Two-stage treatment of a secondary aortoesophageal fistula after thoracic endovascular aneurysm repair.

Secondary aortoesophageal fistula is a relatively rare but very often lethal complication that may develop after thoracic endovascular aneurysm repair (TEVAR). The clinical syndrome is well explained by the Chiari triad: midthoracic pain and/or dysphagia, and sentinel minor hematemesis followed by massive hematemesis. The incidence of this serious complication has increased with the growing number of patients undergoing TEVAR. This case report describes a patient who was seen in the emergency department at this hospital because of fever, sepsis and thoracic pain radiating to the back and unresponsive to drug therapy, diagnosed with a secondary aortoesophageal fistula and subsequently treated with a two stage surgical procedure.

Chest wall and hemidiaphragm reconstruction with Gore-Tex mesh and omolateral latissimus dorsi flap. A case report.

There are various method of reconstruction when chest wall resection is performed for the treatment of tumors of the chest wall. In this case a chest wall resection and reconstruction was performed using an omolateral latissimus dorsi flap, together with Gore-Tex mesh. A 42-year-old woman was diagnosed as having a huge low grade chondrosarcoma and underwent surgical resection which interested the anterior chest wall from the level of the IV to X rib and the right hemidiaphragm. Gore-Tex mesh was fixed to the residual chest wall and an ipsilateral pedicled latissimus dorsi muscle flap was placed on the alloplastic mesh. The patient was discharged from the hospital 17 days postoperatively. The postoperative course was uneventful and the wound was fine.

Epidermal growth factor receptor overexpression correlates with a poor prognosis in completely resected non-small-cell lung cancer.

BACKGROUND: We designed a prospective study to test epidermal growth factor receptor (EGFR) expression by immunohistochemistry (IHC) in resected stage I-IIIA non-small-cell lung cancer (NSCLC) and to correlate overexpression with survival. PATIENTS AND METHODS: EGFR expression was evaluated in 130 consecutive NSCLC patients after radical surgery (60 squamous cell carcinomas, 48 adenocarcinomas, 22 large cell carcinomas: stage I, 41 (31%); stage II, 37 (29%) and stage IIIA, 52 (40%). RESULTS: Overall, 101 of 130 (78%) specimens expressed EGFR, and with a cut-off value of 10% positive cells 48 cases (37%) were classified as positive. At univariate analysis, EGFR was significantly more expressed in stage III (50%) than stage I (20%) and stage II (25%) (P <0.03). No correlation with histotype was found. After a median follow-up of 84 months, both median survival time (18 versus 50 months), 2-year (43% versus 70%) and 5-year (31% versus 46%) survival rates of positive cases were significantly lower than negative ones [P <0.001; hazard ratio 1.96; 95% confidence interval (CI) 1.16-3.30]. At the multivariate analysis, EGFR overexpression and stage emerged as independent factors for cancer-related mortality. CONCLUSION: In patients with radically resected stage I-IIIA NSCLC, EGFR overexpression predicts shorter survival, thus representing a valuable prognostic factor.

[The use of metal vascular prosthesis in the palliative treatment of neoplastic esophago-gastric stenosis]. / Impiego di protesi metalliche vascolari nel trattamento palliativo delle stenosi neoplastiche esofago-gastriche.

The paper reports the authors' experience regarding the use of expandable metal prostheses designed for vascular stenoses but adapted for unoperable esophago-gastric stenoses. Their first impressions are very positive so much so that they affirm that these prostheses are close to being ideal since they are flexible and have an insertion diameter of 3 mm which does not therefore require dilatation. As a result: 1) they involve limited trauma to the patient; 2) reduce the risk of perforation to virtually zero. Moreover: 3) they can be inserted in twisted and angled stenoses and in esophaguses with difficult access due to axial deviations and restriction of the upper cervical aperture; 4) they function well even in notoriously "difficult" sections such as the cardia and esophago-jejunal anastomoses; 5) the unfastening system is easy and rapid. On the strength of these characteristics the authors suggest that these prostheses should be used in an outpatient setting, as occurred in the case of the last of the 10 patients treated, and even at a preoperative stage in preparation for resective surgery so as to preserve normal oral feeding. The structure of these prostheses renders them contraindicated for use in stenoses associated with fistulas in air paths and requires an evaluation of long-term results to verify the incidence with which the following occur: 1) tumoral growth between the mesh; 2) food obstruction; 3) hemorrhage due to compressive necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Neoadjuvant chemotherapy with adriamycin, cisplatin, vincristine and cyclophosphamide (ADOC) in invasive thymomas: results in six patients.

BACKGROUND: Locally advanced malignant thymomas are usually radically resectable in about 60% of stage III but hardly ever in stage IVA. Neoadjuvant chemotherapy followed by surgery could improve both resection rate and curability. Cisplatin containing regimens have repeatedly been found to be highly active in advanced disease, with overall response rates ranging from 80%-90%. PATIENTS AND METHODS: 3 patients with stage III and 3 with stage IVA invasive thymomas, according to Masaoka staging, entered the study. Histology was: lymphoepithelial 4 cases, epithelial 2 cases. 4 cycles of the ADOC scheme--Adriamycin (40 mg/sqm), cisplatin (50 mg/sqm) on day 1, vincristine (0.6 mg/sqm) on day 2, and cyclophosphamide (700 mg/sqm) on day 3, every 21 days--were administered to 5 patients, while 1 patient received 5 cycles. RESULTS: 5/6 patients (83.3%) attained partial responses and underwent radical surgery followed by two further ADOC cycles. The disease-free intervals were 5+, 6+, 15+, 16+, 26+ months. One patient showing stable disease at the end of the fifth cycle was referred to radiotherapy. Toxicity was tolerable: grade III (WHO) nausea/vomiting and leukopenia grade III occurred in 2 patients each. CONCLUSIONS: These results suggest that the ADOC scheme is active as a neoadjuvant approach in invasive thymoma stages III and IVA, rendering possible radical resectability in 83% of patients.

Rebound thymic hyperplasia following high dose chemotherapy and allogeneic BMT.

We describe a child with acute lymphoblastic leukemia who showed mediastinal widening 8 months after allogeneic BMT. Total thymectomy was carried out by the transcervical approach. Histologic examination showed only thymic hyperplasia. The immunohistologic investigation revealed a normal distribution of thymic cell elements, without evidence of clonal proliferation of lymphocytic subpopulations. This case supports the hypothesis that thymic hyperplasia following chemotherapy may be merely a rebound phenomenon. The patient had an uneventful postoperative recovery and remains in remission more than 1 year after BMT.

In vivo priming of human normal neutrophils by granulocyte-macrophage colony stimulating factor: effect on the production of platelet activating factor.

The effect of granulocyte-macrophage colony stimulating factor (GM-CSF) (recombinant, mammalian, glycosylated, Sandoz, Schering Plough; 4 micrograms/kg every 12 h for 3 d, s.c.) on platelet activating factor (PAF, 1-O-alkyl-2-acetyl-sn glycero-3 phosphorylcholine) production from neutrophils was studied in five cancer patients with normal haemopoiesis. Peripheral blood counts, PAF production and lyso-PAF: acetyl transferase (EC 2.3.1.67) (AT) activity in neutrophils were evaluated before treatment, during treatment and 3 d after treatment had been discontinued. GM-CSF induced a three-fold increase in the number of circulating neutrophils. Neutrophils obtained during treatment produced about twice as much PAF than before treatment in response to a variety of stimuli (N-formyl-methionyl-leucyl-phenylalanine, tumour necrosis factor-alpha, phagocytosis of baker's yeast spores opsonized with C3b). This increased PAF synthesis and release is concomitant with a 2-3-fold increase in AT activity. Moreover, lower concentrations of stimuli are sufficient to induce PAF synthesis from neutrophils obtained during GM-CSF treatment. Three days after treatment had been discontinued, stimulus induced PAF production had returned to baseline levels. Since GM-CSF induces a marked shift to the left in the Arneth score, the increased PAF release might have been due to the presence of younger granulocytes. This was, however, ruled out by experiments showing that normal neutrophils primed in vitro with GM-CSF produce more PAF when challenged with the same stimuli. The potential relevance of this effect of GM-CSF treatment lies on the crucial role of PAF in inflammatory reactions and its intervention in some immune reactions, including delayed hypersensitivity, and in endotoxic shock. Lastly, increased PAF production from neutrophils may explain some toxicities observed during treatment with high doses of GM-CSF.

The role of induction chemotherapy in inoperable ovarian cancer.

Thirty patients with bulky advanced ovarian cancer surgically not resectable, received combination chemotherapy (median of 4.1 cycles; range, 3-7) including cisplatin or carboplatin, followed by a second surgical effort. Clinical CR + PR was observed in 24/30 (80%) patients after chemotherapy. Our study deals only with these 24 patients, and the 6 patients who did not respond to chemotherapy are not part of this report. At debulking, 7/24 (29.1%) patients had a complete macroscopic resection; 9/24 (37.5%) patients had a partial resection (residual tumor less than 2 cm). These data suggest that debulking is feasible and successful after chemotherapy containing cisplatin or its derivative. Overall median survival from diagnosis was 18.9 months; the 3-year survival rate was 28%. Median progression-free survival from diagnosis was 13.5 months. The results observed in our study indicate that the use of induction chemotherapy can play an important role in increasing the chances of optimal debulking in patients presenting with unresectable ovarian cancer.

[Assessment of human papilloma virus colposcopic findings of the cervix (in the Italian colposcopic classification]. / L'inquadramento dei reperti colposcopici da HPV in sede cervicale (nella classificazione colposcopica italiana).

HPV-induced flat condylomatosis is not only much more frequently observed on the hexocervix than the florid type, but it also induces colposcopic changes in the epithelium without completely altering its morphology. HPV-induced changes have now been largely identified and are recognisable in colposcopy. They can therefore be classified in the various patterns that characterise colposcopically the transformation epithelium, with undeniable advantages not only from the point of view of their correct classification but also from that of their prognostic evaluation. This is important because viral modifications ANTZ have a different diagnostic and prognostic significance from those observable in the notice squamous epithelium. A classification proposal of the various findings of flat HPV condylomatosis based on italian colposcopic classification is therefore presented.

Cardiac arrhythmias following lung resection in patients treated and untreated with digitalis prophylaxis.

Cardiac arrhythmias and failure following lung resection in patients treated and untreated with digitalis prophylaxis have been evaluated. In 82 patients without digitalis (1st group) 11% tachyarrhythmias and 5.7% cardiac failures were noted. In 100 patients treated with digitalis (2nd group) 7% arrhythmias and no cardiac failures were registered. Among cardiac complications only one death in the first group was observed. The mean period of incidence of arrhythmias appears dilated in the digitalis group (3rd vs. 5th postoperative day) and this could be attributed to the early suspension of the drug.

Kinetics of human hemopoietic cells after in vivo administration of granulocyte-macrophage colony-stimulating factor.

The kinetic changes induced by granulocyte-macrophage colony-stimulating factor (GM-CSF) on hemopoietic cells were assessed in physiological conditions by administering GM-CSF (8 micrograms/kg per d) for 3 d to nine patients with solid tumors and normal bone marrow (BM), before chemotherapy. GM-CSF increased the number of circulating granulocytes and monocytes; platelets, erythrocytes, lymphocyte number, and subsets were unmodified. GM-CSF increased the percentage of BM S phase BFU-E (from 32 +/- 7 to 79 +/- 16%), day 14 colony-forming unit granulocyte-macrophage (CFU-GM) (from 43 +/- 20 to 82 +/- 11%) and day 7 CFU-GM (from 41 +/- 14 to 56 +/- 20%). The percentage of BM myeloblasts, promyelocytes, and myelocytes in S phase increased from 26 +/- 14 to 41 +/- 6%, and that of erythroblasts increased from 25 +/- 12 to 30 +/- 12%. This suggests that GM-CSF activates both erythroid and granulomonopoietic progenitors but that, among the morphologically recognizable BM precursors, only the granulomonopoietic lineage is a direct target of the molecule. GM-CSF increased the birth rate of cycling cells from 1.3 to 3.4 cells %/h and decreased the duration of the S phase from 14.3 to 9.1 h and the cell cycle time from 86 to 26 h. After treatment discontinuation, the number of circulating granulocytes and monocytes rapidly fell. The proportion of S phase BM cells dropped to values lower than pretreatment levels, suggesting a period of relative refractoriness to cell cycle-active antineoplastic agents.

Cisplatin and cyclophosphamide in early epithelial ovarian carcinoma.

Toxicity and efficacy of adjuvant cisplatin-based chemotherapy were assessed in 41 patients with FIGO stage I-II ovarian carcinoma. Chemotherapy consisted of cisplatin 50 mg/m2 and cyclophosphamide 600 mg/m2 administered on a one-day schedule q 28 d for six courses. Inclusion criteria were based on appropriate staging procedures and absence of macroscopic disease after primary surgery; patients with stage IAi G1-G2 or with borderline tumors were excluded from the study. Second look laparotomy was performed 2 months after termination of chemotherapy. At 60 months the actuarial survival is 77.5%. Recurrences were observed in 8 patients; in 1 case relapse was diagnosed at second look laparotomy. Toxicity was acceptable with only 1 treatment drop-out due to reversible neurotoxicity. Our results demonstrate that short-term chemotherapy including cisplatin is a safe and effective regimen and is suitable for administration on a outpatient basis. In our experience second-look laparotomy has limited value for early detection of relapses.