High-Grade Poorly Differentiated Neuroendocrine Carcinomas of the Gastroenteropancreatic System: from Morphology to Proliferation and back

Poorly differentiated neuroendocrine carcinomas (PDNECs) of the gastroenteropancreatic system (GEP) are a heterogeneous group of aggressive malignancies with a high propensity for distant metastases and an ominous prognosis. They have traditionally been divided into small and large cell subtypes on morphological grounds. However, histological diagnosis needs to be supported by immunohistochemistry to avoid possible misdiagnoses either with the more frequent poorly differentiated adenocarcinomas and squamous cell carcinomas or with lymphomas and mesenchymal neoplasms. Although it is well known that GEP PDNECs are associated with a poor prognosis, data from some published studies seem to suggest that there is a fraction of patients with PDNECs who have better survival than expected. GEP PDNECs are currently classified according to the criteria proposed in the 2010 WHO classification. They are simply called neuroendocrine carcinomas (NECs) and are defined by mitotic count >20?×?10 HPF and/or Ki-67 labeling index >20 %. However, a few recent papers have indicated that some NECs, as defined by the 2010 WHO scheme, do not show a poorly differentiated morphology as expected. This category seems to show a better prognosis and, especially, does not respond to cisplatin-based chemotherapy, which represents the goal standard therapeutic approach to high-grade PDNECs. In the present review, the main morphological, immunohistochemical, and prognostic features will be discussed as well as the opportunity to introduce a new category characterized by well to moderately differentiated morphology associated with high proliferation (mitotic count >20?×?10 HPF and/or Ki-67 index >20 %).     

COVID-19 in a liver transplant recipient: Could iatrogenic immunosuppression have prevented severe pneumonia? A case report

BACKGROUNDCoronavirus disease (COVID) is a new and highly contagious infectious disease caused by the coronavirus (COVID-19 or severe acute respiratory syndrome coronavirus 2). There is limited data regarding the incidence and management of COVID-19 in immunocompromised patients’ post-transplantation. In the pre-COVID-19 era, these patients were already at an increased risk of developing opportunistic infections. These often manifested with atypical symptoms.CASE SUMMARYWe report another case of uneventful COVID-19 pneumonia in a 58-year old male who was 18 mo’ post liver transplantation. He received tacrolimus monotherapy since July 2019. The clinical manifestations included only epigastric pain radiating to the right hypochondrium, nausea and vomiting. He had no fevers, cough, shortness of breath, anosmia or dysgeusia even if the chest computed tomography scan revealed an extension of the multiple patchy ground-glass density shadows to the upper lobe of the left lung too. He was hospitalised and received a course of oral chloroquine (200 mg × 3 per day) for a period of 10 d. Interestingly, the COVID 19 infection was uneventful though there were no modifications to his tacrolimus dosing. He was successfully discharged. We performed subsequent follow-up via telemedicine.CONCLUSIONIn light of the current pandemic, it is even more important to identify how the liver recipient’s patients present and are managed, especially for immunosuppression treatment.     

European Society of Hypertension scientific newsletter: hypertension and aortic diseases

Hypertension, one of the major cardiovascular risk factors, promotes the formation of atheromatous lesions in the large arteries, including the aorta. It also favors aortic aneurysm and acute aortic syndrome such as aortic dissection or hematoma. In patients with aortic disease, beta-blockers and/or renin-angiotensin-aldosterone system inhibitors should be preferentially used to decrease blood pressure and improve arterial wall properties.     

Complications in lumbar spine surgery: A retrospective analysis

Background:

Surgical treatment of adult lumbar spinal disorders is associated with a substantial risk of intraoperative and perioperative complications. There is no clearly defined medical literature on complication in lumbar spine surgery. Purpose of the study is to retrospectively evaluate intraoperative and perioperative complications who underwent various lumbar surgical procedures and to study the possible predisposing role of advanced age in increasing this rate.

Materials and Methods:

From 2007 to 2011 the number and type of complications were recorded and both univariate, (considering the patients’ age) and a multivariate statistical analysis was conducted in order to establish a possible predisposing role. 133 were lumbar disc hernia treated with microdiscetomy, 88 were lumbar stenosis, treated in 36 cases with only decompression, 52 with decompression and instrumentation with a maximum of 2 levels. 26 patients showed a lumbar fracture treated with percutaneous or open screw fixation. 12 showed a scoliotic or kyphotic deformity treated with decompression, fusion and osteotomies with a maximum of 7.3 levels of fusion (range 5-14). 70 were spondylolisthesis treated with 1 or more level of fusion. In 34 cases a fusion till S1 was performed.

Results:

Of the 338 patients who underwent surgery, 55 showed one or more complications. Type of surgical treatment (P = 0.004), open surgical approach (open P = 0.001) and operative time (P = 0.001) increased the relative risk (RR) of complication occurrence of 2.3, 3.8 and 5.1 respectively. Major complications are more often seen in complex surgical treatment for severe deformities, in revision surgery and in anterior approaches with an occurrence of 58.3%. Age greater than 65 years, despite an increased RR of perioperative complications (1.5), does not represent a predisposing risk factor to complications (P = 0.006).

Conclusion:

Surgical decision-making and exclusion of patients is not justified only by due to age. A systematic preoperative evaluation should always be performed in order to stratify risks and to guide decision-making for obtaining the best possible clinical results at lower risk, even for elderly patients.     

Midterm results of surgical treatment of displaced proximal humeral fractures in children

Purpose

To analyse the clinical outcomes of 26 children treated surgically for displaced proximal humerus fracture.

Materials and methods

From January 2008 to December 2012, 26 children/adolescents (14 boys, 12 girls) were treated surgically for displaced fractures at the proximal extremity of the humerus. Ten were grade III and 16 were grade IV according to the Neer–Horowitz classification with a mean age of 12.8 ± 4.2 years. Twenty young patients were surgically treated with a closed reduction and direct percutaneous pinning; six required an open approach. To obtain a proper analysis, we compared the Costant scores with the contralateral shoulder (Δ Costant).

Results

The mean follow-up period was 34 months (range 10–55). Two grade IV patients showed a loss in the reduction after percutaneous treatment. This required open surgery with a plate and screws. On average, the treated fractures healed at 40 days. The mean Δ Costant score was 8.43 (range 2–22). There was a statistically significant improvement in the mean Δ Costant score in grade III patients. In grade IV patients, there was a significant improvement in the mean Δ Costant score in those treated with open surgery versus mini-invasive surgery.

Conclusions

Our study shows excellent results with percutaneous k-wires. This closed surgery had success in these patients, and the excellent outcomes noted here lead us to prefer the mini-invasive surgical approach in NH grade III fractures. In grade IV, the best results were noted in patients treated with open surgery. We suggest an open approach for these patients.

Level of evidence

III.

     

Ultrastructural evidence of Tropheryma whippelii in PAS-negative granulomatous lymph nodes

The presence of Tropheryma whippelii was demonstrated in the PAS-negative mesenteric granulomatous lymph nodes of a patient affected by Whipple disease. Ultrastructurally a few bacteria, enclosed by a membrane characteristic of Tropheryma whippelii, were found in the extracellular spaces and remnants of bacteria were found in the phagocytic vacuoles of macrophages. The scarce number of bacilli, probably due to the fact that the disease was at an initial phase, could explain the absence of PAS positivity. This case confirms the role of the electron microscopy in the diagnosis of Whipple disease, especially for extra-intestinal lesions and at the initial phase of the disease, when the characteristic PAS-positive macrophages can be absent.