[Perianal Bowen's disease: a case report and review of the literature]. / Perianal Bowen's disease: a case report and review of the literature.

Perianal Bowen's disease is a uncommon, slow growing, intraepidermal squamous-cell carcinoma (carcinoma in situ) of the anal region and may be a precursor to squamous carcinoma of the anus. It is associated with cervical and vulvar intraepithelial neoplasia and have human papillomavirus as a common cause. Both sexes and all races are affected, with the highest prevalence in patients aged 20 to 45 years. The symptoms of anal Bowen's disease are unspecific and the clinical findings are uncharacteristic and include pain, itching, bleeding and a disturbing lump. Biopsy and histopathologic examination is required for diagnosis and to distinguish other perianal dermatoses; thus an anogenital warts that fail to respond to conventional therapy, or change in appearance, warrant a biopsy and, where the technique is available, DNA typing to identify the viral pathogen. Infact the etiologic agent, the human papillomavirus (HPV), has been classified by DNA techniques into at least 42 types, of which 16 and 18 are considered to carry a high risk for cancer. The intraoperative findings is a lesion at the anocutaneous line: perianal or intra-anal tumor, erosion or ulceration as well as lichenoid lesion or hyperpigmentation. The disease has a proclivity for recurrence and there are many controversies concerning treatment that effectiveness remains uncertain and range from aggressive wide local excision with skin grafting when necessary to laser vaporization (argon or CO2), radiotherapy or a new immune response modifier (Imiquimod). We report a case of a 50-years-old woman with recurrence of Bowen's disease associated with vulvar HPV infection and review the literature.

[Combined treatment of inoperable liver metastases from colorectal cancer]. / Combined treatment of inoperable liver metastases from colorectal cancer.

AIMS: Liver resection improves survival in selected patients with colorectal liver metastases. However, the majority of patients with colorectal liver metastases have an inoperable oncological disease. The aim is to investigate whether intra-arterial infusion of chemotherapy, improves response to treatment and may convert a selected group of patients with irresectable liver metastases into an operable state. MATERIALS AND METHODS: Thirty-sex patients (pts) with inoperable hepatic metastases from colorectal cancer were treated with intra-arterial chemotherapy, by angiographic technique. All patients underwent a short 5-FU-based locoregional infusion and the 13 non pretreated patients also received systemic therapy. Evaluation of response was made by CT scan. RESULTS: Total cycles administered angiographically: 132 (range, 1-11). There were no complications associated with the angiographic procedure and no cases of > grade 2 toxicity. One heavily pretreated pt experienced moderate cholangitis and superficial gastric erosion. Thirty-one pts were assessable (20 pretreated and 11 not); there was 1 complete response (CR), 3 partial remissions (PR), 2 stabilizations (SD) among non-pretreated pts (6/11; CR + PR + SD = 55%) and 1 PR and 8 SD among pretreated pts (9/20; PR + SD = 45%). The remaining 16 pts progressed. Four pts became eligible for radical hepatic resection (1 refused surgery and 3 patients were operated on). There was no peri-operative deaths. Median survival of these 3 pts was 24, 28 and 39+ months. CONCLUSIONS: Our data, even if based on a relatively small case series, appear to confirm effective local disease control in this clinical setting. Regional chemotherapy used singly or in combination with systemic chemotherapy may convert a selected group of patients with irresectable liver metastases to an oncological disease that can benefit from surgical treatment.

[Are small-size depressed-type colorectal neoplasias really the expression of a early stage of colorectal cancer. Apropos of a clinical case]. / Le neoplasie colo-rettali depresse di piccole dimensioni sono realmente espressione di uno stadio precoce del cancro colo-rettale? A proposito di un caso clinico.

A route of colorectal cancer development other than the adenoma-carcinoma sequence has recently become an issue due to the discovery of the depressed-type early colorectal cancers. Despite the protruding shapes of depressed-type early colorectal cancers, they probably have biological characteristics which differ from those of the usual polyp lesions. They show more aggressive behavior than the polypoid type and can arise de novo. Depressed-type lesions, in contrast to flat-type or protruded-type lesions, tend to invade the submucosa rapidly, so it is better treat them surgically from the outset. We report a case of a small depressed-type colorectal cancer involving the caecum of a 79-year-old male patient.

[Locoregional chemotherapy of locally advanced breast cancer in a pre-treated patient: case report]. / Chemioterapia locoregionale nel carcinoma mammario localmente avanzato in paziente pre-trattata: case report.

We report of the use of intra-arterial chemotherapy in one case of locally advanced breast cancer, that had been systemically pre-treated. Locoregional chemotherapy was delivered via percutaneous access. The catheter tip was placed into the subclavian artery and into origin of the internal mammary artery; it was removed after every cycle of treatment. The schedule of chemotherapy was: epirubicin 30 mg/m2, mitomycin 7 mg/m2 and 5 fluouracil 1000 mg. Three cycles were administered, and the treatment was well tolerated. The patient responded to intra-arterial chemotherapy, and she subsequently underwent complete surgical resection. Intra-arterial chemotherapy for breast cancer in an uncommon approach to the treatment of locally advanced disease. Nevertheless, in selected cases, it could be a more effective therapeutic option for patients with systemic chemotherapy-resistant disease.

[Adjuvant adoptive immunotherapy in patients with stage III and resected stage IV melanoma: a pilot study]. / Adjuvant adoptive immunotherapy in patients with stage III and resected stage IV melanoma: a pilot study.

Adoptive immunotherapy trials with tumor infiltrating lymphocytes (TIL) and interleukin-2 (IL-2) were carried out in the treatment of advanced melanoma with a 34% of overall responses (OR). However, theoretically it should be of greater benefit as adjuvant therapy, especially in high-risk stages (stage III and resected stage IV). In a pilot study, 22 patients (aged 23-72 years) with stage III-IV melanoma who underwent radical metastasectomy were reinfused with TIL cultivated and expanded in vitro with IL-2 from surgically removed metastases. IL-2 (starting dose 12 x 10(6) IU/m2) was co-administered as a continuous infusion according to West's scheme. A total of 8/22 (36.3%) patients were disease-free (DF) at a median follow-up of 5 years. DF survival (DFS) and overall survival (OS) in the remaining 14 patients were 44% and 37% and 52% and 45% at 2 and 3 years, respectively. The CNS was the only site of disease recurrence in 57% of patients who relapsed. DF patients received a higher median dose of IL-2 than those who progressed (total dose 110 x 10(6) vs 86 x 10(6) IU/m2, respectively). The progressive reduction in IL-2 dosage allowed all patients to complete treatment without permanent grade 4 toxicity. The effects of tumor immunosuppression in lymphocytes inside the tumor (TCR z and e chains, p56lck, FAS and FAS-ligand) confirmed that the potential function of TIL, immunodepressed at the time of metastasectomy, was significantly restored after in vitro, culture with IL-2. Adjuvant adoptive immunotherapy with TIL and IL-2 seems to improve DFS and OS, in comparison with literature data. Further studies are required to determine its role in the adjuvant treatment of patients with high-risk melanoma.

[Reoperations in lung surgery]. / I reinterventi in chirurgia polmonare.

A second thoracotomy in patients who have undergone previous chest surgery can be performed soon or immediately after the first operation and is usually aimed at resolving severe or even life-threatening postoperative complications. Late reoperations, on the other hand, are either performed to resolve complications of previous surgery or to remove second primary lung tumors (SPLCs) or metastases. The most exacting reoperation in this context is completion pneumonectomy, which is particularly indicated in the case of failure of the residual lobe to re-expand after primary surgery; it is also used for--rarely occurring--fistulas of the lobar bronchi and for new ipsilateral primary lung tumors. This type of surgery is technically complicated and has been associated, in our experience and that of others, with a certain mortality. Technically less difficult is a second ipsilateral thoracotomy for exploratory purposes or minor parenchymal resection, and the same is true of contralateral lobar or sublobar resections. Lastly, Abruzzini's operation, for fistulas of the primary bronchus, is relatively complicated but often leads to good results; we have performed 15 such operations with only one death occurring due to acute myocardial infarction.

[Neurogenic tumors of the mediastinum]. / Tumori neurogeni del mediastino; neurogenic tumors of mediastinum.

Neurogenic neoplasms represent approximately 20% of the space-occupying lesions in the mediastinum. They are primary tumors originating from structures belonging to the peripheral or sympathetic nervous system, they are most commonly diagnosed in subjects in the age range between 10 and 30 years. Benign forms are significantly more frequent than malignant forms, an observation that was confirmed by our own experience; whether these tumors have a predilection for the male or female sex cannot be concluded from the various case series studied to date. Surgical resection can be considered the treatment of choice on the basis of the long-term results, which are greatly satisfactory in benign tumors and encouraging in the malignant variants.

[False aneurysm on dacron prosthesis, 20 years after aortofemoral bypass]. / Faux anévrysme sur prothèse en dacron, vingt ans après pontage aortofémoral.

A 85-year-old male developed a false, non septic, non anastomotic aneurysm, 20 years after right aorto-femoral Dacron grafting for claudication. On account of the proximity to the femoral anastomosis, and the association with a profunda femoris stenosis, a conventional surgical repair was preferred to an endovascular treatment. The patient underwent a successful aneurysm resection followed by PTFE interposition between the primary graft and the profunda femoris artery, with uneventful recovery.

[Inguinal hernia repair in a teaching course for surgeons. A training program]. / L'intervento di riparazione dell'ernia inguinale nell'iter formativo del chirurgo. Proposta di un percorso didattico.

The Authors suggest a training programme for surgeons in post graduates courses. With this object in view, the inguinal hernia repair by Lichtenstein has been chosen as the most suitable one. The training course has been divided into theoretic lessons and surgical practice in the operating theatre, carried out in stages as assistant and then as operating surgeon. The good standard achieved, together with the clinical results obtained, demonstrates the effectiveness of the teaching method.

[The surgery of tumors and "limited situations"]. / Chirurgia dei tumori e "situazioni--limite".

The term "limit" applied to cancer surgery, denotes the ideological moment beyond which one cannot and should not propose any aggressive treatment. Such limits may concern the operability of a patient and may be represented by some general characteristics independent of the patient's current disease status (e.g. very old age, poor performance status, poor cardiac, respiratory, renal hepatic or mental conditions). They may concern the neoplastic involvement of the organ affected by the tumor: if undertaken, surgery should guarantee a reasonable duration of life, and a quality of life that makes it worth living. Other factors to be taken in consideration are the possibility the tumor spread to local or distant sites, as well as certain extreme conditions such as cancer, cachexia, liver/kidney failure, irreversible septic-toxic shock, ect. Moreover, there may be limits related to the structural conditions of the establishment where the operation is to be carried out (facilities, equipment, pharmacological supplies, medical and paramedical personnel) and to the social environment and the economic situation of the patient, in view of the assistance required following surgery. Lastly, a severe assessment of one's own fitness to perform any specific task should be part of the daily preparation of any surgeon.

[Major surgery in thoracic injuries]. / La chirurgia maggiore nei traumi del torace.

Chest injuries have a high and steadily increasing incidence in western countries, but only some of the most common problems they create require an emergency thoracotomy or surgical video thoracoscopy. Flail chest, persistent pneumothorax, massive haemothorax, mediastinal emphysema, cardiac tamponade and intrathoracic foreign bodies can be identified as major surgical problems. Some of such patients (i.e. those with flail chest or foreign bodies) would be immediately candidates for major intervention. Other require fast but diagnostic procedures, because the choice of a therapy is dependent upon a precise identification of the damage. Injuries of trachea and primary bronchi, oesophagus, diaphragma, vena cava, great lung vessels, heart and aorta may represent important surgical emergencies; some leading rapidly to death. Fortunately, major surgical procedures are not really frequent in the management of thoracic traumas. Only 42 (3.5%) of nearly 2,000 patients with non-penetrating thoracic injuries had a thoracotomy or an surgical video thoracoscopy. The figure is far different for penetrating wounds; in fact 12 patients (41%) of 29 underwent mayor surgery.

[Current indications for sublobar resection in non-small-cell bronchogenic carcinoma]. / Indicazioni attuali alle resezioni sublobari nel carcinoma broncogeno non microcitoma.

Over the past 30 years, there has been considerable controversy regarding the role of segmental and wedge resections in the management of stage I (T1-T2N0M0) non-small-cell lung cancer. Recently, a prospective randomized trial (Lung Cancer Study Group, 1995) revealed unfavorable results after limited resection, which, in early stage lung cancer, remains a reasonable option for patients with compromised pulmonary reserve, especially those in whom a previous contralateral resection has been performed. The following report describes the role of limited resection in the management of patients with T1-T2N0 non-small-cell lung cancer and presents a retrospective review of our series of 125 limited resections out of 1356 resections performed for lung cancer. In particular, long term survival and the frequency of local/regional recurrence were noted in 92 cases operated on with a curative intent. 26.6% vs 12.5% local/regional recurrence rates were observed among patients undergoing limited resections for T2 and T1 lung cancer, respectively. The five year survival in the limited resection group was 13.5% for T1 and 60% for T2 vs 51% and 72% in the standard procedure group, respectively. The lobectomy results were superior to those of sublobar resection. The latter should be reserved for patients in poor general condition contraindicating a standard lobectomy.

Transsternal approach to closure of bronchopleural fistulas after pneumonectomy. A fifteen cases report.

A treatment method for main bronchus fistula after pneumonectomy via median sternotomy was described by P. Abruzzini in 1961. This operation is performed in an area not involved with infection. Fifteen patients underwent the procedure in our surgical department; one of them died of myocardial infarction while all the others survived for different periods of time, closely associated with the original disease; seven were long-term survivors. The transmediastinal approach seems an effective means of managing such a difficult complication.

Distal polytetrafluoroethylene bypasses in patients older than 75 years.

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.

[Angiodysplasia of the large intestine: unusual rectal localization]. / L'angiodisplasia del grosso intestino: una rara localizzazione rettale.

The authors report a case of lower gastrointestinal hemorrhage in a 69-year-old male, in which the sequence colonoscopy-angiography identified the source of bleeding as a rare Angiodysplasia (AD) of the rectum. Such vascular abnormalities are one of the most common causes of major lower gastrointestinal tract bleeding in the elderly and usually occurs predominantly in the right side of the colon. The clinical presentation of Angiodysplasia is varied and accurate diagnosis usually requires a combination of diagnostic techniques such as colonoscopy and angiography. The optimal management is uncertain and should be individualized for each patient depending on severity and rate of rebleeding. A conservative medical approach is indicated for many patients, while endoscopic treatment does not seem modify the risk of recurrent bleeding. In case of massive hemorrhage or recurrent bleeding surgery still represents the definitive treatment for Angiodysplasia. However the risk of rebleeding following surgery is a considerable problem and varies in literature from 5% to 30%.

[Lymphadenectomy in the surgical treatment of bronchogenic carcinoma]. / Il problema della linfadenectomia nel trattamento chirurgico del cancro broncogeno.

Bronchogenic carcinoma is one of the tumors with the statistically most markedly rising incidence, at least in western countries. For many years both the resectability and the long-term results have remained invariable due to the serious delay with which the disease is usually diagnosed. In addition, the success of treatment appears to be closely correlated with disease stage; in particular lymph node involvement has a major influence on the long-term survival following adequate treatment. As a consequence, a strong conviction has established itself in recent years, that radical removal of all mediastinal lymph node stations ipsilateral to the operated lung represents not only a necessary staging procedure, but also a useful measure to improve the prognosis of these patients. However, the real utility of radical lymphadenectomy is questioned by a number of groups: on the one hand the supporters of lymph node "sampling", inasmuch as the usefulness of radical lymphadenectomy has not been demonstrated by randomized clinical trials; on the other hand those workers, in particular from Japan, who on the basis of observations of the lymphatic flow in the mediastinum stress the necessity to extend lymph node clearance to the nodal station contralateral to the tumor. The current opinion is changing under the influence of recent developments, for instance the possible use of the sentinel technique also in lung cancer, and the possibility of "reasonable" or targeted lymphadenectomies, planned in relation to the lobar location of individual tumor. Whichever of these approaches is chosen--and this choice is still a matter of debate--many agree about the importance of neoadjuvant treatment not only to render patients eligible for surgery but also to improve the prognosis for patients at the most advanced stages of the disease.

Results of distal revascularization in elderly patients for critical ischemia of the lower limbs.

Thirty eight patients over 75 years of age were operated upon of 40 distal arterial revascularizations for critical ischaemia of the lower limbs. Arterial reconstruction was proposed to ambulatory, self sufficient patients, with a patent artery of the leg or the foot in continuity with pedal arch, at arteriography. The revascularized artery was the peroneal in 14 cases, the anterior tibial in 11, the posterior tibial in 9, the dorsalis pedis in 5, and the external plantar artery in 1 case. Postoperative mortality was 2.6%. No postoperative arterial occlusion occurred and no postoperative amputation needed to be performed. The mean follow-up of 37 patients surviving operation was 21 months (ext. 2-52 months). At 36 months interval, patients' survival was 43%, primary patency rate was 57%, and limb salvage rate was 76%, at life-table analysis. Distal revascularization enables a good number of elderly patients in critical ischaemia of the lower limb, to enjoy an active, independent life, with a viable limb.

Seat-belt-related injuries to the supra-aortic arteries.

Five seat-belt-related injuries occurring in four adults are reported. One injury involved the common carotid artery, two the internal carotid and two the subclavian arteries. Three of the four injured persons were asymptomatic and one had delayed-onset symptoms; none suffered stroke. There was no operative mortality or morbidity. Overall, the functional results of arterial reconstruction were good, with satisfactory patency at follow-up averaging 15 months.

Metastasis to the breast of a renal carcinoma: a clinical case.

The breast is an unusual site for metastatic disease, and generally the lesion appears same times after the diagnosis of the primary malignancy. Authors report a case of a breast metastasis from a hypernephroma, six years after nefrectomy.

Surgical treatment of T3 lung cancer invading the chest wall.

Lung tumors invading the chest wall are classed as belonging to the T3 group and are considered potentially resectable. Their management, however, is controversial, and extrapleural resection, when possible, is preferred to en bloc resection which is regarded as a far more invasive and dangerous operation. Five year survival rates for completely resected cases range in the literature from 25 to 35%, but survival rates are much worse if lymph node metastases are present. These poor outcomes have prompted the development of combined surgical approaches: preoperative radiation therapy, with or without chemotherapy, has been used with an improvement in resectability rates, but only modest results in terms of median survival; in a number of case series, increased operative morbidity and mortality have been reported with this approach. The present report relates to 122 patients treated by en bloc (20 cases) or extrapleural (102 cases) resection, 31 of whom also received neoadjuvant treatment. The operative mortality was 4.6%. Median survival was 17 months after en bloc resection and 19 months after extrapleural resection. Though no statistically significant difference was found, extrapleural resection would appear to yield better results than the en bloc procedure.