Phyllodes tumor of the breast: problems of differential diagnosis and therapeutic approach from an analysis of 17 cases.

Retrospective analysis of 17 cases of phyllodes tumor with a follow-up of almost 1 year revealed no close correlation between histological pattern and clinical course, since local relapse occurs even after histological findings of benign lesion in the primary tumor. Phyllodes and fibroadenoma patterns are often associated in the same patient and extensive surgery is not recommended owing to the fact that recurrences are observed both after subcutaneous mastectomy and after simple resection. We conclude that local control of the disease by wedge resection and strict follow-up may be the most rational approach.

Mastectomy and immediate breast reconstruction: oncological considerations and evaluation of two different methods relating to 88 cases.

The authors consider 88 cases of mastectomy and immediate breast reconstruction mainly performed using the skin expander plus prosthesis method or latissimus dorsi myocutaneous flaps. At the same time, 53 patients underwent contralateral mastopexy for symmetry. The mean follow-up was 21 months (range 2-102). Progressive disease was observed in nine cases: one patient presented scar relapse, one axillary relapse, two contralateral tumor, two contralateral tumor and distant metastasis, three distant metastases and one death from distant metastasis. Reconstruction complications were capsular contracture in 12 cases, infection in nine, skin necrosis in two, skin expander breakage in three and implant dislocation in one. The final result was judged good in 54 cases, fair in nine, poor in 11 and unevaluable in 14. In conclusion immediate breast reconstruction does not seem to interfere with the disease or oncological therapy. After analysing separately, and comparing the results and complications of the two main techniques used, latissimus dorsi seems to be the most reliable method in the majority of cases but skin expanders can be a good technique in patients with small and firm breasts and without complicating risk factors.

[Thoracoplasty today. Review of a technique of the past]. / La toracoplastica oggi. Rivisitazione di una tecnica del passato.

Thoracoplastic operations had ruled the field in the past as treatment of choice in the surgical antituberculous collapse therapy; they have had a notable revival during the last years as an efficient therapeutic modality in the treatment of chronic empyemas of the most various etiologies. They are thoracoplasties done with particular modalities, imposing, setting out case by case to suppress the infected pleural space. It is usually joined with a thoracotomy and it permits also the execution of other surgical intrathoracic manoeuvres such as decortications, treatment of fistulas, myoplasties. Situations such as chronic empyemas, without any solution before, have found a brilliant solution by the use of this operation.

Cholecystostomy and PTBD in the treatment of obstructive jaundice (a comparative study).

The Authors compare two groups of patients suffering from obstructive jaundice due to neoplasia of the head of the pancreas or the terminal bile duct who undergo bile drainage by means of cholecystostomy via the percutaneous transhepatic route, in order to reduce icterus, and subsequently undergo a duodenocephalopancreatectomy. The two groups are then compared with a third group in which duodenocephalopancreatectomy was performed without a preoperative reduction in the jaundice. The decrease in bilirubin and alkaline phosphatase, the drainage period, the nature and length of the post-operative course and the average total hospitalisation period are analysed. Whereas the recovery of hepatic function is comparable in the three groups, in the group undergoing percutaneous transhepatic bile drainage the post-operative course is decidedly better (lower morbidity and a shorter period of hospitalisation).

[Major hepatic resections for angioma]. / Resezioni epatiche maggiori per angioma.

6 cases of solitary angioma of the liver, treated with major hepatic resections, are presented (2 rt hemihepatectomies - 2 lt hemihepatectomies - 1 lt lateral sect. and 1 segmentectomy of the VIth). Their anatomopathological definition (solitary angioma, multiple angiomas, hemangiomatosis) is discussed in relation to the various therapeutic possibilities. From the diagnostic standpoint, an outstanding part is played by angiography. In addition to demonstrating the presence of hepatic mass, C.A.T. can, according to their experience, also allow diagnosis of quality on the basis of demonstration of vascular lacunae. It is considered that the treatment of choice of for solitary angiomas is surgery, which must be performed by skilled surgeons and consist in hepatic resections conduced by typical route. This is especially true for the giant forms, owing to their particular tendency to growth and spontaneous rupture. For small angiomas it is considered better in principle to remove them, generally by small cuneiform resections, unless they are situated in sites difficult to attack surgically and with high risk. In this case frequent check-up is necessary since, although they are sometimes found to be stationary and even in exceptional cases regressive, personal experience (2 cases) has demonstrated a tendency to expansion.

[Surgical treatment of pulmonary metastases of colorectal cancer]. / Il trattamento chirurgico delle metastasi polmonari da cr. del colon retto.

The pulmonary metastatic locations due to colorectal cancer were considered, in not remote times, not worthy of surgical treatment. At present, according to our experience and some other Authors' one, the surgical removal of metachronal pulmonary metastases should be considered suitable to improve the period of life free from symptoms and the survival. The surgical treatment has improved the survival in the single or double pulmonary locations, whereas the monolaterality of multiple pulmonary lesions, in respect of the bilaterality, was not significantly bettered the prognosis (Hiroshi Takita, Francis Edgerton). The survival, moreover, seems to be affected by the interval free from illness and by the doubling time of the metastatic location. The surgical indication to the pulmonary metastasectomy is done on condition of the absence of any metastases in other organs. In our experience, out of 742 interventions with radical purposes for colorectal cancer, we documented 15 cases where lung appeared as the first and sole metastatic filter (many patients were lost for their non-cooperation in the follow-up). In 7 cases pulmonary resections were performed, in patients selected and free from secondary locations in other organs, with a satisfactory result. Casuistry and personal results are reported.

[A rare case of colonic invagination due to leiomyosarcoma]. / Su di un raro caso di invaginazione colica da leiomiosarcoma.

The authors report on a case of leiomyosarcoma with intussusception of the large bowel. They stress the importance of the clinical suspicion in targeting preoperative instrumental instrumental investigations.

[Zuckerkandl tubercle of the thyroid gland (anatomo-surgical study: preliminary considerations)]. / Il tubercolo di Zuckerkandl della tiroide. (Studio anatomo-chirurgico: considerazioni preliminari).

The presence of tubercle of Zuckerkandl (TZ) of the thyroid gland has been investigated in 20 specimens obtained from patients died from diseases not concerned to the cervical area. The project mas undertaken to elucidate the presence and the role of TZ as normal anatomical landmark. Special attempt has been paid to the relationships of the TZ with parathyroid gland and recurrent laryngeal nerve and the branches of the inferior thyroid artery. The tubercle was constantly found on the postero-medial surface of the thyroid lobe which showed constant relations with the branches of the inferior thyroid artery, superior parathyroid gland and recurrent laryngeal nerve. The outcomes of this preliminary report prove that TZ is an useful anatomical landmark to detect both superior parathyroid gland and laryngeal nerve in thyroid surgery.

[Perforation of the esophagus during pneumatic dilatation in achalasia]. / La perforazione dell'esofago nella dilatazione pneumatica per acalasia.

Esophageal perforation is a serious complication of pneumatic dilatation. We studied the cases of 4 patients (2 men and 2 women, mean age 58 years, range 56-62) who had surgical treatment for achalasia, two of which had had previous dilatation. The main symptoms were pain and dyspnea. Pneumomediastinum was present in all patients, pleural effusion in 2 and cervical emphysema in 1. Esophagographic results showed evidence of perforation in all four cases and gastric patches were surgically placed on the esophageal tear within 12 hours. Three patients received enteral nutrition for an average of 13 days. Mean hospital stay was 14 days. No post-operative complications were exhibited although one patient did develop gastroesophageal reflux 3 months later and underwent surgery to repair a hernia in the thorax 5 years later. Early and aggressive treatment is considered the best therapy and the gastric patch, in our opinion, is an effective and reliable technique for esophageal perforation repair in achalasia patients.

Strangulated traumatic hernia of the diaphragm. A report of two cases.

The herniation of abdominal viscera in the thorax can immediately follow diaphragmatic rupture or be delayed even years after the injury. The herniated viscera can strangulate; this consequence may lead to a dangerous misdiagnosis which could be lethal for the patient. Radiological procedures, serial chest X-ray studies, CT and MRI scans are mandatory to confirm diagnosis. The insertion of a naso-gastric tube is a very helpful method in ruling out hypertensive pneumothorax in the presence of an air-fluid level in the thorax. We report 2 cases of strangulated traumatic hernia of the diaphragm occurring just a few hours (case 1) and 18 months (case 2) after the trauma. During thoracotomy, a rupture of the left diaphragmatic cupola was demonstrated with herniation of the stomach in case 1, the stomach, spleen and transverse colon in case 2. No postoperative mortality or morbidity were detected.

Long-term results of aggressive surgical treatment of primary and recurrent retroperitoneal liposarcomas.

The aim of this study was to establish the role of surgery in the treatment of retroperitoneal liposarcomas. Data concerning 28 patients submitted to surgery for retroperitoneal liposarcoma in our department over the period from 1972 to 1999 were reviewed retrospectively and analysed. Seventy-four operations were performed; in 54% of the operations it was necessary to resect contiguous organs (kidney 60%, colon 50%, adrenal gland 35%). In 89%, grossly curative resection was achieved at the first operation; 20 patients had at least one local recurrence after first operation (median time interval: 22 months). The mean follow-up was 80 months; median survival time was 51 months and 5-year actuarial survival time 51%. Patients with low-grade liposarcoma showed a statistically significant improvement (P < 0.001) in median survival (153 months) versus those with medium- (37 months) and high-grade sarcomas (8 months). At present surgery is still the treatment of choice in the treatment of primary and recurrent liposarcoma; in the case of low-grade liposarcomas especially, an aggressive surgical approach can result in long-term survival.

[Anastomotic complications in the surgical treatment of rectal neoplasms]. / Le complicanze anastomotiche nel trattamento chirurgico delle neoplasie rettali.

The authors review the problems relating to the healing of colorectal anastomotic complications following anterior resection. They report on their own experience with 328 anastomoses, 281 of which constructed manually and 47 using a mechanical suturing gun. Following manual anastomosis, the reported incidence of clinical dehiscence was 1%, as against a 10.3% incidence of radiologically detectable dehiscence. In the cases of mechanically produced anastomoses the incidence of clinical dehiscence was 6.4%. In 2 cases stenosis developed as a result of the clinically manifest dehiscence following manual anastomosis. In the patients undergoing mechanical anastomosis, occlusion occurred in one case and stenosis in another, without any concomitant peri-anastomotic inflammatory processes; these complications were caused by a membrane extending between the margins of the anastomosis. The authors ascribe the greater incidence of clinically important dehiscence following mechanical anastomosis to a greater sensitivity of the mechanical suture to colonic contamination compared to the manual suture. According to the authors, the stenosis is attributable to inflammatory processes resulting from the dehiscence in the manual anastomosis cases and from the anastomotic structure in the mechanical-suture case.

[Biliary cystadenoma and cystadenocarcinoma]. / Cistadenoma e cistadenocarcinoma biliari.

The authors present their experience with 5 biliary cystadenomas (BCA) and 1 cystadenocarcinoma (BCAC). BCA are rare but intriguing lesions of the liver for the possibility of the former to evolve into malignant lesion. Preoperative diagnosis is often difficult also at ultrasound and CT scan. The possibility of BCA and BCAC should be always ruled out in every cystic lesion of the liver. In every doubt lesion surgical exploration is indicated and at least a biopsy should be performed. The procedure of choice for BCA is radical resection, while palliative procedures may be justified only in poor risk patients.

[Major hepatectomies in liver neoplasms]. / Le epatectomie maggiori nelle neoplasie del fegato.

The development of major hepatic resective surgery during the last 50 years is due to a better knowledge of both hepatic regenerative capacity and intraparenchymal vascular and biliary anatomy. Two approaches of major hepatic resection have been described: 1) primary hilar approach; 2) primary transparenchymal approach. The authors review the indications of major hepatic resections in the treatment of hepatic tumors and discuss the advantages and the disadvantages of primary hilar and primary transparenchymal approaches, reviewing the data from the literature and the experience gained at the Clinica Chirurgica of the University of Verona from 1970 to 1989 of 289 major hepatic resections.

Delayed traumatic hernia of the diaphragm presenting with hypertensive pneumothorax. Case report and review of the literature.

The diagnosis of traumatic hernia of the diaphragm can be obtained at the time of injury or months-years after the trauma. The Authors report a case of traumatic hernia of the diaphragm, diagnosed 3 years after a blunt thoracic trauma in a 47-year-old man. The patient was admitted to the hospital for a pneumothorax caused by perforation of the herniated colon. He underwent colonic resection and reduction of the herniated viscera but unfortunately he died of septic shock on the 40th postoperative day. Pneumothorax is a very rare complication of traumatic diaphragmatic hernia and few cases are reported in literature. The diagnosis in the delayed phase is not easy since the correlation with the trauma is not always clear.

[Thymoma, aplastic anemia, hypogammaglobulinemia and malignant pulmonary neoplasm: a case report]. / Timoma, anemia aplastica, ipogammaglobulinemia e neoplasia polmonare maligna: presentazione di un caso.

A 67 year old man presented with non-invasive thymoma, associated aplastic anemia and important hypogammaglobulinemia; the postoperative course has been characterized, three months later, by thrombocytopenia (kept under control with steroid therapy) and, two years later, by squamous lung cancer, not susceptible of surgical treatment. The patient died five years after operation because of progression of the lung cancer. Anemia improved only partially after operation; there where no effects on hypogammaglobulinemia. Thymoma has been reported in literature in 50% of patients with aplastic anemia, 7-13% of adult patients with hypogammaglobulinemia is affected by thymoma, in 21% of patients that presented with thymoma other tumors have been discovered through clinical history.