Predictability of hypoadrenalism occurrence and duration after adrenalectomy for ACTH-independent hypercortisolism.

OBJECTIVE: To evaluate if the parameters of hypothalamic-pituitary-adrenal (HPA) axis activity could predict the occurrence and duration of post-surgical hypocortisolism (PSH) in patients with Cushing's syndrome (CS) and with adrenal incidentaloma (AI). METHODS: We studied 80 patients (54 females, age 53.3 ± 11 years), who underwent adrenalectomy for CS (17 patients) or for AI (53 patients). Before surgery, we measured adrenocorticotroph hormone (ACTH), urinary free cortisol (UFC) and serum cortisol after 1 mg dexamethasone suppression test (1 mg-DST) levels. After surgery, all patients were given a steroid replacement therapy, and PSH was searched after 2 months by a low-dose (1 µg, iv) corticotropin stimulation test, that was repeated every 6 months in PSH patients for at least 4 years. RESULTS: The PSH occurred in 82.4 and 46% of CS and AI patients, respectively. In the whole sample and in AI patients separately considered, the PSH was independently predicted by the preoperative cortisol levels after 1 mg-DST, however, with a low (< 70%) accuracy. In AI patients the PSH occurrence was not ruled out even by the cortisol levels after 1 mg-DST lower than 1.8 µg/dL (50 nmol/L). In the 50% of CS patients and in 31% of AI patients the PSH lasted more than 18 months and in 35.7% of CS patients it persisted for more than 36 months. In AI patients, the PSH duration was not predictable by any parameter. However, a PSH duration of at least 12 months was significantly predicted before adrenalectomy (sensitivity 91.7%, specificity 41.2%, positive predictive value 52.4%, negative predictive value 87.5%, p = 0.05) by the presence of at least 2 out of low ACTH levels, increased UFC levels and cortisol levels after 1 mg-DST ≥ 3.0 µg/dL (83 nmol/L). CONCLUSION: The PSH occurrence and its duration are hardly predictable before surgery. All patients undergoing unilateral adrenalectomy should receive a steroid substitutive therapy.

Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.

STUDY QUESTION: Which essential items should be recorded before, during and after endometriosis surgery and in clinical outcome based surgical trials in patients with deep endometriosis (DE)? SUMMARY ANSWER: A DE surgical sheet (DESS) was developed for standardized reporting of the surgical treatment of DE and an international expert consensus proposal on relevant items that should be recorded in surgical outcome trials in women with DE. WHAT IS KNOWN ALREADY: Surgery is an important treatment for symptomatic DE. So far, data have been reported in such a way that comparison of different surgical techniques is impossible. Therefore, we present an international expert proposal for standardized reporting of surgical treatment and surgical outcome trials in women with DE. STUDY DESIGN, SIZE, DURATION: International expert consensus based on a systematic review of literature. PARTICIPANTS/MATERIALS, SETTING, METHODS: Taking into account recommendations from Consolidated Standards of Reporting Trials (CONSORT), the Innovation Development Exploration Assessment and Long-term Study (IDEAL), the Initiative on Methods, Measurement and Pain Assessment in Clinical trials (IMMPACT) and the World Endometriosis Research Foundation Phenome and Biobanking Harmonisation Project (WERF EPHect), a systematic literature review on surgical treatment of DE was performed and resulted in a proposal for standardized reporting, adapted by contributions from eight members of the multidisciplinary Leuven University Hospitals Endometriosis Care Program, from 18 international experts and from audience feedback during three international meetings. MAIN RESULTS AND THE ROLE OF CHANCE: We have developed the DESS to record in detail the surgical procedures for DE, and an international consensus on pre-, intra- and post-operative data that should be recorded in surgical outcome trials on DE. LIMITATIONS, REASONS FOR CAUTION: The recommendations in this paper represent a consensus among international experts based on a systematic review of the literature. For several items and recommendations, high-quality RCTs were not available. Further research is needed to validate and evaluate the recommendations presented here. WIDER IMPLICATIONS OF THE FINDINGS: This international expert consensus for standardized reporting of surgical treatment in women with DE, based on a systematic literature review and international consensus, can be used as a guideline to record and report surgical management of patients with DE and as a guideline to design, execute, interpret and compare clinical trials in this patient population. STUDY FUNDING/COMPETING INTERESTS: None of the authors received funding for the development of this paper. M.A. reports personal fees and non-financial support from Bayer Pharma outside the submitted work; H.T. reports a grant from Pfizer and personal fees for being on the advisory board of Perrigo, Abbvie, Allergan and SPD. TRIAL REGISTRATION NUMBER: N/A.

Economic Evaluation of the effect of Quitting Smoking on Weight Gains: Evidence from the United Kingdom.

OBJECTIVE: This article estimated the causal effect of quitting smoking on body weight gains in the United Kingdom to evaluate whether savings in health costs deriving from smoking prevention and its related diseases are greater than the costs associated with increased obesity. METHODS: We used a longitudinal data set extracted from two waves (2004-2006) of the British Household Panel Survey, which includes information on smoking and a large number of sociodemographic variables. We modeled the effect of quitting smoking on body weight accounting for heterogeneous responses from individuals belonging to different clinical classes of body mass index (BMI) (i.e., overweight and obese individuals). National Health Service costs associated with smoking were then used to implement a cost-benefit analysis, comparing the advantages of smoking reductions with the costs associated with increased obesity. RESULTS: The BMI was found to increase by 0.26 points for quitters compared with those who continued to smoke. The estimated BMI increase was larger for overweight (0.49 points) and obese (0.76 points) people. This result does not change when different control groups are examined. From an economic perspective, the National Health Service cost reductions attributable to quitting smoking were £156.81 million whereas the lost benefit for unintended increases in body weight was £24.07 million. CONCLUSIONS: This article found that the health benefits associated with quitting smoking are greater than the costs associated with increased overweight and obesity.

Localization of peripheral autonomic neurons innervating the boar urinary bladder trigone and neurochemical features of the sympathetic component.

The urinary bladder trigone (UBT) is a limited area through which the majority of vessels and nerve fibers penetrate into the urinary bladder and where nerve fibers and intramural neurons are more concentrated. We localized the extramural post-ganglionic autonomic neurons supplying the porcine UBT by means of retrograde tracing (Fast Blue, FB). Moreover, we investigated the phenotype of sympathetic trunk ganglion (STG) and caudal mesenteric ganglion (CMG) neurons positive to FB (FB+) by coupling retrograde tracing and double-labeling immunofluorescence methods. A mean number of 1845.1±259.3 FB+ neurons were localized bilaterally in the L1-S3 STG, which appeared as small pericarya (465.6±82.7 µm2) mainly localized along an edge of the ganglion. A large number (4287.5±1450.6) of small (476.1±103.9 µm2) FB+ neurons were localized mainly along a border of both CMG. The largest number (4793.3±1990.8) of FB+ neurons was observed in the pelvic plexus (PP), where labeled neurons were often clustered within different microganglia and had smaller soma cross-sectional area (374.9±85.4 µm2). STG and CMG FB+ neurons were immunoreactive (IR) for tyrosine hydroxylase (TH) (66±10.1% and 52.7±8.2%, respectively), dopamine beta-hydroxylase (DßH) (62±6.2% and 52±6.2%, respectively), neuropeptide Y (NPY) (59±8.2% and 65.8±7.3%, respectively), calcitonin-gene-related peptide (CGRP) (24.1±3.3% and 22.1±3.3%, respectively), substance P (SP) (21.6±2.4% and 37.7±7.5%, respectively), vasoactive intestinal polypeptide (VIP) (18.9±2.3% and 35.4±4.4%, respectively), neuronal nitric oxide synthase (nNOS) (15.3±2% and 32.9±7.7%, respectively), vesicular acetylcholine transporter (VAChT) (15±2% and 34.7±4.5%, respectively), leu-enkephalin (LENK) (14.3±7.1% and 25.9±8.9%, respectively), and somatostatin (SOM) (12.4±3% and 31.8±7.3%, respectively). UBT-projecting neurons were also surrounded by VAChT-, CGRP-, LENK-, and nNOS-IR fibers. The possible role of these neurons and fibers in the neural pathways of the UBT is discussed.

Randomised clinical trial: low-volume bowel preparation for colonoscopy - a comparison between two different PEG-based formulations.

BACKGROUND: Low-volume bowel preparations with polyethylene glycol (PEG) have been shown to provide an equivalent cleansing with improved tolerability as compared with standard PEG bowel preparation for colonoscopy. A new iso-osmotic sulphate-free formulation of PEG-Citrate-Simethicone (PEG-CS) in combination with bisacodyl has been recently developed. AIM: To compare the quality of bowel cleansing with PEG-CS with bisacodyl vs. PEG-Ascorbate (PEG-ASC) in adult out-patients undergoing colonoscopy. METHODS: Randomised, observer-blind, parallel group study in adult out-patients undergoing colonoscopy in five Italian centres. Both preparations were taken the evening before the procedure. Subjects were instructed to take 2-4 tablets of 5 mg bisacodyl at 16:00 hours and 2 L of PEG-CS at 20:00 hours or 2 L of PEG-ASC plus 1 L of additional water the day before colonoscopy. Bowel cleansing was evaluated according to the Boston Bowel Preparation Scale (≥6 scores were considered as 'clinical success'), and mucosal visibility according to a 3-point scale. Tolerability, acceptability and compliance were also evaluated. RESULTS: Four hundred and eight patients were randomly allocated to PEG-CS and bisacodyl (n = 204, male patient 48%, mean age 59.1 years) or PEG-ASC (n = 204, male patient 51%, age 59.4 years). In the planned per-protocol analysis, the rate of successful preparation was 79.1% following PEG-CS with bisacodyl, and 70% following PEG-ASC (P < 0.05). Mucosal visibility was evaluated as optimal in 56.1% in the PEG-CS and bisacodyl and 46.3% in the PEG-ASC group (P < 0.05). There were no serious adverse events (AE) in each of the two experimental groups. Two subjects in the PEG-ASC group discontinued the study because of AE. CONCLUSIONS: Polyethylene glycol-Citrate-Simethicone in combination with bisacodyl was more effective for bowel cleansing than PEG-ASC for out-patient colonoscopy. Tolerability, safety, acceptability and compliance of the two low-volume bowel preparations were similar.

Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging.

BACKGROUND: The purpose of the study was to compare the accuracy of double-contrast barium enema (DCBE) and magnetic resonance imaging (MRI) in the diagnosis of intestinal endometriosis using the histological examination on resected specimen as comparative standard. METHODS: Eighty-three consecutive patients with suspected intestinal endometriosis, resected between 2005 and 2007, were prospectively evaluated. All of the women underwent preoperative DCBE and MRI on the same day. We evaluated number, site (rectum, sigmoid, cecum), and size of the lesions. The imaging findings were correlated with those resulting at pathology. RESULTS: Among the 65 women who underwent surgery, 50/65 (76.9%) were found to have bowel endometriosis, with 9/50 (18%) patients presenting two lesions; DCBE allowed to detect 50/59 (84.7%) lesions. MRI allowed to detect 42/59 (71.1%) lesions. DCBE showed sensibility, specificity, PPV, NPV, and accuracy of respectively 84.7, 93.7, 98.0, 62.5, and 86.6%, MRI of 71.1, 83.3, 93.3, 46.8, and 74.6%. CONCLUSION: DCBE is more accurate than unenhanced MRI in the diagnosis of bowel endometriosis, and should be preferred in the preoperative management of this disease, since it usually enables a proper surgical planning.

Laparoscopic treatment of bowel endometriosis in infertile women.

BACKGROUND: The purpose of the study was to determine the influence of bowel endometriosis on fertility, and to study whether its removal improves fecundity in women with endometriosis-associated infertility. METHODS: Three groups of infertile patients were included in the study. Group A (60 women) consisted of patients who underwent surgery for endometriosis with colorectal segmental resection. In group B, 40 patients with evidence of bowel endometriosis underwent endometriosis removal without bowel resection. Group C consisted of 55 women who underwent surgery for moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The women were clinically evaluated before laparoscopy and then at 1 month, at 6 months and at each year up to 4 years after surgery. Main outcome measures were surgical complications as well as post-operative pregnancy rate, time to conception and monthly fecundity rate. RESULTS: The monthly fecundity rates (MFR) in groups A, B and C were 2.3, 0.84 and 3.95%, respectively. The difference in the MFR between groups was significant (P < 0.05). CONCLUSIONS: The presence of bowel infiltration by endometriosis seems to negatively influence the reproductive outcome in women with endometriosis-associated infertility. The complete removal of endometriosis with bowel segmental resection seems to offer better results in terms of post-operative fertility.

Targeted therapy with trastuzumab in dysplasia and adenocarcinoma arising in Barrett's esophagus: a translational approach.

AIM: Human epidermal growth factor receptor (HER2) protooncogene, overexpressed/ amplified in preneoplastic lesions and in adenocarcinoma (ADC) of the esophagus, can be considered a target for treatment of esophageal dysplasia/ADC. The aim of this study was to evaluate the therapeutic role of the anti-HER2 monoclonal antibody, trastuzumab, in the management of ADC originating from HER2-positive Barrett's esophagus (BE). METHODS: Two patients with high-grade dysplasia and ADC of the esophagus after esophageal mucosectomy and no metastatic disease were studied. Patients were not eligible for radical surgery or chemo-radiotherapy because of age and comorbidities. HER2 status was assessed by immunohistochemistry and fluorescence in situ hybridization. Additional immunohistochemical analyses were performed. The whole panel was analysed at baseline, after treatment and at follow-up. RESULTS: At baseline, the two patients showed HER-2 overexpression/amplification in all areas of dysplasia and ADC but not in BE. Six months after treatment no significant differences in terms of endoscopical and histological patterns of the disease were found. HER-2, EGFR, TOPOII-alpha and anti-ssDNA analysis demonstrated a down-regulation of these markers and increased apoptosis. CONCLUSION: This study demonstrates that this treatment is feasible. No clear evidence of dysplasia regression was observed. However, HER2 and TopoII-alpha downregulation and induction of apoptosis occurring 6 months after treatment encourages further investigation.

Double labelling immunohistochemical characterization of autonomic sympathetic neurons innervating the sow retractor clitoridis muscle.

Retrograde neuronal tracing and immunohistochemical methods were used to define the neurochemical content of sympathetic neurons projecting to the sow retractor clitoridis muscle (RCM). Differently from the other smooth muscles of genital organs, the RCM is an isolated muscle that is tonically contracted in the rest phase and relaxed in the active phase. This peculiarity makes it an interesting experimental model. The fluorescent tracer fast blue was injected into the RCM of three 50 kg subjects. After a one-week survival period, the ipsilateral paravertebral ganglion S1, that in a preliminary study showed the greatest number of cells projecting to the muscle, was collected from each animal. The co-existence of tyrosine hydroxylase with choline acetyltransferase, neuronal nitric oxide synthase, calcitonin gene-related peptide, leu-enkephalin, neuropeptide Y, substance P and vasoactive intestinal polypeptide was studied under a fluorescent microscope on cryostat sections. Tyrosine hydroxylase was present in about 58% of the neurons projecting to the muscle and was found to be co-localized with each of the other tested substances. Within fast blue-labelled cells negative to the adrenergic marker, small populations of neurons singularly containing each of the other enzymatic markers or peptides were also observed. The present study documents the complexity of the neurochemical interactions that regulate the activity of the smooth myocytes of the RCM and their vascular components.

Screening for and surveillance of Barrett's esophagus is clinically indicated.

Barrett's esophagus (BE) is a complication of chronic gastroesophageal reflux disease (GERD) and is the precursor of esophageal adenocarcinoma (EA), through a progression from intestinal metaplasia (IM), through high-grade dysplasia (HGD). Although the progression from BE to EA seems to be infrequent (0.5% per year), endoscopic and bioptic surveillance would play a significant role in the evaluation of HGD and the detection of EA in early, curable stage, improving survival rates after treatments. The severity and the duration of GERD could be helpful in the assessment of the risk for BE and to enroll these subjects into screening protocols to detect any dysplastic or neoplastic change. The benefits of screening-surveillance programs could be furthermore enhanced by an improvement in diagnostic methods, such as high-resolution endoscopic techniques and the use of biomarkers for the histological examination seems to play a primary role in the cancer risk stratification; in such way, endoscopic resection techniques (mucosal resection and submucosal dissection) can be considered as a helpful method to stage dysplastic changes in BE.

Epidemiological overview on the effectiveness of mass screening for female cancer in Umbria, Italy.

Using incidence, survival and mortality we tried to verify the effectiveness of mass-screening interventions for cervical uterine, breast, and colorectal cancer in females. Mortality data concern the period from 1978-2002. Incident cases derived from an ad hoc survey for 1978-1982 data and from the RTUP from 01/01/1994 to 31/12/2002. Relative survival rates were calculated for 1978-1982, 1994-1997 and 1998-2002 time intervals. All standardized mortality figures showed a steady trend. Incidence rates concerning cervical uterine cancer showed a decrease starting from the 1978-1982 period, whereas those for breast cancer had a constant increasing trend, and those for colorectal cancer increased up to 1997-1999 and later remained constant. For breast cancer the 5-year survival rate increased about 15% compared to the first period, for colon cancer there was less of an increase and the increase for cervical uterine cancer survival was only for the 1998-2002 period compared to the former ones. With constant incidence rates, improvement in survival from cervical uterine cancer may be due to a high number of cancer cases detected at an early stage. The effect of breast cancer screening on incidence is evident, though differences still did not influence mortality and survival. Colorectal cancer epidemiology can be considered as a prescreening pattern. Mortality, incidence and survival data allow a good overview for the effectiveness of screening procedures.

The laparoscopic treatment of bladder endometriosis. A retrospective analysis of 21 cases.

AIM: Endometriosis is the presence of endometrial tissue, including endometrial glands and stroma, outside the uterine cavity. The incidence of endometriosis in the general population is almost unknown, because it varies between 1% and 50%, depending on the paper considered. In any case, the incidence of bladder endometriosis is generally considered about 1% or less of endometriotic patients. The aim of this study is to evaluate the effectiveness of preoperative exams and the effectiveness of laparoscopic treatment. METHODS: We enrolled 21 patients operated laparoscopically for a severe stage of endometriosis, including at least a bladder localization of 10 mL; in 60% of cases a bowel surgery was associated in the cause of a digestive endometriosis. A complete preoperative and follow-up evaluation was carried out for all patients. RESULTS: The preoperative investigation, especially abdominal sonography, predicted endometriotic bladder invasion in only 38% of cases. Urinary symptomatology was present in only 61.9% of cases. The postoperative follow-up showed the remarkable effectiveness of laparoscopic treatment for the cancellation of pain and to improve the quality of life for patients. CONCLUSIONS: Finally, the treatment of severe endometriosis is possible and effective by laparoscopy even in the cases where there is a bladder localization and when, in the absence of specific symptomatology, it isn't diagnosed preoperatively.

Urban-rural differences in gynaecological cancer occurrence in a central region of Italy: 1978-1982 and 1998-2002.

Differences in gynaecological cancer incidence and mortality in the urban and rural areas of the Umbria region (central Italy) were investigated. All women with primary invasive breast cancers, uterine cervix and uterine corpus, and ovarian cancers diagnosed during the periods 1978-1982 and 1998-2002 were identified and analysed according to place of residence (either urban or rural). Mortality data were supplied by the National Institute of Statistics (ISTAT) for the period 1978 to 1982, whereas for the 1994-2002 period they were supplied by the Regional Nominative Causes of Death Registry (ReNCaM). Incident cases considered were taken from an ad hoc survey for the first period and from the Umbrian Population Cancer Registry database for the second one. For each site the age-adjusted incidence (AAIR) and mortality (AADR) rates were calculated. The expected number of rural cases was obtained from indirect standardisation with urban incidence and mortality rates of several sites. The significance of the observed expected ratios (SIRs for incidence and SMRs for mortality) and the corresponding 95% confidence intervals were based on the Poisson distribution. Urbanisation levels were established following the classification of the Italian Institute of Statistics. For all sites, excluding the ovary during the most recent period, the SIR relative to rural areas was below 1, but the rates were statistically significant only for breast cancer in both periods (SIR 0.81, 95% CI 0.74-0.88 and SIR 0.82, 95% CI 0.77-0.88, respectively) and for cervix uteri in the first period (SIR 0.77, 95% CI 0.59-0.94). The lower breast cancer incidence in the rural area could also be due to lesser compliance with screening procedures which, up until 2002, were not provided in the form of mass-screenings throughout the region by the Regional Health Department. These results underscore the need for continued efforts to provide preventive health services to medically underserved women throughout Umbria, including rural communities. Underutilisation of preventive healthcare services may result in failure to identify healthcare problems that might be successfully managed with medication or lifestyle changes, as well as missed opportunities to prevent potentially life-threatening diseases.

Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible?

BACKGROUND: Little is known about the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function. METHODS: We performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non nerve-sparing technique (control group-group A n=20) and a nerve-sparing technique (case group-group B n=25). At initial gynaecological evaluation, and at follow-up details on dysmenorrhoea, pelvic pain, dyspareunia and dyschezia were evaluated using an interview-based questionnaire (10-point analogue rating scale: 0=absent, 10=unbearable). RESULTS: The mean (+/-SD) follow-up period was 15.3+/-10 months (range, 8.8-23 months) for group A and 3.5+/-2.1 months (range, 0.3-5.2 months) for group B. In the immediate postoperative course, in group A three women required blood transfusion vs seven women in group B (P=0.003). The median time to resume the voiding function was significantly shorter in group B (12.5 vs 3.0 days; P<0.01). At the time of follow-up a higher proportion of patients in group B were 'very satisfied' than those in group A (87.7% vs 59.0%, P=0.013). CONCLUSIONS: Laparoscopic nerve-sparing complete excision of endometriosis seems to be feasible and offers good results in terms of bladder morbidity reduction with apparently higher satisfaction than classical technique. Larger series with longer follow-up are needed to confirm our results.

[Survival of men with upper aerodigestive cancer in Umbria, Italy. 1978-82 and 1994-98]. / Sopravvivenza del cancro delle vie aerodigestive superiori nei maschi in Umbria. 1978-82 e 1994-98.

The aim of this study is to analyze the upper aerodigestive cancer survival in Umbria, a central Italian region, in the periods 1978-82 and 1994-98. The cases' data diagnosed in the period 1978-82 were derived from an ad hoc survey carried out in Umbria and for the years 1994-98 from Umbria Population-based Registry (RTUP). In the period 1994-98 the relative survival has lightly improved compared with the previous one. Comparison among five year relative standardized survival for head and neck, oesophagus and larynx, in Umbria region and in the other Italian registries, shows a quite high survival that could be further improved with an early diagnosis and, consequently, less destroying treatments.

[Decrease of frequency of male lung cancer in Umbria region. 1978-1982 and 1994-1999]. / Diminuzione della frequenza del tumore polmonare nei maschi umbri. 1978-1982 e 1994-1999.

In Umbria, region of Central Italy, lung cancer is the leading cause of death due to cancer in males. The aim of this work is to highlight decrease of mortality from lung cancer in males in Umbria, in the last 20 years and to describe relationship among incidence, mortality and survival of this cancer. The incidence data derived from an ad hoc survey carried out over the period 1978-1982 and for 1994-1999 from the Umbrian Population Cancer Registry (RTUP). The mortality data were derived from official publications of the Italian Central Institute for Statistics (ISTAT) and covered the entire period 1978-1999. Estimated annual percent change (EAPC) was calculated by joinpoint regression analysis. Decrease of mortality from male lung cancer in Umbria began in the 1990-ies due to reduced quantity of tar in cigarettes, decreasing consumption of tobacco and increasing of survival derived from the quality and the effectiveness of the oncological health care system.

[Trends in gastric cancer incidence, mortality and survival in the Umbria region of Italy. 1978-82 and 1994-99]. / Trend di incidenza, mortalità e sopravvivenza del carcinoma dello stomaco in Umbria: 1978-82 e 1994-99.

Gastric cancer, despite the decrease observed in the last 50 years, is yet the fourth cause of death for malignant tumor in Italy. Data from the Registro Tumori Umbro di Popolazione have been used to assess incidence, mortality and survival rates for this cancer over the period 1994-1999. The results have been compared with the data of an ad hoc study realized in the period 1978-1982 and with the ones of the other population-based cancer registries. Mortality and incidence rates are among the highest in Italy, confirming the existence of a high risk area for gastric cancer in central Italy; anyway, both mortality and incidence decrease during the study period. Also survival rates from gastric cancer recorded in Umbria over the period 94-99 were among the highest respect to other Italian cancer Registries. A case-control study carried out in a neighbouring area, aimed to explain the elevated incidence of gastric cancer, found that the consumption of a "traditional" diet--rich in proteins (particularly from sausages), nitritis and nitrous compound, alcohol, coffee, and fibres--was an important risk factor for gastric cancer. Survival over the period 94-99 is significantly improved, if compared to 1979-82 survival rate. The high survival rate recorded in the Umbria region could be related both to the number of cases treated in Umbria and to the quality of the regional oncologic system; in fact, in Umbria we reported high survival rates for several malignancies.