Prognostic significance of pulmonary multifocal neuroendocrine proliferation with typical carcinoid

Background. Clinical significance of multifocal pulmonary neuroendocrine proliferations (MNEP), including tumorlets and pulmonary neuroendocrine cell hyperplasia, in association with Typical Carcinoid (TC), is still debated. Methods. A large retrospective series of TC with long-term follow-up data prospectively collected from two institutions was evaluated. Recurrence or new TC development was followed-up. Patients with TC alone and MNEP+TC were compared. Results. 234 TC patients undergone surgery were included: 41 MNEP+TC (17.5%) and 193 TC alone (82.5%). In the MNEP+TC group older age (p<0.001), peripheral tumors (p=0.0032), smaller tumor size (p=0.011) and lymph-nodal spread (p=0.02) were observed in comparison with TC group. Relapses occurred in 8 patients (19.5%) in the MNEP+TC group and in 7 (3.6%) of the TC group. The 10-years progression-free survival were 96.1% in TC and 83.8% in MNEP+TC (p<0.001). After matching, in 36 pairs of patients a significantly higher 5-years progression-free survival was calculated for TC group (p<0.01). Furthermore the odds of belonging to MNEP+TC group was higher with work-related exposure to inhalant agents (p=0.008), asthma/bronchitis (p=0.002), emphysema, fibrosis and inflammatory status (p=0.032), micronodules on the chest CT scan and respiratory insufficiency (p=0.036). Conclusions. The identification of MNEP requires careful pathological examination and postoperative follow-up. MNEP seems to be an adverse prognostic factor in patients with synchronous TC. Therefore, suspicion of MNEP during the pre-operative assessment should not be underestimated, enabling changes in the surgical strategy.

Toxic cyanobacteria in water intended for drinking purpose: improvement of cells and toxins’ analyses and of treatments for their removal

Massive proliferations of cyanobacteria in freshwaters have recently increased, causing ecological and economic losses. Their ever-increasing presence in water sources destined to potabilization has become a major threat for public health, since several species can produce harmful toxins (cyanotoxin). Therefore, additional specific measures to improve management and treatment of drinking water(s) are required. The PhD thesis investigates toxic cyanobacteria in drinking waters with a special focus on Emilia-Romagna (Italy), throughout three separated chapters, each with different specific objectives. The first chapter aims at improving the fast monitoring of cyanobacteria in drinking water, which was investigated by testing different models of multi-wavelength spectrofluorometers. Inter-laboratories calibrations were conducted using mono-specific cultures and field samples, and both the feasibility and the technical limitations of such tools were illustrated. The second chapter evaluates the effectiveness of drinking water treatments in removing cyanobacterial cells and toxins. Two chlorinated oxidants (sodium hypochlorite and chlorine dioxide) already in use for pre-oxidation during water potabilization, were tested on cultures of the toxic cyanobacterium Microcystis aeruginosa posing a specific focus on toxin removal and revealing that pre-oxidation can cause the release of toxins and unknown metabolites. Innovative treatments based on non-thermal plasma were also tested, observing an effective and rapid inactivation of cyanobacterial cells. The third chapter presents a study on a cyanobacterium isolated from a drinking water reservoir of Emilia-Romagna and investigated by combining biological, chemical, and genomic methods. Although the strain did not produce any known cyanotoxin, high toxicity of water-extract was observed in bioassays and potential implications for drinking water were discussed. Overall, the PhD thesis offers new insights into toxic cyanobacteria management in drinking water, highlighting best practices for drinking water managers regarding their detection and removal. Additionally, the thesis provides new contributions to the understanding of the freshwater cyanobacteria community in the Emilia-Romagna region.