Diaphragmatic rupture with right colon and small intestine herniation after blunt trauma: a case report.

INTRODUCTION: Traumatic diaphragmatic hernias are an unusual presentation of trauma, and are observed in about 10% of diaphragmatic injuries. The diagnosis is often missed because of non-specific clinical signs, and the absence of additional intra-abdominal and thoracic injuries. CASE PRESENTATION: We report a case of a 59-year-old Italian man hospitalized for abdominal pain and vomiting. His medical history included a blunt trauma seven years previously. A chest X-ray showed right diaphragm elevation, and computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy, at which time the colon and small intestine were reduced back into the abdomen and the diaphragm was repaired. CONCLUSIONS: This was a unusual case of traumatic right-sided diaphragmatic hernia. Diaphragmatic ruptures may be revealed many years after the initial trauma. The suspicion of diaphragmatic rupture in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only curative treatment for diaphragmatic hernias. Prosthetic patches may be a good solution when the diaphragmatic defect is severe and too large for primary closure, whereas primary repair remains the gold standard for the closure of small to moderate sized diaphragmatic defects.

Is complete axillary dissection necessary for all patients with positive findings on sentinel lymph node biopsy? Validation of a breast cancer nomogram for predicting the likelihood of a non-sentinel lymph node.

AIM AND BACKGROUND: Axillary dissection in patients positive for sentinel lymph nodes is currently under discussion in the literature, since approximately only 50% of such patients has metastases in the remaining lymph nodes. To identify patients at risk for non-sentinel lymph nodes metastases, a nomogram was developed by the Breast Service of the Memorial Sloan-Kettering Cancer Center. The aim of this study was to assess the nomogram's predictive accuracy in a population of Italian breast cancer patients in our hospital. MATERIALS AND METHODS: The system of calculation used as variables prognostic factors of breast cancer: pathologic size, tumor type and nuclear grade, lymphovascular invasion, multifocality, estrogen receptor status, method of detection of the sentinel lymph nodes metastases (frozen section, serial hematoxylin-eosin, routine hematoxylin-eosin, and immunohistochemistry), number of positive and number of negative sentinel lymph nodes. RESULTS AND CONCLUSIONS: To measure the discrimination of the nomogram, a receiver-operating characteristic curve was construed, and the area under the curve was calculated. However, the area under the curve was 0.72, a very high value considering that the limit of acceptability is 0.70-0.80. The calculation system developed by the Memorial Sloan-Kettering Cancer Center provides a predictive value on the histopathologic state of sentinel lymph nodes.