Differentiated thyroid cancer: role of the lymph node dissection.

Thyroid cancer is the most common endocrine malignancy with the highest mortality, so it has generated considerable debate and voluminous literature by endocrinologists, surgeons, and nuclear physicians. If total thyroidectomy is the primary treatment for patients with differentiated thyroid cancers (DTC) and it has proven to be effective and safe, the extent of lymph nodes dissection remains controversial among experts in the field. This controversy persists largely due to the lack of a prospective randomized controlled trial to define whether the addition of central lymph node dissection (CLND) to total thyroidectomy for papillary thyroid cancer (PTC) confers an increased risk of permanent hypoparathyroidism and permanent nerve injury. According to the Consensus Conference of the UEC's Club therapeutic modified radical neck dissection (MRND) should be performed only in the patients with evidence of neoplastic multiple lymph node involvement. Although central lymph node dissection may increase the risk of hypoparathyroidism and nerve injury when compared with total thyroidectomy without CLND, it may decrease recurrence of PTC and likely improves disease specific survival and offers a sufficient alternative to routine prophylactic modified radical neck dissection. Selective central lymph node dissection should be performed, under the care of experienced surgeons, in high risk patients (50 years or older aged, large tumor expansion within the thyroid, or with extrathyroid extension), with the extension to the station II-III-IV in case of single lymph node involvement.

Clinical features of hemorrhoidal disease in renal transplant recipients.

Hemorrhoidal disease is a frequent cause of morbidity among the general population with a reported incidence of 4.4%, but little is known about its incidence and clinical features in kidney transplant recipients. Among 116 patients who had undergone kidney transplantation and were evaluated for hemorrhoidal disease, 82 had no hemorrhoids (70.6%), 28 (24%) had grade I hemorrhoids, and 6 (5.4%) had grade II hemorrhoids at the pretransplantation evaluation. Twenty-seven out of 116 recipients (22.4%) developed grade III or IV hemorrhoids after transplantation and underwent surgery. Hemorrhoidal disease was more frequent in patients with a pretransplantation history of hemorrhoids, with a rapid weight increase in the posttransplantation period, or who were aged between 30 and 50 years. Immunosuppressive therapy may play an important role in the worsening of hemorrhoidal disease among kidney transplant recipients. A prompt diagnosis and surgical treatment, whenever necessary, is mandatory for patients with clinical signs of worsening of hemorrhoids.

Psoas abscess: a rare complication of Crohn's disease.

UNLABELLED: Psoas abscess is a rare complication of Crohn's disease. METHODS AND MATERIALS: We evaluated the incidence of psoas abscess on 312 patients with Crohn's disease, seen at our institution between 1992-2001. RESULTS: We encountered three cases of psoas abscess (0.9%). One patient was managed with ileocolic resection and immediate anastomosis, while in two patients a percutaneous drainage was first performed and then, after 12 days of total parenteral nutrition, a resection of the diseased bowel with immediate reconstruction was carried out. CONCLUSIONS: A correction of the nutritional deficiencies is mandatory. Percutaneous computed-tomography guided drainage of the abscess with intestinal resection with immediate anastomosis, performed after a parenteral hyperalimentation, should be the method of choice in the management of such patients.

Severe gastrointestinal bleeding in Crohn's disease.

INTRODUCTION: Acute gastrointestinal bleeding is rare in Crohn's disease. METHODS: We characterized the clinical features and course of such hemorrhage in patients seen at our institution from 1992 to 2000. RESULTS: Five patients had gastrointestinal bleeding during Crohn's disease. All patients had a known Crohn's disease, with a mean duration of the disease of 6 years. The source of bleeding was identified in four patients (80%). Endoscopy was, in all patients, the first diagnostic procedure. An Hartmann total colectomy with closure of the rectal stump and ileostomy was performed in three patients, while two patients with ileal massive bleeding were treated conservatively. One patient had a recurrence of bleeding from the small bowel one week later but he didn't required surgical treatment. One patient with pancolic Crohn's disease died on 10th postoperative day because of multiorgan failure and septic complications. CONCLUSIONS: Gastrointestinal bleeding is rare in Crohn's disease, with a predilection for site of involvement. The preoperative diagnosis of the site of bleeding is not easy, and enteroscopy should be mandatory in such patients. Surgery is required for half of cases and recurrent haemorrhage should be an appropriate indication for surgery.

A rare surgical complication of Crohn's diseases: free peritoneal perforation.

BACKGROUND: Free peritoneal perforation is a rare complication of Crohn's disease. METHODS: We evaluated the incidence of free peritoneal perforation among 208 patients with Crohn's disease surgically treated in the period 1992-2000. RESULTS: Five patients (2.4%) suffered from free peritoneal perforation. In 1 patient free peritoneal perforation was the first symptom of Crohn's disease. In 3 cases the perforation was in the small bowel and in 2 in the large bowel. All patients underwent surgery: all cases had a resection of the involved bowel and in two cases an ileostomy was performed in order to prevent severe peritonitis. We did not observed mortality or major complications. CONCLUSIONS: Free peritoneal perforation is rare with about 100 cases reported in literature. No correlation seems to exist with previous corticosteroid treatment. The surgical treatment is mandatory. Simple suture should be avoided. The most appropriate treatment, whenever it is feasible, is resection of the involved bowel with immediate or, in case of severe sepsis, delayed anastomosis.

[Surgical tactics in abdominal wall neoplasia]. / La tattica chirurgica nelle neoplasie della parete addominale.

Abdominal wall neoplasms represent more or less 1% of human neoplasms in the adult. The authors reports their own experience based on 9 cases during over 20 years. The prognosis of these tumors is almost influenced from a lot of factors such as: histology, localization, staging, grading, sex, surgical margins, number of local recurrences. Abdominal wall neoplasm are less aggressive for compartmentalization of muscle layer and with a better prognosis because of their localization, and surgical opportunities of extensive resection (not less of 2 cm from tumor's macroscopic limits) allowed by modern prosthetic reconstruction techniques. Polipropilene seems to be the ideal material for such kind of reconstruction even if also mersilene, PTFEe and others were employed. PTFEe and Dual-meshes could be useful in those malignant tumors in which peritoneum resection is necessary.

[Is it possible to improve survival in patients with Klatskin tumors?]. / E possibile migliorare la sopravvivenza dei pazienti con tumore di Klatskin?

BACKGROUND: This retrospective study was undertaken to evaluate if a high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer. METHODS: Between 1985 and 2001, 50 patients (34 males and 16 females) with proximal bile duct cancer were treated. The tumor site were classified according to Bismuth-Corlette's classification: 9 lesions (18%) were Bismuth type I, 23 lesions (46%) type II, 12 lesions (24%) Type IIIa, 5 lesions (10%) type IIIb and only 1 resected tumor (2%) was type IV. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent non surgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-enY cholangiojejunostomy with two or three divided segmental hepatic ducts; in ten, the cholangiojejunostomy was performed with 4 or 5 divided segmental hepatic ducts. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins. RESULTS: There was no operative mortality. Overall 1-year, 3-year and 5-year survival of the entire surgical group was 61%, 22.5% and 9% respectively. In the 19 patients treated with curative intent the survival at 1,3, and 5 years was 66%, 30% and 15%, respectively, while in the palliative group it was 45%, 15% and 0%, respectively. CONCLUSION: Only margins free from tumor may guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better 5-year survival.

[Bilateral breast cancer]. / Il carcinoma mammario bilaterale.

Bilateral breast cancer has a cumulative incidence of 3-13% in patients with primary breast cancer, and the majority of these lesions are metachronous. The synchronous and metachronous bilateral breast cancer have at greater risk for distant metastasis than unilateral breast cancer. There was no difference in overall survival when comparing metachronous and synchronous bilateral patients to those with unilateral disease.

[Breast cancer screening in the elderly]. / Lo screening del carcinoma mammario in età geriatrica.

The incidence and mortality of breast cancer increase with increasing age, and almost half of all breast cancer cases are diagnosed in women aged 65 years and older. Moreover many studies have indicated that the elderly are less screened, and have lesser and frequently inferior treatment. In contrast, clinical trials focusing on the elderly suggest that they do as well with surgery, radiation, and standard chemotherapy regimens as their younger counterparts. Our study suggest that in women aged 65 years, and older, breast cancer can be detected at an earlier stage by mammographic screening.

[Undifferentiated carcinoma of the thyroid]. / Il carcinoma indifferenziato della tiroide.

Anaplastic thyroid carcinoma is a rare and highly lethal cancer. Between 1969 and 2002, 9 cases with anaplastic carcinoma were reviewed. Surgical treatment with radiotherapy and chemotherapy were performed in all cases. All patients died of their disease within 5 years. The mean survival was 10 months. There is still controversy as to what constitutes adequate treatment for anaplastic thyroid carcinoma, and combined multimodal therapy seems to be the most common management strategy for this aggressive disease.

[Early de novo neoplasia after renal transplantation]. / Neoplasie de novo precoci dopo trapianto renale.

INTRODUCTION: The chronic use of immunosuppressive therapy in transplant recipients to prevent acute rejection increases the long-term risk of cancer. The overall incidence of de novo malignancies (DNM) after kidney transplantation ranges from 6% to 11%. PATIENTS AND METHODS: Between January 2000 and December 2002, 135 renal and 3 combined kidney-pancreas transplantations were performed. RESULTS: Of 138 solid organ transplant recipients, a total of 16 (11.6%) cancers were diagnosed in 10 renal transplant recipients (7.2%). Six patients were male and three female, with a mean age of 47 years (range, 19-63, years). Tumor presented at a mean time of 14 months (range, 2-24, months) after transplantation. There were three patients with skin cancers, three with Kaposis's sarcoma, one with renal cell cancer, one with bladder carcinoma and one with breast cancer. CONCLUSIONS: Although the DNM occurs more frequently many years after a kidney transplantation, our experience demonstrated that they can occur early in the follow-up. Skin malignancies had the best prognosis, probably because of early detection and treatment. Kaposi's sarcoma benefits from reduction or cessation of immuno-suppression, but there is a higher risk of graft loss. Solid organ de novo malignancies are often more aggressive than in normal population, and the life expectancy of these recipients is very low. Careful long-term screening protocols are needed for detection of such malignancies in an early stage.

[Plug-technique for umbilical hernia repair in the adult]. / La tecnica del piccolo plug nella riparazione dell'ernia ombelicale nell'adulto.

BACKGROUND: Umbilical hernia represents 6% of all abdominal wall hernias in the adult. Surgical repair should always be carried out due to possible occurrence of complications. Aim of this paper is to evaluate the efficacy of the plug-technique. METHODS: From October 1995 to April 2000, the authors performed 21 operations for acquired umbilical hernia with a defect smaller than 4 cm. Local anesthesia was used and a light intravenous sedation added in particularly anxious patients. The repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect. RESULTS: All patients were up and about straightaway and were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in only 19% of cases and domiciliary analgesia in 24%. During a follow-up ranging from 6 to 60 months (mean 30), only one recurrence has been recorded. CONCLUSIONS: This tension-free technique allows immediate rehabilitation, with few complications and a low recurrence rate.

[Breast carcinoma in the elderly]. / Il carcinoma della mammella in età geriatrica.

Breast cancer represents 40% of all carcinomas and is responsible for the 20% of deads due to a cancer in female population. Patients in more of 50% age over 65 years. 150 patients with breast cancer older then 65 years underwent surgery. T1 and T2 < 2 cm patients were treated with quadrantectomy and radiotherapy. T2 > 2 cm and T3 patients underwent radical mastectomy. T4 patients were treated with neoadjuvant chemotherapy before surgery. Mean follow up was 48 (range 12-78) months. 43 patients (28.6%) had a progression of the neoplasia. Five years mortality rate was 18.6%. Surgery nowadays represents the treatment of choice for breast cancer even in elderly woman. Associated diseases in these patients shouldn't always considered an absolute contraindication for surgery.

[Carcinoma of the male breast: reconstructive technique]. / II carcinoma della mammella maschile: tecnica ricostruttiva.

Male breast cancer is a rare neoplasm. Adhesions in its deeper and superficial levels and axillary adenopathies (50-60%) are often found at the diagnosis time. Surgery is considered the main step in the treatment of the male breast cancer. Radical mastectomy often leads to a wide asportation of the skin consequently causing some problems in the management of the chest-wall defect. Otherwise inadequate resections can cause local recurrences. The Authors, after a brief analysis of the main aspects concerning the prognosis and the management of the male breast cancer, report the use of transverse thoracoepigastric skin flap in the reconstruction of surgical wound after mastectomy.

[Gastrointestinal metastasis of melanoma: a case study]. / Metastasi da melanoma a carico dell'apparato gastrointestinale: a proposito di un caso clinico.

The Authors report on a case of multiple metastases located in the jejunum (where it caused intussusception), the omentum, and retroperitoneum having originated from a malignant melanoma with subungual primary site on first finger of left hand. After thoroughly surveying the specific literature, the Authors deal in more detail with current treatments and therapeutic prospects for this kind of neoplastic disease.

[Repair of large vesical wall defects with lyophilized dura mater. Experimental research (author's transl)]. / Riparazione di ampi difetti della parete vescicale con dura madre liofilizzata. Ricerche sperimentali.

In order to evaluate whether and how far a fuller case documentation can contribute to a better knowledge of the real possibilities of the lyophilised human dura mater in the field of vesical alloplastic surgery, the Authors present and discuss the results they obtained during the course of experimental research. In the light of personal histological documents, they stress the absence of reject phenomena, a property which, together with the absence of precipitates, the complete re-epithelialisation of the transition epithelium and the possibility of ensuring good vesical capacity, evidence that lyophilised human dura mater has full rights to a place in repair surgery of large vesical wall defects.