Stent-Assisted Coil Embolization of a Saccular Visceral Aortic Aneurysm: Case Report and Review of the Literature.

PURPOSE: We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally. CASE REPORT: After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown. CONCLUSION: Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended. CLINICAL IMPACT: This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Personal technique for treatment of perianal fistulas in outpatients.

AIM: Presentation of a personal technique for the treatment of perineal fistulas in outpatients. MATERIAL OF STUDY: 17 patients with complete non-complex linear intersphincteric or trans-sphincteric fistulas were treated with this technique. First we facilitated the cannulation, then we used the same catheters to place the "seton". We had to use a more subtle and smooth, rugged nylon thread, instead of the floss, due to the difference between the large size of the silk thread and the small lumen of the cannula. RESULTS: The elastic traction has determined not only a valid mean of capillary drainage, but also a rapid passage through the tissues without any functional impairment, in times ranging from 2 to 4 weeks. DISCUSSION: The traditional surgery is burdened by a significant number of relapses . This is due to the anatomical characteristics of the anal canal, to the difficulty to ensure the integrity of the sphincteric structures and to the position of the fistula. It's essential to identify the whole extension of the fistula to avoid it's partial removal and the persistence of granulation tissue therefore. With our technique, we got a good drainage of the fistula, avoiding to leave any residues or to create false paths causing relapses as may happen with the explorers. CONCLUSIONS: The discomfort suffered by patients was minimal and the results achieved led us to support a greater diffusion of this technique in outpatients.

Cystosarcoma phylloides of the breast: a rare diagnosis. A case report and review of the literature.

Sarcoma of the breast is a rare condition, with one possible meaning of relapse ad metastastasize, and behaves biologically as a stromal tumor. Surgery is the first choise and mastectomy is the best procedure adopted in these tumors. The aim of our study was to assess diagnostic and treatment options for PT, based on a review of the literature and our experience with a case of breast sarcoma arising from a phyllodes tumor.

Observations and considerations on a case of Mondor's syndrome associated with gigantomastia.

AIM: The study of the Mondor's syndrome as a possible complication of gigantomastia. MATERIAL AND METHOD: A 49 year old woman, with gigantomastia, came to our observation for the presence of a large superficial vein of the left breast affected by thrombophlebitis, compatible with Mondor's syndrome. RESULTS: A "Thorek" breast reduction was performed; the patient was discharged on the second postoperative day and the follow up was smooth and fee from any complications. DISCUSSION: In the case we observed, gigantomastia had a clear role in the pathogenesis of the Mondor's disease; in fact, the excessive weight of the breasts caused stretching of the mammary dorsal vein evolving in phlebitis. In literature, among the causes related to Mondor's disease the pendulous breast is described, probably with the same dynamic we have seen in this patient, but has never reported, so obviously, the correlation between the two events. It's considered as good practice in the pre-operative evaluation, to make differential diagnosis with any cancer, that, in a certain percentage, is associated with Mondor's syndrome, and once established the causes of the pathology, it is imperative to eliminate them to prevent any relapses. CONCLUSION: Among the various causes recognized as predisposing to Mondor's syndrome, there has never been described gigantomastia so far. The observation and treatment of a patient in whom the gigantomastia certainly led to the onset of Mondor's disease, has led us to consider this as one of the possible complications of gigantomastia, providing an additional cue to the treatment of this condition even at an early stage.

An uncommon association between parathyroid adenoma and Hodgkin disease.

The Authors refer their experience of a patient operated for adenoma of the inferior parathyroid of left lobe associated to a limphoadenopathy fom HD. Diagnostic and therapeutical approach are described. The literature of these last decades reports a single case with similar characteristics, but not with the same association. Numerous neoplasias associated more frequently with parathyroid adenoma are mentioned and the probable causes of this association. Although the associations with other affections of the hemolymphopoietic system are relatively frequent, the causes of the rarity of the association between parathiroid adenoma and HD remain unknown.

Cardiological assessment of cardiac patients undergoing non-cardiac surgery (usefulness of surveys).

AIM OF THE STUDY: The aim of the study was to considerate the effective usefulness of preoperative stress test and echocardiography in adult patients with coronary artery disease, undergoing non-cardiac surgery. MATERIALS AND METHODS: In the last three years, 200 patients aged 58-85, affected by stable ischemic pathology, undergoing non cardiac surgery, and treated with oral drugs, were enrolled for an assessment orotocol including anamnesis, objective examination, blood pressure, RCG, blood chemistry analysis, and was performed a cardiac risk evaluation. A second 50 patients control cohort of the same class was subjected to the same tests, and preoperative and exercise stress test. RESULTS: All patients showed a good hemodynamic compensation and a quick recovery, and the group of 200 patients for whom the risk was closed without further investigation has concluded the process on average three days before the group underwent echocardiography and exercise stress test. DISCUSSION: The clinical evaluation of cardiac patients waiting for non-cardiac surgery, performed through anamnesis, examinations and the ECGs, is the cornerstone of cardiac risk stratification. It also important the type of surgery, as well as some priority conditions like certain neoplastic: diseases, where it seems appropriate to speed up the diagnostic program. CONCLUSIONS: When patients are hemodynamically stable and their conditions controlled by appropriate therapy, it is sufficient to perform first-level tests for the preoperative stratification of cardiovascular risk. It's recommended to perform echocardiogram and stress test when the first level tests are abnormal, when there is a worsening of the conditions prior to admission, or when the patient is not hemodynamically stable.

[Ectopic breast tissue and a carcinoma in atypical positions]. / Ectopie mammarie e carcinomi in sede atipica.

AIM: The aim of the study was to considerate neoplams of ectopic breast tissue in particular concerning the diagnostic and surgical related problems, analysing our experience in this extremely rare pathology. MATERIALS AND METHODS: A group of five women affected by neoplasm of ectopic breast tissuehave been examinated, four of them in axillary breast tissue and the other one in parasternal area. They came to our clinical observation (UOC BCG 21, UOC BCG 27-Policlinico Umberto I,-Università "Sapienza" di Roma) between 2006 and 2008. All the patient underwent surgical intervention in our department. DISCUSSION: According to the literature we can assess that this is a rare pathology and so the diagnostic and surgical choices are different from case to case depending on the size, the localization , the local invasion. CONCLUSIONS: This rare pathology can occur in many different forms and areas. This fact makes impossible to create a guideline of diagnosis and treatment. This one must be acted in respect of radicality and when it is possible, of aesthetic criteria.

Outpatient experimental treatment for uncomplicated perianal fistulas.

Driven by the necessity of reducing in-hospital time of patients and the number of patients to treat in day surgery, the authors developed an experimental outpatient treatment for uncomplicated perianal fistulas, which, applied on selected cases, seems to offer encouraging prospects.

Cystic hygroma of the breast: a rare lesion.

Lymphangiomas are congenital malformations of lymphatic vessels. More than 50% of these lesions are present at birth; 90% are diagnosed by the age of 2. These lesions do not expand very rapidly but they tend to infiltrate surrounding tissues; their degeneration into malignant tumors is an extremely rare occurrence. They are mostly located in the neck region and the axilla; breast lymphangioma is very rare. Surgery is usually performed for aesthetic reasons and in order to make a differential diagnosis with other, more common lesions. The surgical procedure involves the excision of the mass; other methods, such as radiotherapy and sclerotherapy, have proved to be completely ineffective.

Inflammatory breast cancer.

The very original definition of carcinomatous mastitis suggests the main diagnostic difficulty of this onchologic condition. Actually it is more correctly appointed as inflammatory breast cancer, because notwithstanding the inflammatory appearance, it is a true systemic breast cancer, for which surgery represents an only marginal treatment resource. If is now well known that radical mastectomy is ineffective and only a combination of CT and RT offers survival results of some value. But the actual correct multi modal treatment cannot be undertaken if not after a correct diagnostic confirmation, avoiding an anti-inflammatory therapeutic attempt that is time consuming and possibly deceptive. Surgery and histology can be the only means of a correct diagnosis when FNAB is falsely negative, but the lymph nodes must be the preferential tissue to examinate to avoid long lasting drainage from the breast parenchyma after a biopsy, that delays the beginning of the true treatment.

Nipple-sparing Mastectomy in Patients with Preoperative Diagnosis of Non-invasive Breast Carcinoma. A Single-center Experience.

BACKGROUND: Nipple-sparing mastectomy (NSM) is a recognized treatment for selected patients with breast cancer (BC). Our study aimed to analyze 7 years' experience in NSM and breast reconstruction for patients with preoperative diagnosis of non-invasive BC. PATIENTS AND METHODS: All NSMs with breast reconstruction, performed between January 2007 and December 2013 in patients with preoperative diagnosis of non-invasive BC, were considered. RESULTS: Thirty-five NSMs were performed, 23 cases confirming the diagnosis of non-invasive BC, and in 12 patients it also resulted in findings of an invasive component. Patients were stratified into two groups: breast reconstruction was performed i) with silicone definitive implant, ii) with a temporary breast tissue expander. An invasive component at the postoperative histological examination was significantly associated with tissue expander reconstruction (p=0.03). CONCLUSION: In selected cases, NSM is a valid and safe procedure. Further critical evaluations are required for more evidence on this argument.

Oncoplastic central quadrantectomies.

Tumors localized in the central quadrant (centrally located breast tumors) have always represented a challenge for the surgeon because of the critical aesthetical matters related to the nipple-areola complex (NAC). Many years of experience with breast cancer patients treated by using various oncoplastic techniques, has allowed us to develop the modified hemibatwing for the treatment of central breast tumors, where the NAC is involved. Modified hemibatwing-along with the removal of the NAC-is a useful oncoplastic technique and it represents an ideal option for the treatment of central tumors because it assures oncological safety, a reduced surgical timetable and greater aesthetical results.

Wire-guided Localization in Non-palpable Breast Cancer: Results from Monocentric Experience.

BACKGROUND: Breast-conserving surgery (BCS) is considered the gold-standard treatment for early breast cancer. Ultrasound-guided percutaneous biopsy or stereotactic biopsy of a breast lesion allows preoperative histological diagnosis. Various techniques have been proposed for identifying non-palpable breast tumors, but the most popular method is the wire-guided localization (WGL) technique. The aim of this study was to propose an alternative technique for optimizing the WGL procedure, facilitating breast surgery and reducing complications. PATIENTS AND METHODS: We performed a prospective study on 40 patients with a single non-palpable breast lesion. For the preoperative localization of mammary lesions, patients were divided randomly into two groups: 20 patients underwent conventional WGL technique and 20 underwent 'optimized' personalized technique. RESULTS: In the group treated with the optimized technique, dislocation of the wire occurred in only 2/20 cases, whereas in those with the conventional technique, dislocation occurred in 9/20 cases (p=0.03). In 5/20 cases of the conventional WGL technique, the wire was accidentally cut by the surgeon, whereas no similar complications were observed in the group that underwent the optimized technique (p=0.047). Re-excision of the surgical margins was necessary in 6/20 cases with the conventional technique, while re-excision was not required for any case using the optimized technique (p=0.02). CONCLUSION: The proposed optimized technique ensures good esthetic results, enabling the surgeon to identify the lesion and perform oncoplastic breast surgery, and allows surgical time to be reduced.

A Randomized Pilot Study of Inositol in Association with Betaine and Boswellia in the Management of Mastalgia and Benign Breast Lump in Premenopausal Women.

Benign mammary lumps and mastalgia are the most common breast disorders; yet, there is no clear-cut consensus about the best strategy for their treatment. We hypothesized that a combination, including boswellic acid, betaine, and myoinositol, would be beneficial in breast disorders by exerting a pleiotropic effect on multiple pathways. Indeed, myoinositol has already been proven to modulate some factors involved in the genesis of breast diseases, such as fibrosis and metabolic and endocrine cues. In our study, 76 women were randomly assigned to either the experimental or the placebo arm. After six months of treatment, statistically significant differences between the two groups were recorded for pain relief (56% vs 17%) and breast density reduction (60% vs 9%). Furthermore, benign breast mass dimension showed a reduction in the experimental group (40% vs 16%). The combination of boswellic acid, betaine, and myoinositol has been demonstrated to be effective in the treatment of breast pain and radiologically and histologically confirmed benign breast mass and in the reduction of breast density, one of the pivotal risk factors for the development of breast cancer, without any side effects.

Breast Mondor's disease: Diagnosis and management of six new cases of this underestimated pathology.

Mondor's disease is an unusual and little-known pathology of the breast, characterized by superficial thrombophlebitis. The causes are still unresolved. Most of the patients do not fall under case studies of the scientific literature, given the reported incidence rate between 0.5% and 0.8%. The Mondor's disease patients are not always properly identified, and they are frequently treated as outpatients, even considering the benign course of the disease which often spontaneously resolves without any medical therapy. We report here six new cases of Mondor's disease, two of them were likely due to a trauma and were easily resolved with the use of non-steroidal anti-inflammatory drugs; the third one was apparently due to the stretching of the mammary veins in a patient with gigantomastia; the fourth one was subsequent to hormonal stimulation for in vivo fertilization and following gestation; and the last two cases (one was a man) were diagnosed after undergoing surgery for breast carcinoma.

Rare chondrosarcoma of the breast treated with quadrantectomy instead of mastectomy: A case report.

Breast chondrosarcoma is a rare sarcoma that mainly occurs in females >50 years old. To the best of our knowledge, only 16 cases were reported in the literature prior to 2013 and all patients were surgically treated by mastectomy, with or without lymphadenectomy, which was occasionally preceded by neoadjuvant chemotherapy. However, the literature does not report the benefit of mastectomy compared with a more conservative surgery. The present study reports a novel case of extraskeletal chondrosarcoma of the breast. A 63-year-old female patient presented with a neoplasm localized in the upper-outer quadrant of the right breast. The palpable lesion with sharp margins was a firm parenchymatous mass, which was confirmed by ultrasonography and mammography. The patient underwent conservative quadrantectomy instead of mastectomy, followed by post-surgical chemotherapy. A positron emission tomography scan performed five months subsequent to the surgery revealed no remnants of the disease. The patient underwent a strict clinical and instrumental follow-up, and two and half years after surgery, there are no signs of recurrent disease. In conclusion, the present case is currently one of the two cases in which a more conservative quadrantectomy was performed, instead of mastectomy. This surgical approach did not lead to metastasis and resulted in a good follow-up for the patient.

Schwannoma of the parotid gland. Case report.

Schwannoma is encapsulated benign tumors arising from nerve cell. Of which ancient schwannoma is one of five variants. Intraparotid facial nerve schwannoma is been documented sporadical throught the medical literature, althought a few ancient schwannomas have been reported in different locations in the head and neck region. In this report, a 31 year old man patient with an misunderstanding tumor of the parotid gland is described and the histopathologic exam was performed to diagnosed the schwannoma.

Typical and atypical lymphatic flows in breast carcinoma.

AIM: The study of sentinel lymph node has greatly increased the knowledge about lymphatic drainage in breast cancer. MATERIAL OF STUDY: The experience of 181 patients operated for breast carcinoma in the last two years, of which 70 undergoing SLN biopsy, allowed us to highlight some peculiarities of lymphatic drainage of the breast and led us to physiological and pathological considerations about lymphatic flow in patients for breast carcinoma. We studied patients undergoing lymphoscintigraphic mapping with SLN biopsy who were candidates for breast cancer surgery. RESULTS: Searching for SLN's location, we found that in 88.6% cases the SLN was at level I, in 8.6% it was at level II, in no case it was at level III and in 2.8% we found lymphatic drainage to the contralateral axilla. DISCUSSION: Thanks to this dynamic study we were able to highlight a preferential subcutaneous lymphatic path from the breast parenchyma reaching the contralateral axilla, crossing anteriorly the thorax. Literature review showed CAM incidence ranges from 3.6% to 6% and can be caused by occult primary cancer of the contralateral breast, contralateral spread of breast cancer and presence of another kind of tumor. CONCLUSIONS: The presence of contralateral axillary metastasis, although known, allowed us to scintigrafically document (for the first time) the pathway of an alternative lymph flow and to suppose the possible causes. Thanks to this observation, considerations can be drawn about clinical, pathophysiological and oncological implications, with an impact on post-operative follow-up.

Peliosis hepatis: Personal experience and literature review.

Peliosis hepatis (PH) is a disease characterized by multiple and small, blood-filled cysts within the parenchymatous organs. PH is a very rare disease, more common in adults, and when it affects the liver, it comes to the surgeon's attention only in an extremely urgent situation after the lesion's rupture with the resulting hemoperitoneum. This report describes the case of a 29-year-old woman affected by recurring abdominal pain. Computed tomography scans showed a hepatic lesion formed by multiple hypodense areas, which showed an early acquisition of the contrast during the arterial phase. Furthermore, it remained isodense with the remaining parenchyma during the late venous phase. We decided on performing a liver resection of segment VII while avoiding a biopsy for safety reasons. The histopathologic examination confirmed the diagnosis of focal PH. PH should always be considered in the differential diagnosis of hepatic lesions. Clinicians should discuss the possible causes and issues related to the differential diagnosis in addition to the appropriate therapeutic approach. The fortuitous finding of a lesion, potentially compatible with PH, requires elective surgery with diagnostic and therapeutic intents. The main aim is to prevent the risk of a sudden bleeding that, in absence of properly equipped structures, may have a fatal outcome.

Adjuvant Ovarian Suppression, High-dose Chemotherapy and Immunotherapy for Premenopausal Patients with High-risk Breast Cancer.

BACKGROUND: Premenopausal patients with breast cancer and more than 10 positive axillary nodes (BC>10) have a poor prognosis: In these patients the best adjuvant therapy (CT) has not yet been established. PATIENTS AND METHODS: Forty-two BC>10 received, in sequence, the following adjuvant treatments: luteinizing hormone releasing hormone (LH-RH) analog for 5 years; anthracycline-based induction chemotherapy; radiation therapy; platinum-based high-dose CT, with autologous bone marrow transplantation; immunotherapy with interleukin 2 (IL2) and 13-cis retinoic acid (RA); anastrazole given 5 years to estrogen receptor-positive patients. Primary endpoints of the study were disease-free survival (DFS) and overall (OS) survival. A secondary endpoint was toxicity. RESULTS: The median age of patients was 41 years, and the mean number of positive axillary nodes was 14. Estrogen and progesterone receptors were positive in 57% and 29% of patients respectively, while 14% of patients had triple-negative disease. With a median follow-up of 120 months for patients remaining alive at the end of study, median DFS and OS, had not yet been reached. The 20-year DFS and OS rates were 63.8%, and 81.6%, respectively. One to two years after the end of the therapy, three patients had had four full-term pregnancies. CONCLUSION: Treatment with LH-RH analog, high-dose CT, peripheral blood progenitor cells and IL2 with RA for patients with BC>10 is feasible, has moderate toxicity, while preserving ovarian function, seems to improve the expected DFS and OS for these high-risk patients.