There are no specific guidelines for the treatment of cardiac metastases as the therapeutic approach varies with the clinical features of the patient. This article is protected by copyright. All rights reserved.

Background There is no universally-accepted classification of Spitzoid tumors. This makes it difficult to assign a correct diagnosis and select a treatment that minimizes the risk of overestimating, or worse, underestimating, the malignant potential of these tumors. The aim of this study was to describe the clinical-pathological and epidemiological features of Spitzoid tumors, as well as to assess mortality in these patients. Methods This retrospective cohort study looked at data on Spitzoid tumors excised in 1999-2012 at the Dermatologic Clinic of the Turin University Hospital. Spitzoid melanoma specific survival curves were generated with the Kaplan-Meier method and compared using the log-rank test. Results In this time period, 1663 lesion were described at the pathologic report as Spitzoid. 262 (15.75%) were Spitz nevi, 307 (18.46%) Reed nevi, 827 (49.73%), 810 (48.71%) Spitzoid dysplastic nevi, 17(1.02%) atypical Spitzoid tumors, and 267 (16.06%) Spitzoid melanomas. Median follow-up time was 9 years. Out of the entire cohort only 24 patients died from melanoma. All of them received a diagnosis of Spitzoid melanoma. None of the patients with a diagnosis of not melanoma Spitz tumor died for melanoma during the follow-up. Conclusions In the large majority of the cases, Spitz tumor should be considered as benign lesion and excised only if melanoma features are seen. The used clinical pathological classification avoid misdiagnoses, inappropriate treatment and the risk of death for melanoma.

The role of vitamin D in melanoma is still controversial. Although several Authors described a correlation between vitamin D deficiency and poor survival in metastatic melanoma patients, clinical trials exploring the effects of vitamin D supplementation in this clinical setting were mostly inconclusive. However, recent evidence suggests that vitamin D exerts both anti-proliferative effects on tumor cells and immune-modulating activities, that have been widely explored in auto-immune disorders. On the one hand, vitamin D has been shown to inhibit T-helper17 lymphocytes, notoriously involved in the pathogenesis of immune-related adverse events (iAEs) which complicate immune-checkpoint inhibitor (ICI) treatment. On the other hand, vitamin D up-regulates PDL-1 expression on both epithelial and immune cells, suggesting a synergic effect in combination with ICIs, for which further investigation is needed.

As for all types of cancer, the incidence of melanoma increases with age. However, naevus counts (the principal risk factor for melanoma) decrease with age; hence the relationship between ageing and melanoma is complex. Subjects who maintain a high naevus count after the age of 50 years are more likely to be affected by melanoma, as their lesions do not senesce. Longer telomere length, which is strongly related to age, is linked to high naevus counts/melanoma risk; thus melanoma biology is influenced by factors that slow down ageing. Age is also an important prognostic factor in melanoma. Increasing age leads to worse survival in stages I, II and III. Sentinel lymph node (SLN) status, which is a strong predictor of melanoma survival, is also affected by age, as SLN positivity decreases with age. However, the prognostic value of SLN on survival increases with age, so, again, these relationships are complex. In patients with stage IV melanoma, age impacts on survival because it affects responses to treatment. This review examines the effects of age on melanoma risk, prognostic factors and responses to treatment.

Histological regression in primary cutaneous melanoma occurs in 10-35% of cases. Although there is a large body of literature on histological regression and prognosis in melanoma patients, not clear data concerning this feature has been reported. In the current review, a comprehensive overview of the main aspects of regression will be provided. The clinical utility of regression as a prognostic factor has been challenged recently. Nowadays evidences reported that this feature is protective on SLN metastases. Despite its association with poor prognostic factors, it maintained a favourable prognostic role in many different survival studies.

Summary The prognostic significance of histological regression in primary melanoma has been debated for many years. We aim to review the evidence to see how histological regression may affect prognosis. A systematic review was performed by searching in MEDLINE, Scopus and the Cochrane Library from 1 January 1966 to 1 August 2015. All studies reporting hazard ratios or data on survival and histological regression were included. Primary random-effects meta-analyses were used to summarize outcome measures. Heterogeneity was assessed using the χ2-test and I2-statistic. To assess the potential bias of small studies we used funnel plots and the Begg and Mazumdar adjusted rank correlation method. Summaries of survival outcomes were measured as hazard ratios or relative risk of death at 5 years according to the presence of histological regression of primary melanoma. In total, 183 articles were reviewed out of 1876 retrieved. Ten studies comprising 8557 patients were included. Patients with histological regression had a lower relative risk of death (0·77, 95% confidence interval 0·61–0·97) than those without. Examination of the funnel plot did not provide evidence of publication bias. The results showed that histological regression is a protective factor for survival.

The prognosis of stage IV metastatic melanoma is poor. An overall 1-year survival of 25.5% and a median survival of 6.2 months were reported without any significant improvement during the last 30 years before the introduction of new drugs (immune checkpoint inhibitors and targeted therapies) which completely modified the therapeutic approach and induced an overwhelming improvement on the survival rates of these patients. This review will analyze the therapeutic tools available for the treatment of patients with metastatic melanoma, including adjuvant interferon and locoregional therapies (surgery, radiotherapy and electrochemotherapy) and will mainly focus on the presentation of results obtained by the new treatments (checkpoint inhibitors and targeted therapies).

In many centers, Stage I-II melanoma patients are considered "cured" after 10 years of disease-free survival and follow-up visits are interrupted. However, melanoma may relapse also later. We retrospectively analyzed a cohort of 1,372 Stage I-II melanoma patients who were disease-free 10 years after diagnosis. The aim of this study was to characterize patients who experienced a late recurrence and to compare them to those who remained disease-free to identify possible predictive factors. Multivariate Cox proportional-hazards regression analyses were carried out to evaluate the influence of different factors on the risk of recurrence. Seventy-seven patients out of 1,372 (5.6%) relapsed, 52 in regional sites and 25 in distant ones. The majority of patients (31 out of 52) experienced late recurrence in regional lymph nodes. Brain and lung were the most common site of single distant recurrence (24% each). Patients with multiple distant metastases showed a brain and lung involvement in, respectively, 40 and 48% of cases. A Cox proportional-hazards regression model analysis showed the independent role of age under 40 years, Breslow thickness >2 mm, and Clark Level IV/V in increasing the risk of Late Recurrence. These patients should be followed-up for longer than 10 years. The pattern of recurrence suggests that melanoma cells can be dormant preferentially in lymph nodes, brain and lung. A particular attention should be reserved to these anatomic sites during the follow-up after 10 years of disease-free.

Herein we demonstrated the utility of dermoscopy and RCM in the monitoring of BRAF inhibitore therapy for melanoma skin metastases. Dermoscopically, after therapy all nodules and papules were typified by the presence of bluish colour with crystalline structures and peppering feature. RCM revealed a honeycombed pattern as typical finding of healthy skin; at dermal level, grossly arranged collagen fibers were detected along with small bright particles corresponding to inflammatory cells. Notably, no atypical melanocytes or any other malignant features were seen at all skin levels. This article is protected by copyright. All rights reserved.

10038Background: advanced age is associated with comorbidities and impairment of the immune system: these aspects may influence efficacy and tolerability of immune checkpoint inhibitors. Limited da...

Vitiligo is an acquired hypomelanotic disorder characterized by depigmented macules resulting from the loss of functional melanocytes. Many different etiological hypotheses have been suggested for vitiligo, the most recent of which involves a combination of interacting environmental and genetic factors. Among the various pieces of evidence in support of an autoimmune origin of vitiligo, there is the epidemiological association with several autoimmune diseases. The most frequently reported association is with autoimmune thyroiditis; however, other diseases such as rheumatoid arthritis, diabetes mellitus, pernicious anemia and chronic urticaria have been described in variable percentages, depending upon the genetics of the population studied. Among the diseases described in association with vitiligo there are the so-called autoimmune polyglandular syndromes (APS). Here we report 31 cases of APS diagnosed in 113 vitiligo patients, according to the newest classification. Autoimmune association was more present in generalized non segmental vitiligo and was more frequent in females. The most frequent association was with thyroid autoimmune disease, followed by autoimmune gastritis and alopecia areata. ANA positivity was similar to that reported previously in the general population. We stress the importance of an assessment for autoimmune diseases in vitiligo patients.

Two-thirds of 152 patients treated for high-grade cervical disease, free of persistence/recurrence, and followed-up both with human papillomavirus (HPV) DNA testing and HPV genotyping cleared their high-risk HPV infection within 1 year. Viral clearance continued at diminishing rates during the second and the third year, at the end of which it was virtually complete.

Several surgical and/or medical emergencies/urgencies may occur in gynecologic patients and in pregnant women during the first trimester. Particularly, ectopic pregnancies, ruptured or hemorrhagic ovarian cysts, ovarian or adnexal torsions, threatened or inevitable miscarriages, phlogistic gynecological disorders, complications involving the uterine fibroids, endometriosis, and spontaneous uterine rupture are possible acute complications. The diagnosis is suspected on the basis of symptoms (acute pelvic and/or abdominal pain, with or without vaginal bleeding or discharge, until acute abdomen with peritonitis), by means physical evaluation (abdominal, pelvic, and bimanual gynecological examinations), by means of transabdominal (TAS) and/or transvaginal (TVS) sonography, and laboratory tests. However, the diagnosis is often not that simple, especially when the symptoms and clinical signs are minimal, and ultrasound (US) examination is not diriment. The differential diagnosis of abdominal/pelvic pain is broad and includes primarily gastrointestinal and urogenital disorders. Generally, TAS should usually be used in conjunction with TVS for evaluation of the female pelvis. If the US examination is not conclusive, CT or MRI, especially in pregnant patients, should be considered.Diverse emergenze/urgenze chirurgiche e/o mediche possono interessare le pazienti ginecologiche e le gravide al primo trimestre. In particolare, le gravidanze ectopiche, le cisti ovariche rotte o torte, le torsioni ovariche o annessiali, le minacce d’aborto o gli aborti inevitabili, le patologie infiammatorie ginecologiche, i fibromi uterini complicati, l’endometriosi e la rottura uterina spontanea rappresentano possibili complicanze acute. La diagnosi può essere sospettata in base alla sintomatologia (algie pelviche e/o addominali acute, con eventuali perdite vaginali, fino a un quadro di addome acuto con peritonite), alla visita (valutazione addominale, pelvica ed esplorazione ginecologica bimanuale), all’ecografia transaddominale (TAS) e/o transvaginale (TVS), e agli esami di laboratorio. Tuttavia, la diagnosi spesso non è semplice, soprattutto quando i sintomi e i segni clinici sono lievi e l’ecografia non è dirimente. La diagnosi differenziale del dolore addominale/pelvico comprende un’ampia varietà di disordini, in particolare gastrointestinali e urogenitali. Generalmente, la valutazione della pelvi femminile dovrebbe essere eseguita mediante ecografia sia transaddominale che transvaginale. Se l’esame ecografico non consente di fare diagnosi, dovrebbero essere presi in considerazione la TC o, specialmente nelle donne gravide, la RMI.

Extracorporeal photopheresis (ECP) is a therapeutic procedure in which leukapheresed peripheral blood mononuclear cells are exposed to ultraviolet A in the presence of the photosensitizer 8-methoxypsoralen and then reinfused. Several guidelines recommend ECP as a treatment of choice in erythrodermic primary cutaneous T-cell lymphomas (E-CTCL). However, the level of evidence is low due to the rarity of this disease and the lack of randomized controlled trials. We performed a review of the English literature, restricting our analysis to studies including erythrodermic patients and more than 10 cases. Based on these criteria, we identified 28 studies, with a total of 407 patients. The median response rate in erythrodermic patients was 63% (range 31-86%), with a complete response rate ranging between 0 and 62% (median 20%). In our experience, we treated 51 patients with E-CTCL since 1992. A clinical response was obtained in 32 of 51 patients (63%), with a 16% complete response rate. The median time for response induction was eight months (range: 1-23). The median response duration was 22.4 months (range six months to 11 years). The treatment was generally well tolerated without systemic toxicities grade III-IV. The pretreatment parameters significantly associated with a higher likelihood to obtain a clinical response were the B-score in the peripheral blood, CD4/CD8 ratio, and amount of circulating CD3+CD8+ cells. Literature data together with our personal experience clearly support the clinical activity and tolerability of ECP in patients with E-CTCL. Prospective controlled clinical trials are strongly recommended to better document the evidence.

To review the treatments of the cesarean-induced isthmocele in restoring infertility, associated techniques, and the risks of complications associated with their use.Isthmocele is a reservoir-like pouch defect on the anterior wall of the uterine isthmus located at the site of a previous cesarean delivery scar. The flow of menstrual blood through the cervix may be slowed by the presence of isthmocele, as the blood may accumulate in the niche because of the presence of fibrotic tissue, causing pelvic pain in the suprapubic area. Moreover, persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, interfere with embryo implantation, leading to secondary infertility. The removal of the local inflamed tissue may be performed by laparoscopic, combined laparoscopic-vaginal, or vaginal surgery, and operative hysteroscopy, a minimally invasive approach to improve symptoms and restore fertility.Isthmocele occurs after cesarean section, a common method of delivery and one of the most frequent surgical procedures, so that its upward incidence appears likely to continue in the near future. Because of its minimal invasiveness, resectoscopy may be the better choice for treatment, yielding good therapeutic results.

In a retrospective case-control study, we compared the effectiveness of hysteroscopic correction and hormonal treatment to improve symptoms [postmestrual abnormal uterine bleeding (PAUB), pelvic pain localized in suprapubic site] associated with isthmocele. Women (n = 39; mean age ± SD, 35 ± 4.1 years) were subdivided in Group A [patients (n = 19) subjected to hysteroscopic surgery (isthmoplasty)] and, Group B [women (n = 20) undergoing hormonal treatment consisting of one oral tablet containing 0.075 mg of Gestodene and 0.030 mg of Ethynylestradiol for 21 days, followed by 7 days of suspension]. Resolution and/or improvement of menstrual disorders; patients degree of satisfaction with the treatment were measured 3 months later, by office hysteroscopy (Grop A) or phone call. PAUB and pelvic pain resolution was achieved in all patients: Group A had significant lower numbers of days of menstrual bleeding (P0.001), prevalence of pelvic pain in the suprapubic area (P = 0.04) and, higher degree of satisfaction (P0.001) compared to Group B. In conclusion, resectoscopic surgery is a valid way to treat patients with symptoms of prolonged postmenstrual uterine bleeding caused by isthmocele. Data from this study also indicate that resectoscopy may be the first choice because it is minimally invasive and yields good therapeutic results.

The reproductive outcome in 41 consecutive patients with cesarean-induced isthmocele and secondary infertility was evaluated prospectively. Patients included menopausal women (mean [SD; 95% CI] age, 35 [4.1; 29-42] years), with fertility duration of 3 to 8 (4.6 [28]) years with isthmocele, postmenstrual abnormal uterine bleeding, and suprapubic pelvic pain. Transvaginal ultrasound and office hysteroscopy were used to diagnosis isthmocele. Complete fertility tests were performed to exclude other causes of infertility in both female and male participants. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of isthmocele via operative hysteroscopy was successful in all cases evaluated. Patients became pregnant spontaneously between 12 and 24 months after isthmoplasty. Thirty-seven of the 41 patients (90.2%) delivered via cesarean section, and 4 (9.8%) had a spontaneous abortion in the first trimester. Isthmoplasty resulted in resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in all patients. Thus, it was concluded that surgical treatment of cesarean-induced isthmocele using a minimally-invasive approach (operative hysteroscopy) restores fertility and resolves symptoms in women with a cesarean section scar and secondary infertility.

The PATER study assessed the frequency of high-risk (HR) and low-risk (LR) human papillomavirus (HPV) in HPV-induced lesions in patients with borderline cytology.This retrospective observational cohort study was designed to evaluate ASCUS patients detected through a local cervical cancer screening programme and referred to the Department of Gynaecology and Obstetrics at the S. Orsola-Malpighi University Hospital in Bologna, in the period between January 2000 and December 2007.In 1047 patients aged 38.4 ± 9.6 years (range 23-65 years), 34.8% (n = 364) was positive for HR- or LR-HPV DNA. The mean age of women with HPV infection was significantly lower compared with the negative group (36.8 ± 9.4 versus 39.3 ± 9.6 years; p 0.001). Overall, 357 (34.1%) women had cervical lesions: 279 (26.6%) had CIN1, 18 (1.7%) CIN2, and 60 (5.7%) CIN3+. HR-HPV genotype was detected in 83.3%, and 91.5% of patients with CIN2 and CIN3+ respectively. Among the 124 CIN1 HPV-positive women, 8.9% harboured LR-HPV genotypes, 80.6% HR-HPV and 10.5% a combination of HR- and LR-HPV. HPV-6 and 11 accounted for 19.4% of all HPV-positive CIN1 lesions.Our study suggest that: in ASCUS patients over 40 years there is a low risk of positivity for HPV infection; the HPV DNA testing in patients with CIN3+ and a mean age close to 40 years is highly sensitive (98.3%) and acceptably specific (75.5%); the frequency of LR-HPV (alone or in combination with HR) in ASCUS cytology is not negligible. A tetravalent-based HPV vaccination alongside the screening programme would provide considerable clinical, organizational, and economic benefits.

Objective: To evaluate the feasibility of the hysteroscopic resection of type II submucous fibroids regardless of the myometrial free margin separating them from the serosa and to report the dynamic changes the margin undergoes after the various phases of resection. Design: A prospective observational study. Setting: A tertiary-level university hospital. Patient(s): Thirteen women with single type II submucous fibroids of ≤5 cm in diameter regardless of the myometrial free margin. Intervention(s): Hysteroscopic myomectomy and ultrasound evaluation of myometrial free margin before and after each phase of the procedure. Main Outcome Measure(s): The possibility of a complete one-step resection, the incidence of intraoperative or postoperative complications, and the analysis of the dynamic changes occurring in myometrial free margin. Result(s): Complete resection was performed successfully in all patients. No complications were registered. The myometrial free margin decreased on the distension of the uterine cavity and then increased progressively and significantly after the various phases of resection. Conclusion(s): In selected cases and in experienced hands, hysteroscopic myomectomy of type II submucous fibroids may be performed successfully and safely regardless of the myometrial free margin. Myometrial free margin increases progressively with each step of the procedure probably leading to an increasing margin of safety. Copyright © 2011 American Society for Reproductive Medicine, Published by Elsevier Inc.