The first case of breast cancer in thalassemic patient: case report and review of literature.

Thalassemias are genetic disorders characterized by decreased synthesis of one of the globin chains. Beta-thalassemia is caused by impairment in the production of beta-globin chains leaving the excess alpha chains unstable. With better treatment approaches and improvement in chelation therapy, thalassemic patients are living longer. As a consequence, new complications and associations with other conditions including malignancy have emerged. The occurrence of malignancies in thalassemia has rarely been reported, and our review of the literature revealed only few cases. We report the first case of a thalassemic patient developing breast cancer and discuss the possibility of a link between the two disease entities. This case is intended to alert physicians of the possibility of a malignancy in thalassemia patients.

Pathologic features of endometrial carcinoma in elderly women.

It has been estimated that more than two-thirds of cancers occur in people over 65 years of age: endometrial cancer (EC) is the most common gynaecologic cancer in the U.S. and represents the fourth most common malignancy in women. Some authors have reported that EC in elderly women was more aggressive, histologically less-differentiated and often non-endometrioid when compared with EC in the younger population. The purpose of this retrospective study is to evaluate the pathologic features of EC in women 70 years old or over compared with those of younger patients. Between 1987 and 1997, 174 patients with EC were surgically treated: 52 women were 70 years old or over. Two-thirds of both groups had surgical Stage I tumors: 54% of surgical Stage I tumors in the elderly had myometrial invasion more than 50% compared with 32% in the younger group (p<0.01). On the whole 37% of elderly patients had Stage IC tumors compared with 21% in younger women (p<0.01). Seventy-five percent of elderly women had Grade 2 or 3 tumors compared with 55% of younger patients (p<0.005). The majority of EC was endometrioid in both groups: 8% of elderly patients had clear-cell carcinomas compared with 4% of younger women (p not significant). No elderly patients showed nodal metastasis (0 out of 10): 9% of younger women had pelvic or para-aortic metastasis. The median follow-up was 78 months. The overall survival in the elderly and in the younger group was 80% and 93%, respectively (p<0.01): in elderly women overall survival significantly varied according to histotype and depth of myometrial invasion in Stage I tumors. In conclusion patients 70 years old or over have a high probability of surgical Stage I EC but a significantly higher probability of deep myometrial invasion and less-differentiated tumors than younger women: the prognosis w as good but poorer than for younger patients.

Lymph nodal metastases and the clinical stage of cervix carcinoma.

It has been proved that surgery is essential both for therapy and for diagnostic staging of gynaecological cancer. We have studied 131 patients who underwent pelvic and paraaortic lymphadenectomy. Out of the cases of the 1st clinical stage, the staging error was 16.4%. 10 cases were understage: 3 belonged to the 2nd surgical stage, 6 to the 3rd one and 1 to the 4th one. Out of 61 patients at the 2nd clinical stage, 44.2% were overstaged and 36.1% were understaged; in fact 16 belonged to the 3rd and 6 to the 4th surgical stage. 1 woman of the 6 belonging to the 3rd stage was at the 4th surgical stage. All 3 patients of the 4th stage had both clinical and surgical correct staging. The results show the determinant meaning of node metastases and their spreading for a correct surgical staging. According to the regular distribution of metastases, it has been shown that in 81.1% there is a regular rule while in 18.9% there is not a metastatic regular distribution. This study confirms the reliability of our surgical statement based on lymph nodal radical excision.

Primary tumor receptorial status and axillary metastases: their prognostic significance.

Data on the prognostic value of receptorial status are controversial. On the basis of our results, receptorial status has no significance as an independent role; only the number of involved nodes and hormonal therapy have this prognostic role. Free of disease survival curves according Kaplan and Meier show that there are no statistically significant differences either in patients with low neoplastic recurrences (pN0) or in those patients with high risk (pN1) among women with tumor ER+ and ER-. Among 291 pN0 patients there was no relation between receptorial status (negative from 3 to 9 fmol/mg) and results of therapy on the follow-up. Among 248 pN1 patients therapy with tamoxifen had an influence on free interval both in the group with a low receptorial status and in particular in that with high receptorial level; no effects of therapy on the ER- patients. In the group of 248 pN1 patients with high receptorial status, the therapy was more successful in the group with a medium lymph nodal risk (from 1 to 3 positive nodes) and also in the group with G1 or G2. With regard to the study of the relation between lymph nodal metastases and receptorial status, we can state that lymph nodal levels data gives the main prognostic factor of risk. Therefore lymphadenectomy involving the three lymph nodal levels appears to be the crucial point in diagnostic and therapeutic surgical strategy of breast carcinoma.

Primary choriocarcinoma of the fallopian tube: report of a case.

A case of the relatively rare condition of a choriocarcinoma in the fallopian tube is presented. The patient apparently recovered completely and quantitative beta hCG assay demonstrated negative results after TAHBSO and adjuvant chemotherapy. This brings the total cases reported to 77.

The place of pelvic exenteration in surgical management of advanced and recurrent pelvic tumors.

A series of 28 exenterations for advanced pelvic tumours is presented. The operative mortality (within 90 days) was 17.8%. The actuarial survival (expressed as a two-year disease-free interval) was 35.7%, and better in cases with negative lymph nodes. The types of urinary and bowel diversions adopted are discussed in terms of longer survival.

Two cases of clinical Ib stage cervix carcinoma with exclusive metastases to presacral lymph-nodes.

There is regular progression of metastases through different stations of pelvic lymph nodes as far as para-aortic lymph-nodes in 81.1% of the cases examined of cervix carcinoma. In this paper we report two cases of squamous carcinoma of the cervix with metastases limited to one presacral lymph node, while other pelvic and para-aortic lymph nodes were free. These cases are two examples of irregularity of invasion of metastases from cervix carcinoma. It is extremely rare that presacral station is single and first invaded without extension of lower lymph nodal level. Our technique of pre-sacral lamina excision in connection with the inferior bridge of para-aortic and para-caval connective tissue during para-aortic lymphadenectomy is confirmed. The fatal outcome of the first patient's case is related to such risk factors lymph nodes metastases, deep infiltration of the cervix and involvement of lower section of the uterus. The second patient was free of disease within four months from surgery.

Pelvic and para-aortic lymph nodal positivity in the ovarian carcinoma: its prognostic significance.

Our study is based on 29 patients with ovarian carcinoma in early stage (IA-IIB) having undergone total abdominal hysterectomy, with bilateral salpingo-oophorectomy, omentectomy, appendectomy and pelvic and paraaortic lymphadenectomy selective and bioptic. Out of the 29 patients 11 were classified I stage and 18 II stage. Within 3 years, out of 10 patients with node metastases, 1 is alive and free of disease, 6 deceased from the tumor and 3 are alive with residual tumor at various stages of invasion. Out of the 19 patients without nodes metastases 14 are alive and free of disease, 4 deceased from the tumor and 1 is alive with residual carcinoma. Survival related to histological type shows no statistically significant differences. Grading III has a survival of 27.6%, while the other two grades have a survival of 70% without significant differences. We can affirm that lymph nodes metastases represent the most reliable marker of high risk patients among the 3 risk factors (grading, histotype and nodes metastases) even if considered on a limited number of patients on the basis of preliminary data so obtained.

Radical vulvectomy and inguinal lymphadenectomy versus inguino-pelvic lymphadenectomy combined with radical vulvectomy and the role of radiotherapy.

We studied 39 patients with stromal invasion exceeding 1 mm. Among them 3 underwent emivulvectomy and 8 simple vulvectomy; all had selective inguinal lymphadenectomy of one side the first and bilaterally the others. 17 women underwent radical vulvectomy and inguinal lymphadenectomy while 11 had radical vulvectomy and inguino-pelvic lymphadenectomy. Out of 21 patients with lymph nodal metastases, 11 had one side inguinal metastases, 2 had a single metastasis, 2 had double metastases, 1 had three metastases and 2 multiple ones. Survival rate decreased from 54.5% to 20.0% when patients had more than 3 monolateral inguinal metastases or bilateral ones, with increase of pelvic lymph nodal metastases; therefore, in those cases, pelvic lymphadenectomy can be associated to inguinal lymphadenectomy or, when the carcinoma is situated in the clitoridis, Bartolino's gland or vagina (the same could be done for melanoma of the vulva). The usefulness of radiotherapy is limited by the small response of vulvar tissue. In a series of 45 patients with clinical diagnosis of inguinal metastases, who could not undergo operation, only therapy, with electron beam therapy (9 meV) associated to inguinal fields (15 meV), had positive influence in 27% of the cases.

Techniques of pelvic and para-aortic lymphadenectomy in the surgical treatment of cervix carcinoma.

402 radical hysterectomies (17 ultraradical) were performed with lymphadenectomy. Positive metastatic nodes (N+) rate was 23.6% with an arithmetic mean of 22 excised lymph nodes. Single N+ belonged mostly to the obturatory group, double N+ to obturatory and external iliac groups, while multiple N+ (24 cases) had no particular site. Neoplastic invasion, embolism and grading were studied in 122 cases. The parametrium, vagina and uterine corpus were interested more in N+ cases. The cervical stroma was divided into internal, middle and external parts and invasion rate was respectively 3.6%, 7.2%, 89.2% in N+ cases and 35.1%, 22.3%, 42.6% in N--cases.

Complications of axillary, inguinal, pelvic and para-aortic lymphadenectomy.

Post-axillary lymphadenectomy complications have been checked in 1097 patients. Lymphedema occurred in 4.6% of cases, brachial injuries in 2% and necrosis with wound dehiscence in 0.44%. Pelvic lymphadenectomy complications have been studied in 139 patients who underwent Wertheim's operation and in 4 cases treated with Schauta-Mitra's operation for cervix or endometrium cancer. Para-aortic and pelvic lymphadenectomy complications have been considered in 92 patients who underwent Wertheim's operation, in 10 patients treated with anterior pelvic exenteration and in 1 patient who underwent posterior pelvic exenteration. The complications of para-aortic and pelvic selective lymphadenectomy have been checked in 101 patients. We had 3 peri-operatory deaths, 5 severe gastrointestinal complications (3 deceased for fistulae) and 2 intra-operatory iliac vessel injuries. Uretero-vaginal fistulae occurred in 6.2% of the cases also treated with radium-therapy and in 2.2% of the others. Intra/post-operatory bleeding was respectively 1500 +/- 450 ml and 450 +/- 300 ml. The complications of inguino-femoral and inguino-pelvic lymphadenectomy for vulvar cancer have been checked in 35 patients who had necrosis and wound dehiscence in all cases and lower limb thrombophlebitis in 2 cases.

Hormonal and surgical treatment of endometrial adenocarcinoma: actuarial survival.

We studied the survival period in two groups of patients with endometrial adenocarcinoma treated at the Chair B Institute of Gynecology and Obstetrics. The first series includes 30 of the 52 patients treated from 1976 to 1979. The second series includes 81 patients treated from 1980 to 1986. Lymph nodal positivity was present in 5 cases out of 30 patients belonging to Group I: all the interested lymph nodes were in the pelvic areas. Lymph nodal metastases were, instead, present in 10 cases as regard patients of Group II. Pelvic lymph nodes were involved in all the cases; in 5 of them also the paraaortic nodes were involved.

Hormonal and surgical treatment of endometrial adenocarcinoma.

From January 1st 1980 up to December 31st 1986, 93 endometrial adenocarcinomas were treated at the Chair B of the Institute of Gynecology and Obstetrics. Full anatomopathological and hormonal data are available for 81 cases on whom diagnostic and therapeutic protocols were applied. In this selected group, positive lymph nodes were shown in 10 cases. Lymph node positivity was compared with miometrial infiltration grade: there were only two cases of lymph nodal positivity among 49 adenocarcinomas in which the invasion was more than 10 mm from the serosa, 8 lymph nodes metastases out of 32 adenocarcinomas with a distance between 10 and 5 mm and with distance less than 5 mm.

Lymph nodal metastases and pathological patterns in cervical cancer: a critical review.

We analyzed 8 pathological factors in order to recognize which of them are statistically significant in worsening the stage of cervical cancer. Three factors (external third invasion, CLS, parametrial invasion) are highly significant (p less than 0.001) as regards lymphatic metastases, while no one statistical relation has been found among grading or histotype and cervical canal invasion. Comparing the 8 pathologic factors among themselves, we have observed that parametrium, corpus and CLS are highly related to external third (p less than 0.001); in the same way corpus is related to cervical canal and parametrium to CLS (p less than 0.001).

Surgical strategy management following lymph nodal positivity at the three levels (a retrospective and perspective study).

The purpose of this study is to evaluate the type of distribution, regular or irregular, of metastases in lymph nodes of I, II and III level. We inted also to establish if the levels of lymph nodal areas represent an evaluation index of prognostic risk more effective than other ones. The results evidenced that in 19.2% of all the classes N+ metastases were not increasing regularly from the level I to the level III. The influence of seven factors on disease free survival has been evaluated: pT, pN, number of metastatic nodes, ER+ or ER-, PgR+ or PgR-, grading, metastatic level at axillary lymph nodes. The present report points out that only the extent of tumor and lymph nodal level have a statistically significant influence on disease free survival. Comparison among disease free survival curves stage N0 with N+ at I level and with N+ at II level revealed that there is no significant difference of survival among these classes, while the comparison between the first 3 classes and N+ at III level is statistically significant.

Treatment failure in cervical cancer: high risk factors of relapse.

Actuarial survival in 178 patients treated with radical surgery and lymphadenectomy from 1977 to 1987 have been evaluated. The survival rate at 60 months in the 124p N0 patients was 95%; in the 57 p N1 patients was 20.2%. The survival in patients with only 1 or 2 metastatic lymph nodes was 39.7%, while it was 13.1% with 3 or more lymph nodes involved. Survival rate related to lymph nodal metastatic level was 36%, 32%, 17% respectively when the first, second and third levels were involved. We demonstrated a statistically significant relation between survival and external thirds, CLS, vaginal, parametrial invasion. A multifactorial analysis also showed the remarkable significance of the simultaneous negativity of vaginal, CLS, external third invasion (survival rate 98.4%). When the positivity of the external invasion was associated with simultaneous negativity of vaginal and CLS invasion the survival rate was 79.4%. The survival rate in patients with positive vaginal and external third invasion was 26%. This showed the decisive importance of vaginal invasion in cervical cancer survival.

[Amniotic fluid embolism in trial of labor. A case report]. / Embolia amniotica in travaglio di parto. Descrizione di un caso.

Amniotic fluid embolism is a rare complication of pregnancy, which accounts for about 10% of all maternal deaths. A case of acute embolic episode occurred during labor in a 36-year-old patient with spontaneous rupture of membranes is described. Caesarean section was performed immediately, followed by hysterectomy; the baby survived but the mother died because of DIC and cardiorespiratory arrest.

[Delivery in multiple pregnancies]. / Il parto nelle gravidanze multiple.

BACKGROUND: A knowledge of clinical physiognomy in pathologies related to multiple births is indispensable for improving maternal and feto-neonatal prognosis. This study is a contribution to the solution of this problem. METHODS: A meta-analysis of data for multiple births at Department B of the Gynecology and Obstetrics Clinic at the University of Turi during the decade 1989-1998 was carried out, focusing on the arrangement and presentation of fetuses, the various types of birth, the gestational age at which birth occurred, the weight of neonates, neonatal mortality and maternal morbidity. RESULTS: Out of 11,523 births, there were a total of 194 (1.68%) multiple births, including 190 sets of twins and 4 triplets. 154 (79.38%) premature births were reported; 20 occurred <32(nd) week (10.29%). There was a high incidence of podalic presentation (26.30%) and shoulder presentation (5.61%) among twins; 202 were delivered using a cesarian section (51.53%) and 190 by vaginal birth (48.47%), of which 172 (90.52%) spontaneously. Surgical birth was an important means of extracting fetuses rapidly from a pathological environment. two hundred and sixty-two neonates (66.84%) were LBW (<2500 g), including 28 (7.14%) VLBW (>1500 g). The perinatal mortality rate was 3.82%. Maternal complications mainly occurred during the placental state, in the immediate postpartum and in puerperio. CONCLUSIONS: The authors feel that a more careful medical and social assistance, preventive hospitalisation, early recognition of the risk, constant monitoring for the optimal timing of birth, and lastly, qualified medical assistance during labour (expert gynecologist, trained obstetric staff) with other medical personnel (anesthetist, neonatal specialist) represent winning strategies to solve the problems arising during multiple pregnancies.

[Cervix cerclage. A 20-year case load]. / II cerchiaggio cervicale. 20 anni di casistica.

Uterine cervical incompetence is the most common cause of habitual abortion in the second trimester of pregnancy and premature delivery; cervical cerclage still represents the only surgical treatment for cervical incompetence. In the last 20 years (1971-1990) we performed 272 Mac Donald cervical cerclages in patients between the 8th and the 34th week of pregnancy. In 16 cases the outcome of pregnancy is unknown; 198 women (73.3%) subsequentely delivered healthy infants later than 37 weeks' gestation or weighing more than 2500 g.

[Comparison of metroplasty by Strassman's method and by Tomkins' method. Retrospective study of 30 years]. / Confronto tra metroplastica sec. Strassman e sec. Tompkins. Studio retrospettivo di 30 anni.

The study aimed to evaluate the usefulness of metroplasty to improve gestational ability in the presence of uterine malformations. From the analysis of results, it is clear that this surgical operation is undoubtedly efficacious when performed in selected patients (earlier negative obstetric outcome). The comparison of the two techniques (Strassman vs Tompkins) confirms that the latter produced better results in this series of patients.