Transanal endoscopic microsurgery for the treatment of selected patients with distal rectal cancer: 15 years experience.

BACKGROUND: Local therapy for early rectal cancer is a valid alternative to the classical radical operation, which has a higher morbidity and mortality rate. The use of high-dose preoperative radiation appears to enhance the options for sphincter-saving surgery even for T2-T3 rectal cancer patients with effective local control. The authors report their experience with transanal endoscopic microsurgery (TEM) used to manage selected cases of distal rectal cancer without evidence of nodal or distant metastasis (N0-M0). METHODS: The study enrolled 196 patients with rectal cancer (51 T1, 84 T2, and 61 T3). All the patients staged preoperatively as T2 and T3 underwent preoperative high-dose radiotherapy, and since 1997, patients younger than 70 years in good general condition also have undergone preoperative chemotherapy. RESULTS: Minor complications were observed in 17 patients (8.6%) and major complications in only 3 patients (1.5%). The definitive histology was 33 pT0 (17%), 73 pT1 (37%), 66 pT2 (34%), and 24 pT3 (12%). Eight patients (5 pT2 and 3 pT3) experienced local recurrence (4.1%). The rectal cancer-specific survival rate at the end of the follow-up period was 100% for pT1, 90% for pT2, and 77% for pT3 patients. CONCLUSIONS: Patients with T1 cancer and favorable histologic features may undergo local excision alone, whereas those with T2 and T3 rectal cancer require preoperative radiochemotherapy. The results in the authors' experience after TEM appear not to be substantially different in terms of local recurrence and survival rate from those described for conventional surgery.

A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy.

BACKGROUND: This study aimed to compare the oncologic results for local excision via transanal endoscopic microsurgery (TEM) and those for laparoscopic resection (LR) via total mesorectal excision in the treatment of T(2) N(0), G(1-2 )rectal cancer after neoadjuvant therapy with both treatments, incorporating a 5-year minimum follow-up period. METHODS: The study enrolled 70 patients whose malignancy was staged at admission as T(2) N(0), G(1-2 )rectal cancer located within 6 cm of the anal verge with a tumor diameter less than 3 cm. Of these patients, 35 were randomized to TEM and 35 to LR. The patients in both groups previously had undergone high-dose radiotherapy (5,040 cGy in 28 fractions over 5 weeks) combined with continuous infusion of 5-flurouracil (200 mg/m(2)/day). RESULTS: The median follow-up period was 84 months (range, 72-96 months). Two local recurrences (5.7%) were observed after TEM and 1 (2.8%) after LR. Distant metastases (2.8%) occurred in one case each after TEM and LR. The probability of survival for rectal cancer was 94% for TEM and 94% for LR. CONCLUSIONS: The study shows similar results between the two treatments in terms of local recurrences, distant metastases, and probability of survival for rectal cancer.

Spontaneous regression of hepatitis B virus-associated cirrhosis developed in childhood.

We reported two cases of hepatitis B virus infection-related cirrhosis developed during childhood and followed up for more than 20 years. Both the subjects remained untreated, and ultimately regression of cirrhosis was documented by clinical (including ultrasound) and histological examination. Recent studies have already suggested that hepatitis B virus-related cirrhosis may regress after treatment, but this is the first demonstration that hepatitis B virus-associated cirrhosis developed in childhood may be a spontaneously reversible process. Subsidence of virus replication and of necro-inflammatory process and the efficiency of liver regeneration and repair might contribute to this favourable outcome.

Hepatitis C virus (HCV) genotypes in 373 Italian children with HCV infection: changing distribution and correlation with clinical features and outcome.

BACKGROUND AND AIMS: Little is known of hepatitis C virus (HCV) genotypes in HCV infected children. This retrospective, multicentre study investigated genotype distribution and correlation with clinical features and outcome in a large series of Italian children. METHODS: Between 1990 and 2002, 373 HCV RNA positive children, consecutively recruited in 15 centres, were assayed for genotypes by a commercial line probe assay. RESULTS: The following genotype distribution pattern was recorded: genotype 1b = 41%; 1a = 20%; 2 = 17%; 3 = 14.5%; 4 = 5%; other = 2.5%. The prevalence of genotypes 1b and 2 decreased significantly (p<0.001) among children born from 1990 onwards compared with older children (46% v 70%) while the rate of genotypes 3 and 4 increased significantly (from 8% to 30%). Children infected with genotype 3 had the highest alanine aminotransferase levels and the highest rate of spontaneous viraemia clearance within the first three years of life (32% v 3% in children with genotype 1; p<0.001). Of 96 children enrolled in interferon trials during the survey, 22% definitely lost HCV RNA, including 57% of those with genotypes 2 and 3. CONCLUSION: HCV genotypes 1 and 2 are still prevalent among infected adolescents and young adults in Italy but rates of infection with genotypes 3 and 4 are rapidly increasing among children. These changes could modify the clinical pattern of hepatitis C in forthcoming years as children infected with genotype 3 have the best chance of spontaneous viraemia clearance early in life, and respond to interferon in a high proportion of cases.

Interferon treatment in children with chronic hepatitis C: long-lasting remission in responders, and risk for disease progression in non-responders.

BACKGROUND AND AIM: Large interferon-based therapeutic trials are still lacking in children with hepatitis C and the long-term safety and efficacy of interferon is unknown. This study describes the outcome of hepatitis C in 43 children enrolled in an open-label interferon trial, and were followed up to 66 months after stopping treatment. PATIENTS AND METHODS: All patients received interferon alfa2a (5MU/m(2)) thrice weekly for 6 months; children with genotype 1b received 3MU/m(2) thrice weekly for 6 additional months. RESULTS: Nine children discontinued interferon for adverse events and three were not compliant to treatment. Eight (19%, intention to treat analysis), including 2/20 (10%) with genotype 1b and 6/12 (50%) with genotypes 2 or 3, were sustained responders 12 months after stopping therapy. During further follow-up (mean+/-S.D.: 44.7+/-14.6 months), response was maintained; two non-responders cleared viremia, while a young boy progressed to cirrhosis. CONCLUSIONS: Small sample size and therapy withdrawal are the major limitations in the interpretation of our results. Nevertheless, our data, suggesting that response to interferon in children with hepatitis C is genotype-related and stable, agree with the results of large studies in adults. The outcome in non-responders was variable, including persistence of viremia and mild-moderate cytolysis (most cases), progression to cirrhosis, or eventual sustained viremia clearance.

The impact of organised screening programmes on the stage-specific incidence of breast cancer in some Italian areas.

The aim of this study was to examine the effects of mammographic screening programmes on stage-specific incidence of breast cancer. The study compared prescreening and screening periods in seven areas in Italy, primarily evaluating the first screening round. All 17617 breast cancers (16554 invasive, 1063 in situ) registered in women aged 40-79 years between 1988 and 1999 were analysed through age-standardised rates and Poisson regression models. For all areas, independent of the baseline rates, the introduction of screening increased incidence for invasive cancers overall and, more markedly, for early cancers (screening/prescreening ratio: range 1.07-1.47 and 1.23-1.82, respectively), modifying the pattern of age-specific rates. The multiple regression analysis showed that the percentage of cases diagnosed at screening explained most of the increase; a residual effect of diagnosis period (screening versus prescreening) suggested a role for 'spontaneous' early detection in ages outside of the screening programme. Advanced cases did not show consistent variations across the registries for those aged 40-79 years (range: 0.91-1.21), whereas a more coherent picture was observed for those aged 50-69 years. In one area, a moderate reduction in the number of 'advanced' cases in the second screening period was observed. For all stages, the age-specific incidence rates of cases diagnosed outside of the screening programme for the age groups 50-69 years were lower than the corresponding rates in the prescreening period, suggesting a shift from the usual clinical services to the screening programme. Our results confirmed the increase in early-stage cancers occurring at the start of screening, and substantially explained the rise in breast cancer incidence. In addition, our study confirms the importance of cancer registries in monitoring the effect of breast cancer screening and the validity, for this purpose, of the linkage between cancer registries and screening programme databases.

[Adrenal incidentaloma: a dopamine-secreting pheochromocytoma with an atypical clinical picture. A case report and review of the literature]. / Incidentaloma surrenalico: feocromocitoma dopaminico con quadro clinico atipico. Presentazione di un caso e revisione della letteratura.

INTRODUCTION: The increasing and consolidated uses of US and CT scan in the diagnosis of abdominal diseases has improved the detection of adrenal asymptomatic masses. Current literature points out that these nodules are identified by 1:100 abdominal CT every year. On the other hand, about 50% of the adrenal tumors are discovered by autopsy. The diagnostic difficulties may be due both to clinical silence and to atypical clinical expressions of the neoplasm--as in the case report--where a pheochromocytoma shows non-specific abdominal symptoms rather than the typical signs of catecholamine overproduction. CASE REPORT: Author,s report a suprarenal right pheochromocytoma, secreting dopamine prevalently. The tumor showed abdominal symptoms without history of hypertensive paroxysms, or better still in normotension regimen. DISCUSSION AND CONCLUSIONS: According to current literature, abdominal symptoms occur in about 7% of all suprarenal pheochromocytomas. Most of these tumors prevalently secrete dopamine, that seems to make the prognosis worse. US, CT scan and CT-guided fine needle biopsy weren't able to characterize the real nature of the adrenal incidentaloma. On the contrary, the hormonal screening--by monitoring the urinary VMA and fractioned catecholamines through 24 hours--was decisive for the diagnosis of pheochromocytoma. The adrenal incidentalomas diagnostic significance is tied to the concept that adrenalectomy can change their prognosis, especially in case of pheochromocytoma, where a recovery rate about 90% can be achieved. Authors agree that adrenalectomy my must be performed in all case of "functioning" adrenal tumors and "nonfunctioning" ones with > 6 cm size. Of last years the laparoscopic approach has extended the adrenalectomy's indications to mass with size ranging between 3 and 6 cm., while lesions < 3 cm. size require only a follow up by means of imaging techniques and hormonal monitoring.

[Environment microbiological control in a department with patients at great risk (author's transl)]. / Controllo microbiologico ambientale in un reparto con pazienti ad alto rischio.

Microbic flora has been studied in the Centro di Rianimazione of the Ospedali Riuniti in Chieti to control validity of the antibacterial systems and to verify efficacy of the filter systems that allow the admission into the isolation boxes, stopping great bacterial exogenous increases. These inspection have been executed by suction system Batteriological Air Pollution Detector.