[Non-recurrent inferior laryngeal nerve: anatomy, frequency and surgical considerations]. / Il nervo laringeo inferiore non ricorrente: anatomia, incidenza e considerazioni chirurgiche.

AIM: Systematic exposure and isolation of the inferior laryngeal nerve in thyroid surgery is a secure method to prevent complications. The knowledge of the nerve anatomy and its anomalies is essential to reduce laryngeal nerve injuries. By a re-examination of literature we underline the importance and some particular anatomical aspects of the anomalies which, even if rare, present an incidence of about 1%. METHODS: From January 1995 to December 2002 in our hospital we performed 299 interventions for thyroid diseases: total thyroidectomy (254 cases), partial thyroidectomy (45 cases). In 2 cases we observed a high variant (type I) of non recurrent laryngeal nerve. RESULTS: The global incidence of non recurrent laryngeal nerve was 0.66% (2/299 operations) and 0.72% if we consider the explorations of the cervical right side (2/274) where this anomaly is more frequent. The incidence of nerve injuries was 2/299 (0,66%); we had no complications in the 2 cases of non recurrent nerve observed. CONCLUSIONS: Our experience in thyroid surgery confirms the common opinion that only the knowledge of the laryngeal nerve anatomy and the awareness of its anomalies, associated to the systematic exposure of the nerve during surgery can prevent surgical injuries.

Bowel obstruction after biliopancreatic diversion: a deceptive complication.

BACKGROUND: Although obesity surgery is now practiced in most of the world, many general surgeons, faced with an emergency, are not experienced in the diagnostic problems associated with these techniques, or about the most suitable treatment to resolve the acute pathology while preserving the weight loss. The biliopancreatic diversion (BPD), because of its complexity, could cause a delay in the diagnosis and therapy, with possible catastrophic consequences for the patient. METHODS: We report 3 patients with bowel obstruction after BPD. In the first patient intestinal occlusion was due to an adhesion obstructing the alimentary tract; in the other two patients the occlusion was localized to the biliopancreatic tract, due to a serrate stenosis of the entero-entero anastomosis in one patient and due to volvulus of the biliopancreatic loop in the other patient. RESULTS: Signs and symptoms were different according to whether the obstruction was in the alimentary tract or the biliopancreatic tract. In all cases a prompt gastrointestinal x-ray with barium and ultrasound scan and/or CT scan induced us to a mandatory laparotomy with resolution of the obstruction. CONCLUSIONS: After BPD, diagnosis of an intestinal obstruction must be made promptly. Even colleagues who express doubts must be persuaded to perform immediately an upper gastrointestinal tract x-ray and an U/S or CT scan. In this way, it may be possible to avoid intestinal resection and catastrophic complications.

Severe recurrent ureteral stricture: the combined use of an anterograde and retrograde approach in the prone split-leg position without X-rays.

We report on a 50-year-old woman first treated by us in 1990 for uroseptic fever. Urography showed occlusion of the terminal tract of the lower third of the left ureter. The patient was submitted to successful left ureteroneocystostomy (UNCS). Three months later, she had a relapse of uroseptic fever, and urography showed right ingravescent dilation and excellent functional activity of the left urinary tract. Right UNCS was performed. A further relapse on the right side was again treated with UNCS and psoas-hitch bladder, but both the dilation and the occlusion persisted. Considering the state of the patient, and in order to remove the right nephrostomy that had been applied in the meantime, and to reduce the state of inflammation in view of further surgery, it was decided to treat the right ureteral total stenosis with ureteroscopic resection through the ureter facilitated by an other luminous flexible ureteroscope inserted upstream via nephrostomy. This technique is based on concepts searching for stenotic ureteral zones in transplanted kidneys, with the help of an adequate luminous catheter. An X-ray follow-up 9 months later evidenced that the maneuver was totally successful.

Neo-adjuvant organ-preserving chemotherapy in the management of locally advanced oral cavity and oropharynx cancer.

We designed an open, non-randomized clinical study to assess as the first endpoint the feasibility of sparing surgery and of preserving organ/function by using neo-adjuvant chemotherapy (NAG) in oral cavity and oropharynx cancer patients, and, as the second endpoint, the clinical response to this treatment approach and its duration. Moreover, an attempt was made to scale the extent of surgery by means of an Arbitrary Scale assigning different percentages to the different extents of surgical resection. Twenty-five patients with primary oral cavity and oropharynx cancer (stage III-TV) were enrolled in the study and were assigned to either the classical Al-Sarrafs regimen (1) (n=15) or to a regimen (2) consisting of cisplatin 80 mg/m(2) i.v. on day 1, 5-FU 600 mg/m(2) on days 2-5 and vinorelbine 20 mg/m(2) on days 2 and 8 (n=10). The 25 patients were all evaluable for response to NAC and 20 of them were evaluable for organ preservation. The overall response (OR) rate was 86.6% (13/15 patients) for regimen 1 (cisplatin + 5-FU) and 80% (8/10 patients) for regimen 2 (cisplatin + 5-FU + vinorelbine). The median follow-up duration was 20.6 months. 5/20 (25%) patients completely avoided surgery, 5/20 (25%) patients had a reduced extent of surgical resection, while: 10/20 (50%) patients received the previously planned surgical resection. Altogether, 10/20 (50%) patients treated with NAC either avoided or achieved a reduction in the previously planned surgical resection. Moreover, organ function was evaluated to support the assessment of treatment outcome in our patients. For this purpose we selected the Performance Status Scale for Head and Neck Cancer Patients: as expected, no significant impairment was detected in the area of comprehensibility of speech, but we were rather surprised that no significant impairment was found in the two areas of eating in public and normalcy of diet. NAG-associated toxicity was moderate and similar in the two chemotherapy regimens. The most relevant contributions offered by our study are represented by i) a Scale aimed at measuring as precisely as possible the reduction of surgical resection made possible by NAC compared to surgery planned before NAC and ii) an attempt to support the results with an assessment of treatment outcome.

Neo-adjuvant (primary) organ-preserving chemotherapy in the management of locally advanced laryngeal carcinoma.

We designed an open, non-randomized, phase II clinical study to assess as the first endpoint the feasibility of sparing surgery and of preserving organ/function by using neoadjuvant chemotherapy (NAC) laryngeal cancer patients, and, as the second endpoint, the clinical response to this treatment approach and its duration. 32 patients with primary laryngeal cancer (stage III-IV) were enrolled in the study and were assigned to either the classical Al-Sarrafs regimen (20 patients) or to a regimen consisting of cisplatin 80 mg/m(2) i.v. on day 1, 5-FU 600 mg/m(2) on days 2-5 and vinorelbine 20 mg/m(2) on days 2 and 8 (12 patients). The patients were divided into 2 groups: A) those requiring total laryngectomy (TL) and B) those not requiring TL, i.e. patients eligible for conservative for conservative surgery. The 32 patients were all evaluable for response to NAC and 31 were evaluable for The complete remission rate was 50% (16/32) and the partial remission rate was 46.9% (15/32) with an overall response rate of 96.9%. The median follow-up duration was 20.2 months. Overall, 23 patients required TL (group A) and 8 patients a conservative laryngectomy (group B). 7/23 (30.5%) patients of group A did not undergo surgery (score 4) and 6/23 (26%) achieved a partial larynx preservation (3/23 score 3, 1/23 score 2, 2/23 score 1), while 10/23 (43.5%) received the previously planned TL (score 0). 5/8 (62.5%) patients of group B did not undergo surgery, whereas 3/8 (37.5%) received the previously planned surgery (score 0). Therefore, 12/31 patients (38.7%) completely avoided surgery and 6/31 (19.4%) achieved a reduction in the extent of planned surgical resection, that is 18/31 patients (58.1%) achieved a reduction in the extent of previously planned surgery attributable to NAG. Moreover, 3/31 patients underwent the previously planned conservative surgery consisting of H-SGL/HG. Altogether 21/31 (67.7%) patients preserved function. The most relevant contributions offered by our study are represented by i) a scale aimed at measuring as precisely as possible the reduction of surgical resection made possible by NAC compared to surgery planned before NAC and ii) by an attempt to support the results with an assessment of patients treatment outcome. Although the scale provided by us is an arbitrary one, it must be emphasized that our goal was to address the issue of quality of life in cancer patients by a more precise quantification of organ/function preservation.

[The immunological assessment of a combined therapeutic approach (chemo- + radiotherapy +/- surgery) including immunotherapy in neoplasms of the head and neck area at an advanced stage]. / Valutazione immunologica di un approccio terapeutico combinato (chemio + radioterapia +/- chirurgia) includente l'immunoterapia nelle neoplasie del distretto cervico-facciale in stadio avanzato.

Fourty-eight patients entered the study, 37 of whom were evaluable, who underwent a nonrandomized combined modality approach plus a randomized immunotherapy treatment assigning the patients to one of the three arms: 1) thymostimulin, 2) beta IFN, 3) thymostimulin + beta IFN. The patients enrollment started in May 1991 and was closed in February 1993: the final evaluation was in February 1994. An immunological evaluation was made for all patients enrolled. The immunological assessment confirms some previous reports, such as the defective proliferative response of PBMC, the high serum level and the low production in culture of soluble IL 2 receptor (s IL 2 R), the low serum level and the low production of IL 2, and moreover shows new data. It is noteworthy that the significant increases--especially for cytokines and s IL 2 R, except for IL 1 alpha which has decreased, both for serum levels and for culture production--are induced by treatment with beta IFN (or with thymostimulin + beta IFN), suggesting that beta IFn is the immunologically effective moiety.

Cytotoxic activity of some gold(III) complexes.

The [Au(N-MeIm)Cl3], [Au(2-MeBO)Cl3] and [Au(2,5-diMeBO)Cl3] complexes (where N-MeIm = N-methylimidazole, 2-MeBO = 2-methylbenzoxazole and 2,5-diMeBO = 2,5-dimethylbenzoxazole), had been previously prepared and characterized by the Author. These compounds, when tested in vitro against murine leukemia cell lines L1210, human ovarian carcinoma A2780 and their sublines L1210/CDDP and A2780/CDDP resistant to cisplatin, in comparison with cisplatin and carboplatin, showed an interesting cytotoxicity, extended to resistant sublines.

[Fentanyl prevents the pain at the site of propofol injection]. / Il fentanyl previene il dolore nella sede di iniezione del propofol.

The effect of fentanyl, administered immediately before propofol, when pain is experienced at the site of propofol injection was studied in 28 children undergoing elective surgery. The intravenous administration of fentanyl (2 micrograms/kg) significantly reduced such pain compared with a control group receiving saline. The results suggest that the administration of fentanyl may be a valid procedure in relieving pain on injection of propofol.

[Propofol and fentanyl in Sanfilippo disease. Surgical intervention with adenotonsillectomy]. / Propofol e fentanyl nella malattia di Sanfilippo. Intervento chirurgico di adenotonsillectomia.

An intravenous anesthesia with propofol and fentanyl was used for adenotonsillectomy in a child affected by mucopolysaccharidosis. This technique proved to be safe and convenient without peri- and postoperative complications.

[Radiosensitivity of lymphocyte subpopulations in subjects with systemic lupus erythematosus. An in vitro preliminary study]. / Radiosensibilità delle sottopopolazioni linfocitarie in soggetti affetti da lupus eritematodes sistemico. Studio preliminare "in vitro".

The Authors have studied the radiosensitivity of lymphocyte cultures of patients affected by systemic lupus erythematosus in the active phase, and in the remissive phase after treatment with cyclosporine and fluocortolone, compared to a group of normal subjects. Total lymphocyte cultures and cultures of T, B, NK lymphocytes, T helper/inducer and T suppressor cytotoxic obtained with specific monoclonal antibodies were used and then irradiated with Co-60 gamma photons at scale doses between 0 and 10 Gy. Damage due to irradiation was evaluated using 3H-TdR. Patients in the clinically active phase of the disease showed an increased lymphocytic sensibility of the total lymphocytic population as well as of the various populations and T subpopulations studied. Radiosensitivity tended to become normal in patients in the remissive phase of the disease. The Authors conclude that a preliminary study of the lymphocytic sensitivity should be carried out in all patients treated with radiotherapy with autoimmune pathologies in order to avoid damages due to irradiation. Moreover, the Authors retain that a test for lymphocytic sensitivity to radiation could apply with regard to the evaluation of the clinical remissive conditions of patients affected by systemic lupus erithematosus.

[Antibiotic prophylaxis with netilmicin in patients undergoing cystoscopic study]. / Antibiotico-profilassi con netilmicina in pazienti sottoposti ad indagine cistoscopica.

Thirty adults of either sex, in several cases affected by severe urinary pathology, underwent check cystoscopy. An intramuscular injection of netilmicin 200 mg was administered one hour before the diagnostic procedure as antibiotic prophylaxis. Treated patients were controlled up to three months after cystoscopy, in order to verify the presence of urinary infections. Data obtained proved the efficacy of netilmicin in preventing postcystoscopy urinary infections in 87% of the cases. Safety was very good in all patients.

Peripheral blood lymphocyte response to exogenous interleukin 2 by PHA-prestimulated and non-PHA-prestimulated cells in patients with cancer.

The study aims were to assess the response of peripheral blood lymphocytes (PBL) of cancer patients to exogenous Interleukin 2 (IL 2) either by PHA-prestimulated or non PHA-prestimulated PBL, and to carry out preliminary experiments for a direct quantitative evaluation of endogenous IL 2 production by PBL cultures of cancer patients in order to define the actual role of IL 2 in the disease. Analysis of PBL subsets was also carried out with monoclonal antibodies in a selected group of patients. A total of 134 patients entered the study. Cancer sites were: larynx 32, breast 36, lung (NSC) 24, colorectal 17 and gynecologic 25. In the former 3 cancer sites staging showed localized or only locally advanced disease, and in the last 2 sites disseminated disease. Our results provided evidence that cancer patients exhibit a T-cell functional immunodepression, which progresses during tumor growth, so that the localized disease shows a low-grade defect, and advanced disease a high-grade defect. Our data also clearly suggested that the factor involved with a primary role in this functional immune impairment is the IL 2 deficiency. A perspective may be drawn on the therapeutic administration in vivo of IL 2 and IL 2-activated lymphokine-activated killer cells in controlled clinical trials of selected groups of cancer patients.

Radiosensitization by tinidazole: pharmacokinetic study.

In previous study on cell-cultures, the authors have proved that tinidazole had radiosensitizing properties on hypoxic cells similar to those of metronidazole. The radiosensitizing activity of tinidazole becomes useful in vitro using a concentration of 1 millimol. The purpose of this study was to determine the dose of tinidazole necessary to produce a useful radiosensitizing effect in patients cured by radiotherapy. The pharmacokinetic properties of tinidazole were studied by treating patients with 1.5-3-4.5 g of the drug per day, using single doses for two consecutive days. The plasma concentration was determined by 15 series samples during a period of 48 h. Moreover endotumoural concentrations of tinidazole were studied in a group of patients using high pressure liquid chromatography techniques. The results showed that a dose of 4.5 g of tinidazole was sufficient to reach plasmatic and endotumoural concentrations similar to those which provide a radiosensitizing effect in vitro with an enhancement factor ratio of approximately 1.5. The initial dose and the accumulation factor were also determined in order to maintain the above-mentioned concentrations for a time sufficient to be able to apply multiple daily fractions of radiotherapy. The tolerance of the drug throughout the study was excellent.

Necrotizing emphysematous pyelonephritis: a case report.

Emphysematous pyelonephritis (EP) is comparatively rare in urological practice. From 1898 to the present time only 45 cases have been described. In this report we describe the case of a 43-year old diabetic man, with right EP without obstruction of the urinary tract and with a urinary infection of E. Coli. This appears to be rather rare as it is more frequently associated with obstruction of the urinary tract. Surgical exploration enabled us to discover a fistula between the kidney and the wall of the vena cava which would have caused fatal complications if it had not been discovered. The micro-organisms more frequently involved were E. Coli, Proteus, Aerobacter and various anaerobes. Mortality has been reported as 75% in patients receiving medical therapy only and 23% in those undergoing surgery. The authors therefore believe that surgical exploration even with no urinary tract obstruction makes it possible to detect complicating pathologies which may remain undiscovered by medical examination and the urinary excretory tract and renal sheath drained. This provides a better opportunity of estimating possible reversibility of the renal lesion.

[Prognostic value of CEA in postoperative monitoring of colorectal cancers]. / Valore prognostico del CEA nel monitoraggio post-operatorio dei carcinomi del colon-retto.

The prognostic value of CEA for the purposes of postoperative monitoring assessed in 45 patients with cancer of the colon and rectum. Values were obtained 1-36 months after surgery in all operable cases. Means were also evaluated statistically at various follow-up times. In patients who relapsed, values stayed significantly higher for up to 6 months after surgery than in those who did not. Cockran's method showed that the prognostic significance of this difference 6 months after surgery was p less than 0.05.

Evaluation of the specificity of the leukocyte migration inhibition test against histologically homologous and heterologous neoplastic antigens in cancer patients.

The aim of the present study was to verify whether the CMI response of the host's lymphocytes is directed towards tumor-associated antigens (TAA) specific for each histological type of tumor. The leucocyte migration inhibition (LMI) test was selected for this purpose, utilizing the cancer patients' leucocytes and, as neoplastic antigens, formalin-fixed cells of surgically removed cancer tissue. Two hundred and eighteen patients were studied, 110 of whom were affected by breast cancer, 48 by digestive tract and 60 by laryngeal cancer. The total amount of tests performed was 278. The leucocytes of 93 normal subjects were tested against the different tissues' cancer antigens, as were the leucocytes of 41 patients with cancer of different organs tested against the corresponding normal tissues' antigens. The breast cancer patients (122 tests performed) showed 82.35% positive tests against homologous antigen, 72.72% and 95.24% against heterologous (digestive tract and laryngeal cancer, respectively) antigens. The digestive tract cancer patients (69 tests performed) showed 70.27% positive tests against homologous, 66.66% and 43.48% against heterologous antigens (breast and laryngeal cancer respectively). The laryngeal cancer patients (87 tests performed) showed 74.29% positive tests against homologous, 38.10% and 80.65% against heterologous antigens (breast and digestive tract, respectively). The results led to the conclusion that the LMI test response of cancer patients was not "tissue specific": the test did not discriminate between the homologous and the heterologous cancer antigens, and it seems that the response was not directed towards specific TAA but only towards wide-range or "group" TAA, showed by several types of tumors.

Response to neoplastic antigens in human oncology: assessment and results of LIF (leucocyte inhibitory factor) test in breast cancer patients.

The leucocyte inhibition factor (LIF) test, revealing the inhibition of leucocyte migration from capillary tubes, was studied with leucocytes from 47 patients with breast cancer, from 14 patients with benign breast tumors, and from 56 normal subjects. As antigens we used formalin-fixed tumor cells. The LIF assay was positive in 38/47 (80.8%) breast cancer patients, in 10/14 (71.4%) benign breast tumor patients, and in 13/56 (23.2%) normal subjects. The negative LIF assays were higher with leucocytes from patients with metastases than with those from patients with no metastases. We found no correlation between the LIF-test response and the histopathologic pattern of the tumors, type of treatment (almost always surgical), and remission or relapse state of our patients at the time of testing.