Orbital metastases from breast cancer: A single institution case series.

BACKGROUND AND OBJECTIVES: Among orbital tumors, metastatic lesions have a prevalence of 1% to 13%; on the other hand, breast cancer is the most common malignancy causing orbital metastases. The aim of this study is to present our experience dealing with orbital metastases caused by breast cancer, to assess characteristics and clinic-pathological data of patients suffering from this rare occurrence and to find indexes related with their prognosis and survival. METHODS: Records of 28 patients diagnosed with orbital metastases from breast cancer at the Department of Ophthalmology, Humanitas Clinical and Research Centre of Milano over a 27-year period (1992-2018) were retrieved and analyzed. RESULTS: Mean patients' age at breast cancer diagnosis was 56.29 ± 14.63 years. Mean time interval between breast cancer diagnosis and orbital metastasis occurrence was 5 ± 4.17 years. All lesions were estrogen receptor-positive; 79% of patients harbored progesterone receptor-positive lesions. Interestingly, the majority of deceased patients presented orbital lesions with MIB-1 index >50% (P = .0265) and had concomitant lung metastases (P = .0452). CONCLUSIONS: The occurrence of orbital metastasis from breast cancer represents a challenging finding. Patients' clinical picture can include exophthalmos, edema, tumefaction, proptosis and/or diplopia. Significant symptomatic improvement can be achieved through surgery and other adjuvant treatments, such as radiation therapy and chemotherapy.

Intraoperative sonography for nonpalpable breast lesions: Additional indications for a consolidate technique.

This prospective study evaluated the intraoperative ultrasound scan (IUSS) for nonpalpable breast lesions' detection. A total of 108 consecutive female patients underwent surgery using IUSS: Frozen sections demonstrated clear margins in 95.5% of neoplastic patients. Only four (4.5%) patients underwent local re-excision in the same operation. IUSS demonstrated to be quick, accurate, useful, effective, and safe for the intraoperative management of neoplastic nonpalpable breast lesions when performed by a surgeon who has undergone US training, particularly for people in whom alternative approaches can show some limitations due to contraindications or because of scheduling constraints, costs, and patient discomfort.

Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution.

INTRODUCTION: Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision. METHODS: In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation. RESULTS: We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001). CONCLUSIONS: We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.

Maxillofacial and concomitant serious injuries: An eight-year single center experience.

PURPOSE: Maxillofacial injuries are frequently associated with multiple trauma and can determine functional and aesthetic bad outcomes. The severity of maxillofacial injuries may be considerable and can divert clinicians' attention from other concomitant injuries which is less evident but potentially life-threatening. The aim of this study was to find out the concomitant injuries in patients referred to the Emergency Department (ED) of the University Hospital of Messina (North-East Sicily, Italy) for maxillofacial traumas. METHODS: We retrospectively evaluated data of 240,833 patients admitted at the ED of the University Hospital of Messina from January 2008 to December 2015 because of maxillofacial injuries leading to hospitalization and surgical treatment. Patients who primarily received treatment care at different institutions, pediatric trauma patients and adult patients who were transferred in accordance with pre-existing agreements in case of paucity of beds were excluded. Finally we included 447 (0.2%) patients over the 8 years. Data were evaluated with emphasis on epidemiology (age, gender, mechanism of trauma), primary survey and abnormalities and pattern of trauma. RESULTS: The most frequent cause of maxillofacial trauma was road accidents (319 patients, 71.4%), among which motorcycle ones were prevalent. The maxillofacial injured who presented major lesions were 98 patients and minor lesions occurred in 349 patients; 443 (99.1%) patients underwent maxillofacial surgery, immediate or delayed depending on the severity of concomitant injuries (χ2 = 557.2, p < 0.0001). Five concomitant neglected lesions were found to be associated with severe maxillofacial traumas (χ2 = 17.13, p < 0.0001 vs minor lesions). All of the neglected lesions occurred in paucisymptomatic patients who showed painless abdomen, no hemodynamic instability, no signs of hematoma of anterior and posterior abdominal wall or other suspicious clinical signs and symptoms. CONCLUSION: Among the patients admitted firstly in other surgical wards different from the Maxillofacial Surgery Unit, diagnosis was more difficult, especially for blunt abdominal traumas, in which patients showed only vague and nonspecific symptoms concealing serious and life-threatening injuries. We recommend the routine use of whole body CT scan, when the maxillofacial injuries appear prevalent, mainly in patients affected by maxillofacial major lesions.

Nonfatal Cervical-Neck Lesion With a Wooden Foreign Body: Diagnosis and Management.

Penetrating cervical lesions caused by a foreign body are rare events. The neck is a complex and delicate body region, given the important vascular structures it holds. The most frequent fatal complications often involve vascular injuries, and as a consequence, the mortality rate increases by approximately 50%. Civilian patients are mainly victims of violence or motor vehicle accidents and rural accidents involving neck are not very common. When a cervical lesion is because of a wooden foreign body, infectious risk increases for its organic peculiarity. The authors report a rural nonfatal cervical lesion in a civilian, and its management.

[How to manage disasters: learning from recent experiences in the Emergency Department of a University Teaching Hospital, Italy]. / Come gestire i disastri: proposta di gestione economica degli eventi catastrofici.

The medical approach to disasters has been always a problematic issue for emergency departments. The authors of this paper reflect on possible efficient solutions for managing a massive influx of casualties in an Emergency Department, by analysing the responses to previous local catastrophic events, such as the collision of 'Segesta Jet', the great fire of Patti, the floods of Giampilieri/Scaletta and Saponara. The authors' point to a need for providing more extensive training of medical students in clinical aspects of disaster medicine.

Short-stay hospitalisation for benign thyroid surgery: a prospective study.

We report our prospective experience of short-stay hospitalisation for benign thyroid surgery. Post-operative outcome, complication rate and duration of hospitalisation were evaluated for 200 similar patients with bilateral multi-nodular goitres treated surgically by total thyroidectomy. All subjects gave written informed consent. A short-stay regimen, with discharge within 24 h of admission, was possible in 92.5 %. Fourteen (7 %) were discharged on the second post-operative day and one on the fourth post-operative day. Causes of the 15 delayed discharges beyond 24 h were 11 hypocalcaemia (5.5 %), 3 haematoma (1.5 %) and 1 dysphonia (0.5 %). All compressive haematoma were treated by urgent reoperation. No mortality occurred. None required tracheostomies. Transient complications were diagnosed in 36 cases: 25 with hypocalcaemia and 11 with recurrent laryngeal nerve injuries. Permanent complications were observed in three patients: two with hypoparathyroidism and one with nerve damage. All patients were carefully counselled about potential thyroid surgery complications and a 24-h emergency-contact number was provided. Short-stay hospitalisation represents safe and cost-saving surgical management for benign thyroid surgery.

[Management of maxillofacial injuries in an emergency unit: our experience]. / I traumi maxillo-facciali in Pronto Soccorso: casistica di un dipartimento d'emergenza e d'accettazione del Sud Italia.

Maxillofacial injuries are relatively frequent. These may be complicated by cranioencephalic injuries or large facial wounds. We report our experience with the initial management of these lesions in an emergency unit setting. In 2007, we observed 105 patients with maxillofacial injuries. Maxillofacial injuries were associated with cranio-encephalic injuries in 69 patients (65.7%) and with polytrauma in 31(29.5%), while in 5 cases (4.8%) they were isolated. The main causes of trauma were motorcycle accidents (60%). All patients were treated in accordance with the Advanced Trauma Life Support guidelines and assessed by computed tomography. No mortality was observed after diagnosis in the emergency unit or in the month following the trauma. Seventy-seven patients (73.3%) were admitted and 28 (26.7%) were treated and discharged. Accurate diagnosis and appropriate initial management yield good clinical outcomes with functional restoration and fewer aesthetic complications.

High frequency of empty sella, with gender differences, in the early neuroradiology evaluation of patients with traumatic brain injury. A prospective study.

One-hundred four persons aged ≥ 18 years (62 males and 42 females) who were admitted for traumatic brain injury (TBI) underwent brain computed tomography (CT) scan and assay of serum cortisol, insulin-like growth factor 1 (IGF-1), thyrotropin (TSH) and free thyroxine (FT4). The main purpose was to assess any gender difference and the rate of empty sella (ES). Women were more likely to have empty sella (19/42 [45.2%] vs 19/62 [30.6%], P = 0.15, OR = 1.9), which was more frequently total ES or TES (16/19 [84.2%] vs 3/19 [15.8%], P = 0.0025, OR = 11.6). Neuroradiology was normal in the remaining 65 patients. Patients with TES were approximately 20-30 years older than both patients with partial ES (PES) and normal sella, but only the comparison with normal sella was significant (P = 0.001 all patients, P = 0.005 males). Presumed deficiency of IGF-1, cortisol or TSH occurred in 33 persons (31.7%; 20 Males [32.2%], 13 Females [30.9%]), 14 (13.5%; 10 M [16.2%], 4F [9.5%]) or 8 (7.7%; 1 M [1.7%], 7F [16.7%]), with only TSH deficiency having significant intergender difference (P = 0.007). The highest or lowest rates of IGF-1 deficiency occurred in men with PES (41.7%) or men with TES (14.3%), of cortisol deficiency in men with PES (33.3%) or women with PES (zero), and TSH deficiency in women with TES (18.7%) or both men and women with PES (zero) and men with normal sella (zero). Within ES, males with no deficiency were older compared to males with at least one hormone deficiency (75.7 ±â€¯17.4 vs 55.6 ±â€¯18.9, P = 0.022); in turn, the former males were also older compared with normal sella males having no hormone deficiency (54.1 ±â€¯25.2, P = 0.023). In conclusion, ES is detectable in almost 40% of persons who undergo CT within 24 h from TBI. A number of intergender differences concerning ES and the hormones evaluated are apparent.

Characterization and preventability of adverse drug events as cause of emergency department visits: a prospective 1-year observational study.

BACKGROUND: Adverse drug events (ADEs) are a significant cause of emergency department (ED) visits, with a major impact on healthcare resource utilization. A multicentre observational study, aimed to describe frequency, seriousness and preventability of ADEs reported in four EDs, was performed in Sicily (Italy) over a 1-year period. METHODS: Two trained monitors for each ED supported clinicians in identifying ADEs of patients admitted to EDs between June 1st, 2013 and May 31st, 2014 through a systematic interview of patients or their caregivers and with an additional record review. A research team analyzed each case of suspected ADE, to make a causality assessment applying the Naranjo algorithm and a preventability assessment using Schumock and Thornton criteria. Absolute and percentage frequencies with 95% confidence interval (CI) and medians with interquartile ranges (IQR) were estimated. Logistic regression models were used to evaluate independent predictors of serious and certainly preventable ADEs. RESULTS: Out of 16,963 ED visits, 575 (3.4%) were associated to ADEs, of which 15.1% resulted in hospitalization. ADEs were classified as probable in 45.9%, possible in 51.7% and definite in 2.4% of the cases. Moreover, ADEs were considered certainly preventable in 12.3%, probably preventable in 58.4%, and not preventable in 29.2% of the cases. Polytherapy influenced the risk to experience a serious, as well as a certainly preventable ADE. Whilst, older age resulted an independent predictor only of serious events. The most common implicated drug classes were antibiotics (34.4%) and anti-inflammatory drugs (22.6%). ADEs due to psycholeptics and antiepileptics resulted preventable in 62.7 and 54.5% of the cases, respectively. Allergic reactions (64%) were the most frequent cause of ADE-related ED visits, followed by neurological effects (10.2%) that resulted preventable in 1.9 and 37.3% of the cases, respectively. CONCLUSION: ADEs are a frequent cause of ED visits. The commonly used antibiotics and anti-inflammatory drugs should be carefully managed, as they are widely involved in mild to severe ADEs. Polytherapy is associated with the occurrence of serious, as well as certainly preventable ADEs, while older age only with serious events. A greater sensitivity to drug monitoring programs among health professionals is needed.

An unusual presentation of secondary involvement of B-cell chronic lymphocytic leukemia. A case report.

Extramammary tumors rarely metastasize to the breast. The commonest tumors to metastasize in breast tissue are lymphoproliferative diseases, melanoma, lung cancer and gynecological malignancies. Primary breast lymphoma has been reported in the literature with a maximum percentage of about 0.5% of all breast malignancies, while secondary localizations of lymphomas in the breast are less well studied in the literature than primary ones. The authors report a rare case of a secondary localization of B-cell chronic lymphocytic leukemia to the breast in which the diagnosis was obtained by histopathology and immunohistochemistry and further confirmed by molecular data. This occurrence must be considered in the differential diagnosis of a breast lump so that the primary hematological disease can be adequately treated and the correct type of breast surgery performed.

[Major emergency management in ship collusion]. / Gestione della maxi-emergenza nella collisione tra navi. Nostra esperienza.

AIM OF THE STUDY: To prove that a correct management of a major emergency allowed a quick triage, trauma team, appropriate treatment, discharge and treatment of many patients injured patients when, in January 2007, a crush between a merchant ship and an hydrofoil happened in the Messina strait, that separate Sicily and Calabria. MATERIALS AND METHOD: Four deaths and 105 injuries were observed. Our experience in the emergency care refers to 25 patients of them. All patients were investigated with routine blood tests, imaging techniques and classified according to AIS and ISS. Their classification in colour code was green for 14 of them (7 Males, 7 Females); yellow for 9 (5M, 4F) and red for 2, both males. RESULTS: Of the 105 injured patients, twenty five patients were referred to our Accident and Emergency Department. Ten were affected by cranial trauma, 6 by spinal injuries, 5 by thoracic injuries, 3 had bone fractures and 1 patient with severe wounds. Among all patients, 18 had an ISS <15; 7 had an ISS of 28 (range 17-45). Mean emergency room stay, discharge and transport of patients to wards was 103 minutes. Twelve patients were admitted to the hospital; 9 refused hospitalization, 4 were discharged. DISCUSSION: Twenty six ship-collisions occurred in the Messina Strait between 1950 and 2007, were documented 10 deaths, and other four death of Segesta Jet accident. The approach to Major Emergency was carried out in according to ATLS and P.E.I.M.A.F. This allowed specific and efficacious investigations.

Preoperatively undiagnosed papillary thyroid carcinoma in patients thyroidectomized for benign multinodular goiter.

OBJECTIVE: Incidental thyroid cancers (ITCs) are often microcarcinomas; among them, the most frequent histotype is the papillary one. The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. SUBJECT AND METHODS: We retrospectively evaluated the histological incidence of PTC in 207 consecutive patients who, in a 1-year period, underwent thyroidectomy for benign multinodular goiter. All patients came from an iodine-deficient area (Orleans, France) with three nuclear power stations located in the neighboring areas of the county town. RESULTS: Overall, 25 thyroids (12.1%) harbored 37 PTC, of which 31 were microcarcinomas. In these 25 PTC patients, mean age was 55 ± 10 years (range 30-75), female:male ratio 20:5 (4:1). In 10 patients (40% of 25 and 4.8% of 207), PTCs were bilateral, and in 7 (2 with microPTCs) the thyroid capsule was infiltrated. These 7 patients underwent central and lateral cervical lymph node dissections, which revealed lymph node metastases in one and two cases, respectively. Radioiodine treatment was performed in 7 cases. Neither mortality nor transient and permanent nerve injuries were observed. Four (16%) transient hypocalcaemias occurred as early complications. At last follow-up visit (mean length of follow-up 17.2 ± 3.4 months), all patients were doing well and free of any clinical local recurrence or distant metastases. CONCLUSION: With a 12% risk that multinodular goiter harbors preoperatively unsuspected PTCs, which can have already infiltrated the capsule and that can be accompanied by PTC foci contralaterally, an adequate surgical approach has to be considered.

[Breast abnormalities: a retrospective study of 208 patients]. / Anomalie mammarie. Studio retrospettivo su 208 casi.

Ectopic breast tissue occurs in 0.4-6% of the general population. Usually, these tissues develop along the embryonic milk line but other sites are reported in the literature. Accessory breasts are commonly axillary and may undergo hormonal changes. Some pathologies of normally positioned breasts can occur in ectopic breast tissue, including carcinoma, and therefore require traditional senological flow-charts and imaging strategies. Supernumerary nipples are generally asymptomatic but may sometimes be associated with urological malformations. In our 10-year experience, 208 patients were observed (138 polythelia and 70 polymastia) and 159 surgical procedures were performed, 97 for supernumerary nipple excision and 67 for accessory breast ablation. Five neoplastic lesions and 25 fibrocystic mastopathies were detected in specimens; normal nipple or breast tissue was found in 129. In view of the potentially malignant transformation of accessory breasts, thorough physician evaluation is needed. Surgery is currently suggested in cases of suspected malignancy, in symptomatic cases and for cosmetic problems.

[Personal experience using radioimmunoguided surgery (RIGS)]. / L'utilizzo della chirurgia radioimmunoguidata nella nostra esperienza.

Radio Immuno Guided Surgery (RIGS) is a technique that has numerous uses in oncology. It is characterised by a multidisciplinary approach by nuclear physician and surgeon for diagnosis and treatment; it uses colloid radiotracers, monoclonal antibodies or non-immunological tracers. We adopted this technique in 281 patients: 256 (91.9%) (range 26-82) with breast disease (breast cancer or occult breast lesions) and 25 (8.9%) (range 42-84) with colorectal cancer localized or recurrent. We used monoclonal antibodies (ArcitumoMab 99mTc-labelled) for colorectal carcinomas and aggregates of human serum albumin 99mTc-labelled for Radioguided Occult Lesion Localization (ROLL) and Sentinel Lymph-Node Biopsy (SLNB). All patients were studied preoperatively by routine blood tests, instrumental exams and tumoral markers. Amongst patients with breast disease, 142 breast cancers and 114 occult breast lesions were found. Among patients with colorectal disease, 8 cases had localized colorectal cancer and 17 cases had locoregional recurrence and/or metastasis. In all cases pathologic sites were detected by probe during surgery. The RIGS is indicated for ROLL and SLNB; nevertheless it is also suggested for pre- and intraoperatively staging of primary and recurrent colorectal cancers. This method gives a chance for a radical surgical and oncologic treatment in localized and recurrent cancer. Prospective studies are needed in order to estimate survival and usefulness of this methodology.

Thyroid nodules coexisting with either cystic or solid breast nodules: a new clue for this association between nodules coming from ultrasonography.

BACKGROUND: Thyroid and breast nodules (BNs) are common, their prevalence varying based mainly on the population (including age, residence in area of different iodine availability) studied and methods used. The coincidence of thyroid and breast diseases remains controversial and the majority of the studies evaluate the association between breast cancer and thyroid disorders. Here we describe our experience of such association in a non-oncological series. METHODS: Between the years 2000 and 2005, 3,372 patients from outpatient clinics were referred for thyroid ultrasonography (US) at our University Hospital; concurrent breast US in the 1,896 women revealed the presence of BNs in 127. The 127 women were divided into two groups, based on the cystic or solid nature of the BN(s). RESULTS: In 84/127 (66.1%) the single or multiple BN was/were cystic (group 1), while in the remaining 43 (33.9%) the single or multiple BN was/were solid [group 2; 19/43 had one thyroid nodule (TN) and the remaining 24/43 had ≥2 TNs]. When BN were cystic the coexisting TN(s) was/were more likely to be concordant in localization (i.e., right/right or left/left localization) whereas, when the BN were solid, the coexisting thyroid nodule/nodules was/were more likely to be discordant. In women with cystic BNs (CBNs), TNs were more frequently multiple (64% of cases), whereas in cases with solid BNs (SBNs), the frequency of single and multiple TNs was approximately the same. In patients with TNs/CBNs, TNs tend to be subcentimetric and localized in the inferior pole of either thyroid lobe. In patients with TNs/SBNs, TNs tend to be larger and localized in the middle of either thyroid lobe. CONCLUSIONS: In women with BNs associated with TNs, there are interesting differences concerning TNs when patients are stratified based on the cystic or solid nature of the BN.

Colonic acute malignant obstructions: effectiveness of self-expanding metallic stent as bridge to surgery.

BACKGROUND/AIMS: Bowel obstruction is a frequent event in patients with adenocarcinoma, affecting, in some series, almost one-third of the patients. In the last decades, in addition to surgery, self-expanding metallic stents (SEMSs) are available both as a bridge to surgery (BTS) or palliation. The aim of our study was to demonstrate the safety and efficacy of the use of SEMSs as BTS in selected patients with acute colonic malignant obstructions. MATERIALS AND METHODS: In total, 125 patients with malignant colonic obstruction who underwent emergency surgery or stent insertion were retrospectively enrolled in our study; 62 patients underwent surgery initially, whereas 62 were subjected to stenting as BTS. The 6-month and 1-year survival rates after the procedure (stenting or surgery) and short-term and long-term complication rates were considered as primary endpoints; the recanalization rate after Hartmann's procedure and the length of hospitalization were considered as secondary endpoints. RESULTS: On comparing the surgery group (SG) and the BTS group (BG), we observed a lower short-term complication rate (p<0.05) and a reduction in the mean hospital stay (16.1±7.7 vs. 13.5±3.0, p<0.05) in the latter. No differences in long-term complications were found. The recanalization rate after Hartmann's procedure was higher in BG than in SG, although this was not statistically significant. CONCLUSION: Our experience shows that SEMS insertion is a safe and effective technique in selected patients with colonic malignant obstruction; the reduction in hospital stay and short-term complications in BG is an important cost-saving aim.