Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies.

BACKGROUND: Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy. METHODS: We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression. RESULTS: On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced. CONCLUSIONS: Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Deregulated expression of Aurora kinases is not a prognostic biomarker in papillary thyroid cancer patients.

A number of reports indicated that Aurora-A or Aurora-B overexpression represented a negative prognostic factor in several human malignancies. In thyroid cancer tissues a deregulated expression of Aurora kinases has been also demonstrated, but no information regarding its possible prognostic role in differentiated thyroid cancer is available. Here, we evaluated Aurora-A and Aurora-B mRNA expression and its prognostic relevance in a series of 87 papillary thyroid cancers (PTC), with a median follow-up of 63 months. The analysis of Aurora-A and Aurora-B mRNA levels in PTC tissues, compared to normal matched tissues, revealed that their expression was either up- or down-regulated in the majority of cancer tissues. In particular, Aurora-A and Aurora-B mRNA levels were altered, respectively, in 55 (63.2%) and 79 (90.8%) out of the 87 PTC analyzed.A significant positive correlation between Aurora-A and Aurora-B mRNAs was observed (p=0.001). The expression of both Aurora genes was not affected by the BRAFV600E mutation. Univariate, multivariate and Kaplan-Mayer analyses documented the lack of association between Aurora-A or Aurora-B expression and clinicopathological parameters such as gender, age, tumor size, histology, TNM stage, lymph node metastasis and BRAF status as well as disease recurrences or disease-free interval. Only Aurora-B mRNA was significantly higher in T(3-4) tissues, with respect to T(1-2) PTC tissues. The data reported here demonstrate that the expression of Aurora kinases is deregulated in the majority of PTC tissues, likely contributing to PTC progression. However, differently from other human solid cancers, detection of Aurora-A or Aurora-B mRNAs is not a prognostic biomarker in PTC patients.

Triple synchronous tumours of the urinary system with different histologies: a case report.

We present the case report of a male patient with a diagnosis of synchronous kidney, bladder and prostate tumours with different histologies: renal oncocytoma, urothelial carcinoma of the bladder, and adenocarcinoma of the prostate. This is the first case report described in the literature in which a complete surgical resection of triple tumours has been performed with surgery in a single session. Recent advances in the field of genetics enable the surgeon to hypothesise new strategies in the early treatment of synchronous tumours, particularly when a number of common tumour markers are positive. One such marker recently identified is the prostate-specific membrane antigen (PSMA), present with high expression in carcinoma of the prostate and in the vascular endothelium of solid tumours; only overexpression of PSMA is to be regarded as diagnostic, inasmuch as this antigen is normally expressed in the renal tubular epithelium. Recent knowledge in the field of genetics has led to new strategies for the early treatment of synchronous tumours, but clinical data and instrumental diagnostics are still of fundamental importance, in that they may enable the surgeon to diagnose the presence of synchronous tumours at an early stage. The execution of prompt surgical treatment remains of basic importance for the purposes of guaranteeing oncological radicality also of synchronous tumours, in association with more sensitive and accurate instrumental diagnostics.

A rare case of aggressive squamous-cell carcinoma of the breast skin: Marjolin's ulcer. A case report.

Marjolin's ulcer is an epidermoid carcinoma arising in a scar or chronic wound and is characterised by an aggressive course. We present a clinical case of ulcerated skin carcinoma of the breast arising in an 80-year-old woman, who at history taking reported a burn occurring 30 years earlier on the breast skin, with subsequent chronic ulcerative scar formation. The definitive histological examination identified a "squamous-cell carcinoma of the breast skin". We have assessed this case and reviewed the literature on Marjolin's ulcer. The patient presented a metastatic relapse of local disease after aggressive surgical treatment. In the clinical history of patients with chronic ulcers it is important to analyse the morphological changes with biopsies and subsequently with the most appropriate diagnostic techniques for the purposes of early initiation of a therapeutic program, since, in the advanced stages, even an aggressive surgical treatment may prove inadequate.

Simultaneous occurrence of medullary carcinoma and papillary microcarcinoma of thyroid in a patient with MEN 2A syndrome. report of a case.

We report a case of simultaneous multifocal medullary carcinoma and papillary microcarcinoma in a patient with several distinctive features of MEN 2A. The patient underwent total thyroidectomy and central lymph node dissection. The extreme rarity and pathological features of this occurrence are discussed. There is no known common cause of these 2 different tumor types; it may be a stochastic exception. However, several other possibilities such as a common precursor cell or a common tumorigenic stimulus offer interesting perspectives for speculation.

The sentinel lymph node in papillary cancer of the thyroid including histological subtype.

BACKGROUND: The aim of this work was to reveal through sentinel node study the intraoperative presence of preoperatively undetected pathological lymph nodes. MATERIALS AND METHODS: At the Surgical Science Department of La Sapienza University of Rome The Authors studied from January 2003 to June 2004 18 patients with papillary carcinoma of the thyroid, who presented no clinical evidence of lymph node metastasis; they performed a total thyroidectomy in all cases, removing and histologically examining all lymph nodes of the upper anterior mediastinum. Where negative they were then subjected to immunohistochemical analysis with Pan Cytokeratin. RESULTS: The method was positive in 10 patients: 2 pure papillary carcinomas, 1 papillary carcinoma with poorly differentiated areas, 1 tall cell papillary carcinoma, 5 sclerosing carcinoma and 1 follicular variant papillary carcinoma; and negative in 8:5 pure papillary carcinomas, 2 sclerosing carcinoma and 1 case of follicular variant papillary carcinoma. Lymph node micrometastasis was found in 2 cases through study with Pan Cytokeratin on final histological examination. CONCLUSIONS: Analysis of the Authors' preliminary data shows that sentinel lymph node detection has 83.3% sensitivity and 100% specificity for Upper Anterior Mediastinum lymph nodes. The Authors can propose two main applications: select for dissection only patients with a positive sentinel node and reduce the number of cases to be subjected to postoperative treatment with iodine ablation, in patients with "low risk" thyroid tumours and negative sentinel nodes.

Papillary thyroid carcinoma in thyroglossal duct cyst: case reports and literature review.

Although thyroglossal duct cysts represent a common developmental abnormality of the thyroid gland, malignant transformation is rare and occurs in only 1% of cases. This article describes four clinical cases observed at the Surgical Science Department of "La Sapienza" University of Rome between 1996 and 2000. Histologic examination indicated two pure papillary carcinomas, a sclerosing papillary carcinoma, and a follicular variant of papillary carcinoma. In all cases, treatment involved removal of the body of the hyoid bone and total thyroidectomy, which we associated with removal of the thyroglossal duct cyst. In one case, laterocervical lymphectomy was performed. Carcinoma multifocality was found in one patient. We recommend associating total thyroidectomy with removal of the tumor of the thyroglossal duct and of the body of the hyoid bone, because the carcinoma may be multifocal and there may be lymphatic invasion of the thyroid and to ensure a correct follow-up.

Prognostic importance of sclerosing variant in papillary thyroid carcinoma.

The diffuse sclerosing variant (DSV) of papillary thyroid carcinoma is known for its high aggressiveness, high incidence of lymph node metastases, and high incidence of pulmonary metastases, and thus its consequently poorer prognosis. In this study, we undertook a retrospective analysis of papillary thyroid carcinomas to assess whether DSV can be considered a predictive factor for prognosis. We performed a retrospective evaluation of the Department's database of patients with papillary thyroid carcinoma who had undergone total thyroidectomy from January 1992 to December 2000. Group I consisted of 83 DSV patients and Group II was 168 pure papillary carcinoma (PC) patients. A significant prevalence of multinodular thyroid disorder on diagnosis was found for PC (P < 0.05), whereas with DSV, there was a significantly higher prevalence of post-thyroiditis nodular thyroid disorder than with PC (P < 0.001). The incidence of laterocervical lymph node pathology on diagnosis was significantly higher for DSV (P < 0.05). In 3.6 per cent of PC patients and 15.7 per cent of DSV patients, we observed recurrences in the regional lymph nodes (P < 0.001). We found 1.2 per cent distant metastases in PC patients and 7.2 per cent in DSV patients (P < 0.05). One PC patient (0.6%) and three DSV patients (3.6%) died of tumor-related causes (P < 0.05). Our study demonstrated that diffuse sclerosing carcinoma leads to a poorer prognosis to the extent that its classification as an autonomous clinical pathological entity is justified. In conclusion, we can state that DSV is a form of papillary thyroid tumor characterized by its higher aggressiveness, diffuse intrathyroid growth, and high incidence of lymph node and pulmonary metastasis. Ultimately, this means a poorer prognosis. In the presence of risk factors indicating a possible increase in biological aggressiveness, adequate postoperative treatment and close follow-up become essential.

Bilateral synchronous parathyroid carcinoma in a patient on long-term hemodialysis: presentation of a rare clinical case and review literature.

Synchronous bilateral carcinoma of the parathyroid in subjects undergoing prolonged hemodialysis is an extremely rare pathology. After observing a clinical case, we reviewed the literature on parathyroid carcinoma. We describe the clinical case of a 61-year-old man with synchronous bilateral carcinoma of the parathyroid. He had a long history of terminal renal insufficiency and had been undergoing hemodialysis for about 18 years before being referred to us with a diagnosis of secondary hyperparathyroidism. The patient underwent total parathyroidectomy and total thyroidectomy. The interoperative parathormone assay displayed a 68% decrease in parathyroid hormone (PTH) compared with baseline value, and the histologic examination of the two inferior parathyroid glands revealed the presence of invasive parathyroid carcinoma. After reviewing the case, we hypothesized that in the presence of chronic parathyroid stimulation, the hyperplasia of the gland may subsequently be transformed into carcinoma. In patients undergoing hemodialysis, the predominance of females in cases of carcinoma of the parathyroid might be accounted for by a hormonal mechanism or by statistical artifacts attributable to the small number of case histories available. Further analysis was made of the apparently favorable prognosis of this type of patient compared with sporadic parathyroid carcinomas; the mean follow-up period reported in the literature was 42.2 months, with a relapse rate of 15.8%.

Sclerosing papillary carcinoma arising in a lingual thyroid: report of a case.

Ectopic lingual thyroid tissue is an uncommon congenital anomaly. Tumors with identical pathological characteristics to those arising in thyroid tissue may be present in ectopic locations, but there are very few cases of malignant ectopic thyroid tumors reported in the literature. We present a review of this phenomenon and report a case of papillary carcinoma of the base of the tongue, located in ectopic lingual thyroid tissue, in a 30-year-old woman. The patient's presenting symptoms were dysphagia and oral bleeding, and we performed radical resection of the neoformation at the base of the tongue with part of the muscles of the floor of the mouth and the body of the hyoid bone, as well as total thyroidectomy. Histological examination revealed a "sclerosing" papillary carcinoma. The patient was treated with 131I and substitutive thyroid hormonal therapy. An ultrasonogram done 5 years later showed bilateral laterocervical lymph node recurrence, which was effectively treated with bilateral laterocervical lymphectomy.

Prognostic importance of histologic vascular invasion in papillary thyroid carcinoma.

OBJECTIVE: To conduct a retrospective study of 39 patients with papillary carcinoma of the thyroid with histologic vascular invasion (VI+) and 361 patients without any sign of vascular invasion (VI-). SUMMARY BACKGROUND DATA: In the present study, we undertook a retrospective analysis of papillary carcinoma of the thyroid to assess whether histologically determined vascular invasion can be considered a predictive factor for prognosis. METHODS: By means of a retrospective study, we evaluated the department's database of patients with papillary thyroid carcinoma who had undergone total thyroidectomy from January 1993 to December 1999. RESULTS: Group I consisted of papillary carcinoma without any sign of vascular invasion (VI-) comprising 361 patients. Group II consisted of papillary carcinoma with vascular invasion (VI+) comprising 39 patients. At the time of diagnosis, we observed no metastases in patients with VI-, whereas a pulmonary metastasis was observed in 1 patient with VI+ (P = 0.0023). In 3.6% patients with VI- and in 20.5% patients with VI+, we observed recurrences in the regional lymph nodes (P < 0.001); we observed 6 (1.66%) distant metastases in patients with VI- and in the 12.8% patients with VI+ (P < 0.001). Three patients with VI+ (7.7%) and 2 patients with VI- (0.6%) died of tumor-related causes; these figures were found to be statistically significant (P < 0.001). CONCLUSIONS: In papillary carcinoma, it should be noted that histologic vascular invasion may be considered as a sign of an increased tendency toward hematogenic invasion and consequent increase in the relative percentage of metastases; ultimately, this means a poorer prognosis. In the presence of risk factors indicating a possible increase in biologic aggressiveness, adequate postoperative treatment and close follow up become essential.

Prognostic significance of the age factor in the thyroid cancer: statistical analysis.

BACKGROUND AND OBJECTIVES: To determine whether thyroid carcinoma in elderly patients presents any peculiar characteristics, whether the greater biological aggressiveness of the neoplasm modifies the surgical treatment selected, and whether age greater than 70 years represents an independent prognostic factor. METHODS: Retrospective analysis of case histories from the Department of Surgery of "La Sapienza" University of Rome; 403 patients subjected to total thyroidectomy between 1993 and 1999, with a minimum follow-up period of 3 years subdivided into three groups: group I (patients aged between 20 and 50 years), group II (patients aged between 51 and 70 years) and group III (patients aged >70 years). The surgical and postoperative treatment is uniform in all study groups. RESULTS: Age greater than 70 years entails a significant increase in mortality; the mortality rate in the three groups was found to be 3%, 9% and 54%, respectively. Prognosis is significantly worse in the elderly patients group (group III) than in group I (P < or = 0.001) and in group II (P < or = 0.001); group II mortality was significantly higher than that of group I (P = 0.005); in group III, the neoplasm displays features of greater biological aggressiveness (greater incidence of undifferentiated forms, presence of lymph nodes at diagnosis and vascular invasion, locally advanced forms, greater incidence of stage IV). CONCLUSIONS: Statistical analysis shows that the greater biological aggressiveness of the neoplasm in elderly patients worsens the prognosis, although an age exceeding 70 years itself represents an unfavourable prognostic factor; total thyroidectomy does not present any counter-indications in elderly patients.

Epithelioid haemangioendothelioma of the parotid salivary gland: a case report.

Haemangioendothelioma is a vascular tumour characterised by the proliferation of endothelial cells with an epithelioid appearance. The behaviour of this neoplasm is intermediate between haemangioma and angiosarcoma. It may be localised in a wide range of sites, with a preference for soft and bone tissue. It is only rarely localised in the head and neck and even more rarely in the salivary glands. We describe a case of haemangioendothelioma in a 28-year-old man that originated in the retroneural region of the parotid gland, compressing the gland tissue and posteriorly infiltrating the muscular plane. A total parotidectomy surgical operation including the removal of lymph nodes in the region was performed followed by radiotherapy. An immunohistochemical investigation, carried out using the oxidase-antiperoxidase method, indicated that the neoplastic elements of the marker of the endothelial cells CD34 were positive for vimentine and for muscle-specific actin, showing a moderate proliferative action of the cellular elements with MIB-1 positivity estimated at around 6%. The peculiarity of the case we describe resides in the rarity of the haemangioendothelioma localisation in the parotid gland.

Prognostic factors of insular versus papillary/follicular thyroid carcinoma.

The study aims were to characterize patients with insular thyroid cancer and to provide data on patient outcome after surgical therapy. We compared nine patients with insular thyroid cancer at the Department of Surgical Science of "La Sapienza" University of Rome with 27 patients of similar age and tumor size who had follicular and papillary cancer, for a minimum follow-up period of 24 months (range, 24-72 months). All of the patients examined underwent total thyroidectomy. Vascular invasion was observed in 44.4 per cent of insular carcinomas (P < 0.05 vs papillary carcinomas). No significant differences were observed regarding diagnostic method, multifocality, tumor nodes metastases (TNM), or stage. The death rate of patients with insular carcinoma (33.3%) was found to be higher than that of patients with follicular carcinoma (P < 0.05) and papillary carcinoma (P < 0.01). Relapsing lymph-node pathologies were observed in 4 patients (44.4%) with insular carcinoma (P < 0.05 vs those with follicular and papillary carcinomas). Distant metastases were observed in 66.6 per cent of insular carcinomas (P < 0.005 vs follicular carcinoma and P < 0.001 vs papillary carcinoma). At the end of follow-up, 2 patients (22.2%) with insular carcinoma were disease-free (P < 0.001 vs those with follicular and papillary carcinomas). Our study demonstrates an unfavorable prognostic role of the insular phenotype of thyroid cancer, such that this tumor can be classified as an autonomous clinical and pathological entity.

Synchronous bilateral renal tumour: a case report.

We report a case of synchronous bilateral renal carcinoma treated by partial nephrectomy on the right and total nephrectomy on the left. Follow-up at 42 months after surgery showed no recurrence of the disease. The increasing use of diagnostic imaging techniques such as ultrasound tomography, computerised tomography and nuclear magnetic resonance now allows even small-sized renal formations to be identified. Synchronous bilateral renal tumour has a favourable prognosis, especially when compared with single or asynchronous renal tumours. The recommended intervention is total monolateral nephrectomy combined with partial nephrectomy. The treatment of neoplasms at a more advanced stage, of such a nature as to necessitate bilateral nephrectomy or chemotherapy, results in a significant increase in mortality. Recently, biological therapy has been proposed as a more promising short-term option using interferon-alpha (IFN-alpha) and gamma.

Control results on a sample of patients subjected to total thyroidectomy for papillary carcinoma: proposal for a personal diagnostic-therapeutic follow-up.

Well-differentiated thyroid neoplasms may be included among the most frequently occurring thyroid carcinomas. Papillary ca. is without doubt the best behaved type. The aim of the present work is to perform a retrospective case history study to assess patients with con papillary ca. who have been treated surgically over the last 17 years and have been subjected to periodic checks. A sample of patients was therefore extrapolated who had all undergone total thyroidectomy for papillary ca. of the thyroid. The incidence of local recurrence of the disease was verified, together with the results at distance. Furthermore, the assessments performed were evaluated and compared. From the sample of patients observed we inferred that papillary carcinoma of the thyroid can have a good prognosis over time provided periodic random checks are carried out.

Relapsing secondary hyperparathyroidism due to multiple nodular formations after total parathyroidectomy with autograft.

Total parathyroidectomy with autograft represents an optimal surgical technique in the treatment of secondary hyperparathyroidism. Relapsing hyperparathyroidism due to miliary-type nodular formations scattered over the autograft site represents a complication that is rarely described in the literature. We examined five case histories of patients relapsing as a result of miliary-type nodular formations in the autograft site; in four cases the relapse was localized in the upper limb and in one case in a pouch of the sternocleidomastoid muscle. The patients underwent removal of the hyperfunctioning parathyroid formations accompanied by demolition of the surrounding muscle tissue. The relapsing hyperparathyroidism caused by multiple miliary-type nodular formations is a rare occurrence, akin to parathyromatosis. The increasingly widespread use of total parathyroidectomy with autograft to treat secondary hyperparathyroidism can lead to an increase in the incidence of this complication. Correct surgical technique and a careful selection of the parathyroid tissue to be autografted can prevent this complication. Furthermore, extensive demolition of the muscle tissue in the autograft site can prevent further relapses. Intraoperative rapid parathormone assay was found to be predictive of the disease's persistence and recurrence.

[Ontogenesis of congenital abnormalities of the left gonadal vein and their clinical relevance]. / Ontogenesi delle anomalie congenite della vena gonadica sinistra e loro rilevanza clinica.

The anatomy of the gonadal vein has been the subject of several studies relating particularly to the aetiology and therapy of varicocele and left ovarian vein syndrome. Venography shows the presence of valves, the collateral branches, the anastomoses between the left gonadal vein and the retroperitoneal venous networks and the effective pathways of venous reflux. The authors observed a particular congenital anomaly of the left gonadal vein in the dissection of a female cadaver, and studied the venographic pattern of a male patient with left idiopathic varicocele. The aim of this study was to investigate, with the aid of a review of the literature, the embryo-pathogenetic basis of congenital abnormalities of the left gonadic vein, stressing those factors most conducive to errors in the diagnosis and therapy of varicocele and left ovarian vein syndrome, particularly in the scleroembolisation therapy of idiopathic varicocele.

Peripheral primitive neuroectodermal tumor (PPNET) of pelvic origin: report of a case arising from an unusual location.

We report a rare case of a peripheral primitive neuroectodermal tumor (PPNET) originating from the left ileopsoas muscle in an adult patient with neoplastic thrombosis of the left external iliac vein, the common femoral vein and the left popliteal vein. We performed a median laparotomy with an oblique left inguinal incision to remove the neoplasm, which consisted of a large mass surrounding the iliac-psoas muscles, extending from the transverse apophysis of the spinal column to Scarpa's triangle, and passing through the lacuna musculorum. Histopathological examination revealed a primitive neuroectodermal tumor (PNET) with focal areas of necrosis, hemorrhage and vascular invasion. Immunophenotyping was positive for CD99, NSE, and focally for CK. Ultrastructural examination of the neoplastic cells showed often multiple nuclei with dense chromatin and very large nucleoli. The patient was discharged ten days after the operation. Adjuvant treatment consisted of radiotherapy at a dose of 2000 cGy in five fractions followed by six cycles of chemotherapy. The venous thrombosis was treated by anticoagulant therapy and recanalization of the occluded veins was obtained after two months of therapy. An MRI scan, carried out 12 months later, showed a local relapse, which was treated with chemotherapy and arterial chemoembolization.

Papillary microcarcinoma of the thyroid gland: analysis of prognostic factors including histological subtype.

OBJECTIVE: To evaluate the prognosis of papillary microcarcinoma (PMC) of the thyroid. DESIGN: Prospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 89 patients treated for papillary micro carcinoma of thyroid and followed up for at least 6 years (range 6-12). INTERVENTION: Total thyroidectomy and, for lymph node metastases, laterocervical lymphadenectomy. MAIN OUTCOME MEASURES: Sex distribution, mode of onset of disease, diameter of tumour, histological type, histological stage, presence of lymph node metastases at the time of operation and type of operation. RESULTS: When the disease presented with laterocervical lymph nodes it was histologically more aggressive and included follicular (n = 3) and sclerosing (n = 4) types. CONCLUSION: Papillary microcarcinoma has an excellent prognosis if managed initially by total thyroidectomy.