Acute tension pneumocephalus secondary to whole spine pneumorrhachis as an unusual presentation of a colon cancer complicated by a transsacral cerebrospinal fluid leak.

A 52-year-old woman who was having chemotherapy for treatment of an adenocarcinoma of the colon, was admitted to the emergency department because of a moderate neurological impairment. Head CT scan showed bifrontal pneumocephalus without fractures or discontinuities of the skull base. A few hours later, following the patient's neurologic deterioration, a new CT scan showed tension pneumocephalus with air diffusion throughout the posterior cranial fossa and cervical spine. Because of air bubbles into the cervical spine, an MRI of the entire spinal canal was done. This exam revealed a whole spine pneumorrhachis along with a transforaminal air passage through the first right sacral foramen and a pyogenic collection anterior to sacral bone. An abdomen CT scan showed a massive relapse of the colon cancer and confirmed a hypodense collection contiguous to the anterior sacral surface, causing erosion of the sacral bone and dural layer with air penetration into the spinal canal. Neurosurgical treatment by a lumbosacral laminectomy and duraplasty was followed by tumour removal and omental covering of the pelvis. Her neurological symptoms were resolved completely. One month later, the patient began adjuvant chemotherapy.

A nationwide audit of the use of radiotherapy for rectal cancer in Italy.

BACKGROUND: There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated. METHODS: We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis. RESULTS: Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients corresponding to 58% of rectal cancers operated by SICCR members in 2005. Radiotherapy was used in 307/682 (45.0%) patients. Preoperative radiotherapy was used in 236/682 (34.6%), postoperative radiotherapy in 71/682 (10.4%) cases and no radiotherapy in 375 (55.0%) cases. Of the 236 patients who underwent preoperative radiotherapy, only 24 (10.2%) received short-course radiotherapy, while 212 (89.8%) received long-course radiotherapy. Of the 339 stage II-III patients, 159 (47%) did not receive any radiotherapy. Radiotherapy was more frequently used in younger patients (P < 0.0001), in patients undergoing abdominoperineal resection (APR) (P < 0.01) and in the north and center of Italy (P < 0.001). Preoperative radiotherapy was more frequently used in younger patients (P < 0.001), in large volume centers (P < 0.05), in patients undergoing APR (P < 0.005) and in the north-center of Italy (P < 0.05). CONCLUSION: Our study first identified a treatment disparity among different geographic Italian regions. A more systematic audit is needed to confirm these results and plan adequate interventions.

Morphological and immunohistochemical features of brown adipocytes and preadipocytes in a case of human hibernoma.

BACKGROUND AND AIM: The role of brown adipose tissue physiology and pathology in humans is debated. A greater knowledge of its developmental aspects could play a pivotal role in devising treatments for obesity and diabetes. METHODS AND RESULTS: Tissue from a rare case of hibernoma, removed from a 17-year-old boy, was examined by light and electron microscopy, morphometry and immunohistochemistry. The tumour was well vascularised and innervated and contained mature adipocytes with the characteristics of both brown and white adipocytes. Numerous, poorly differentiated cells resembling brown adipocyte precursors were seen in a pericytic position in close association with the capillary wall. On immunohistochemistry mature brown adipocytes were seen to express the marker protein UCP1. On morphometry the intensity of uncoupling protein 1 (UCP1) immunostaining varied in relation to the morphological features of adipocytes: the "whiter" their appearance, the weaker their UCP1 immunoreactivity. CONCLUSIONS: Our data suggest that in humans, as in rodents, brown adipocyte precursors arise in close association with vessel walls and that intermediate forms between white and brown adipocytes can also be documented in human adults.

Incidental small ampullary somatostatinoma treated with ampullectomy 2 years after diagnosis.

Somatostatinomas are rare tumors; ampullary somatostatinomas are very rare. We report a case of a small pure somatostatin-producing neuroendocrine tumor of ampulla of Vater in a 54-year-old woman with neither neurofibromatosis nor somatostatinoma syndrome, "incidentally" discovered during an abdominal computed tomography. The patient initially refused other adjunctive exams but after 2 years she was admitted, presenting with itch, night sweats, severe fatigue, and unintentional weight loss. The size of the tumor (1.5 cm) and the other radiologic findings had not changed since the abdominal CT scan 2 years before. The somatostatin, gastrin, glucagons, serotonin, vasoactive intestinal peptide, dopamine, norepinephrine, epinephrine, and calcitonin plasma levels were normal. ERCP-obtained biopsies revealed a neuroendocrine tumor with psammoma bodies; immunohistochemical profile was positive for chromogranin and somatostatin. The patient underwent surgery; intraoperative histologic examination of lymph nodes sampling of perihepatic and periduodenal lymph nodes was negative for metastasis. We performed, therefore, a transduodenal ampullectomy. The patient continues to do well at 3 years' follow-up with no evidence of local or distance recurrence of disease.

Perioperative anemia and blood transfusions as prognostic factors in patients undergoing resection for non-small cell lung cancers.

We hypothesised that anemia could represent an important prognostic factor and perioperative blood transfusions do not reduce the risk of relapse. In order to explore this topic, we assessed the correlation of preoperative anemia and blood transfusions with survival in patients with resected non-small cell lung cancer (NSCLC). Patients who underwent radical surgery for NSCLC at the Department of Thoracic Surgery of Università Politecnica delle Marche from January 1996 through December 2001, were included in our study. Four hundred and thirty-nine patients were eligible for our analysis. Survival appeared worse in patients with haemoglobin (Hb) < or =10 g/dl versus Hb >10 g/dl (p=0.012). Stratifying patients in three groups on their Hb level (group 1: Hb < or =10 g/dl; group 2: Hb=10-12 g/dl; group 3: Hb > or =12 g/dl), we observed a worse prognosis in patients with lower Hb levels, too (p=0.0325) and also in the transfused population (p=0.046). At multivariate analysis, only the age of patients, pathological stage and Hb levels resulted indicators of prognosis. Our results suggested that anemia could represent an important prognostic factor in resected NSCLC and correction of anemia in the perioperative setting does not reduce the risk of relapse.

Stair-climbing test to evaluate maximum aerobic capacity early after lung resection.

BACKGROUND: The aim of this study was to investigate the extent of reduction in maximum oxygen consumption in the early postoperative period after lung resection for lung carcinoma. METHODS: A total of 115 patients who underwent lung resection (95 lobectomies, 20 pneumonectomies) performed a maximal stair-climbing test the day before operation and the day of discharge from the hospital (8 +/- 3.3 days after the operation). RESULTS: The postoperative test showed a 15% reduction in maximum oxygen consumption (VO2max) with respect to the preoperative test (Student's t test, p < 0.0001). This reduction was greater after pneumonectomy (21.4%) than after lobectomy (14%) (Student's t test, p < 0.05). A multiple regression analysis showed that the only significant independent predictors of both preoperative and postoperative VO2max were the age of the patient and the level of arterial oxygen content. CONCLUSIONS: The early postoperative reduction in VO2max was greater after pneumonectomy than after lobectomy and the exercise performance was significantly influenced by the level of arterial oxygen content both before and early after the operation.

Internal comparative audit in a thoracic surgery unit using the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM).

OBJECTIVE: The aim of the study was to use the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) to assess the performance of our thoracic surgery unit during two successive periods of activity. METHODS: From 1992 through 1997, 801 candidates for thoracic procedures at our institution were considered for the study. After validation of the logistic regression model, including the POSSUM score, observed and POSSUM-predicted morbidities were compared within two groups of patients divided by year of operation (group 1: 1992-1994, n=362; group 2: 1995-1997, n=439) by means of the z-test for the comparison of a proportion with an expected value. RESULTS: The POSSUM-predicted morbidity was significantly lower than the observed one in the first period of activity of our unit (19.6 vs. 24.3%, respectively; z-test for the comparison of a proportion with an expected value, 2.25; P=0.01), whereas no difference was found in the second period (20.5 vs. 19.1%, respectively; z-test for the comparison of a proportion with an expected value, -0.71; P=0.76). CONCLUSIONS: The result suggests a worse-than-expected performance of our unit in the first period of activity, showing that POSSUM can be reliably applied as an instrument of internal comparative audit in a thoracic surgery unit.

Pleural tent after upper lobectomy: a prospective randomized study.

BACKGROUND: The aim of the present study was to assess the cost/efficacy of the pleural tent procedure after upper lobectomy. METHODS: A prospective randomized analysis was performed on 50 patients submitted to upper lobectomy and divided into two groups: group 1 (25 patients) with pleural tent; group 2 (25 patients) without pleural tent. RESULTS: The univariate comparison between the two groups did not show any significant difference in terms of age, gender, spirometry, smoking history, chronic obstructive pulmonary disease index, side of tumor, arterial oxygen tension, arterial carbon dioxide tension, size and location of tumor, presence of pleural adhesions, length of the stapled parenchyma, and operative time. Pleural tent significantly reduced the days of postoperative air leak (1.2 versus 5.8, p = 0.01), chest tubes (5.4 versus 10.4, p = 0.01), and hospital stay (6.9 versus 10.8, p = 0.01). Moreover, no difference was noted between the two groups in terms of pleural effusion in the first postoperative 48 hours, need of postoperative blood transfusion, and occurrence of other complications. CONCLUSIONS: Pleural tenting after upper lobectomy is a safe and effective procedure and its routine use is warranted.

Paraneoplastic syndromes in 68 cases of resectable non-small cell lung carcinoma: can they help in early detection?

The aim of this study was to assess the importance of paraneoplastic syndromes as an early sign of non-small cell lung cancer (NSCLC). A procedure for searching paraneoplastic syndromes, based on 40 years of reports in the literature, was established and the prevalence of paraneoplastic syndromes estimated in 68 patients with resectable NSCLC. Stages I and II were considered eligible for surgery straight away. Patients in Stage IIIA underwent surgery if partially or completely responsive to three courses of neo-adjuvant chemotherapy. Paraneoplastic syndromes were assessed and confirmed in nine patients (13%). Motor-sensory neuropathy, arthritis and arthralgias to the knees, periarthritis to the shoulder, hypertrophic osteopathy, clubbing, pruritus were observed. Only three patients with painful osteoarthropathies were diagnosed with NSCLC by tracing their paraneoplastic syndrome, whereas most of them (36/68) were diagnosed incidentally through a chest radiograph taken for tumour-unrelated symptoms. A careful research of paraneoplastic syndromes in high risk patients may guide the doctor to a resectable NSCLC diagnosis. Recent onset arthritis and arthralgias, which cannot be explained otherwise, should be considered to be early clues of lung cancer.

POSSUM scoring system as an instrument of audit in lung resection surgery. Physiological and operative severity score for the enumeration of mortality and morbidity.

BACKGROUND: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system that was validated in general surgery with the aim of being used as an instrument to evaluate surgical outcome. We applied POSSUM to a population of lung resection candidates to assess its capability to predict postoperative complications. METHODS: Two hundred fifty lung resection candidates were prospectively evaluated from 1993 through 1996. The POSSUM value was entered along with other variables (sex, smoking history, type of resection, pulmonary function tests, arterial carbon dioxide, serum albumin level, total lymphocyte count, neoadjuvant chemotherapy and radiotherapy, and diabetes) in a multivariate analysis to identify independent predictors of postoperative morbidity. RESULTS: Logistic regression analysis showed POSSUM was predictive of postoperative complications, showing no significant difference between predicted and observed morbidity (chi2 test, p > 0.05). CONCLUSIONS: We think POSSUM can be appropriately used as a tool of surgical audit in lung resection operations.

Evaluation of the POSSUM scoring system in lung surgery. Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity.

The current study was designed to test the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) in a population of lung resection candidates, and to propose its use as an instrument of evaluation of surgical outcome and quality in thoracic surgery. 250 consecutive patients submitted to lung resection from 1993 through 1996 at our institution were prospectively evaluated. Two significant predictive models were than yielded by logistic regression analysis (model I: POSSUM alone; model II: Combining POSSUM Physiological Score with predicted postoperative FEV1 ) and compared with each other by means of ROC curves analysis. The study of the areas under the ROC curves showed that these models were equally predictive of postoperative complications (area of model I=0.66; area of model II=0.67). Both models showed no significant differences between predicted and observed morbidity (chi-square test p > 0.05). In particular, in model II there was perfect agreement between observed and predicted morbidity in the group of patients with a predicted morbidity above 60%. These results suggest that POSSUM may be appropriately used as a tool of surgical audit even in lung surgery.

[Comparison between the diagnostic accuracy in diagnosis of thyroid nodules with fine needle biopsy an intraoperative histological evaluation of frozen tissue]. / Raffronto dell'accuratezza diagnostica nella diagnosi dei noduli tiroidei fra biopsia con ago sottile e valutazione istologica intraoperatoria su tessuto congelato.

BACKGROUND: The aim of this study was to compare the diagnostic accuracy of fine needle biopsy (FNB) and intraoperative frozen-section biopsy (FS) regarding the surgical management of thyroid nodules. METHODS: A total of 812 patients with solitary nodule or dominant nodule in a multinodular goiter were evaluated. The patients underwent preoperative FNB and intraoperative FS diagnosis. RESULTS: The definitive histological diagnosis (HD) was: i) 222 malignant lesions (118 papillary, 67 follicular, 16 anaplastic and 8 medullary cancers); ii) 590 benign lesions. FNB accuracy was 90.6%, sensitivity 96.8% and specificity 87.1%. FS accuracy was 97.4%, sensitivity 91.3% and specificity 100%. False negative (FN) were 10 for FNB and 21 for FS. False positive (FP) were 74 for FNB and 0 for FS. FS was less sensitive for the diagnosis of papillary cancer (more FN) and more specific for the diagnosis of follicular thyroid cancers (no FP). CONCLUSIONS: In conclusion, FS is useful in patients undergoing surgery for a thyroid nodule having a "suspicious" cytology. It adds no information in patients with an FNB diagnosis of malignancy and is of limited use in those in whom an FNB benign lesion is diagnosed.

Pulmonary arteriovenous fistula in a patient with Rendu-Osler-Weber syndrome.

Pulmonary arteriovenous fistula (PAVF) is an abnormal connection between pulmonary arteries and veins. Patients with PAVF may have the Rendu-Osler-Weber syndrome, a disease transmitted by autosomal dominant mechanisms. Here we describe a case of PAVF in a 56-year-old woman, who was admitted to our department because of dyspnea, hemoptysis, and a mass in the left lower lung found on chest X-ray. The diagnosis of PAVF was suspected according to clinical and physiological criteria and confirmed by magnetic resonance imaging of the chest. The PAVF was removed by left lower lobectomy. Anamnestic and clinical investigations of the patient's relatives led to the diagnosis of the Rendu-Osler-Weber syndrome.

Transthoracic forequarter amputation and left pneumonectomy.

We describe a variation of the technique of transthoracic forequarter amputation, consisting of a completely anterior approach, removal of the left forequarter en bloc with the chest wall and lung, and sparing of the scapula. This latter bone is mobilized and is used, along with the transposition of the lower ribs, to stabilize the chest wall.