Post-occupational health surveillance of asbestos workers.

BACKGROUND: Italian law requires an extensive health surveillance of workers after cessation of their employment status in the case of occupational exposure to carcinogens, including asbestos. Nonetheless, Italian law does not specify the timeframe of these clinical checks, nor who has financial and organizational responsibility for this surveillance. A literature search confirmed a lack of consensus around the objectives and methods to follow up workers with past occupational exposure to asbestos. OBJECTIVES: To develop an updated evidence-based methodology for an appropriate health surveillance programme. METHODS: We present an overview of the field experience developed by the Veneto Region from 2000 to 2011, and new studies that could contribute to establishing a national policy for the medical surveillance of workers with past asbestos exposure. RESULTS: There were three specific topics: (1) definition of a reliable method to identify asbestos workers (through multiple sources and procedures that meet current confidentiality regulations); (2) detection of asbestos fibres in biological media (to support the etiological diagnosis of asbestos-related diseases); (3) creation of a national protocol of health surveillance (through the assessment of policies developed by other Regions in this field, and recruiting from these regions a cohort of past-exposed workers: the epidemiological study should offer relevant suggestions for specific surveillance approaches, based on either estimated cumulative asbestos exposure or detection of x-ray patterns of pleural plaques and/or asbestosis). CONCLUSIONS: These studies will support the Regions in setting up health care policies directed at workers with past asbestos exposure.

[The role of Italian regional coordination for a collaboration policy of the different occupational medicine professionals]. / Il Ruolo del Coordinamento delle regioni per una politica di concentrazione delle varie figure della Medicina del Lavoro.

The article describes workplace prevention strategy adopted by Italian Regions in institutional coordination with Ministry of Labor and Ministry of Health. This strategy is finalized to contrast the most common and serious occupational hazards. Results are reported in terms of system efficiency and quality improvement. It's suggested a possible future collaboration between occupational medicine professionals, aimed at a further improvement of prevention efficacy.

[A procedure for estimating the rate of occupational accidents in non-European-Union workers with irregular immigrant status]. / Una procedura per la stima del tasso di infortunio nei lavoratori extracomunitari irregolari.

BACKGROUND: Statistics on occupational accidents provided by the Italian Institute for Occupational Diseases and Accidents (INAIL, Italian acronym) include only events that occurred in workers with regular employment status. OBJECTIVES: The aim of the study was to establish a procedure in order to estimate the rate of occupational accidents in non-European-Union (non-EU) workers with irregular employment status and/or irregular immigrant status. METHODS: The sources of data were the clinical records of the Emergency Department of San Bonifacio Hospital, and the population data of District 4 of Local Health Authority 20 of Verona, which was considered the catchment area of this hospital. RESULTS: Among 419 cases of accidents occurred in the numerator of the rate. The denominator of the rate was estimated by calculating: (1) the subjects of working age resident in District 4 (= 83714); (2) the total number of non-EU workers, assuming that the percentage was similar to that in San Bonifacio Municipality (= 0.115); the number of irregular non-EU workers, assuming that the percentage was similar to that in north-eastern Italy (= 0.103). Non-EU workers with irregular employment status and/or irregular immigrant status should, according to these calculations, be 992 (= 83714 x 0.115 x 0.103). The rate--147.2 (= 146/992) occupational accidents per 1000 irregular non-EU workers--is more than twice as high as that calculated in 2004 in Italy in regular non-EU workers (approximately 65 accidents per 1000). The difference can be explained by the fact that irregular workers find employment mainly in agriculture, building and the metallurgic industry, which have a high frequency of accidents, and are more willing to accept risky work and longer work shifts. CONCLUSIONS: On the assumption that the rate of occupational accidents in the 500,000 irregular workers living in Italy in 2004 was 147.2 per 1000 (as in the catchment area of the San Bonifacio Hospital), the number of accidents would be 73,600, against the 116,000 that occurred among regular non-EU workers in 2004 according to INAIL. Official INAIL statistics on occupational accidents therefore show a considerable underestimation.

[Working and health conditions and preventive measures in a random sample of 5000 workers in the Veneto Region examined by telephone interview]. / Condizioni di lavoro e di salute e attività di prevenzione in un campione di 5000 lavoratori del veneto esaminati con questionario mediante intervista telefonica.

BACKGROUND: A survey was carried out in 2000 by the European Foundation for the Improvement of Living and Working Conditions in a random sample of workers from 15 countries of the European Union in order to obtain information on occupational exposure, health problems and preventive measures taken at the workplaces. OBJECTIVES: To obtain similar information in workers in the Veneto Region and compare the results with those of the third European Survey on Working Conditions (ESWC). The results of the survey on Veneto Region workers were further analyzed, investigating the distribution by risk factors in each work sector, and the association between risk factors and reported health problems. METHODS: The ESWC questionnaire was adapted to the requirements of a telephone interview and a sample of 5000 workers (size based on the budget) between 15 and 64 years of age was randomly extracted from the regional list of telephone subscribers. The questionnaire was administered by trained interviewers. No statistical tests were used in the comparison between ESWC and Veneto Region results due to the lack of a priori hypotheses. Odds ratio (OR) was calculated in estimating the association between risk factors and symptoms; and p-value for OR trend across the increasing level of exposure was also obtained. RESULTS: Workers reported to be exposed for more than a quarter of their work time to: vibrations (20%), noise (19%), dusts, fumes vapours, chemicals (18%), repetitive hand/arm movements (50%), tiring/painful positions (46%); working at very high speed or tight deadlines (60%). 54.4% of the subjects reported working with computers. Taking as a reference the third ESWC in 2000, among Veneto Region workers in 2005 exposure was lower as regards physical, chemical and ergonomic risk factors, and similar as regards working at very high speed. The more frequently reported work-related health problems were: stress (26.9%), backache (17.8%), overall fatigue (11.9%), muscular pains in upper limbs (6.8%), headache (6.1%), sight problems (5.4%), anxiety (5.5%), muscular pain in lower limbs (4.3%), irritability (4.0%), hearing problems (2.3%). Except for stress, all symptoms/health problems were two-three times more frequently reported in the ESWC than in the Veneto Region survey where, conversely, the number of persons with at least one new sick- leave spell was higher. Lastly, there was no difference as regards preventive measures taken at the workplace: information on risks (78.2%), wearing personal protective equipment (28.7%), training paid by employer (28.7%). Among the Veneto Region workers, the most often reported risk factors were exposure to physical and chemical risk factors in industry/agriculture, and shift-work and working at very high speed in the services. The most commonly adopted preventive measures were information on risks and wearing of personal protective equipment in industry, and training in services. Moreover, among the Veneto Region workers, a significant exposure-dependent increase was reported for respiratory problems, allergies, dermatitis, hearing loss, accidents, back pain, pain in the upper and lower limbs, and headache. The risk of stress, anxiety, sleeping problems, stomach pain and headache increased when skills were not adequate to cope with job demand. In contrast, the perception of improved health conditions increased with increasing skill discretion, decision authority, social support (which are dimensions of control of job demand), but not with information on risk, training, or use of personal protective equipment. CONCLUSIONS: Data from the present survey provide useful insights on working and health conditions of workers in the Veneto Region, revealing problems that were subsequently investigated using other sources of information, as reported in the studies published elsewhere in this volume.

[Comparison of four measurements of sickness absence in workers in the Veneto Region: interpretation and applicability. Data from Italian National Social Security Institute, 1997-2002]. / Quattro misure di assenze dal lavoro per malattia nei lavoratori del veneto, dati INPS 1997-2002: interpretazione dei risultati e applicabilità.

BACKGROUND: In 2005, 52% of workers in the Veneto Region reported one or more sick leave spells in the previous 12 months, compared with 16% reported in the European Survey on Working Condition in 2000 (ESWC), although health conditions were better in the Veneto Region than in the ESWC. OBJECTIVES: Since the above findings were based on answers to a questionnaire, we used an objective source of information in order to further investigate the problem. METHODS: The source of data consisted of the sick leave records of workers in the Veneto Region, 1997-2002, which were obtained from the Italian National Social Security Institute (INPS). Four measurements were used: (1) frequency = number of sick-leave spells during the study period/number of insured persons at risk for sickness absence during the study period; (2) cumulative incidence = number of persons with at least one new sick-leave spell during the study period/number of insured persons at risk for sickness absence during the study period; (3) sick-leave rate = number of sick-leave days during the study period/number of insured persons at risk for sickness absence during the study period; (4) duration of absence = number of sick-leave days in new sick leave spells during the study period/number of new sick-leave spells during the study period. Cumulative incidence could only be analyzed by statistical methods (binomial regression). RESULTS: The first three measurements gave overlapping results. The values were highest in industry, lowest in agriculture, and intermediate in crafts and services; they were highest in middle-aged subjects and lowest in younger and older individuals; the time trend increased up to 1999 and then decreased slowly. Cumulative incidence was 52.0%, 38.0%, 36.4% and 22.9%, in industry, services, crafts, and agriculture, respectively, and 42.8% in the total population. The results of binomial regression confirmed the above pattern, as well as an excess in women, in white collar workers, and in various occupational categories which, however, were probably not due to occupational exposures since in each occupational category the risk was always higher in industry than in crafts. By contrast, the sick-leave rate was higher in crafts and agriculture and lower in services and industry; it increased exponentially with age and did not show real differences between males and females. CONCLUSIONS: The choice of measurements influences the results; duration of absence could be used to detect areas of suspected work-related diseases, while cumulative incidence might be more helpful to detect areas of suspected absenteeism/presenteeism.

[Occupational injuries and sickness absence: association with job demand, decision latitude, and life style in 2174 workers in the Veneto Region]. / Infortuni sul lavoro e assenze dal lavoro per malattia: associazioni con carico lavorativo, autonomia decisionale e stili di vita in 2174 lavoratori del veneto.

BACKGROUND: Stress was the most frequent (26,9%) health problem reported in a survey on the perception of working and health conditions in 5000 workers in the Veneto Region. OBJECTIVES: The aim of the study was to investigate in the Veneto Region the association between occupational stress and events occurred in the previous 12 months: occupational accidents, or sickness absence for 10 or more consecutive days. METHODS: Perceived occupational stress is correlated, according to Karasek's model, to high job demand (JD) and low decision latitude (DL). Using Karasek's questionnaire (to which questions on smoking and alcohol consumption were added), we examined 2174 subjects working in 30 companies with between 10 and 500 employees, who belonged to the occupational categories of industry and services that are more prevalent in the Veneto Region. The questionnaire was administered by the occupational physician during health surveillance. The subjects were classified on the basis of current exposure to psychosocial factors or, for subjects reporting an event, their exposure at that time. We identified the tertiles of JD and DL; data were submitted to the analysis of multiple logistic regression, estimating odds ratio (OR) and 95% confidence interval (CI). The population attributable risk (PAR) was calculated using the formula (pc (OR-1)/OR), where pc is the fraction of exposed cases. RESULTS: An elevated risk of occupational accidents was found in subjects with regular consumption of alcohol (OR = 2.0; IC = 1.2-3.5), in smokers smoking 10-20 (2.3; 1.3-3.8) or >20 cigarettes/day (3.8; 1.8-7.9), in the highest tertile of JD (2.29; 1.35-3.89) and in the lowest tertile of DL (1.6; 1.0-2.6). PAR was 37.6% for occupational factors (high JD and low DL), 44.5%for non-occupational factors (cigarette smoking and alcohol consumption), and 82.1% overall. The risk of sickness absence increased in subjects smoking 10-20 cigarettes (1.63 = 1.1-2.40), in the highest tertile of JD (1.5; 1.0-2.2) and in the lowest tertile of DL (1.6; 1.1-2.2). PAR was 26.1% for occupational factors (high JD and low DL), 7.6% for non-occupational factors (smoking), and 30.4% overall. While the risk of sick absence increased mainly with the reduction of DL, the risk of occupational accidents increased with increasing JD and, to a lesser extent, with decreasing DL. The current approach to accident prevention is based only on technical and administrative aspects, in spite of the fact that 80% of accidents are not attributable to malfunctioning of machinery. Injury prevention should address technical, personal and psychosocial risk factors together as a whole.

[Association between causes of lNPS compensated disability and occupational category (Veneto Region, 1994-2002): a surveillance method for occupational diseases?]. / Associazione tra causa di invalidita pensionabile INPS e comparto lavorativo (Veneto, 1994-2002): un metodo di sorveglianza delle malattie professionali?

BACKGROUND: According to Italian law, workers are insured against disability through the National Social Security Institute (INPS), whose records contain information on diseases causing disability and occupational histories. OBJECTIVES: Using the INPS data, our objective was to identify any excess risk of disabling diseases in relation to the occupational categories. METHODS: Insurance covers all private sector employees, a small proportion of public sector employees, agricultural labourers, domestic workers, self-employed workers (craftsmen, commercial dealers,farmers), and few other occupational categories. For each insured worker, a database was created containing registry data, occupational history and, for compensated workers, the disease code, for each year from 1994 to 2002. A cohort study design was adopted, in which references were self-employed workers (with mixed exposure) to whom different categories of employees in agriculture, industry, crafts, and services were compared. Data were analyzed by means of Poisson regression, estimating the Incidence Rate Ratio (IRR) and confidence interval (CI) at 99.99%, instead of 95%, in order to set the threshold of error for the entire study at 0.05. RESULTS: In the construction industry there were significantly high risks of disability in both industry and crafts for tumours (industry: IRR = 2.07; IC = 1. 67-2.57; crafts: 2.57; 1.89-3.18), circulatory disorders (industry: IRR = 2.24; IC = 1.65-3.04; crafts.: 3.06; 2.16-4.32), and bone and joint diseases (industry. IRR = 5.0; IC = 3.15-7.94; crafts: 6.58; 5.04-8.59). CONCLUSIONS: The advantage of this approach is to recruit a large number of subjects at limited cost. The procedure here proposed is a mainly exploratory approach aimed at establishing new study hypotheses: disability, in fact, is acknowledged by INPS when its cause is not occupational according to the current literature.

[Safety and health in workers employed in industry. Data from Industrial Accidents Compensation Board (INAIL) and National Social Security Institute (INPS), Veneto Region, 1994-2002]. / Sicurezza e salute dei lavoratori dell'Industria attraverso i dati INAIL e INPS, Veneto, 1994-2002.

BACKGROUND: A decreasing time trend for occupational injuries and sickness absence would be the effect of the new legislation (D.Lgs. 626/94 and successive laws) on prevention in occupational settings. Conversely, the reduction of INPS disability would reflect a health improvement due to non-occupational causes. OBJECTIVES: The aim of the study was to investigate the efficacy of the new legislation among employees in industry (where the law was mainly applied), via the time trend of three standardized rates in the Veneto Region. METHODS: The numerator for the rate of occupational accidents (cases occurring in industry workers in the Veneto Region, broken down for sex, age and calendar years) was supplied by INAIL. The denominator for the above rate, as well as numerators and denominators for disability and sickness absence were supplied by INPS. Data were available from 1994 to 2002 for accidents and disability, and from 1997 to 2002 for sickness absence. In every year from 1994 to 2002, the rates were standardized for age and sex with the direct method, using an internal "standard" population. The time trend of year-specific standardized rates was analyzed by Joinpoint regression software. RESULTS: Among industrial workers in the Veneto Region, occupational accidents increased by 0.4% yearly, while disability decreased by 2.56% from 1994 to 2002. Sick absence increased up to 1999, then decreased. CONCLUSIONS: This epidemiological pattern is difficult to explain. The increase in accidents could be due to the increase of non-European Union workers and/or to the fact that accidents on the way to or from work were recognized as occupational accidents by INAIL starting from 2000. Both these phenomena could have contributed to increase the rate that was otherwise diminishing. On the other hand, this same situation could be due to insufficient efficacy of the legislation (D.Lgs. 626/94 and successive laws) for preventing occupational accidents and diseases.

[Regional planning of prevention measures in work environment: Veneto Region experience]. / La pianificazione regionale delle attività di prevenzione negli ambienti di lavoro; l'esperienza della Regione Veneto.

In Veneto, from 1999, activities for health promotion in workplaces have been defined like a three - years planning, based on European, national and local policy, and on work accidents and injuries epidemiologist data. Activity plans have always been managed by using Plan - Do - Check - Act quality cycle, with in itinere and ex post evaluation steps to control system performances, and to define necessary activities for a never- ending improvement.

Mastectomy and immediate breast reconstruction: oncological considerations and evaluation of two different methods relating to 88 cases.

The authors consider 88 cases of mastectomy and immediate breast reconstruction mainly performed using the skin expander plus prosthesis method or latissimus dorsi myocutaneous flaps. At the same time, 53 patients underwent contralateral mastopexy for symmetry. The mean follow-up was 21 months (range 2-102). Progressive disease was observed in nine cases: one patient presented scar relapse, one axillary relapse, two contralateral tumor, two contralateral tumor and distant metastasis, three distant metastases and one death from distant metastasis. Reconstruction complications were capsular contracture in 12 cases, infection in nine, skin necrosis in two, skin expander breakage in three and implant dislocation in one. The final result was judged good in 54 cases, fair in nine, poor in 11 and unevaluable in 14. In conclusion immediate breast reconstruction does not seem to interfere with the disease or oncological therapy. After analysing separately, and comparing the results and complications of the two main techniques used, latissimus dorsi seems to be the most reliable method in the majority of cases but skin expanders can be a good technique in patients with small and firm breasts and without complicating risk factors.

Urinary thallium: critical problems, reference values and preliminary results of an investigation in workers with suspected industrial exposure.

Using a sensitive ETA ASS method, urinary thallium (Tl-U) has been measured in a group of non-exposed individuals and in two groups of workers with suspected industrial exposure. In non-exposed subjects (72 healthy males aged 41 +/- 11 years) the Tl-U mean value was 0.22 mu/l (range 0.05-0.61). Significantly higher values were found in two groups of workers (30 and 21 subjects) employed in two cement factories and two cast iron foundries (mean Tl-U value: 0.38 and 0.33 mu/l, respectively; range 0.06-1.2). Thallium has been determined in coal, raw materials and, in one factory, also in environmental samples, but no detectable levels were found. The analytical problems connected to urinary thallium determination and the preliminary results of biological monitoring in non-exposed individuals and in workers are discussed.

Hepatoblastoma in adult age: a report of two cases.

Hepatoblastoma in adults is a rare malignancy that presents in the epithelial or mixed epithelial-mesenchymal variants. We report two cases, the former representing the epithelial and the latter the mixed type. A 21 year-old woman with epigastric pain had abdominal ultrasound and CT scans showing a large hepatic mass. A right trisegmentectomy was performed. The first and second recurrences were treated by resection. The third recurrence was treated by hepatic transarterial chemo-embolization, systemic chemotherapy and 19 percutaneous alcohol injections. A careful follow up by abdominal ultrasound and CT scans was able to detect the recurrence at an early stage. The patient is well at 151 months. A 39 year-old man with epigastric pain and dyspepsia had upper-GI series and abdominal CT scan showing a left hepatic mass involving the stomach. Liver resection and Billroth II hemigastrectomy were performed. A recurrence involving the left hepatic lobe, the spleen and the remaining stomach occurred 15 months later and the patient died from multi organ failure. Surgery is the treatment of choice of hepatoblastoma in adults. Recurrences can also be treated aggressively by surgical resections if no extrahepatic organs are involved. Other therapeutic modalities can be attempted whenever surgery is not possible.

Serum copper and ceruloplasmin in early and in advanced hepatocellular carcinoma: diagnostic and prognostic relevance.

To evaluate the prognostic value of serum copper (S-Cu) and ceruloplasmin and their pathophysiologic significance in human hepatocellular carcinoma (HCC), we studied 49 patients with HCC (20 of which were submitted to partial hepatectomy) compared with 110 patients with liver cirrhosis. In HCC both S-Cu and ceruloplasmin were higher than in cirrhosis; moreover, S-Cu was correlated with the extension of HCC, evaluated by instrumental data and by surgical inspection. In cirrhotic patients, mean S-Cu was 122.9 micrograms/dl (SD, 29.3), in early HCC, 153.0 micrograms/dl (SD, 34.5), and in advanced HCC, 193.1 micrograms/dl (SD, 37.7). Variance analysis gave F = 59.4. In HCC patients S-Cu was positively correlated with ceruloplasmin and with fibrinogen. Survival, evaluated by Mantel's test stratified for surgical therapy, was longer in patients with S-Cu levels lower than 175 micrograms/dl and in those at an earlier stage. We therefore conclude that S-Cu has a relevant diagnostic value in detecting HCC also in early stage and allows prognostic evaluation as regards survival.

Repeated hepatic resection.

Sixteen patients underwent repeated hepatic resections over a 16 year period. The cases were divided into two groups: group A, non-planned repeated resections (14 cases), and group B, planned repeated resections (two cases). Group A is composed of patients requiring re-resection as a result of the hepatic re-recurrence of the neoplasia (three hepatocellular carcinomas, nine metastases from colorectal carcinoma, and two metastases from carcinoid tumor). Group B is composed of two cases (hepatocellular carcinoma and metastases of leiomyosarcoma) where the extent of the disease was incompatible with radical resection in a single time thus making necessary to plan for repeated operations. The need for correct preoperative assessment of hepatic performance using CT, US and Tc 99m HIDA scan, as well as intraoperative ultrasonography is stressed.

[Hepatocellular adenoma and focal nodular hyperplasia]. / Adenoma epatocellulare ed iperplasia focale nodulare.

The diagnostic findings of hepatocellular adenoma and focal nodular hyperplasia became more frequent in the last years in our as in western experience. The improvement in diagnostic technique, a correct pathological identification and the diffusion of oral contraceptives explain this increase of incidence. In our series were present 11 hepatocellular adenomas and 19 focal nodular hyperplasias: all the HCA cases were radically resected, while only 15 FNH were resected, only two biopsied and two submitted to periodical follow-up. The tendency to spontaneous bleeding and the presence of diagnostic uncertainty versus well-differentiated hepatocellular carcinoma are mandatory indications for radical resections in all the HCA cases. FNH resection is reserved to symptomatic cases and wide wedge biopsy is at least required in presence of diagnostic doubts: the asymptomatic FNH ("hot spot" on Tc99m-HIDA scintigraphy) may be followed-up only.

[The therapeutic strategy in benign liver tumors: a 20-year experience]. / La strategia terapeutica dei tumori epatici benigni: esperienza di 20 anni.

Therapeutic choices for benign liver tumours have changed over the last 20 years. From 1975 to December 1993, we observed 145 hemangiomas (HMG) (57.2% females-mean age 47.3 years, 42.8% males-mean age 50.4 years): we resected 42 symptomatic hemangiomas: mortality rate was 2.3%. 93 HMG without symptoms were only followed-up: 5 of these increased in size and were resected. 27 symptomatic cases over 50 focal nodular hyperplasia (FNH) were resected, 7 cases were resected and 3 biopsied during laparotomy performed for other pathology. Postoperative mortality was nil. 13 cases were only followed-up after diagnosis by imaging techniques and fine needle biopsy: over a mean period of 23 months. No variations have been recorded. Increases in GGT and ALP were present respectively in 34% and 22% of FNH-cases. Scintigraphic techniques were the most diagnostically accurate (96.2%). All 16 hepatocellular adenomas (HCA) were removed (11 females, 5 males), postoperative mortality was nil: oestrogen administration was present in 36.4% of female cases, histological diagnosis v/s well differentiated hepatocellular carcinoma was difficult in 2 cases, whilst 3 cases had spontaneous rupture. We resected also 8 cases of biliary adenomas in order to determine a precise diagnosis v/s liver metastases, and 4 biliary cystadenomas for their malignant potential. Asymptomatic HMG and FNH for their low tendency to increase, can be only observed, whilst HCA must be fully resected for risk of bleeding and misdiagnosis v/s well differentiated hepatocellular carcinoma.

[Hepatic angiomyelolipoma (considerations on a case brought to our attention)]. / Angiomyelolipoma epatico (considerazioni su un caso giunto alla nostra osservazione).

Liver lipomas are exceedingly rare: the authors present a case of angiomyelolipoma of the liver in a 65-year-old woman resected by right hemihepatectomy. Radiologic findings and indications to surgical treatment are discussed.

[Bilemia. Considerations apropos of a case]. / Bilemia. Considerazioni a proposito di un caso.

The Authors report a case of bilemia, a complication of hepatic biopsy. They analyse the physiopathogenetic problems and those of surgical tactics, and emphasize the importance of retrograde and/or interoperative cholangiography ii the diagnostics of such disease.

[Major hepatic resections for angioma]. / Resezioni epatiche maggiori per angioma.

6 cases of solitary angioma of the liver, treated with major hepatic resections, are presented (2 rt hemihepatectomies - 2 lt hemihepatectomies - 1 lt lateral sect. and 1 segmentectomy of the VIth). Their anatomopathological definition (solitary angioma, multiple angiomas, hemangiomatosis) is discussed in relation to the various therapeutic possibilities. From the diagnostic standpoint, an outstanding part is played by angiography. In addition to demonstrating the presence of hepatic mass, C.A.T. can, according to their experience, also allow diagnosis of quality on the basis of demonstration of vascular lacunae. It is considered that the treatment of choice of for solitary angiomas is surgery, which must be performed by skilled surgeons and consist in hepatic resections conduced by typical route. This is especially true for the giant forms, owing to their particular tendency to growth and spontaneous rupture. For small angiomas it is considered better in principle to remove them, generally by small cuneiform resections, unless they are situated in sites difficult to attack surgically and with high risk. In this case frequent check-up is necessary since, although they are sometimes found to be stationary and even in exceptional cases regressive, personal experience (2 cases) has demonstrated a tendency to expansion.