Automated tru-cut imaging-guided core needle biopsy of canine orbital neoplasia. A prospective feasibility study.

The purpose of this study was to evaluate the diagnostic value of imaging-guided core needle biopsy for canine orbital mass diagnosis. A second excisional biopsy obtained during surgery or necropsy was used as the reference standard. A prospective feasibility study was conducted in 23 canine orbital masses at a single centre. A complete ophthalmic examination was always followed by orbital ultrasound and computed tomography (CT) examination of the head. All masses were sampled with the patient still on the CT table using ultrasound (US) guided automatic tru-cut device. The most suitable sampling approach to the orbit was chosen each time based on the CT image analysis. One of the following different approaches was used: trans-orbital, trans-conjunctival or trans-masseteric. In all cases, the imaging-guided biopsy provided a sufficient amount of tissue for the histopathological diagnosis, which concurred with the biopsies obtained using the excisional technique. CT examination was essential for morphological diagnosis and provided detailed topographic information that allowed us to choose the safest orbital approach for the biopsy. US guided automatic tru-cut biopsy based on CT images, performed with patient still on the CT table, resulted in a minimally invasive, relatively easy, and accurate diagnostic procedure in dogs with orbital masses.

Tumourigenic non-small-cell lung cancer mesenchymal circulating tumour cells: a clinical case study.

BACKGROUND: Over the past decade, numerous reports describe the generation and increasing utility of non-small-cell lung cancer (NSCLC) patient-derived xenografts (PDX) from tissue biopsies. While PDX have proven useful for genetic profiling and preclinical drug testing, the requirement of a tissue biopsy limits the available patient population, particularly those with advanced oligometastatic disease. Conversely, 'liquid biopsies' such as circulating tumour cells (CTCs) are minimally invasive and easier to obtain. Here, we present a clinical case study of a NSCLC patient with advanced metastatic disease, a never smoker whose primary tumour was EGFR and ALK wild-type. We demonstrate for the first time, tumorigenicity of their CTCs to generate a patient CTC-derived eXplant (CDX). PATIENTS AND METHODS: CTCs were enriched at diagnosis and again 2 months later during disease progression from 10 ml blood from a 48-year-old NSCLC patient and implanted into immunocompromised mice. Resultant tumours were morphologically, immunohistochemically, and genetically compared with the donor patient's diagnostic specimen. Mice were treated with cisplatin and pemetrexed to assess preclinical efficacy of the chemotherapy regimen given to the donor patient. RESULTS: The NSCLC CDX expressed lung lineage markers TTF1 and CK7 and was unresponsive to cisplatin and pemetrexed. Examination of blood samples matched to that used for CDX generation revealed absence of CTCs using the CellSearch EpCAM-dependent platform, whereas size-based CTC enrichment revealed abundant heterogeneous CTCs of which ∼80% were mesenchymal marker vimentin positive. Molecular analysis of the CDX, mesenchymal and epithelial CTCs revealed a common somatic mutation confirming tumour origin and showed CDX RNA and protein profiles consistent with the predominantly mesenchymal phenotype. CONCLUSIONS: This study shows that the absence of NSCLC CTCs detected by CellSearch (EpCAM(+)) does not preclude CDX generation, highlighting epithelial to mesenchymal transition and the functional importance of mesenchymal CTCs in dissemination of this disease.

MULTIDETECTOR COMPUTED TOMOGRAPHIC AND LOW-FIELD MAGNETIC RESONANCE IMAGING ANATOMY OF THE QUADRIGEMINAL CISTERN AND CHARACTERIZATION OF SUPRACOLLICULAR FLUID ACCUMULATIONS IN DOGS.

Focal fluid accumulations in the supracollicular region are commonly termed quadrigeminal cysts and may be either subclinical or associated with neurologic deficits in dogs. Little published information is available on normal imaging anatomy and anatomic relationships for the canine quadrigeminal cistern. Objectives of this observational, cross-sectional study were to describe normal quadrigeminal cistern anatomy and determine the prevalence and characteristics of supracollicular fluid accumulations in dogs. Normal descriptions were accomplished using computed tomographic (CT) cisternography in one canine cadaver, and CT and magnetic resonance imaging (MRI) studies of the brain in four prospectively recruited dogs with no evidence of intracranial disease. Prevalence and characteristics descriptions were accomplished using a retrospective review of brain CT or MRI studies performed during the period of 2005-2015. The normal quadrigeminal cistern consistently exhibited a complex H shape and was separated from the third ventricle by a thin membrane. Prevalence of supracollicular fluid accumulations (SFAs) was 2.19% among CT studies (n = 4427) and 2.2% among MRI studies (n = 626). Dogs with SFA were significantly younger than control dogs (P < 0.0001). Shih-tzu (OR = 111.6), Chihuahua (OR = 81.1), and Maltese (OR = 27.6) breed dogs were predisposed (P < 0.0001). Among dogs with SFAs, the following three patterns were defined: (1) third ventricle (49.54%), (2) quadrigeminal cistern (13.51%), and (3) both third ventricle and quadrigeminal cistern (36.93%). Authors recommend that the term supracollicular fluid accumulation (SFA) should be used rather than the term quadrigeminal cyst to describe these focal fluid accumulations in dogs.

Effects of immobilization and remobilization on the ankle joint in Wistar rats

A sprained ankle is a common musculoskeletal sports injury and it is often treated by immobilization of the joint. Despite the beneficial effects of this therapeutic measure, the high prevalence of residual symptoms affects the quality of life, and remobilization of the joint can reverse this situation. The aim of this study was to analyze the effects of immobilization and remobilization on the ankle joint of Wistar rats. Eighteen male rats had their right hindlimb immobilized for 15 days, and were divided into the following groups: G1, immobilized; G2, remobilized freely for 14 days; and G3, remobilized by swimming and jumping in water for 14 days, performed on alternate days, with progression of time and a series of exercises. The contralateral limb was the control. After the experimental period, the ankle joints were processed for microscopic analysis. Histomorphometry did not show any significant differences between the control and immobilized/remobilized groups and members, in terms of number of chondrocytes and thickness of the articular cartilage of the tibia and talus. Morphological analysis of animals from G1 showed significant degenerative lesions in the talus, such as exposure of the subchondral bone, flocculation, and cracks between the anterior and mid-regions of the articular cartilage and the synovial membrane. Remobilization by therapeutic exercise in water led to recovery in the articular cartilage and synovial membrane of the ankle joint when compared with free remobilization, and it was shown to be an effective therapeutic measure in the recovery of the ankle joint.

Adipose tissue displays trophic properties on normal lung cellular components without promoting cancer cells growth.

Surgical removal is the mainstay for early lung cancer treatment and persistent air leaks represent one of the most common clinical complications after lung surgery. Adipose tissue transplantation has been proposed as a new strategy for regenerative therapy after breast cancer surgery; however its efficacy and safety of lung tissue healing after lung resections are unknown. The purpose of this study was to test the biological activity of adipose tissue to facilitate lung tissue healing and evaluate its effect on cancer cells growth, thus providing insight for a possible clinical application. Different in vitro cellular models were used to prove the potential biologic effect of autologous fat tissue (AFT) in repairing injured lung tissue, and in vivo xenograft models were used to evaluate tumor promoting potential of AFT on putative residual cancer cells. Treatment of both embryonic (WI-38) and adult lung fibroblasts and of normal bronchial epithelial cells (HBEC-KT) with AFT samples, harvested from subcutaneous tissue layer of 20 patients undergoing pulmonary metastasectomy, improved wound healing and cell proliferation indicating a trophic effect on both mesenchymal and epithelial cell types. Conversely AFT-conditioned medium was unable to stimulate in vitro proliferation of a lung adenocarcinoma reporter cellular system (A549). Moreover, co-injection of AFT and A549 cells in nude mice did not promote engraftment and progression of A549 cells. These preclinical findings provide preliminary evidence on the potential efficacy of AFT to accelerate lung tissue repair without undesired tumor promoting effects on putative residual cancer cells.

Evaluation of rats´ soleus muscle submitted to remobilization protocol with therapeutic ultrasound associated with static stretching

Despite the deleterious effects, immobilization, is still often used in the treatment of musculoskeletal disorders, even with the occurrence of muscular atrophy, its reversal is a major challenge to rehabilitation. The aim of this study was evaluate the tropism of rats soleus muscle submitted to remobilization with static stretching, preceded by ultrasound, thermal and non thermal. We used 28 rats divided into four groups: G1‑immobilized and remobilized with static stretching, G2-remobilized with stretching preceded by ultrasound 1.0 W.cm–²; G3 – ultrasound at 0.5 W.cm–² , G4 – ultrasound with 0.2 W.cm–². All animals were immobilized in plantarflexion, producing shortening of the right soleus muscle for 15 days. For the groups subjected to remobilization with ultrasound doses were used according to the group, for 3 minutes, for 10 days with an interval of 2 days after the 5th treatment. After treatment with ultrasound (or not for the G1), the animals were subjected to 3 sets of 30 seconds, with 30 seconds interval between them, of static stretching of the soleus. The soleus were dissected, weighed and processed for preparation of histological slides in cross section, and evaluated the smallest diameter of 100 fibers per muscle. There was significant reduction in weight between left and right muscles in all groups, for diameters G3 showed no difference. Conclusion: stretching with or without ultrasound, was unable to reverse the deleterious effects of immobilization on muscle weight, but in the mean dose there was protective effect on the diameter of the fibers.

A huge ovarian cyst in a hysterectomized bitch.

A 11-year-old, spayed, female mixed breed-dog was presented with an abdominal mass that was detected 1 month ago. Upon abdominal palpation a large, firm, oval shaped, movable mass was found in the mid-abdominal region. Survey radiograph of the abdomen demonstrated an oval soft tissue dense mass located on the right side of the abdominal cavity. A large, heteregenous and cystic mass with solid components occupying the majority of the abdomen and a small, cystic mass with solid components caudal to the left kidney were identified by transabdominal ultrasonography. Computed tomography scans revealed bilateral ovarian masses, and a small volume of retroperitoneal fluid on the right side. A cystic, but otherwise solid mass located in the right ovary and small retained left ovary encapsulated in the ovarian bursa were excised surgically by midline laparotomy. Histopathological examination of the excised mass from the right side revealed a large cystic structure consistent with an ovarian cyst and multiple corpora lutea and follicles at different maturational stages were detected in the left ovary. The precise origin of the ovarian cyst could not be determined by morphological appearance. Immunohistochemical staining suggested a cyst of surface epithelial origin. At re-examination 6 months after the surgery, the bitch appeared healthy and the clinical findings were all normal. To our knowledge, the cyst described here is the largest reported in an incompletely ovariohysterectomized bitch.

Spectrum of paraneoplastic disease associated with lymphoma.

OBJECTIVE: To define the frequency and clinical and immunologic characteristics of patients affected by paraneoplastic neurologic syndromes (PNS) and lymphoma. METHODS: Patients fulfilling the criteria for PNS associated with lymphoma collected from the European Commission-funded PNS Euronetwork group database were analyzed. RESULTS: Fifty-three patients with Hodgkin lymphoma (HL) (24 patients, mean age 51, range 16-84) or non-Hodgkin lymphoma (NHL) (29 patients, mean age 64, range 31-82) and PNS were analyzed. The most commonly associated PNS was paraneoplastic cerebellar degeneration, present in 21 cases, with a higher prevalence in HL (16/24 cases). Peripheral nervous system (mainly demyelinating polyradiculopathies) and motor neuron involvement were more common in NHL. Onconeural antibodies were more frequent in patients with paraneoplastic cerebellar degeneration, most commonly against the Tr antigen. Fifty percent of the patients with PNS and HL responded to chemotherapy, whereas neurologic improvement was less frequent (24%) in patients with PNS and NHL. In both groups, the survival rate was good. Overall, 10 out of 53 patients eventually died, with only 2 patients (1 with HL, 1 with NHL) dying from PNS. CONCLUSIONS: PNS in patients with lymphoma are relatively rare. Paraneoplastic cerebellar degeneration, mainly associated with anti-Tr antibodies, is more prevalent in HL and NHL, followed in our study by motor neuron disease in patients with NHL. Involvement of the peripheral nervous system is heterogeneous, with a prevalence of polyradiculoneuritis in patients with NHL.

Low-level laser therapy, at 830 nm, for pain reduction in experimental model of rats with sciatica / Laser de baixa potência, 830 nm, na redução da dor em ratos submetidos à modelo experimental de ciatalgia

Chronic pain, resulting from nerve compression, is a common clinical presentation. One means of conservative treatment is low-level laser therapy, although controversial. The aim of this study was to evaluate the effects of two doses of low-level laser, at 830 nm, on pain reduction in animals subjected to sciatica. Eighteen rats were used, divided into three groups: GS (n=6), sciatica and simulated treatment; G4J (n=6), sciatica and treatment with 4 J/cm²; and G8J (n=6), sciatica and irradiation with 8 J/cm². The right sciatic nerve was exposed and compressed using catgut thread. Five days of treatment were started on the third postoperative day. Pain was assessed by means of the paw elevation time during gait: before sciatica, before and after the first and second therapies, and the end of the fifth therapy. Low-level laser was effective in reducing the painful condition.

A dor crônica, resultante de compressão nervosa, é uma apresentação clínica frequente. Um dos meios de tratamento conservador, é o laser de baixa potência, apesar de controvérsias. O objetivo do estudo foi avaliar os efeitos de duas doses de laser de baixa potência, 830 nm, na redução da dor em animais submetidos à ciatalgia. Foram utilizados 18 ratos, divididos em 3 grupos: GS (n=6) ciatalgia e simulado o tratamento; G4J (n=6) ciatalgia e tratado com 4 J/cm², G8J (n=6) ciatalgia e irradiado com 8 J/cm². O nervo isquiático direito foi exposto e realizada a compressão com fio catgut. No 3º dia pós-operatório, iniciou-se o tratamento, durante 5 dias. Verificou-se a dor, por meio do tempo de elevação da pata, na marcha: anterior à ciatalgia, pré e pós 1ª e 2ª terapias, e ao final da 5ª terapia. O laser de baixa potência foi eficaz na redução do quadro álgico.

Endoscopic transnasal surgical approach for monolateral myopic non-Graves' exophthalmos: a case report.

Transnasal endoscopic orbital decompression is emerging as a new minimally invasive technique that avoids the need for cutaneous or gingival incision. This surgical approach appears to be a safe and effective procedure, even for the treatment of ocular disease, and it can be performed under general or local anaesthesia. The authors present a case of severe monolateral non-Graves' axial exophthalmos, accompanied by severe anisometropic myopia, which was treated successfully with functional endoscopic sinus surgery. The minimally invasive surgical procedure resulted in a marked reduction of exophthalmos without any severe complications and with minimal discomfort for the patient, who was discharged from hospital on the fourth postoperative day.

External auditory canal atresia of probable congenital origin in a dog.

A nine-month-old Labrador retriever was referred to the Clinica Veterinaria Privata San Marco because of frequent headshaking and downward turning of the right ear. Clinical examination revealed that there was no external acoustic meatus in the right ear. Computed tomography confirmed that the vertical part of the right auditory canal ended blindly, providing a diagnosis of external auditory canal atresia. Cytological examination and culture of fluid from the canal and the bulla revealed only aseptic cerumen; for this reason, it was assumed that the dog was probably affected by a congenital developmental deformity of the external auditory canal. Reconstructive surgery was performed using a "pull-through" technique. Four months after surgery the cosmetic and functional results were satisfactory.

Laryngeal paraganglioma: an endoscopic diode-laser-assisted surgical approach: a case report.

Laryngeal paraganglioma is a rare vascular neuroendocrine benign tumour. Surgery is the standard treatment. The pre-operative gold standard is Magnetic Resonance Imaging with Gadolinum contrast. Computed tomography scans and angiography are also useful in making the diagnosis of paraganglioma before surgical intervention. A case of a large supraglottic paraganglioma is described. Complete excision of the tumour was achieved using microlaryngoscopical-laser surgical resection. No severe complications were observed. The patient was discharged from hospital without any complaints on the fourth post-operative day and she was disease-free 36 months after surgery. The effectiveness of this conservative endoscopic surgical procedure compared to the external approaches is discussed and it can be concluded that the endoscopic diode-laser resection of even extended laryngeal paraganglioma provides a good operative field and is a safe and effective technique.

Primary gastric histiocytic sarcoma in a dog--a case report.

A 12-year-old intact female mixed breed dog was presented for chronic, intermittent vomiting and diarrhoea. On endoscopic examination a protruding mass arising from the mucosal surface of the pyloric region was detected. Cytological and histological examination revealed an accumulation of pleomorphic round/oval phagocytic cells suggesting histiocytic origin. This was confirmed by immunohistochemistry. No extra-gastric involvement was detected on clinical examination or at necropsy. This is the first report of primary gastric histiocytic sarcoma in a dog.

Nutrition given to critically ill patients during high level/complex care (on Italian ICUs).

BACKGROUND & AIMS: Within a prospective study on costs in 45 Italian intensive units we reviewed nutrition support practice given during critical illness. METHODS: From June to October 1999, patients with an ICU stay longer than 47 h were studied. Nutrition (i.e. fasting, parenteral, enteral and mixed) and calorie supply by the enteral route were monitored during the first consecutive days (up to seven) of invasive support of organ failure (high-care). RESULTS: 388 patients received high-care for at least 1 day, 200 patients had seven consecutive high-care-days. Some form of nutrition was given in 90.7% of patients, 9.3% were never fed (25.8% of the cardiac patients). Parenteral nutrition was given in 13.9% of patients (78.9% of the abdominal surgery patients), 39.7% received only enteral nutrition, and 36.4% received mixed nutrition. Finally, 77.1% of the patients received nutrient by gut. Nutrition was given in 78.5% of 2115 collected days, 44.1% of the first high-care-days and 93.5% of the 7th days were positive for nutrition. Enteral calorie load on the first day was similar for enteral and mixed nutrition (range 8-14 kcal/kg), it was higher for exclusive enteral nutrition between the 4th and the 7th day (15-19 vs. 11-14 kcal/kg). It differed according to diagnosis group. CONCLUSIONS: In Italian ICUs, in complex critically ill patients, nutrition is consistently given in critical illness, gut is widely used except in abdominal surgery patients.

Giant osteoid osteoma of ethmoid sinus: role of functional endoscopic sinus surgery.

A case of giant ethmoid osteoma treated by functional endoscopic sinus surgery is described. The tumour was closely adherent to the surrounding anatomical structures--lamina papyracea, cribriform plate, spheno-ethmoidal recess--and protruded into the nasopharynx. Complete removal of the tumour, under general anaesthesia, using intranasal drill and diode L.A.S.E.R, was achieved. The principal aspects in favour of this surgical technique vs. open procedures (fronto-basal craniotomy, supraciliar and coronal approach) are discussed. Functional endoscopic sinus surgery is herewith concluded to be a convenient and safe technique with advantages over the open procedures, widely used in the past. The reduced morbidity, length of hospital stay and better cosmetic results are distinct advantages of this technique that has the potential to become the treatment of choice for selected ethmoid tumours, such as giant osteoma, described in the present report.

Use of sedative and analgesic drugs in the first week of ICU stay in high-level-of-care.

AIM: The aim of this study was to update the current practice of pharmacological sedation and analgesia in Italian intensive care units. DESIGN: observational, prospective, cohort study involving consecutive patients admitted during 5 months in 1999. PATIENTS were evaluated for the first 7 days of high-level-of care. SETTING: 45 adult general intensive care units. PATIENTS: 388 fulfilling enrollment criteria: admission diagnosis out of non-traumatic cerebral hemorrage, stroke, respiratory failure in chronic obstructive pulmonary disease (COPD), acute lung injury/distress syndrome (ALI/ARDS), polytrauma, head trauma, cardiac failure and major abdominal surgery; unit stay longer than 47 hours and high-level-of care treatment. RESULTS: Sedation pattern was different among diagnosis-groups. No therapy was registered in 18.8% of overall days in polytrauma vs 67.6% of cardiac patients. Opioids supply ranged from 10.1% of overall days of acute on COPD patients vs 51.4% of polytrauma patients. Propofol was the more prescribed drug, followed by opioids and benzodiazepines. Propofol was at the top in cerebrovascular disease, ALI/ARDS and COPD; opioids in abdominal surgery and trauma, benzodiazepines in cardiac failure. The average number of prescribed drugs per day was 1.5 ranging from 1.2 on COPD to 1.7 in head trauma. CONCLUSION: Diagnosis influences the pattern of sedation-analgesia during high-level-of-care period. Sedation prevalence is reasonably prescribed in trauma groups while it remains low in ALI/ARDS, post-operative, cerebrovascular, COPD and hearth failure. Particularly opioid use remains limited in post-operative patients. This surveys shows a poorly standardised sedation approach to the different phases of the therapy: induction, short and long-term sedation phase.

Improvement in the intestinal processes of hydroelectrolytic absorption and secretion in abdominal pathologies of surgical interest treated with SMS 201-995: experimental protocol.

The hypothesis that octreotide can improve the intestinal absorption and secretion processes in a mixed group of intestinal pathologies, and that this effect varies according to the pathology in question, was tested. One hundred and twenty Wistar rats were randomly assigned to six pathology groups consisting of three intestinal occlusions including (1) complete, (2) partial, and (3) complete with strangulation, and three mesenteric vascular occlusions including (4) partial permanent, (5) total permanent, and (6) total temporary. Each group contained ten control and ten treated rats. The treated animals received octreotide (100 microg/kg body weight) while the controls were given the same quantity of saline solution every 8 h. After the observation period, the contents of the small intestine were extracted and its volume measured before and after centrifugation; the concentration and total content of Na, K, Cl, and bicarbonate was then analyzed. Samples of all the intestines at specific distances from the lesion zone were treated and stained, and then evaluated according to a specific score to quantify the lesions. The concentration and contents of electrolytes in the intestine and its volume (before and after centrifugation) were lower in the treated animals, but varied according to the pathology. There was a nonadditive influence between the type of pathology and treatment for the four electrolytes and intestinal volume. The effects of the drug make it directly or indirectly possible to decrease the intestinal lesions to improve the absorption-secretion processes. Octreotide acts on intestinal secretion and absorption in all the pathologies analyzed except for total permanent intestinal ischemia. Its action also varies according to the type of pathology involved.

Diaminic carbonates, a new class of anti-inflammatory compounds: their biological characterization and mode of action.

Taking advantage of a standard assay on mouse LM cells (murine fibroblast-like cells), we found that several diaminic carbonates, a new class of organic compounds synthesized in our laboratories, were able to inhibit human tumor necrosis factor alpha (huTNFalpha)-induced cytotoxicity in a dose-dependent manner. Structure-function relationship studies indicated precise structural requirements for compounds being active as huTNFalpha inhibitors. ITF1779, one of the most active compounds in inhibiting huTNFalpha-induced cytotoxicity, was selected for further studies. In vitro experiments showed that ITF1779 inhibited not only huTNFalpha-induced cytotoxicity on LM cells but also another response of the same cells, interleukin-1-induced interleukin-6 production. Receptor-binding studies performed under nonequilibrium conditions and morphologic evidence of vacuole formation in cells treated with high concentrations of ITF1779 showed that the effects were strikingly similar to those of chloroquine, a lysosomotropic agent. Consistent with a mechanism of action of diaminic carbonates closely matching that of chloroquine are some structural similarities between the two classes of compounds, in particular their both being diprotic weak bases. Moreover, ITF1779 was shown to be active in vivo because it afforded protection against lipopolysaccharide-induced shock in mice, a systemic inflammatory response crucially dependent on tumor necrosis factoralpha production.

[Comorbidity and the physician's decision: the case of undertreatment in care of breast tumors]. / La comorbidità e l'agire medico: il caso degli ipotrattamenti nella cura del tumore della mammella.

When a physician has to come to a decision while caring for a given patient, he is supposed to take into account several kind of information related to the disease, illness or patients' personal characteristics. Although it is wellknown that the framework in which such decision has to be taken is complex, most of the scientific knowledge is based on pieces of evidence that derive from studies where complexity is avoided by applying restriction rules. The goal of this approach is to enhance the internal validity while preserving the generalizability of the findings. But in some cases this approach raises more doubts than certainty. It is the case of the process to assemble practice guidelines to reduce the gap between the best care and what is observed into practice using the available knowledge (i.e., available literature or experts' recommendations). As a variety of relevant clinical and patients' personal characteristics are not available at all or little is known on their impact on patients global health status, variables that actually do drive the practice are not included in guidelines that are intended to change it. This paper introduces the conceptual model of such debate and assesses the impact of co-morbidity--a variable seldom taken into account in effectiveness, quality and appropriateness studies- on the kind of medical care given to a sample of 1019 patients with early stage breast cancer. Empirical results and future implications are eventually discussed.

Inappropriate Halsted mastectomy and patient volume in Italian hospitals.

To study whether Halsted mastectomy was used only when properly indicated, a prospective survey was undertaken on the process of care of 985 breast cancer patients seen consecutively at 62 general hospitals in Northern and Central Italy. Overall, 79% of Halsted mastectomies were performed inappropriately. The procedure was less likely to be performed on more educated patients and, other factors considered, on those seen at hospitals with larger volume. We conclude that the measurement of utilization of a surgical procedure for which only a few appropriate indications exist may help identify important relationships between hospital characteristics and quality of surgical care.