Comparison of Tonic vs. Burst Spinal Cord Stimulation During Trial Period.

BACKGROUND: Spinal cord stimulation (SCS) is a well-known treatment in patients with failed back surgery syndrome (FBSS). Burst stimulation is a recently developed stimulation modality that seems to be superior to tonic stimulation. METHODS: This observational multicenter study compared tonic and burst stimulation during a trial period in patients with FBSS or radiculopathy. All the patients enrolled underwent two weeks of tonic stimulation followed by another two weeks of BurstDR stimulation, without randomization. The primary outcome was the reduction of pain in the legs and back. Health-related quality of life (EQ-5D) and the pain catastrophizing scale (PCS) were assessed before and after the trial. Patients were reevaluated after 12 months. RESULTS: We recruited 23 patients, 57% of whom had FBSS and 43% had radiculopathies. Five patients failed both the tonic and burst stimulation trials. While tonic stimulation reduced leg pain (p < 0.05), the burst mode added an extra pain reduction (ΔNRS 1.2 ± 1.5) (p < 0.01). No significant reduction in back pain was found (p 0.29). Pain on movement was reduced only by BurstDR (p < 0.01). Both stimulation modalities increased EQ-5D and reduced PCS from the baseline (p < 0.0001). At the end of the SCS trial phase, 26% patients chose tonic SCS, while 74% preferred burst. On 12-month follow-up examination, the benefits recorded at the end of the trial were maintained. CONCLUSIONS: Burst stimulation confers a greater reduction in leg pain intensity at rest and on movement. Reducing axial pain is still a challenge. Further studies are needed in order to provide each patient with the most appropriate stimulation paradigm.

Preoperative interleukin-2 immunotherapy in pancreatic cancer: preliminary results.

BACKGROUND/AIMS: Cancer patients' immunodeficiency, made worse by surgery, represents a poor prognostic factor for postoperative complications and long-term survival. Interleukin-2 has been shown to contrast the immunodeficiency related to the tumor and surgical treatment. The aim of this study is to evaluate the effectiveness of preoperative immunotherapy with interleukin-2 in pancreatic cancer patients. METHODOLOGY: 19 patients with pancreatic cancer undergoing radical surgery were divided in 2 different groups. Group 1: 9 patients treated with preoperative Interleukin-2 (9 million IU of IL-2 s.c. for 3 consecutive days) followed by pancreaticoduodenectomy after 36 hours; group 2: 10 patients who underwent pancreaticoduodenectomy without any neoadjuvant treatment. Two groups were well matched for age, sex, stage of disease, preoperative tumor markers and preoperative hematological assessment. Inflammatory cells' infiltration on the resected specimens, pre- and postoperative blood lymphocyte counts were evaluated as well as postoperative complications and survival and compared between the groups. RESULTS: Hematological and histological findings showed no significant difference between the 2 groups. Postoperative complications were more frequent in the control than in the treated group (p<0.05). Two-year survival was 33% in the treated group compared with 10% in the control (p<0.05). CONCLUSIONS: Preoperative Interleukin-2 administration seems to achieve a positive effect on postoperative complications and survival in pancreatic adenocarcinoma.

Laparoscopic repair of a Morgagni-Larrey hernia.

Morgagni-Larrey hernia is a congenital type of diaphragmatic hernia. It is quite uncommon, particularly when it occurs on the left side of the diaphragm. This is a report of a case of a large left-side diaphragmatic hernia through the foramen of Morgagni treated by laparoscopy. The hernia was repaired by incorporating and fixing a polypropylene double-filament mesh into the defect, leaving the sac in mediastinum. The patient recovered promptly after the hernia repair, and there was no recurrence or complaints 30 months after surgery. Our conclusion is that laparoscopically repairs of Morgagni hernias with a prosthetic material are a safe and effective treatment. A literature review also shows that laparoscopic techniques are the gold standard in diaphragmatic hernias repairs.

Management of small bowel tumors: personal experience and new diagnostic tools.

Small bowel tumors are uncommon lesions that are infrequently suspected. We analyzed the clinical presentation, traditional and new diagnostic tools, surgical treatment, and survival in our experience. This was a retrospective review of 45 patients with small bowel neoplasm over a 20-year period. Preoperative diagnosis was made only in 17 cases (38%). One lesion was shown using a new diagnostic system: wireless capsule endoscopy (WCE). All patients underwent surgery. Mean 5-year overall survival for malignancies was 23%. Female sex and localized disease were positive prognostic factors for survival. Small bowel neoplasms must be considered in differential diagnosis in patients with abdominal symptoms, weight loss, and intestinal bleeding. Because the preoperative diagnosis rarely is made with traditional diagnostic tools, patients are seen late in the course of the disease, and the prognosis is poor. WCE is useful for identifying lesions earlier than by other diagnostic procedures.

Pancreaticoduodenectomy for pancreatic metastases from breast carcinoma.

CONTEXT: Unlike primary pancreatic carcinoma, metastases to the pancreas are rare events and their resection may be performed as a palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases from breast carcinoma. CASE REPORT: Three patients underwent pancreaticoduodenectomy for pancreatic metastases from breast carcinoma between 1990 and 2002. The clinical features of and the results after resection were examined. The presenting clinical symptoms were jaundice, pain and weight loss. In all cases, the pancreatic metastases were solitary lesions located in the head of the pancreas and the intervals between the primary breast carcinoma and the pancreatic metastases were 3, 5 and 7 years. The primary tumor was lobular carcinoma. Metastases were initially misdiagnosed as primary cancers. All patients underwent pancreaticoduodenectomy. One patient died from disseminated metastatic disease 26 months after surgery. The other two patients are alive 37 and 21 months after pancreaticoduodenectomy; the second one has had recurrence of the disease. CONCLUSION: In rare cases, the pancreas may be the presenting site for breast metastases, typically years after treating the primary tumor. Pancreaticoduodenectomy can be performed in the absence of extreme metastatic disease; it can provide worthwhile palliation and improve survival.

Alteration of hypothalamus-pituitary-adrenal glands axis in colorectal cancer patients.

BACKGROUND/AIMS: in advanced cancer patients a cell-mediated immunological impairment, both at baseline and during postoperative period (surgical trauma response) is often found and is associated with poor prognosis. Furthermore it is well known that cortisol is strictly involved in the response to major surgical stress, has an important immunosuppression activity and causes a redistribution of immunological population cells in different tissues. The aim of the study was to verify serum levels and circadian rhythm of cortisol and ACTH in patients with colorectal cancer at baseline before surgery and in the postoperative period, and relate it to the immune status. METHODOLOGY: 40 patients (22 female, 18 male with a median age of 66 yrs) with histologically proven colorectal cancer undergoing to surgery were enrolled in the study. Assessment of total lymphocyte, CD4+, cortisol level, circadian rhythm of cortisol (11 pm and 8 am) was performed at baseline and in 3rd and 7th postoperative days. ACTH levels (11 pm and 8 am) were studied in 18 patients. RESULTS: increase of cortisol serum level in the post-operative period vs baseline was statistically significant both in 3rd and 7th days. A significant decrease of total and CD4+ lymphocytes count was found on both 3rd and 7th postoperative days compared to baseline and to normal values. The rate of patients with an altered circadian rhythm was 68% and 53% at 3rd and 7th postoperative days respectively. At baseline 28% of patients had an altered cortisol circadian rhythm and it was significantly more frequent in patients with nodal involvement (P<0.005) and with metastatic spread (P<0.004). 44% of 18 patients evaluated for ACTH circadian rhythm displayed an alteration and it was significantly higher in patients with nodal involvement and metastatic disease (P<0.05). No relations between lymphocytopenia and alteration of night-cortisolemy, day-cortisolemy and cortisol and ACTH circadian rhythm were found, neither at baseline, 3rd and 7th postoperative days. CONCLUSIONS: it is known that lymphocytopenia, both at baseline and in the postoperative period, is associated with a poor prognosis in cancer patients and that cortisol plays an important role in the immune response. Our data show that lymphocytopenia often present in cancer patients, poor prognostic factor, seems not to be associated with ACTH and cortisol level and circadian rhythm alteration, both at baseline and after surgical stress. Otherwise even if paraneoplastic syndromes seems not to be related to colorectal cancer and no patient showed adrenocortical metastasis, an impairment of circadian rhythm of cortisol and ACTH was found at baseline in 28% and 44% respectively. It was significantly associated with the presence of metastatic disease. These preliminary results suggest further investigations on relation between cancer and endocrine system.

Gallbladder carcinoid: a case report.

Carcinoids are neuroendocrine tumours that rarely originate in the biliary tract. We report a case of gallbladder carcinoid associated with cholelithiasis extending to hepatic segments IV and V. The mass was detected by ultrasound in a 71-year-old-man investigated for recurrent right upper quadrant pain irradiating to the back and associated with dyspepsia. Cholecystectomy, locoregional lymphadenectomy and 4th and 5th hepatic segment resection were performed. The patient underwent chemotherapy and was also treated with somatostatin analogues. Despite this, he died after 12 months. We stress the rarity and aggressive behaviour of gallbladder carcinoid.

Surgical treatment of metastatic tumors to the pancreas: a single center experience and review of the literature.

BACKGROUND: Unlike primary pancreatic carcinoma, metastases to the pancreas are rare, and their resection may be performed as palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases. MATERIALS AND METHODS: Between January 1994 and December 2004 13 patients (nine women and four men; median age: 59 years; range: 36-79 years) were admitted to our institution with metastatic lesion to the pancreas. The clinical features of the treatment and results were examined. RESULTS: Primary tumors were renal cell carcinoma (n=5), lobular carcinoma of the breast (n=3), endometrioid carcinoma of the ovary (n=1), colonic adenocarcinoma (n=1), jejunal leiomyosarcoma (n=1), melanoma (n=1), and non-small-cell lung cancer (n=1). The median interval between primary tumor and pancreatic metastases was 36 months (range: 5-192 months). Six patients (46%) were asymptomatic, while the other seven patients presented with jaundice, pain, and duodenal obstruction. Two patients with extrapancreatic disease underwent palliative surgery, and the remaining 11 patients underwent operative procedures that included seven pancreaticoduodenectomy and four distal pancreatectomies with splenectomy. Postoperative mortality was nil, and the morbidity rate was 30%. The two patients who underwent palliative surgery died after 7 and 9 months, respectively. The median survival of the resected patients was 26 months (range: 13-95 months). Five patients died of disease, eight are alive at the time of this report. CONCLUSION: A trend towards improved survival, even if not statistically significant, was observed in the renal carcinoma patients reported here. Surgical resection can be performed safely in selected patients with isolated metastases to the pancreas, achieving long-term survival as well as good palliation.

Palliative management strategies of advanced gastrointestinal carcinoid neoplasms.

BACKGROUND/AIMS: Optimal management of gastrointestinal carcinoid neoplasms that metastasize to the liver is controversial. Although operative resection seems to be the most effective approach to metastatic disease, hepatic metastases are usually multicentric and often non-resectable. We investigated the effectiveness of several forms of palliative tumor cytoreduction followed by administration of somatostatin analogues in advanced carcinoid neoplasms. METHODS: We reviewed our experience with 34 patients with gastrointestinal carcinoid neoplasms. Eighteen patients had metastases and 14 had hormonal symptoms. Twenty-two patients underwent radical surgery, ten with multiple liver metastases were treated with a combination of debulking (resection, radiofrequency ablation, chemoembolization), followed by medical treatment with long-acting octreotide and eventually by radiolabelled somatostatin analogues, and two patients with intractable disease received only biotherapies. RESULTS: The six patients with metastatic disease who underwent radical curative liver resection had a median survival of 52 months, compared with a median survival of 48 months in the ten patients who underwent palliative debulking. Symptomatic improvement was observed in all the patients after debulking procedures. The two patients who underwent only medical treatment died after 9 and 18 months. CONCLUSIONS: Aggressive tumor debulking should be performed in patients with liver metastases already at diagnosis even when complete resection is not feasible because the combination of cytoreductive procedures followed by biotherapies may provide good long-term survival and achieves symptom control in most patients with advanced disease.

Colorectal cancer with neuroendocrine differentiation in a child.

Colorectal cancer is extremely rare in children and presents with a poor prognosis because of the delay in diagnosis and lack of histological differentiation. We report a case of a sigmoid colon carcinoma with areas of neuroendocrine cells in a 12-year-old patient without familial occurrence of colorectal cancer. Symptoms at presentation were anaemia, anorexia, abdominal pain and weight loss. The patient was treated with radical resection and adjuvant chemotherapy. One year later, a local recurrence and hepatic metastases were diagnosed and she underwent chemotherapy and surgical resection. Twenty-six months from initial diagnosis she is alive with evidence of disease. The clinical presentation, diagnosis and treatment of the previously reported cases of colorectal cancer in children are also reviewed.