Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study.

BACKGROUND: This study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM). METHODS: The study reviewed 69 patients with Tis/T1/T2 rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 Tis, 23 T1, and 21 T2. The median follow-up period was 6.5 years (range 5-10.2 years). RESULTS: The overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for Tis, 8.6% for T1, and 9.5% for T2. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for Tis, 100% for T1, and 70% for T2. The overall cancer-related mortality rate was 7.2%. CONCLUSIONS: After local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent Tis/T1 cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T2 rectal cancers appears inadequate.

TNM staging in lung cancer: role of computed tomography.

Current procedures to determine the clinical staging of disease in patients with lung cancer are lacking in accuracy, particularly regarding the presence of metastatic disease. We have evaluated the use of computed tomography (CT) of the chest, brain, and upper abdomen for clinical staging of the extent of disease in 113 consecutive patients with histologically confirmed carcinoma of the lung. Comparisons with mediastinoscopy and surgical findings were made regarding the extent of primary tumor in 47 patients and nodal involvement in 41 patients. The CT scan showed a sensitivity of 86.9%, a specificity of 91.6%, and an accuracy of 89.3% for extrapulmonary extension of the primary tumor and a sensitivity of 50%, a specificity of 96.5% and an accuracy of 82.9% for mediastinal node involvement. Thirty-two of the 85 patients studied by total body CT scan had distant metastasis, of which 24 (75%) were clinically silent. Thus 28.2% of the 85 patients studied had asymptomatic metastatic disease. We conclude that CT of the chest, brain, and upper abdomen is a reliable procedure for staging lung cancer.

Surgical treatment of adenocarcinoma of the cardia.

BACKGROUND: Adenocarcinoma of the gastric cardia presents different features from other gastric carcinomas. This study was performed to analyze the results of a 40-year experience with these lesions. METHODS: Of the 365 patients reviewed, 211 (57.8%) underwent resection. One hundred fifty patients underwent total gastrectomy with lower esophageal resection (TGER) and 46 underwent proximal gastrectomy with distal esophageal resection (PGER). More recently, 15 patients were submitted to total gastrectomy with subtotal esophagectomy (TGSE) without thoracotomy. RESULTS: The tumors were far advanced in most patients: extraparietal invasion in 77.7% of patients, lymph node involvement in 55%, and distant metastases in 11%. The postoperative mortality rate was 25.1% in patients who underwent resection: 26.7% after TGER, 17.4% after PGER, and 33.3% after TGSE (difference not significant). Cardiovascular and respiratory complications were common causes of death after both TGER and PGER. After TGSE, deaths were related exclusively to local complications, mainly as a result of cervical anastomotic leaks. The actuarial 5-year survival rate for all patients surviving resection was 16.7%. No improvement in the results of surgical therapy was observed during the past 20 years. The actuarial 5-year survival rate was significantly affected by pathologic staging: 61.0% stage I, 23.3% stage II, 9.8% stage III, and 0% stage IV (p less than 0.001). No significant differences in actuarial 5-year survival rates were observed between TGER (17.8%) and PGER (14.9%). Sex, duration of symptoms, and histologic type did not reveal prognostic significance. CONCLUSIONS: In early tumors a total gastrectomy with resection of 10 cm of esophagus above the tumor is advocated.

Popliteal artery entrapment syndrome: the role of early diagnosis and treatment.

BACKGROUND: The purpose of this study was to evaluate whether certain factors could influence arterial impairment at presentation for treatment of popliteal artery entrapment syndrome (PAES) and whether its early diagnosis could optimize long-term results. METHODS: Between 1979 and 1995, 30 patients were treated for PAES at our institution. Patients were characterized by age, risk factors, associated diseases, preoperative symptoms, affected side, dominant limb, duration of symptoms, musculotendinous structure causing the compression, arteriographic findings, arterial status at presentation, type of operation, postoperative complications, and long-term follow-up. RESULTS: Twenty-nine (65%) limbs underwent musculotendinous section (MTS), 15 (33%) limbs underwent vascular reconstruction, and 1 (2%) was surgically explored. Patients submitted to MTS were younger (mean, 31 +/- 3 years) than patients who underwent vascular reconstruction (mean, 41 +/- 4 years; p < 0.05). MTS limbs had a greater number of minor symptoms compared with those that underwent vascular reconstruction (62% versus 20%; p < 0.02). Arteriogram showed that MTS limbs had a greater number of normal findings at rest when compared with limbs that underwent conventional reconstruction (85% versus 0%; p < 0.001). No specific factors influenced the arterial status at presentation. During follow-up, treadmill examination revealed that MTS limbs had a better response (96%) than limbs that had undergone vascular procedures (67%; p < 0.02). MTS limbs had a better long-term patency rate (mean, 87 +/- 7 months) compared with limbs that were submitted to vascular reconstruction (mean, 107 +/- 8 months) (95% versus 65%; p < 0.02). CONCLUSIONS: Because PAES is a progressive disease that can create serious vascular obstructive disease and no specific factors seem to influence the degree of vascular impairment, the detection and treatment of PAES at an early stage permit better long-term results.

Pancreatic carcinoma in childhood: case report of long survival and review of the literature.

A case of exocrine pancreatic carcinoma in a 14-year-old boy is reported. The primary site of the tumor was in the head of the pancreas, and pathologic features were consistent with an anaplastic lesion. Ten years after curative resection the patient is still living. Extensive review of the literature has revealed 27 other cases of pancreatic carcinoma in children under 15 years of age. Aggressive surgical treatment is emphasized by the long survival observed in four patients who underwent radical operations and by this case report.

Shear stress increases the release of interleukin-1 and interleukin-6 by aortic endothelial cells.

BACKGROUND: The aim of this study was to determine the correlation between shear stress and the release of interleukin-1 (IL-1) and interleukin-6 (IL-6) by endothelial cells (EC). METHODS: Bovine aortic EC were seeded in fibronectin-coated cylinders at 1.0 x 10(6) cells/tube and allowed to reach confluence and to adhere for 48 hours. The experimental groups were subjected to a laminar flow of 100 ml/min (6 dyne/cm2). The control group was subjected to similar incubation conditions without flow. The release of IL-1 and IL-6 by EC was measured by enzyme-linked immunosorbent assay. RESULTS: Shear stress increased significantly (p < 0.01) the release of IL-1 and IL-6 by EC. The release of these two cytokines had different kinetics. CONCLUSIONS: Increasing shear stress facilitates release of IL-1 and IL-6 by EC. Previous reports have shown that IL-1 and IL-6 promote vascular smooth-muscle cell proliferation. Thus abnormal flow conditions with increasing shear stress may predispose to smooth-muscle cell proliferation that characterizes early atherosclerotic plaque development by an interleukin-mediated mechanism.

Results of curative gastrectomy for carcinoma.

BACKGROUND: In the western literature, controversy exists regarding the operative management of carcinoma of the stomach. Still debated are the extent of gastric resection, the role of splenectomy, and the significance of lymphadenectomy. STUDY DESIGN: We performed a retrospective study of 646 consecutive patients who underwent curative gastrectomy for carcinoma of the stomach from 1950 to 1989. A multivariate analysis of nine clinicopathologic and treatment-related variables, including type of gastrectomy, splenectomy, and extent of lymphadenectomy was done to assess the relative influence of these variables on survival. RESULTS: The following variables emerged as independent predictors of death: serosal involvement, distant lymph node metastases, and total gastrectomy. Splenectomy and lymphadenectomy were not related to prognosis. However, a separate analysis on defined subsets of patients revealed that radical lymphadenectomy (removal of N2 nodes) provided a survival benefit in patients with T1-2 N0-1 disease. CONCLUSIONS: These findings suggest that although prognosis of carcinoma of the stomach is mainly determined by the stage of disease at time of operation, the choice of the surgeon can affect survival. Total gastrectomy should be avoided when it is not necessary for proximal tumor location. Subtotal gastrectomy in distally located tumors seems to be the best option. Radical lymph node dissection should be performed when nodal involvement is expected to be limited or absent.

Natural history of entrapment of the popliteal artery.

Popliteal artery entrapment (PAE) is described with increasing frequency. Reviewing the world literature and corresponding with some investigators, we were able to collect 375 instances in 291 patients, including our personal experience (33 instances in 24 patients). The present study was done to establish the natural history and evolution of PAE. Two groups of patients were created to verify if an early diagnosis and treatment of PAE is justified. Group 1 included 129 patients treated by a simple musculotendinous section. In group 2, 226 patients were treated by a vascular procedure (bypass, thromboendarterectomy, other). Age, symptoms and arteriographic findings were the parameters considered in the two groups. Results demonstrated that patients in group 1 are younger than those in group 2 (p < 0.001). Preoperative symptoms demonstrated a larger number of mild symptoms (paresthesias, a cold foot and cramping after intensive physical training) in group 1, when compared with group 2 (p < 0.001). Arteriography demonstrated a larger number of patients with normal findings at rest, with popliteal stenosis or occlusion during maneuver, in group 1 than in group 2 (p < 0.001). PAE results in progressive arterial impairment. Early noninvasive screening is mandatory to detect PAE at an early stage. Surgical treatment is thereby limited to a musculotendinous section, which has the best results.

Management of large malignant rectal polyps with transanal endoscopic microsurgery. Is there anything better for the patient?

The authors report their experience with transanal endoscopic microsurgery (TEM), a technique that allows all the standard surgical manoeuvres such as tissue excision, suction, control of bleeding and suturing in the entire length of the rectal cavity. Main indications for TEM are the removal of large sessile polyps and early rectal cancers' (T1, G1-G2). Out of 50 patients submitted to TEM the authors consider in this study 24 cases with a preoperative diagnosis of benign large sessile polyps. The procedures included: 14 (58.3%) total wall excision, four (16.6%) total wall excision with perirectal fat, three (12.5%) mucosectomy, one mucosectomy + total wall excision, one partial wall excision + total wall excision, and the remaining case was converted to laparotomy due to a large intraperitoneal perforation. There was no operative mortality and an 8.3% rate of major complications. With a median follow up of 19 months there was no evidence of local or distant recurrence. The authors compare their results with those of alternative endoscopic and surgical techniques and highlight the advantages of TEM in the management of large and giant rectal polyps.

The role of surgery in the treatment of primary gastric lymphoma.

BACKGROUND: The aim of the study was to analyze the results of surgical treatment in early and advanced primary gastric lymphoma and to evaluate predictive factors for long-term outcome. MATERIAL AND METHODS: A retrospective study of 92 patients resected for primary gastric lymphoma was conducted. Sixty-eight (74%) patients underwent a curative resection 10 (11%) patients had palliative resection and 14 (15%) patients were deemed unresectable: 33 patients (36%) had a stage IE tumor, 12 (13%) stage IIE1, 22 (24%) IIE2 and 25 (27%) stage IVE. RESULTS: Follow-up ranged from 1 to 336 months (means 44 +/- 70 months, median 18 months). Cumulative actuarial 10-year survival rate was 49.1%. Ten-year actuarial survival rates were 78.9% for stage IE and 100% for stage IIE1 whereas 5-years survival rates were 0% for stage IIE2 and 21.7% for stage IVE (P < 0.00001). CONCLUSION: Surgical treatment is the front line therapy for IE and IIE1 stages of primary gastric lymphoma.

Angiogenesis as a prognostic indicator in pancreatic ductal adenocarcinoma.

BACKGROUND: Angiogenesis has gained wide acceptance as a reliable prognostic factor in several solid tumors. However, to date, experience in pancreatic adenocarcinoma is limited. MATERIALS AND METHODS: Specimens from 45 patients radically operated on at our departments from 1988 to 1997 were stained immunohistochemically with the antibodies anti-mutant p53, anti-bcl2, anti Ki67 and anti-CD31. All the slides were reviewed by the same pathologist without knowledge of the patients' outcome. RESULTS: Mutant p53, Ki67 index and vessel count were significantly related to tumoral behaviour and patients' outcome. Among patients with nodal involvement (Stage III), cumulative survival between hypovascular and hypervascular subgroups differed significantly (p = 0.03). Angiogenesis was independent from TNM in assessing the patients'prognosis at COX analysis (p = 0.02). CONCLUSION: In patients with pancreatic adenocarcinoma, angiogenesis is a reliable indicator of tumor extension, lymph node status and survival. Its evaluation as a common procedure may contribute to a further improvement in the management of these patients and to a proper selection of those who could benefit from different follow-up protocols or adjuvant treatment.

In vitro proliferation and in vivo malignancy of cell lines simultaneously derived from a chemically-induced heterogeneous rat mammary tumor.

Identification of clones in primary tumors responsible for proliferation, invasion, and metastasis was carried out. Four different aneuploid established cell lines derived from a ductal infiltrating mammary rat tumor induced by 7,12-dimethylbenz[a]anthracene were studied for proliferative and growth features in vitro and for tumorigenic and metastatic potential in vivo in nude mice. Clones, named RM1, RM2, RM3, and RM4, were characterized by different proliferative activity. Clone RM1 showed the highest proliferative activity by both tritiated thymidine incorporation and S-phase flow cytometry, followed by clone RM4. Conversely, clones RM2 and RM3 showed a lower proliferation rate. Growth-promoting activity, tested on 3T3 Swiss cells, was high in all clones, although RM1 showed significantly lower growth factors-releasing activity. Nude mice tumorigenesis demonstrated a strong tumor induction of line RM1 (100% of the mice after 47 +/- 7 d) and a slightly lower tumor induction of line RM4 (70% of the mice after 69 +/- 9 d). Line RM3 showed tumor induction in 40% of the mice after 186 +/- 16 d. Lines RM2 showed no tumor induction. Metastasis occurred in mice treated with line RM1 only. Therefore, tumorigenesis and metastasis correlate with proliferation but not with the release of growth factors. In conclusion, flow cytometry monitoring of clones from heterogeneous primary tumors proved to be a suitable model for the study of in vivo malignancy and in vitro proliferation.

Transplantation of irradiated heterotopic segmental human pancreas.

The results of three irradiated segmental pancreatic autotransplantations in patients with cancer of the pancreatic head are presented. The grafts with ligated ducts were irradiated with 5000 or 2000 rad. Following irradiation, the pancreatic tails that were tumor-free at the section line were autotransplanted by anastomosing the splenic vessels to the common femoral vessels. The first graft (5000 rad) that was necrotic, was removed on the 15th postoperative day and the patient was placed on insulin therapy. The second and third patient (2000 rad) are both alive with functioning grafts without exocrine secretion and with normal carbohydrate metabolism, 7 months and 1 month after transplantation, respectively. Technically, irradiated pancreas transplantation is a feasible procedure, which could be applicable to patients with cancer of the pancreatic head to avoid secondary complications of diabetes after total pancreatectomy, and to patients with juvenile or chronic pancreatitis. It is possible that high-dose irradiation can completely destroy eventual multicenter tumor foci in the pancreatic tail.

Axillary-to-contralateral brachial artery by-pass in the treatment of arm ischaemia.

Axillary-to-contralateral brachial artery by-pass was applied in two female patients affected by unilateral obstructive lesion of the subclavian artery with significant symptoms of arm ischemia. The result, at 10 and 12 months of follow-up, is good. The technique and its advantages are shortly outlined.

Cross-over axillary by-pass. Treatment of subclavian or innominate artery obstructive lesions.

A 13-year experience consisting on 16 consecutive patients submitted to axillary-to-contralateral artery by-pass in the treatment of obstructive lesions of the subclavian or innominate artery is reported. Nine patients complained of typical subclavian steal syndrome. Extended patency with very satisfactory functional result was achieved in twelve patients. An extensive survey is made of the results of such procedure, as reported in the literature. The theoretical advantages in comparison with other kinds of extrathoracic procedures aiming at the same goal are briefly outlined.

Local excision of rectal tumours with transanal endoscopic microsurgery.

Transanal Endoscopic Microsurgery (TEM) is a novel technique, first introduced by Buess and coworkers in 1983 for the treatment of large sessile polyps of the rectum. Due to the excellent results the indication was then extended also for the removal of low risk early adenocarcinomas (pT1, G1-G2). TEM allows, by using an operative proctoscope of an outside diameter of only 4 cm., all the conventional surgical manoeuvers within the rectal lumen, up to 20 cm. from the anal verge. The Authors report a consecutive series of 53 patients submitted to TEM over a 37 month period; apart from 7 patients excluded for different reasons, postoperative diagnosis showed 30 adenocarcinomas (65.2%), 15 adenomas (32.6%) and 1 epidermoidal carcinoma (2.2%). The low recurrence rate observed both for adenomas (0%) and pT1 adenocarcinomas (9%) coupled with the optimum vision allowed by the 6-fold magnified stereoscopic view, make this technique the method of choice for selected patients with these kind of pathologies.

[Bronchopulmonary carcinoma: influence of type of resection on long term survival]. / Il carcinoma broncopolmonare: influenza del tipo di resezione sulla sopravvivenza a distanza.

A statistical comparison between survival and type of resection: Lobectomy and pneumonectomy was made out of 108 patients who had undergone curative resection for lung cancer (with a minimum 3 years follow-up). Analysis was first made on the whole series, then the patients were classified according to histological type (W-PL) or staging (TNM) and finally stratified in 2 control levels (stage and histological type). There was a better prognosis for lobectomy than for pneumonectomy, referring to a single subgroup, but not in a statistically significant way. There was a better prognosis for patients who had been operated for lobectomy S(2) 2 LOB with a 36 months survival for 85%. There were better results for squamous cell carcinoma stage I and II S(2) 1 PNE, for those patients who had been operated for pneumonectomy with a median survival of 32 months and over 3 years survival for 41.7%.

A new multiparametric classification in lung cancer patients - S.M.I.G.

The classification of bronchogenic carcinoma as a function of the prognosis is still an open field. The evaluation of stage, by use of the TNM system, and histologic cell type is not sufficient to guarantee a correct prognosis. The growth rate of the neoplasm is another important parameter. We propose a classification that takes into account the stage (S), histologic cell type (M), immune status (I) and the growth rate of the primary tumor (G): S.M.I.G. We studied 90 lung cancer patients according to the S.M.I.G. classification and we observed that their prognoses were directly correlated with their S.M.I.G. scores (the higher the score, the higher the 10-month mortality rate). The mortality rates within the first 10 months of follow-up were respectively 0%, 0%, 36.36%, 68%, 90.9% for the 5 groups obtained by S.M.I.G. The difference is statistically significant (P less than 0.0075) and there is a linear correlation between the mortality rate and the score assigned to each group (R = 0.943; P less than 0.05). The S.M.I.G. classification can predict the prognosis more efficiently than the usual classification (TNM) and histological cell type.

Role of delayed cutaneous hypersensitivity reaction in classifying patients with bronchial carcinoma.

Cell-mediated immune response was evaluated in 150 patients with histologically confirmed bronchopulmonary carcinoma using bacterial and fungal recall antigens injected intradermally (PPD, candida, trichophyton). In the study group negative skin test reaction was found in 51 of 150 patients (34.0%), whereas in the control population it was found in 5 of 33 cases (15.1%) (p less than 0.05). Histologic cell type and stage of disease were defined for each patient. It was possible to calculate the growth rate of the primary tumor only in 68 of 150 patients, and it was recorded as doubling time. Evaluation of the skin test reaction in each prognostic subgroup showed no statistically significant differences. The only statistically significant differences were found when each prognostic subgroup was compared with the control population according to the frequency of a negative response to the skin test, particularly in stage III M1 (p less than 0.05) and stage III M0 (p less than 0.02). The delayed cutaneous hypersensitivity studied with recall antigen stimulation was mainly correlated with the stage of disease, and it should not be considered as an independent prognostic factor.

Lipid composition, retention and oxidation in fresh and completely trimmed beef muscles as affected by common culinary practices.

The objective of this study was to determine how and to what extent several culinary practices (i.e. household cooking methods), each applied to the beef muscle deemed most suitable (boiling to infraspinatus, broiling to longissimus lumborum, oven-roasting and microwaving to semitendinosus), could induce significant changes in: lipid and cholesterol contents, fatty acid composition and contents, their true and apparent retention values, and some indices of lipid oxidation. Most nutrients increased their concentration as a consequence of moisture loss through cooking, whilst no substantial variation was induced in fatty acid composition. Nevertheless, each cooking method had its own distinctive heat processing parameters, which interacted with the characteristics peculiar to the pertaining muscle, leading to markedly different evaporative and drip losses, significantly different true retention values for cholesterol and the sum of polyunsaturated fatty acids, distinct responses as to lipid oxidation liability. The selected culinary practices seemed to be able to interact with the composition of the selected muscles, up to the point that pro-oxidant conditions were in some way counteracted by antioxidant effects.