Estimation of coronary flow reserve by sestamibi imaging in patients with mild hypertension and normal coronary arteries.

AIM: Patients with hypertension may exhibit abnormal vasodilator capacity during pharmacological vasodilatation. We assessed coronary flow reserve (CFR) by sestamibi imaging in hypertensive patients with normal coronary vessels. METHODS: Twenty-five patients with untreated mild essential hypertension and normal coronary vessels and 10 control subjects underwent dipyridamole-rest Tc-99m sestamibi imaging. Myocardial blood flow (MBF) was estimated by measuring first transit counts in pulmonary artery and myocardial counts from tomograhic images. CFR was expressed as the ratio of stress to rest MBF. Coronary vascular resistances (CVR) were computed as the ratio between mean arterial pressure and MBF. RESULTS: Estimated MBF at rest was not different in patients and controls (1.11 ± 0.59 vs. 1.14 ± 0.28 counts/pixel/s; P=0.87). Conversely, stress MBF was lower in patients than in controls (1.55 ± 0.47 vs. 2.68 ± 0.53 counts/pixel/s; P<0.001). Thus, CFR was reduced in patients compared to controls (1.61 ± 0.58 vs. 2.43 ± 0.62; P<0.001). Rest and stress CVR values were higher in patients (P<0.001), while stress-induced changes in CVR were not different (P=0.08) between patients (-51%) and controls (-62%). In the overall study population, a significant relation between CFR and stress-induced changes in CVR was observed (r=-0.86; P<0.001). CONCLUSION: Sestamibi imaging may detect impaired coronary vascular function in response to dipyridamole in patients with untreated mild essential hypertension and normal coronary arteries. A mild increase in arterial blood pressure does not affect baseline MBF, but impairs coronary reserve due to the amplified resting coronary resistances.

F-18 FDG PET/CT in the assessment of patients with unexplained CEA rise after surgical curative resection for colorectal cancer.

PURPOSE: We evaluated the role of quantitative assessment by maximum standardized uptake value (SUVmax) on F-18 fluorodeoxyglucose [F-18]FDG positron emission tomography/computed tomography (PET/CT) in stratifying colorectal cancer (CRC) patients with unexplained carcinoembryonic antigen (CEA) rise after surgical curative resection. MATERIAL AND METHODS: Forty asymptomatic patients (mean age, 64 ± 12 years) with previous CRC and current serum CEA levels >5 ng/ml underwent [F-18] FDG PET/CT 13 ± 3 months after complete surgical resection. The SUVmax was registered on anastomosis and peri-anastomotic tissue lesions, if present. The patients were followed for 24 ± 9 months thereafter. Re-intervention, evidence of newly discovered distant metastases, and death were recognized as main events and constituted surrogate end points. The receiver-operator-curve (ROC) analysis was performed to estimate the optimal SUVmax cut-off to predict patients at high risk of main events. PET/CT results were then related to disease outcome (overall survival; OS). RESULTS: The mean SUVmax at the anastomotic site was 6.2 ± 3 (range 2.6-15). At multivariate logistic regression analysis, the anastomotic SUVmax remained as the only significant contributor to the prediction of the events (p = 0.004; OR 1.97). The ROC analysis recognized that the optimal threshold of SUVmax to differentiate patients was 5.7. A worse OS was observed in patients presenting with a SUVmax greater than 5.7 as compared to those having lesser (median survival: 16 vs. 31 months; p = 0.002). CONCLUSIONS: The quantitative assessment by SUVmax on [F-18]FDG PET/CT may be helpful in patients presenting with unexplained CEA rise after curative resection of CRC, by identifying those at risk of main events.

F-18 FDG PET/CT and F-18 FLT PET/CT as predictors of outcome in patients with multiple myeloma. A pilot study.

OBJECTIVES: We evaluated the prognostic significance of the combined use of F-18 FDG (FDG) and F-18 FLT (FLT) PET/CT (PET/CT) in patients (pts) with multiple myeloma (MM) suspected relapse after a first line chemotherapy. METHODS: twenty-eight patients (57 ± 12 years) underwent both PET/CT scans over 2-4 weeks. Patients were grouped according to imaging results (FDG+/-; FLT+/-) and the findings compared to the event free survival (EFS). RESULTS: five pts had FDG+; FLT+, 8 showed FDG+;FLT-, two had FDG-;FLT + and 13 presented FDG-;FLT-, mostly (87 %) of FDG+;FLT- pts had destructive lytic bone lesions. At Cox regression analysis the FDG PET/CT (HR 4.4, 95 % CI 1.3-15.4, p < 0.05) and FLT PET/CT (HR 5.8, 95 % CI 1.7-19.3, p < 0.01) were predictive of worst prognosis. The Kaplan-Meier analysis showed that FDG and FLT PET/CT independently influenced the survival. FDG-;FLT-patients had better EFS as compared to FDG+; FLT + pts and FDG-;FLT + pts, those of FDG+;FLT- group also had worsened EFS. CONCLUSIONS: results from the aggregate use of PET/CT FDG and FLT in MM represent a valuable prognostic indicator for identifying patients at higher risk of undue events and may help to correctly stratify the patients with suspected relapse.

Assessment of Residual Radioactivity by a Comprehensive Wireless, Wearable Device in Thyroid Cancer Patients Undergoing Radionuclide Therapy and Comparison With the Results of a Home Device: A Feasibility Study.

Objective: To investigate the feasibility of using a wireless wearable device (WD) in differentiated thyroid cancer (DTC) patients undergoing radionuclide therapy with I-131 (RAI) and protected hospitalization, this study compared the measurements of residual radioactivity obtained with those registered by a permanent environmental home device (HD). Methods: Twenty consecutive patients undergoing RAI hospitalized in restricted, controlled areas were enrolled. The patients underwent comprehensive monitoring of vital/nonvital parameters. We obtained 45580± 13 measurements from the WD, detecting the residual radioactivity for each patient during approximately 56 hours of hospitalization, collecting data 53 times per hour. The samples, collected during daily activities, were averaged every two hours, and the results correlated with those from the HD. Bland-Altman analysis was also used to evaluate the agreement between the two techniques. Results: A significant relationship between the WD and HD was observed (r = 0.96, p < 0.0001). Bland-Altman analysis recognized the agreement between measurements by the WD and HD. The mean value at the end of the first day of hospitalization was 80.81 microSv/h and 60.77 microSv/h (p = ns for WD and HD), whereas those at the end of the second day were 47.08 and 24.96 (p = ns). In the generalized linear model (GLM), a similar trend in performance across time was found with the two techniques. Conclusion: This study demonstrates good agreement between the residual radioactivity measures estimated by the WD and HD modalities, rendering them interchangeable. This approach will allow both the optimization of medical staff exposure and safer patient discharge. Abbreviations: wireless device (WD); differentiated thyroid cancer (DTC); radionuclide therapy with I-131 (RAI); home device (HD); generalized linear model (GLM).

The clinical impact of a cardiologic follow-up in breast cancer survivors: an observational study.

Anthracycline-containing chemotherapy (A-CHT) can induce late cardiotoxicity adding a considerable burden to cardiovascular risk. Irradiation of left breast cancer has also been associated to an increased risk of cardiovascular disease. The aim of this observational study is to prove the usefulness of an accurate cardiovascular evaluation in left breast cancer survivors treated with radiotherapy (RT) and A-CHT. Patients with left breast cancer, on follow-up after treatment with A-CHT plus RT in an adjuvant setting, were eligible for this observational study. Patients underwent cardiovascular assessment with myocardial perfusion imaging. Thirty patients were enrolled in the study: mean age at diagnosis 55.8 years; stage: I/III; Er and/or pgR status: positive in 24/30 pts; 3 patients in pre-menopausal status. Twenty-two patients (73.3 percent) had normal perfusion imaging, 1 patient (3.3 percent) had a fixed myocardial perfusion defect, 7 patients (23.3 percent) had reversible myocardial perfusion defects; 1 patient (3 percent) with normal perfusion scan showed depressed rest and stress LVEF. Only 1 patient had a large defect and underwent coronary angiography and percutaneous coronary intervention. Five patients with small defect showed normal coronary arteries at Multislice Computed Tomography. Cardiovascular followup may reveal signs of A-CHT or RT-induced cardiotoxicity. A stress test combined with MPI- and GATED-derived data of ventricular systolic performance after stress can give information on the coronary reserve and the contractile reserve and allow early appropriate treatment.

Cardiac performance during exercise in hypertensive patients without ventricular hypertrophy.

BACKGROUND: Reduced systolic reserve on effort may be present in subjects with hypertension but no evidence of hypertensive cardiomyopathy. We assessed the determinants of abnormal cardiac performance during exercise in hypertensive patients without left ventricular hypertrophy. MATERIALS AND METHODS: Thirty-five newly diagnosed, never-treated-earlier hypertensive patients without definite indication for left ventricular hypertrophy at echocardiography underwent radionuclide ambulatory monitoring of left ventricular function at rest and during upright bicycle exercise testing. RESULTS: The patients were classified into two groups according to their ejection fraction response to exercise. In 21 patients (group 1), the ejection fraction increased > or = 5% with exercise and in 14 patients (group 2), the ejection fraction either increased < 5% or decreased with exercise. Patients of group 1 had lower peak filling rate at rest and less augmentation in end-diastolic volume during exercise (both P < 0.01) when compared with patients of group 2. A significant relationship between the magnitude of change in ejection fraction with exercise and both peak filling rate at rest (r = 0.58, P < 0.01) and exercise-induced change in end-diastolic volume (r = 0.45, P < 0.01) was found. CONCLUSIONS: In newly diagnosed, never-treated-earlier hypertensive subjects with no evidence of hypertensive cardiomyopathy, the cardiac response to exercise is dependent on adequate diastolic filling volume to maintain systolic performance.

Usefulness of [111In-DTPA0] octreotide scintigraphy in a family with von Hippel-Lindau disease.

The identification of patients with von Hippel-Lindau (VHL) disease dictates accurate genetic counseling of family members, whereas screening for early detection of visceral and neurological involvement is usually performed by a combination of radiological and nuclear medicine techniques such as ultrasonography or contrast-enhanced computed tomography of the upper abdomen, magnetic resonance imaging of the central nervous system and 131I-metaiodobenzylguanidine-scintigraphy. The role of 111-indium-diethylenetriaminepentaacetic acid [111In-DTPA0] octreotide scintigraphy in this clinical context has never been investigated. Here, we report imaging findings in a VHL patient and in 3 consecutive family members undergoing clinical and radiological screening that included [111In-DTPA0] octreotide scintigraphy in addition to the above-mentioned procedures. Somatostatin receptor expression was investigated in vitro by immunohistochemistry in pancreatic tumor sections. On the basis of in vivo and in vitro findings, octreotide long-acting release treatment followed by 90Y-1,4,7,10-Tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid (DOTA0)-Tyr3-octreotide led to a lack of progression in this patient although this result is a possibility which needs to be proved by further investigation and longer follow-up. The results of this study suggest that [111In-DTPA0] octreotide scintigraphy may be helpful in the routine work-up of VHL patients for diagnostic and therapeutic purposes.

Therapeutic Strategies in HCC: Radiation Modalities.

Patients with hepatocellular carcinoma (HCC) comply with an advanced disease and are not eligible for radical therapy. In this distressed scenario new treatment options hold great promise; among them transarterial chemoembolization (TACE) and transarterial metabolic radiotherapy (TAMR) have shown efficacy in terms of both tumor shrinking and survival. External radiation therapy (RTx) by using novel three-dimensional conformal radiotherapy has also been used for HCC patients with encouraging results while its role had been limited in the past for the low tolerance of surrounding healthy liver. The rationale of TAMR derives from the idea of delivering exceptional radiation dose locally to the tumor, with cell killing intent, while preserving normal liver from undue exposition and minimizing systemic irradiation. Since the therapeutic efficacy of TACE is being continuously disputed, the TAMR with (131)I Lipiodol or (90)Y microspheres has gained consideration providing adequate therapeutic responses regardless of few toxicities. The implementation of novel radioisotopes and technological innovations in the field of RTx constitutes an intriguing field of research with important translational aspects. Moreover, the combination of different therapeutic approaches including chemotherapy offers captivating perspectives. We present the role of the radiation-based therapies in hepatocellular carcinoma patients who are not entitled for radical treatment.

18F-FDG PET/CT focal, but not osteolytic, lesions predict the progression of smoldering myeloma to active disease.

Identification of patient sub-groups with smoldering multiple myeloma (SMM) at high risk of progression to active disease (MM) is an important goal. 18F-FDG PET/CT (positron emission tomography (PET) integrated with computed tomography (PET/CT) using glucose labelled with the positron-emitting radionuclide (18)F) allows for assessing early skeletal involvement. Identification of osteolytic lesions by this technique has recently been incorporated into the updated International Myeloma Working Group criteria for MM diagnosis. However, no data are available regarding the impact of focal lesions (FLs) without underlying osteolysis on time to progression (TTP) to MM. We hence prospectively studied a cohort of 120 SMM patients with PET/CT. PET/CT was positive in 16% of patients (1 FL: 8, 2 FLs: 3, >3 FLs: 6, diffuse bone marrow involvement: 2). With a median follow-up of 2.2 years, 38% of patients progressed to MM, in a median time of 4 years, including 21% with skeletal involvement. The risk of progression of those with positive PET/CT was 3.00 (95% confidence interval 1.58-5.69, P=0.001), with a median TTP of 1.1 versus 4.5 years for PET/CT-negative patients. The probability of progression within 2 years was 58% for positive versus 33% for negative patients. In conclusion, PET/CT positivity significantly increased the risk of progression of SMM to MM. PET/CT could become a new tool to define high-risk SMM.

Relations of left ventricular mass and systolic function to endothelial function and coronary flow reserve in healthy, new discovered hypertensive subjects.

Left ventricular hypertrophy (LVH) is prognostically relevant, associated with major cardiovascular risk factors and with atherosclerosis. However, whether LVH is independently associated with impaired coronary flow reserve (CFR) and with endothelial dysfunction is disputed. We assessed the relationship of LV mass and systolic function to CFR and endothelial function in new discovered never treated subjects with essential arterial hypertension, but without coronary artery disease or microalbuminuria. LVH, ejection fraction (EF) and stress-corrected midwall shortening (MWS, a measure of myocardial contractility) were assessed by echocardiography. CFR was assessed by single-photon emission computed tomography and dipyridamole infusion. Endothelial function was evaluated by assessing 1-min postischaemic flow-mediated dilatation of the brachial artery (FMD); nitroglycerine-mediated dilatation (NMD) of the same brachial artery was used as measure of nonendothelium-dependent vasodilatation. In approximately 1 year, we enrolled 21 subjects who met stringent inclusion criteria (47+/-10 years old, 26.6+/-2.8 kg/m2, 78% men). Five patients showed LVH. Multivariate analyses showed a significant negative correlation of LV mass index with FMD (beta=-0.61, P<0.05) but not with NMD, neither with CFR. Stress-corrected MWS showed independent correlation with CFR (beta=0.51, P<0.05). Thus, in clinically healthy, new discovered hypertensive subjects, never treated and mostly in the early stage of arterial hypertension, LVH can be associated with endothelial dysfunction while maximal dipyridamole- dependent CFR may be preserved; nevertheless, a cardiac phenotype presenting with tendency to impaired myocardial contractility, assessed by stress-corrected MWS, showed association with lower CFR in the early stage of arterial hypertension.

Effects of valsartan on left ventricular diastolic function in patients with mild or moderate essential hypertension: comparison with enalapril.

OBJECTIVE: This study compares the effects of an AT1 angiotensin II receptor antagonist (valsartan) with those of an ACE inhibitor (enalapril) on left ventricular (LV) diastolic function in patients with mild or moderate essential hypertension and no evidence of LV hypertrophy at echocardiography. METHODS: A total of 24 patients (16 men, mean age 47 +/- 8 years) underwent radionuclide ambulatory monitoring (Vest) of LV function at rest and during upright bicycle exercise testing before and after two 4-week treatment periods with valsartan (80-160 mg/day orally) and enalapril (20-40 mg/day orally) according to a double-blind, crossover randomization scheme. RESULTS: In the overall population no differences between the two treatments were found in LV peak filling rate (PFR) either at rest or at peak exercise. In a subgroup analysis it was found that baseline PFR was normal (= 2.5 EDV/sec) in 12 patients (subgroup A) and impaired (< 2.5 EDV/sec) in the remaining 12 (subgroup B). In both subgroups, valsartan and enalapril induced a significant and comparable reduction of systolic and diastolic blood pressure. In subgroup A, valsartan and enalapril did not induce significant changes in PFR. In subgroup B, valsartan increased PFR both at rest (from 2.0 +/- 0.3 to 2.4 +/- 0.3 EDV/sec, P < 0.01) and at peak exercise (from 4.1 +/- 1.1 to 4.4 +/- 1.0 EDV/s, P < 0.05), whereas enalapril did not change PFR either at rest (2.0 +/- 0.4 EDV/s, P < 0.01 versus valsartan) or at peak exercise (3.7 +/- 1.1 EDV/sec, P < 0.05 versus valsartan). CONCLUSIONS: Valsartan-induced renin-angiotensin system blockade is able to improve LV filling in patients with mild or moderate essential hypertension and impaired diastolic function. These findings support the hypothesis of a contribution of the renin-angiotensin system in the control of LV diastolic function in these patients.

Biokinetics of a F(ab')3 iodine-131 labeled antigen binding construct (Mab 35) directed against CEA in patients with colorectal carcinoma.

UNLABELLED: An 131I labeled trivalent antigen binding construct, formed from 3 Fab' fragments of murine anti-CEA monoclonal antibody (Mab) 35, has shown favorable biokinetics in animal studies. OBJECTIVES: The aim of this study was to evaluate biodistribution and tumor uptake of 131I-F(ab')3 in patients and its potential utility for radioimmunotherapy of CEA expressing tumors. PATIENTS AND METHODS: Six patients (5 M, 1 F; age 62 +/- 13 y) with liver metastases of colorectal cancer, scheduled for hepatic surgery were studied by 2-3 whole body scans immediately post infusion of 111-137 MBq of 131I labeled Mab 35 F(ab')3 and up to 72 h. Circulating CEA ranged from 1.2 to 1930 ng/ml. We evaluated plasma and whole body clearance, activity accumulation by post-surgical ex-vivo tissue measurement in primary tumor (T) and metastases (M), and calculated M to blood (M/B) and M to liver (M/L) ratios. RESULTS: All known tumor sites were detected by immunoscintigraphy and confirmed at surgery. Whole body effective T1/2 calculated in two patients was 51.5 h and 55.6 h respectively. Effective serum T1/2 was mono-exponential in 3 patients (short observation interval) with 20.9 +/- 7 h and bi-exponential in three with alpha T1/2 of 6.3 +/- 1 h and beta T1/2 of 38.6 +/- 5 h. In a patient with concomitant colic and hepatic lesions uptake of primary tumor was 0.0071% injected dose per gram of tissue (%ID/g) and mean metastases activity was 0.0275 %ID/g at 48 h. In the 3 patients who had surgery at 48 h, mean uptake in metastases and normal liver was 0.0182 %ID/g and 0.0021 %ID/g, respectively (M/L 8.67). In the single subject followed until 7 days post infusion, residual activity in liver metastases was 10 times higher than in normal parenchyma. CONCLUSIONS: Tumor uptake and tumor to blood ratio, as well as serum clearance of the triconstruct are similar to those observed with intact iodinated anti-CEA antibodies. In the patient studied for 7 days the tumor residence time was favorable. Further improvements, however, need to be obtained before considering this approach for radioimmunotherapy.

Inguinal hernioplasty: the gold standard of hernia repair.

On the basis of a critical review of 936 inguinal hernioplasties performed in 8 years, the authors present their good long-term results with tension-free techniques including the original Lichtenstein technique, Lichtenstein with a sutured mesh and annulorrhaphy of the deep inguinal ring, and Lichtenstein with plug. The only two recurrences in this case series occurred with the original technique. Suturing of the mesh and deep inguinal ring annulorrhaphy proved to be reliable and inexpensive. Results were equivalent with the use of the plug, despite the presence of an additional foreign body. In conclusion, the results obtained with the three variants are practically equivalent, and the choice of technique may depend on the preference and experience of the surgeon.

[Neurogenic tumors of the mediastinum]. / Tumori neurogeni del mediastino; neurogenic tumors of mediastinum.

Neurogenic neoplasms represent approximately 20% of the space-occupying lesions in the mediastinum. They are primary tumors originating from structures belonging to the peripheral or sympathetic nervous system, they are most commonly diagnosed in subjects in the age range between 10 and 30 years. Benign forms are significantly more frequent than malignant forms, an observation that was confirmed by our own experience; whether these tumors have a predilection for the male or female sex cannot be concluded from the various case series studied to date. Surgical resection can be considered the treatment of choice on the basis of the long-term results, which are greatly satisfactory in benign tumors and encouraging in the malignant variants.

[Prognostic markers of the epithelial tumors of the large intestine]. / Indicatori prognostici della patologia tumorale di tipo epiteliale del grosso intestino.

The surgical treatment of large bowel malignant tumors is now the most important therapeutic approach. The aim of our study was to evaluate a possible prognostic implication of ploidy and NM23 expression. The study includes 120 non selected patients who underwent surgery for colorectal cancer. The analysis of ploidy was obtained with cytometric test. The cases with only one gaff G0/G1 were considered as diploid. Patteras with more than one aneuploidic population were classified as multiploidic or poliploidic. While NM23 expression was evaluated with a double blind retrospective study by two separate equipe of authors in different centres. NM23 positivity degree was classified in 3 classes: absent or weak if < 10%; moderate if 10-50%; strong if > 50%. Forty-two patients (35%) were classified as diploidic; 30 patients (25%) as aneuploidic; 40 patients (33.2%) as multiploidic; in 8 cases (6.7%) the material was inadequate. Among the two groups who evaluated NM23 expression the group I a positivity: absent or weak in 32 cases (26.7%); moderate in 62 cases (51.7%); strong in 26 cases (21.6%); while the group II shows positivity: absent or weak in 30 cases (25%); moderate in 52 cases (43.3%); strong in 38 cases (31.7%). We cannot consider ploidy and the NM23 research as independent prognostic factor.

[Indications and surgical treatment of acute complicated diverticulitis]. / Indicazioni e trattamento chirurgico delle diverticoliti acute complicate.

Although the surgical treatment of acute and complicated diverticulitis has been refined over the years, discussion is still ongoing about whether a single or two stage procedure (Hartmann's procedure) should be performed in patients with peritonitis from perforation of a colonic diverticulum. A retrospective review was completed for patients undergoing surgery for acute complicated diverticulitis from 1980 to 1997. All patients were categorized according to Hinchey classification. Of the 186 patients treated, emergency operation was performed in 52 (28 per cent; group I) and an elective operation in 134 (72 per cent; group II). All patients had a resection of the involved colon and anastomosis was performed using CEEA staplers. In the group I, 50 patients underwent resection with immediate reconstruction with or without colostomy and two an Hartmann's procedure. Among the group II, primary anastomosis with or without proximal diversion was performed in 132 patients; two patients underwent an Hartmann's procedure. Post-operative mortality was of 5.76% in the group I and 2.9% in the group II. Nine anastomotic leaks occurred in the group I and 18 in the group II. Comparing these results with the recent literature, we have concluded that primary resection is virtually always possible in acute and complicated diverticulitis. Primary anastomosis with or without colostomy, in expert hands, is a safe procedure for patients in stage I of Hinchey's classification or II, but should be considered on an individual basis in presence of peritonitis. In case of fecal peritonitis, persistent hypotension, ascites, severe immune compromise and extreme malnutrition the Hartmann procedure represent the procedure of choice.

NM23 expression as prognostic factor in colorectal carcinoma.

BACKGROUND: The current most important prognostic indicator in colorectal carcinoma is tumor stage at the moment of diagnosis. The role of NM23 gene as prognostic factor is controversial. The aim of this study was to investigate NM23 expression. PATIENTS AND METHODS: The study population included 104 unselected patients who underwent surgery for colorectal carcinoma between 1992 and 1997. NM23 expression was quantified by estimating the percentage of tumor cells with unequivocal reactivity. The percentage was scored: 0 when no tumor cells showed immunoreactivity; 1 when less than 10% of cells showed immunoreactivity; 2 when 11-50% of cells were positive; 3 when more than 51% of cells were positive. RESULTS: Four cases belonged to group 0.21 to group 1.55 to group 2 and 24 to group 3. CONCLUSION: NM23 cannot be considered an independent prognostic variable.

[Complications of inguinal hernia repair]. / Complicanze dell'ernioplastica inguinale.

It's shown by literature and confirmed by Author's experience that, on account of the excellent results, prosthetic repair of inguinal hernia is more effective than "conventional" (Bassini, Mc Vay, Shouldice). Between January 1993 and December 2000 were observed 875 patients with inguinal hernia (814 monolateral, 61 bilateral); all patients underwent a Lichtenstein repair both in the primary version and in its variations (internal ring plastic, trasversalis plicate, plug repair). The patients were discharged from hospital within 24 hours after surgery in 90% of cases. No important intraoperative complications were observed; the patients restarting work varied from 3 to 15 days after the discharging in relation to patient anxiety, onset of complications and to the type of work. The complications observed were: urine retention (1.6%), superficial haematoma (1.3%), superficial infection (1%), wound suppuration (0.5%), serous effusion (0.7%), postsurgery pain (2.1%), scrotal edema (1.7%), persistent inguinal neuralgia (0.6), local hypoesthesia (4.3%), ischemical orchitis (0.1%), recurrence (0.2%). In conclusion Authors assert that "tension free" repair allows optimal results both for the surgery point (easiness of the technique, repeatability, less invasivity, scanty incident of recurrences, low frequency of postoperative complications) and in economic terms, allowing an early mobilization of the patients. A further improvement would be obtained with more care in surgical and patient management, with more excellent results.

Estimate of the accelerated proliferation by protein tyrosine phosphatase (PTEN) over expression in postoperative radiotherapy of head and neck squamous cell carcinoma.

PURPOSE: To estimate the impact of PTEN expression in terms of effective doubling time (T(d)) and dose per fraction which compensates the accelerated proliferation during the radiotherapy (D(prolif)) when the overall treatment time (OTT) is reduced in accelerated radiotherapy of head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS: Data were carried out from a recent paper comparing the local control rate (LCR) for patients with HNSCC that underwent a conventional (p-CF) or accelerated radiotherapy (p-CAIR) and a pretreatment assessment of PTEN expression. The impact of PTEN over expression was assessed using the Clinical Efficacy Factor (C) and assuming a plausible range of intrinsic radiosensitivity (α). Statistical analysis was made by evaluating the LCR from Kaplan-Meier curves and log-rank test with significance of 0.05. RESULTS: C indexes were 1.46 and 0.23 for the high- versus low-PTEN group, corresponding to a considerable reduction of doubling time of more than six times (6.6 versus 42.2 days). The median estimate of D(prolif) was 0.51 versus 0.08 Gy/day if referred to a median value in the adopted range of α. CONCLUSIONS: The PTEN expression has a significant implication on the clinical management of these patient groups. Our data support the hypothesis that the high-PTEN group would benefit from a hypo-fractionation with a reduction of the OTT to compensate for the increase in the proliferation rate, while the low-PTEN group could benefits from a hyper-fractionation which would result in a reduced toxicity for all the organs at risk.

[18F]FDG-PET-CT for early monitoring of tumor response: when and why.

(18)F-fluorodeoxyglucose positron emission tomography ([(18)F]FDG PET) has been recognized as a suitable tool in tumor response assessment of patients complaining with solid tumors who have undergone chemo- and radiotherapy. It offers the advantage of functional tissue characterization, which is independent from morphologic criteria allowing to differentiate disease relapse from therapy-induced fibrosis. At present, there is a growing body of evidence that PET semi-quantitative assessment of treatment-induced changes in tumor [(18)F]FDG avidity may predict early tumor response and patient outcome. Patient management might be changed. For instance, in non responder patients this novel diagnostic approach would hamper useless ''wait and watch'' attitude in implementing further options or identifying those needing additional therapeutic strategies. On the other hand, for those patients revealing promptly a favourable metabolic response a cost-sparing approach could be implemented avoiding expensive diagnostic procedures during the follow-up as well as the risk of over-treating. In any case, since even a partial metabolic response may be an indication for continuing therapy, the advantage of metabolic assessment over conventional procedures may be clinically relevant. Although a morphological assessment has been considered for long time the standard for detecting therapy response, limitations of conventional computed tomography-based evaluation in solid tumors are well-known. PET provides an independent means of assessing malignancy. However, no consensus has been achieved until now regarding the optimal timing in performing PET during or at completion of treatment.