A phase II trial of combined chemotherapy and surgery in stage IIIA non-small cell lung cancer.

A poor prognosis for patients with Stage IIIA clinical N2 treated by surgery alone has led clinical researchers to find a new treatment modality to improve the curative potential of surgery. Many Phas II trials have been carried out with induction chemo- or chemo-radiotherapy prior to surgery. From June 1988 to July 1991, 46 patients with non-small cell lung cancer (NSCLC) Stage IIIA clinical N2 entered a Phase II induction-chemotherapy trial. Patients received 2-3 cycles of high-dose cisplatin and etoposide. Forty-five were evaluable for response; the response rate was 82% (37/45: 3 CR, 34 PR). Toxicity was primarily hematologic. Surgical resection was performed in 35 patients; radical resection was possible in 28 patients (62%); three patients were incompletely resected and two patients were only explored. Three deaths were surgery-related. Median survival was 24.5 months with a 2-year survival of 53%. Cisplatin with etoposide is an active and safe induction chemotherapy regimen for NSCLC Stage IIIA N2 with a high response rate. The median survival seems to be prolonged and therefore, randomized trials are needed to compare this approach with other treatment modalities.

Induction chemotherapy with cisplatin, doxorubicin, and cyclophosphamide (CAP) in a combined modality approach for locally advanced and inflammatory breast cancer. Long-term results.

Thirty-one patients with locally advanced and inflammatory breast carcinoma (stage IIIA and IIIB) were treated with a combined modality approach between 1985 and 1989. All patients received as induction chemotherapy a combination of cisplatin, doxorubicin, and cyclophosphamide (CAP). Responsive patients and patients with operable stable disease underwent modified radical mastectomy followed by concurrent radiotherapy and CMF (cyclophosphamide, methotrexate, 5-fluorouracil) adjuvant chemotherapy. Thirty patients were evaluable for response to CAP. The rate of objective response to induction chemotherapy was 76.7% with 2 patients (6.7%) obtaining a complete response and 21 patients (70%) a partial response. Twenty-five patients were rendered disease-free after induction chemotherapy and surgery. Only 2 of these had pathological complete response (8%). The median overall survival was 48.7 months, the median time to progression was 22.4 months and the median disease-free survival was 29.1 months. The patients with noninflammatory breast tumor had a significantly better overall survival, disease-free survival, and time to progression. The overall survival and the time to progression were statistically superior in patients with primary tumor size < or = 8 cm. At a median follow-up of 6 years, 29% (95% CI, 13.05 to 45.01) of patients were alive and 28% (95% CI, 10.4 to 45.6) were disease-free. This combined modality treatment seems feasible with quite acceptable toxicity; the CAP combination is an effective alternative to the other standard chemotherapeutic regimens. Our results, although encouraging, are still poor, and new drugs and strategies are required to improve the long-term outcome.

Neoadjuvant cisplatin and etoposide for stage IIIA (clinical N2) non-small cell lung cancer.

In an attempt to improve the curative potential of surgery, 46 patients with unresectable Stage IIIA (Clinical N2) non-small cell lung cancer received neoadjuvant chemotherapy with cisplatin and etoposide. After 2 or 3 cycles, 45 patients were evaluable for response; the overall response rate was 82% (37/45) with 3 complete and 34 partial responses. Toxicity was primarily hematologic. Surgical exploration was performed on 35 patients, but resection was possible in only 33 (73%). Of these, 28 resections were complete (62%). Four patients (2CR, 2PR; 9%) had no tumor in biopsy specimen. Three deaths were surgery-related. Median survival of the entire 46 patients was 24.5 months with a 2-year survival of 53%. Cisplatin and etoposide is an effective chemotherapeutic regimen for regionally advanced non-small cell lung cancer; the resection and survival rates justify further trials to compare this approach to other treatment modalities.

Intraoperative ultrasonography for pancreatic insulinomas.

BACKGROUND/AIMS: Islet cell adenomas of the pancreas are both single and benign tumors in more than 90% of the cases. Even with the use of increasingly innovative diagnostic techniques, a percentage of tumors are not located in the preoperative or, sometimes, even intraoperative phase. This study compares the results of various diagnostic techniques and provides a brief review of the literature. MATERIALS AND METHODS: Between January 1978 and December 1994, 15 patients (11 females and 4 males) averaging 49 years of age (range 27-70) affected by pancreatic insulinoma underwent surgery at the Department of General Surgery of the "R. Silvestrini" Hospital. RESULTS: In 8 cases the tumor intrapancreatic position was indicated in the preoperative stage. On the contrary, intraoperative ultrasonography allowed the correct location in all the cases, but one. Surgery allows for the complete cure from the diseases when the removal of adenoma is complete. All of our patients underwent surgery which involved enucleation or resection of the distal portion of the pancreas. CONCLUSION: The choice of the type of operation to perform, as well as the consequential morbidity and mortality, seems to depend essentially on the size and position of the insulinoma. All of the patients, except for one who died because of a pancreatic fistula, are alive and normoglycaemic.

[Late radiological aspects after vagotomy and gastric drainage]. / Aspetti radiologici tardivi dopo vagotomia e drenaggio gastrico.

Personal experience in 87 cases of vagotomy and gastric drainage is presented. Pyloroplasty according to Heinecke-Mikulicz was performed in 50 cases and drainage according to Judd in 9. Three groups were distinguished on the basis of the presence of a "gastroduodenal canal" and "pseudodiverticula". Twenty-two patients were subjected to a Finney pyloroplasty, radiologically visible is a transparent line from the large curvature of the antrum to the lesser curvature medially. Jaboulay-Alexiu gastroduodenostomy was performed in 6 cases. Here anastomosis between the large curvature and the second duodenal portion was noted, with preservation of the pylorus. Mention is made of the difficulty of recurrent ulcer diagnosis and the exact interpretation of the appearance of the antrum, pylorus and duodenum after drainage operations of this type.

[Experience in the treatment of bleeding esophageal varices]. / Esperienza nel trattamento delle varici esofagee sanguinanti.

Personal experience with respect to the diagnosis and treatment of bleeding oesophageal varices in patients with cirrhosis is described. Diagnosis is directed both to the establishment of the site of bleeding and the disease responsible and to the evaluation of risk in view of the possibliity of portal decompression. Treatment is aimed at stopping bleeding and at lowering this risk so that as many patients as possible can be operated with an acceptable degree of surgical risk.

[Indications and technics of trans-obturator by pass]. / Le indicazioni e la tecnica del bypass trans-otturatorio

Starting from a clinical case in which a trans-obturator by-pass was necessary, the most recent findings as regards the technique of this and its indications are reviewed. The procedure is to be considered a valid alternative in cases of ischaemic revascularization when the usual Scarpa triangle route cannot be used.

[Endoscopic control of patients subjected to vagotomy and drainage for duodenal ulcer. Personal experience]. / Controllo endoscopico in pazienti operati di vagotomia e drenaggio per ulcera duodenale. Nostra esperienza.

The usefulness of endoscopic examination of patients subjected to vagotomy and drainage for duodenal ulcer is stressed, since it permits recurrences and ineffective treatment to be detected, along with the control of other parameters, such as the appearance of the mucosa, the performance of gastric drainage, the features of peristalsis and gastric tone, and the performance of the cardial sphincter. Data from a series of 43 endoscopies performed after 192 vagotomy and drainage operations carried out between 4-1973 and 5-1976 are presented.

[Use of glucagon in the treatment of acute pancreatitis]. / Impeigo del glucagone nel trattamento della pancreatite acuta

Personal experience with glucagon in 15 cases of acute pancreatitis is reported. Complete remission of pain within 2-3 hr after infusion of the drug was noted in 85% of the series, together with normalisation of blood amylase within 48-72 hr. Glucagon inhibits pancreatic secretio&n. Vairous theories concerning its mechanism of action are examined.

[Stenosis of the left angle of the colon caused by chronic pancreatitis]. / La stenosi dell'angolo sinistro del colon da pancreatite cronica.

Case of stenosis of the left flexure of the colon caused by pancreatitis is reported. The relevant literature is surveyed and an account is given of the pathogenesis of this forms, and the examinations required in its diagnosis, particularly coloscopy. A preference is expressed for an internal colic derivation (colon-colon anastomosis) rather than resection, on account of the smaller degree of risk involved.

[Embolisms of the upper extremities]. / Embolie degli arti superiori.

6 cases of upper extremity embolism observed over the past three years are reported. Fogarty embolectomy was carried out in all patients, favourable revascularization results being obtained in 5. Forearm amputations was necessary in 1 case owing to the presence of ischaemic lesions that were already advanced at admittance, further proof that results depend above all on the vitality of the extremity rather than on the duration of the arterial occlusion.

Benign biliary stricture. Personal experience and technical notes.

BACKGROUND: Benign biliary strictures are a binding situation for clinicians when choosing the best treatment. This is a benign disease and needs safe, effective and lasting therapy. Up to day non surgical treatment have been suggested as the first therapeutical option but surgery seems to support the best late results. METHODS: The authors report their experience in 206 patients, 64 males and 142 females, aged from 27 to 77 years, affected by postoperative (160 patients) or inflammatory (46 patients) biliary strictures. All the patients but three had been treated by surgical procedures. RESULTS: Postoperative morbidity and mortality were 18.4% and 3.4% respectively. Follow-up ranged from 2 to 16 years. Late stricture of bilio-enteric anastomosis has been observed in 8.2% of patients and peptic ulcer or cholangitis in 4.9% of cases. Restenosis appeared after a mean time of 2.5 years (range 20 months-6 years), supporting the need for a long term follow-up. Effective late results have been reported in 91.5% of patients. No late complications of ineffective results have been observed after transduodenal sphincterotomy. CONCLUSIONS: The authors propose some guidelines for choice charce of treatment, analysing the limits of non surgical therapy and underlying the best surgical tactics. Bilio-enteric anastomosis is a safe, effective and lasting therapy for biliary strictures; Hepp-Couinaud hepatico-jejunostomy is the best choice for high-medium stricture; transduodenal sphincterotomy preserves its important role in low biliary stenosis.

[Intrahepatic bilio-jejunal anastomosis]. / Anastomosi bilio-digiunali intraepatiche.

Personal experience in intrahepatic biliojejunal anastomosis is described, along with the operative tactics and techniques now employed. Stress is laid on the importance of peroperative cholangiography in the division of patients into two groups with respect to drainage of intrahepatic bile, depending on whether or not a wide pathway exists between the two halves of the liver. The strategy to be used for each group is explained.

[Mannhein index in the prognosis and treatment of acute peritonitis]. / L'indice di Mannheim nella prognosi e nel trattamento della peritonite acuta.

BACKGROUND: Early prognostic evaluation of patients affected by acute peritonitis is really desirable to program a correct therapeutic plan, selecting high-risk patients for more aggressive therapeutic procedures. The Mannheim peritonitis index is reliable and easy to apply, so its use is possible without the need of intensive care units. METHODS: Between 1991 and 1995 a total of 235 patients were operated on for acute peritonitis. A retrospective study on this group of patients was performed in order to estimate prognostic reliability of Mannheim peritonitis index. RESULTS: The overall mortality was 8.1%; for patients with a score less than 26 the mean mortality rate was 2% and for score greater than 26, 40.5%. This score is the threshold over which the therapeutic approach have to be more aggressive; planned multiple laparotomies or the open abdomen technique could be the best options to explore and clean up the peritoneal cavity from septic debris. In personal experience, all patients who died had residual sepsis in peritoneal cavity.

[Repair of inguinocrural hernias with subperitoneal prostheses]. / La riparazione delle ernie inguino-crurali recidive con protesi sottoperitoneali.

An original technique for the repair of recurrent inguinocrural hernia destruction of the inguinal ligament is presented. A prosthetic lamina is applied in the subperitoneal space against the deep fascia of the inguinocrural musculature. It is held in place by intra-abdominal pressure and ordinary stitches. The subumbilical median route is used and the peritoneum and hernia sac are stripped from the abdominal wall.

[The axillo-axillary bypass]. / Il by-pass axillo-axillare.

Personal experience with two cases of symptomatic occlusion of the subclavian artery treated with axillo-axillary by-pass is reported. The operating technique, in which the second portion of the axillary artery and a dacron blood conductor are employed, is described and the various transthoracic and extrathoracic operations that have been proposed are reviewed along with the advantages and disadvantages of each. It is concluded that axillo-axillary by-pass is a simple solution for a complex haemodynamic, clinical and therapeutic problem.

[Current trends in the therapy of bleeding duodenal ulcer]. / Orientamenti attuali di terapia nell'ulcera duodenale sanguinante.

A distinction is drawn between two main groups of patients with continuous and massive haemorrhage respectively in bleeding duodenal ulcer, and the criteria upon which this distinction is based are described. The two main types of surgery proposed for the treatment of this complication of duodenal ulcer (vagotomy and gastric resection) are examined. The conclusion is drawn that vagotomy (truncular with drainage, or superselective with or without drainage) is to be preferred to gastric resection in the light of personal experience, and with particular reference to operative mortality and the recurrence of haemorrhage and ulcers.

[Perforated duodenal ulcer. Personal experience]. / Ulcera duodenale perforata. Nostra esperienza.

Reference is made to personal experience in affirming that the treatment of perforated duodenal ulcer should set out to resolve both the perforation and the ulcer at the same time. Troncular vagotomy combined with pyroloplasty is put forward as an effective way of achieving this, and long-term results on a par with those obtained electively are described.

[Surgery after neo-adjuvant therapy of non-small cell lung cancer. Preliminary results]. / Chirurgia dopo terapia neo adiuvante del cancro del polmone non a piccole cellule. Risultati preliminari.

The Authors report their personal experience of surgical treatment following neo-adjuvant therapy in NSCLC (III a N2) in order to assess: 1) the feasibility and safety of surgical treatment following major responses to neoadjuvant chemotherapy; 2) the sectile rate; and 3) the survival rate. Preliminary results show that: 1) chemotherapy using cisplatin and VP-16 gives a high rate of major responses in these patients; 2) surgery is feasible; 3) there is high radical sectile rate; 4) further research is needed to obtain statistical significance.

[Hemobilia caused by rupture of a false aneurysm of the left branch of the hepatic artery]. / Emobilia da rottura di falso aneurisma del ramo sinistro dell'arteria epatica.

The pathogenetic and diagnostic features of false aneurysm of the left branch of the hepatic artery are discussed in the light of a personal case. It is felt that ligation of the vessel constitutes the treatment of choice, whereas hepatic resection should be undertaken in the case of very peripheral aneurysms.