Isolated pancreatic metastasis from melanoma. Case report.

Pancreas is frequently site of isolated metastasis, approximately in the 40% of cases in patient with previous history of malignant neoplasia, more frequently from renal cell carcinoma. The melanoma metastasis can also interest the pancreas in case of disseminated disease (50% of the cases); more rarely the pancreas is site of isolated metastases from melanoma. The treatment of the pancreatic metastases from melanoma is controversial: the therapeutic choices are few and the role of surgery is not well defined. If the metastasis are confined to the pancreas, the surgical treatment can be useful for better long time survival. We report a rare case of melanoma with pancreatic isolated metastasi in a patient with a previous melanotic metastasis to the inguinal lymph nodes without evidence of primitive tumor.

Metachronous liver metastases and resectability: Fong's score and laparoscopic evaluation.

BACKGROUND AND AIMS: The aim of this retrospective study was to establish whether Fong's risk score can predict rate of resectability and whether laparoscopic exploration with ultrasonography can reduce the number of useless laparotomies to any extent. MATERIAL AND METHODS: Fong's score was calculated for each of the 43 potential resectable patients. We analysed: the relation between score and resectability; the probability of unnecessary laparotomy with respect to each level of score; and which of the five Fong parameters was the most indicative of non-resectability. None of our patients was submitted to preoperative laparoscopic staging. RESULTS: All patients with Fong's score 0 were submitted to liver resection, whereas only 76.9% with score 1, 58.3% with score 2, and 66.6% with score 3. No patients had score 4 and 5. "CEA level" is the parameter that best predicts the "non-resectability" of metastases. In the subgroup with score 0-1, laparoscopy would have spared 12% of unnecessary laparotomies, whereas in subgroup 2-3 this percentage would have risen to 38.9. CONCLUSIONS: The above data allowed us to quantify statistically the risk associated with non-resectability of liver metastases in a directly proportional manner as the score progresses.

[Our experience in the surgical treatment of mesenchymal gastric tumors]. / La nostra esperienza nel trattamento chirurgico dei tumori mesenchimali dello stomaco.

A retrospective review on 22 patients with gastric mesenchymal tumors, who underwent surgical treatment in the period 1974-2003, is presented. The aim of the study was to review our cases in the light of the new pathologic and immunohistochemical definitions and to analyse the value of clinical signs, diagnostic methods and principles of surgical technique. The Authors conclude that no specific clinical signs have been detected. Endoscopy plays a very important diagnostic role and CT-scan is the most sensible technique in the evaluation of location, size, invasion of adjacent organs and metastasis. The aim of treatment must be the complete resection of the tumor and the prognostic prediction on the basis of histologic findings is quite difficult.

[Milligam-Morgan hemorrhoidectomy and stapled mucoprolapsectomy. Clinical comparison of the results]. / L'emorroidectomia secondo Milligan-Morgan e la mucoprolassectomia con stapler. Valutazione clinica comparativa dei risultati.

The aim of this retrospective study was to assess the results of treatment for hemorrhoids by Milligan-Morgan hemorrhoidectomy and by stapled mucoprolapsectomy in terms of operative time, postoperative pain, lenght of hospital stay, incidence of early and late complications, time to return to work and to normal social activities and patient satisfaction. Between January 2002 and December 2003, a total of 65 patients with hemorrhoids (35 men and 30 women with a mean age of 46.9 years) underwent surgical treatment: 41 patients underwent conventional hemorrhoidectomy and 24 patients stapled mucoprolapsectomy. All patients were contacted by phone or were reviewed in the outpatient clinic with a mean follow-up of 2 months (range 8-31). The Authors emphasize that it is difficult to make an objective comparison between hemorrhoidectomy and stapled mucoprolapsectomy because the two procedures are completely different in terms of rationale and technique; however, stapled circumferential mucosectomy in their experience causes less postoperative pain and bleeding and can be considered a valid therapeutic option for third- and fourth-degree disease.

Multiple primary malignancies. A rare case of five metachronous tumours.

The Authors report on a patient admitted several times for the occurrence of five multiple metachronous primary malignancies (laryngeal carcinoma, endometrial adenocarcinoma, rectal cancerous polyp, Vaterpapilla carcinoma and transverse colon cancer). All five carcinomas were independent primary cancers and the lenghty time intervals between the onsets of each individual tumours confirm their independent non-metastatic origin. Classification, pathogenesis, genetic and environmental interactions of these tumours are discussed; in the case reported a family history of colon cancer was present, while no genetic markers abnormalities or chronic exposure to carcinogens were found. The case report suggests that an aggressive, appropriate surgical approach together with a through follow-up monitoring offers a chance of long-term survival for patients with metachronous malignant primary tumours.

[Correlation between positive lymph nodes and metastasis of colorectal cancer. Personal experience]. / Correlazione tra numero di linfonodi positivi e metastasi da cancro colorettale. Esperienza personale.

The authors, in a group of 190 patients treated with curative surgery for colorectal cancer, have studied the correlation between lymph nodes positive of primary tumor and rising of liver metastases. Even if the B2 stage nodes were negative, liver metastases were found in 6.25% of the patients probably due to an understaging; in C1 + C2 stage the rate of liver metastases was 28.1%, however in this group has not been demonstrated a statistical correlation with the number of positive nodes as a predictive negative prognostic factor.

Comparative retrospective study on the use of plastic prostheses and self-expanding metal stents in the palliative treatment of malignant strictures of the esophagus and cardia.

Palliative treatment of malignant strictures of the esophagus and cardia is usually carried out by the endoscopic placement of a prosthesis. The aim of this retrospective study was to evaluate short- and long-term outcomes of the use of expandable stents, compared with conventional plastic prostheses. One hundred and thirteen endoscopic intubations were carried out in 120 patients affected by malignant stenosis of the esophagus and cardia using plastic prosthesis and self-expanding metal stents. Dysphagia was scored according to Atkinson and Ferguson's classification and the preoperative median score (3.6) was comparable in both groups. The technical success rate was 94.4% with plastic prosthesis and 93.7% with self-expanding metal stent while the functional success rate was, respectively, 85.2% and 88.8%. Three deaths occurred with plastic prostheses (4.4%), while no deaths were observed with metal stents. A comparative analysis of the results of this study suggests that the endoscopic placement of self-expanding metal stents is effective and safe and has to be preferred to the conventional plastic prosthesis for easier implantation and lower morbidity.

[Our experience in the surgical treatment of gastrointestinal stromal tumors]. / La nostra esperienza nel trattamento chirurgico dei tumori stromali gastrointestinali.

The authors carry out a retrospective review of 30 patients with gastrointestinal stromal tumours (GISTs) who underwent surgical treatment over the period from 1974 to 2001. Sixteen were male and 14 female, with an average age of 60.9 years. Histologically, 19 tumours showed evidence of differentiation towards smooth muscle elements (10 benign and 9 malignant), 9 towards neural elements (3 benign and 6 malignant) and 2 iacked differentiation towards either cell type. Twenty-one tumours were located in the stomach, 1 in the duodenum, 3 in the jejunum and 5 in the ileum. The main symptoms were abdominal pain and abdominal masses, and the most sensitive diagnostic techniques were abdominal CT scan and endoscopy in gastroduodenal locations. In 21 gastric GISTs, the surgical procedures were local resection (15 cases), partial gastric resection (3 cases), subtotal gastrectomy (2 cases) and total gastrectomy (1 case). In 8 small bowel GISTs, we performed a typical intestinal resection while duodenal undifferentiated GIST was managed by pancreatico-duodenectomy. There was no operative mortality or morbidity. Among the 13 patients with benign GISTs, 1 died of causes unrelated to the disease, while 12 patients are still alive and in good health after a mean follow-up of 148.5 months (range: 6-262). Among patients with malignant muscular GISTs (6 gastric and 3 ileal), 3 with gastric tumours were lost to follow-up, 3 with gastric and 1 with ileal neoplasms are alive and free from disease after a median follow-up of 58 months (range 3-108), while 2 patients with ileal neoplasms died of metastatic disease 39 and 29 months after the surgical procedure. Among 6 patients with malignant neural GISTs (2 gastric, 2 jejunal and 2 ileal) 1 with a gastric tumour and 1 with a jejunal tumour were lost to follow-up, while 3 are still alive and in good health after a median follow-up of 67.6 months (range 19 to 94); another with jejunal disease developed liver metastases 14 months after small bowel resection and died 12 months later. The two patients with undifferentiated GIST both died of liver metastasis 38 months after pancreatico-duodenectomy and 43 months after total gastrectomy. The most frequent symptoms were abdominal pain and a palpable mass, but no specific signs were detected. In gastroduodenal lesions endoscopy plays a very important diagnostic role and CT scan is the most sensitive diagnostic technique in the evaluation of location, size, invasion of adjacent organs and metastases. Prognostic prediction on the basis of histological findings is difficult and in our experience undifferentiated tumours are always malignant.

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation.

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.

[Dermatofibrosarcoma protuberans: authors' experience]. / Dermatofibrosarcoma protuberans: nostra esperienza.

Dermatofibrosarcoma protuberans is an uncommon slow-growing cutaneous neoplasm. Surgical excision is an effective therapeutic approach although a significant number of local recurrences has been documented in the literature. In the present paper the Authors report 3 cases of dermatofibrosarcoma protuberans. All cases have been surgically treated with a wide local excision extended up to 3 cm from the tumor borders. No local recurrence has been reported. The Authors conclude that the surgical technique employed could reduce the local recurrence rate of dermatofibrosarcoma protuberans.

[Self-expanding stents for the palliation of esophageal and gastric cardia cancer]. / L'impiego delle protesi autoespansibili nel trattamento palliativo del carcinoma dell'esofago e del cardias.

Twenty-one endoscopic tube implantations were carried out in 24 patients with malignant stenosis of esophagus and gastric cardia using self-expanding metallic stents. The indications to endoscopic intubation were advanced stage of the tumor in 17 cases and risk factors which made resection inadvisable in 7 cases. In 3 patients it proved impossible to implant a stent endoscopically because the Authors were not able to pass the guide wire through the stenosis, while correct stent placement was achieved in 21 patients. Functional results were good in 18 patients, while 3 patients did not have any improvement of symptoms. Complications occurred in 9 patients (42.85%): 2 bleedings, 3 neoplastic obstructions, 1 food obstruction and 3 distal dislodgements of the prostheses were observed, but could readily be corrected. No death occurred. The median survival time was 151 days (range 25-545). This study suggests that endoscopic placement of metallic self-expanding stents is safe and has to be preferred to plastic stents for easier implantation and lower morbidity.

[Emergency treatment of caustic lesions of the upper digestive tract]. / Il trattamento in urgenza delle lesioni da caustici del tratto digestivo superiore.

The role of an early multidisciplinary approach to the management of upper digestive tract caustic lesions in the acute phase is stressed. The accurate evaluation of the lesions through early endoscopy, performed within 24-48 hours of ingestion, is the best means of assessing the degree of injury after caustic ingestion. Massive gastric and/or oesophageal necrosis, tracheoesophageal fistula, massive gastric haemorrhage, gastric and/or duodenal perforation are indications for emergency surgery. Management techniques of acute lesions are controversial because results of the different surgical procedures proposed are not satisfactory. Surgery of complications is mandatory, but up to date morbidity and mortality rates are still high.

[J-reservoir in the treatment of ulcero-hemorrhagic rectocolitis]. / II reservoir a J nel trattamento della R.C.U.E.

The Authors report their experience on ileal-anal anastomosis with a J-pouch. A videotape illustrates the surgical technique. At last functional results are shown.