Management of recurrent nasopharyngeal carcinoma: current perspectives.

Nasopharyngeal carcinoma is a rare disease in Western countries. Nevertheless, its incidence in China, Singapore, and other Eastern countries reaches 20 cases per 100,000 people. Being an extremely chemo- and radiosensitive disease, upfront treatment often consists in the association of intensity-modulated radiation therapy and concurrent cisplatin. Unfortunately, about 20% of the patients suffer from a radioresistant disease which recurs after upfront therapy. For these patients, mainly available therapeutic options consist in systemic therapy, in particular poly-chemotherapy. In those showing a single locoregional recurrence, chemotherapy is not considered to be the preferred approach and other different strategies may be employed. Re-irradiation and surgery are strategies that are always used more often, albeit related to high risk of morbidity. Immunotherapy and targeted therapy, such as heavy ions-based re-irradiations, are experimental but very intriguing options.

Surgical treatment with Ligasure Precise of schwannoma of brachial plexus: case report.

English version We present a case of bulky schwannoma arising from the brachial plexus treated by a new surgical device. A 38-year-old man presented with a slow-growing left-sided supraclavicular mass and complained paresthesia of the third and forth fingers of the hand and forearm weakness. Physical examination revealed Tinel's sign. A CT-scan revealed a solid mass situated in the left profound supraclavicular fossa. The tumour was resected with the utilization of bipolar vessel sealing system (Ligasure Precise). This device is very useful in sutureless removal of masses localized in deep supraclavicular fossa. During the operation, care was taken to preserve the nerve function.

A multicentric phase II clinical trial on intra-arterial hepatic radiotherapy with 90yttrium SIR-spheres in unresectable, colorectal liver metastases refractory to i.v. chemotherapy: preliminary results on toxicity and response rates.

BACKGROUND: In patients locally progressing after two lines of chemotherapy, some locoregional approaches showed encouraging results in terms of local control of disease. The aim of our study was to evaluate toxicity, clinical response and quality of life in 48 patients with unresectable colorectal liver metastases submitted to selective internal radiotherapy (SIRT). MATERIALS AND METHODS: Up to now 35 patients with unresectable colorectal liver metastases, refractory to two lines of chemotherapy, underwent intra-arterial infusion of resin microspheres with yttrium-90 (SIR-spheres). Pre-treatment evaluation included a CT scan, blood tests, a PET scan and arteriography of celiac trunk, hepatic and superior mesenteric artery; extrahepatic uptakes and pulmonary shunts more than 10% were excluded by a Scinti-scan. The gastroduodenal artery was embolized before the SIR-spheres injection. Other exclusion criteria were liver dysfunction and anatomical vascular anomalies. The clinical response was evaluated by CT-scan following the RECIST criteria. Median follow-up was 4 months. RESULTS: Median number of metastases was 4 (range, 1-15), 38% of cases presenting hepatic involvement < 25%. The median SIRT dose delivered was 1.7 GBq. Median pulmonary shunt was 6%. No operative mortality occurred; early toxicity (within 48 hours) was 20.6%, shown as fever, acute pain and leucocytosis. The late toxicity was 24.1% with chronic pain, jaundice and nausea being the most frequent. All the toxic events were graded 2 or 3 according to the WHO scale. Preliminary results were available in terms of clinical response after 6 weeks: 12.5% had a partial response, 75% a stable disease, while progression of disease, was observed in 12.5% of the patients. CONCLUSION: SIRT is a safe treatment in terms of acute and late toxicity. Intra-arterial microspheres could represent a good therapeutic option for patients with progressing liver metastases only, after two lines of systemic chemotherapy.

Gastrointestinal tumours in elderly.

The Authors report their experience concerning 129 cases of gastrointestinal neoplasms (gastric, colonic, anorectal), recorded during the last years among patients aged between 70 and 81 years, who underwent radical surgery. The main issues evaluated were: anaesthesiological risk, stage, post-operative mortality and morbidity. Elderly seems not to be a contraindication, nor a limit for surgery if the patient is correctly and strictly managed pre and post-operatively.

Factors predictive of pelvic lymph node involvement and outcomes in melanoma patients with metastatic sentinel lymph node of the groin: A multicentre study.

INTRODUCTION: The optimal extent of the groin lymph node (LN) dissection for melanoma patients with positive sentinel LN biopsy is still debated and no agreement exist on dissection of pelvic LN. This study aimed at investigating predictors of pelvic LN metastasis and prognostic significance of having metastasis in the pelvic LNs. METHODS: Clinicopathologic data of 740 patients with positive groin sentinel LN who underwent ilioinguinal completion LN dissection at four Italian centre were analysed. Multivariable logistic and Cox regression analysis was used to identify independent predictors of pelvic LN metastasis and to adjust prognostic significance of pelvic LN metastasis. RESULTS: More than a quarter (26%) of patients had positive non-SLNs after inguinal and pelvic lymphadenectomy, which were located in their pelvis in the 12% of cases. Older patients [(OR) 1.69; 95% confidence interval (CI) 1.02-2.78] having thick primary (OR 1.6; 95% CI, 1.01-2.53) and ≥ 2 positive SLNs (OR 2.5; 95% CI, 1.4-4.47) were more likely to harbour pelvic LN metastasis. Interestingly, 4% of all patients (34% of patients with positive pelvic LNs) had pelvic LN metastasis with negative inguinal LNs. Pelvic LN metastasis was independently associated with higher risk of recurrence and lower survival. 5-year disease free and overall survival was 30% and 50%, respectively, for patients with pelvic LN metastasis. CONCLUSIONS: Pelvic LNs are frequently positive after ilioinguinal lymphadenectomy and it should be considered for all patients, especially those who are older, have thick primary and ≥ 2 positive SLN. Patients with pelvic LN metastasis have worse prognosis.

[Treatment for microcarcinoma of the thyroid. Clinical experience]. / Il trattamento dei microcarcinomi della tiroide. Esperienza clinica.

According to WHO, small papillary cancer represents a papillary carcinoma < or = 1 cm in greatest dimension. The autoptic incidence is more elevated showing a low aggressivity. In fact lower mortality and local relapse have been reported. The AA report their results of 17 pt operated on for benign thyroid pathology in last three years. The diagnosis has been "incidental cancer" with 7 mm of mean diameter. Surgical treatment consisted of 9 total thyroidectomy, 3 near total thyroidectomy, 3 subtotal thyroidectomy, 2 lobo-isthmusectomy, with completion on the fifteenth day. Radioiodine therapy was administered in the case of uptake > 3.5%. There were no significant complications. Only in parathyroidectomy for secondary hyperparathyroidism, we have definitive hypoparathyroidism. Age, capsular infiltration, multifocality and lymphonodal dissemination represent main prognostic factors. In the treatment of SPC we recommend a total thyroidectomy or a near total in association with iodine-131 radioiodine therapy.

[Giant Spigelian hernia associated with inguinal hernia. Repair with polypropylene prosthesis]. / Ernia di Spigelio "gigante" associata ad ernia inguinale. Riparazione con protesi di polipropilene.

Spigelian or lateral ventral hernia is a rare pathology, representing about 2% of all abdominal wall hernias. This kind of hernia can be found in the area limited from the umbilicus and anterosuperior iliac spine, near the lateral edge of the rectus abdominis. The authors describe a rare case of "giant" Spigelian hernia related with homolateral direct inguinal hernia. A seventy-year-old and obese patient had a painless huge intumescence in the right side of periumbilical area, and besides--he had a homolateral direct inguinal hernia. Abdominal computerized tomography visualized a hernial gap, which diameter is larger than 7 cm, in pararectal subumbilical site and a wide herniated bowel in interaponeurotic site. This double hernial pathology has been treated in an only solution, placing an only subfascial polypropylene prosthesis, overlapping both hernial defects. The authors believe prosthetic "tension free" repair, previous suture of the defect, represents a gold standard in the treatment of Spigelian hernia. Such refined technique allows an effective repair especially when aponeurotic defect is out of size and/or is related with subsequent homolateral hernia, also allowing an early patient's rehabilitation.

[The role of surgery in the treatment of adrenocortical carcinoma]. / Il ruolo della chirurgia nel trattamento del carcinoma del corticosurrene.

The authors evaluate the role of surgery in the treatment of primary adrenocortical cancer. They describe a case-report of a "giant" surrenalic cancer in a young woman affected by chronic hepatitis B related, submitted to "en bloc" surgical resection, locoregional lumphectomy and omolateral nefropexy. The adjuvant post-operative therapy consisted in six cicles of chemioterapy with Mitotane (op'DDD) at conventional dose. Postoperative course was unevenful and the patient was discharged after four days. Postoperative adjuvant therapy was well tolerated and after one year the patient is disease free. In Italy adrenocortical cancer represents about the 10% of adrenal neoplasms and causes a mortality--cancer related--about of 0.1% among all cancers. The incidence of relapse is about 25% after "en bloc" resection with 5 years survival of 54% in stage I-II, 21.4% in stage III, 6.5% in stage IV, respectively. The age < 40 years a functional activity of the mass, stage and resecability of neoplasm represent the most important prognostic factors. The use of mitotane in the postoperative adjuvant therapy is still controversry with variable results. Surgery represents the treatment of choice in case of primary adrenocortical cancer and is well indicated also for patients with advanced stage and recurrent loco-regional disease.

[Neoadjuvant chemo-radiotherapy in the treatment of rectal cancer: preliminary results]. / Chemio-radioterapia neoadiuvante nel trattamento del cancro del retto: risultati preliminari.

Many studies in the literature have confirmed the role of combined therapy in the treatment of rectal neoplasms. Aim of the Authors' study was to evaluate the efficacy of preoperative neoadjuvant radiochemotherapy in these patients. The study group consisted of 15 patients, affected by rectal adenocarcinoma T < 4 M0 with age < 75 years, observed from January to August 1998, who underwent to RT of pelvis with three fields--total dose 32 Gy- in ten days associated with 5 FU(500 mg/m2) during the first five. After restaging the patients were operated on. Anterior resections (AR) were followed by mechanical colorectal anastomosis in 10 patients, coloendoanal anastomosis in 4, while in 1 case an abdominoperineal resection (APR) was performed. The protocol was well tolerated in every patient and perioperative complications were similar to those in the control group. A considerable reduction of the mass was obtained in a great percentage of patients studied, confirmed by pathologic examination like "down staging" of cancer. In no case a complete response to the therapy was observed (pT0N0). Survival in the patients operated on for rectal adenocarcinoma in about 50% and local relapse is the most important site of recurrent disease. The aim of neoadjuvant protocol is the control of lymphatic spread and reduction rectal neoplasm allowing coloanal anastomosis in the treatment of the 1/3 inferior rectal cancer. Literature data confirm a significant decrease of local relapse, probably with a better survival. The Authors study confirms that combined preoperative therapy is well tolerated in most of the cases and it represents the protocol of choice in the patient affected by rectal cancer.

[Role of ultrasound-guided percutaneous alcohol administration in the treatment of solitary cysts of the liver]. / Il ruolo della alcolizzazione percutanea ecoguidata nel trattamento delle cisti solitarie del fegato.

Non-parasitic liver cysts represent a frequent pathology, but rarely they cause compressive symptoms so to require a suitable treatment. The Authors report a case of solitary large cyst localized in the left liver lobe, causing compressive symptoms in a cardiopathic old woman in whom surgical treatment was contraindicated. The treatment consisted in US-guided percutaneous puncture, decompression and sclerotherapy by 300 cc of ethylic alcohol (90 degrees). The patient showed a moderate alcoholic intoxication, associated with fever. This treatment been repeated fifteen days after for the large dimension of the cyst. Twelve months later the results were excellent with a complete relief of compressive symptoms and a remarkable reduction of the cyst at the CT scan. The Authors conclude that, in case of non operable large liver cysts, percutaneous ethanol injection is the treatment of choice, with low cost and morbidity, and mild recurrence rate.

[Interstitial laser treatment of small hepatocarcinoma on cirrhosis without anesthesia: feasibility study]. / Laserterapia interstiziale del piccolo epatocarcinoma su cirrosi senza alcuna anestesia: studio di fattibilità.

OBJECTIVE: We evaluated if interstitial laser photocoagulation (ILP) under ultrasound (US) guidance of intraparenchymal small HCC (<2 cm) in cirrhosis can be safely and effectively performed without any anesthesia. PATIENTS AND METHODS: Twelve cirrhotic patients with 14 nodules of HCC (diameter 1.2-2.0 cm; mean: 1.7) underwent ILP. All procedures were performed without local or general anesthesia. Necrosis of the nodules was evaluated with triphasic contrast-enhanced CT. RESULTS: Post-treatment CT showed complete necrosis in all cases. Pain occurred in 5 patients during the treatment was treated with iv pain-killer and only in 1 case the procedure was stopped before the scheduled time. No major complication occurred. CONCLUSIONS: ILP under US guidance is feasible without any anesthesia in patients with small intraparenchymal HCC.

Multidisciplinary approach to locally advanced rectal cancer: results of a single institution trial.

Locally advanced rectal cancer carries out a dismail prognosis despite optimal surgery in terms of local and distant relapses. Neoadjuvant chemoradiation offers good results with tumor downstaging and downsizing and leads to more radical surgery with conservative intent. Selection of patients and an intensive chemotherapy may improve long term results. Our experience with a combined polichemotherapy and radiotherapy for low advanced rectal cancer is presented.

Combined multistep approach in a locally advanced rectal cancer with sacral invasion: case report.

Composite pelvic resection with sacrectomy may provide good local control in case of locally advanced rectal cancer infiltrating the sacral bone. A combined multidisciplinary approach including chemotherapy and radiotherapy is here presented for a case of rectal tumor invading the sacrum.