Radioguided thyroidectomy for follicular tumors: Multicentric experience.

BACKGROUND: The diagnosis of thyroid nodular diseases requires an integrated approach that has been widely established over the past years. This strategy includes: ultrasonography (US) with; implemented Color-Power-Doppler, conventional scintigraphy also with positive indicators, specific pathological studies targeted by immunohistochemically-assays, and the fine needle; aspiration biopsy (FNAB), which, usually, in case of "Follicular Lesions" (10-20%) findings is; unable to distinguish carcinoma from follicular adenoma, then indicating the necessity of surgery to; obtain a correct diagnosis. The aim of this study was to evaluate the role of the scintigraphy with; positive indicators, both preoperatively in diagnostic approach of the thyroid nodules and; intraoperatively as a guide to the extension of the surgical excision. METHODS: On 4482 Thyroidectomy performed, we selected 360 cases of follicular neoplasms (192; females and 168 males). In the preoperative phase, these patients underwent 99 m Tc-sestaMIBI; scintigraphy with both early (10 min) and late (2 h) image acquisition, which were later; compared to the ones obtained by image subtraction of means 99 m Tc-pertechnetate. Following the; sestamibi administration before intervention, we selected the most up-taking nodularity with the; assistance of a specific surgical probe (Neoprobe), quantifying uptake with relation to the surgical pathology, for an amount of 324 total thyroidectomies and 36 hemi thyroidectomies. RESULTS: In all cases of multinodular goiter the benign nodules showed an intraoperative low sestamibi uptake whereas follicular carcinomas showed both a high preoperative uptake and, as a; percentage, the highest values of intraoperative uptake; on the other hand, follicular adenomas had; both pre-and intraoperative mean values of uptake. On the contrary, papillary carcinomas only; showed a mild uptake. CONCLUSIONS: Preoperative sestamibi scintigraphy confirmed its importance in improving the information obtained through different diagnostic investigations. Also intraoperatively, it pointed; out high-risk nodules more accurately. Therefore, radio (Sestamibi) guided surgery could have an; interesting rule in the thyroid follicular lesion treatment.

Effects of 4-nonylphenol on proliferation of AGS gastric cells.

OBJECTIVES: Nonylphenol (NP) is present ubiquitously in both aquatic and terrestrial environments. This compound is considered an important endocrine disruptor and its toxic/oestrogenic activity has been investigated in a number of in vitro and in vivo studies. Human exposure to NP may occur by cutaneous absorption, ingestion of contaminated food or water and inhalation. Moreover, while the cytotoxic effects of NP are known and studied, its effects on cell death and related mechanisms are not known. Our group decided to investigate NP effects on a gastric epithelial cell line (AGS), in particular NP effects on AGS cell cycle and apoptosis. MATERIALS AND METHODS: Cell cycle was analysed by flow cytometry, p21 and p27 induction, and apoptosis was analysed by flow cytometry and annexin-V assays, Fas, Fas-L, caspase 8 and caspase 3 activation. RESULTS: We have demonstrated that NP affected cell cycle and apoptosis in a time- and dose-dependent manner, reaching the most notable effect at concentration of 10(-7)m, for 48 h. Flow cytometry revealed that treatment with 10(-7) m NP led to accumulation of cells at G(2) /M transition and increased percentage population of apoptotic cells. Results have shown that NP at concentration 10(-7) m induced marked increase in Fas and Fas-L expression. Moreover, 10(7) m NP induced activation of caspases 8 and 3, but not activation of caspase 9. CONCLUSIONS: The results reported suggest that gastric cells can be useful as screening population for appropriate study of developmental toxicity.

[Retroperitoneal dedifferentiated liposarcoma (DDLS) with hyperglycemic activity: case report and literature review]. / Liposarcoma dedifferenziato retroperitoneale con attivita ipergligemica: caso clinico e review della letteratura.

The authors describe a Retroperitoneal De Differentiated LipoSarcomas (DDLs), that for its clinical behavior shows peculiar characteristics and original aspects: typical is the recurrence due to local invasiveness, but absolutely original seems to be the surviving time, maybe correlated to its histological evolution (dedifferentiation from leiomyosarcoma to liposarcoma) and an interesting correlation from the tumor recurrence and the glycemic curve first and after the surgical treatments. A 66-year-old woman, presenting typically with very big abdominal masses, treated three times in almost three years, every time with aggressive surgical treatments. Histological response was leiomyo-sarcoma in the first two operations and liposarcoma in the last treatment and in every preoperative phase the patient, normally prediabetic, started to have problem of glycemia balancing, needing an insulin support until the postoperative phases when its glycemia was coming back in normal value without insulin needs, of course until a new tumor recurrence. This last aspect, not depending on pancreas involvement or hormonal activity (immune-histo-chemistry was never conforming a neuro-endocrine activity), seems probably due directly to a mass and metabolic effect of the tumor. Beginning from the description of this case and its interesting biology and reviewing most of the literature on the argument, authors hope to give our support to still debated and partially unknown aspects of these kinds of tumors.

[Thyroid ectopia: problems in diagnosis and therapy]. / L'ectopia tiroidea: problemi di diagnosi e terapia.

The Authors report the cases of ectopic thyroid (n=22) observed among the thyroid pathologies that underwent surgical approach in the last 20 years (n=2670), to discuss their clinic characteristics other than the diagnostic and therapeutic approaches. Sometimes asymptomatic or emerged after thyroidectomy, the ectopic thyroid may generate functional troubles or, most frequently, local compression that require surgical approach that, in the opinion of these authors, is ever indicated also for asymptomatic forms. Based on author's experience, also if statistically rare, it is not possible to neglect the neoplastic degeneration, elapsed in two out of 22 cases analyzed.

Surgical treatment of differentiated thyroid carcinoma: a retrospective study.

INTRODUCTION: We carried out a retrospective analysis of our experience in the management of Differentiated Thyroid Carcinoma (DTC), in order to better define prognostic factors (age, gender, histological type, stage) and outline a standard procedure, where it's possible, for surgical treatment. PATIENTS AND METHODS: Patient population consisted of 432 cases, operated from 1978 to 2003. We carried out 285 operations of total thyroidectomy of which 39 associated to some kind of lymphadenectomy, 66 totalization (21 pts had been operated in other institutes), 60 subtotal thyroidectomies and 21 lobo-isthmectomies. Survival and mortality curves for age, sex, histological type, grading and staging have been calculated. Kaplan-Meyer statistical elaboration for disease-free interval and Mann-Whitney test for the comparison of different clinical and pathological data have been employed. RESULTS: The statistical analysis puts in evidence that on 432 cases examined, with a follow-up from 1 to 25 ys (median = 6.33 ys) and with a drop-out of 60 cases (13.8 %), total mortality for cancer has been of 24 cases (6,4%), with a median interval free by disease of 4.2 ys (range 5 months to 25 ys), and a probability to stay free by disease at 12 and 24 months respectively of 95.1% and 91.6%. The median survival is resulted of 5.8 ys (range 1 to 25 ys) with a probability of survival at 24 and 48 months respectively of 97.5% and 94.3%. The multivariate analysis evidences the most important variables, i.e. age > 45 ys, tumor of intermediate malignancy, with size 1.5 cm, operative M+, significantly condition the prognosis, noticeably getting worse it, independently by the kind of carried out operation. CONCLUSION: Our present therapeutic choices are: 1. total thyroidectomy in the treatment of the apparently benign pathology when bilaterally with spread; the checking at the final histological exam of a cancer makes however think adequate the carried out operation; 2. lobo-isthmectomy in the treatment of unilateral benign pathology or with suspect FNAB for follicular neoplasm; the histological checking of a cancer makes think the operation adequate only in presence of favourable prognostic parameters, but in presence even of just one unfavourable variable, we consider necessary the totalization; 3. total thyroidectomy in presence of a certain or strongly suspected preoperative diagnosis of cancer.

Communication of information to patients with inflammatory bowel disease: A European Collaborative Study in a multinational prospective inception cohort.

BACKGROUND AND AIMS: Communication to patients of information about their disease has become increasingly important in modern medicine, and particularly with chronic nonfatal disorders like inflammatory bowel disease (IBD), but the subject is not adequately researched or understood. METHODS: We studied the media and preferences for communication of information in a multi-national community-based inception cohort of European and Israeli patients with IBD and 10 years follow-up, using structured questionnaires categorizing demographics, disease status, current and preferred sources of information, use of electronic media, role of patients' associations, and satisfaction level. RESULTS: The 917 patients completing the questionnaire were derived from northern (60%) and southern (40%) countries. The mean age was 48.3 years (62% under 50 years); 51% were males; 67% had ulcerative colitis, 33% Crohn's disease. Sixty-six percent of patients designated the specialist as their primary source of information, 77% indicated satisfaction with their current information, and 65% reported not receiving information about medical treatment in the past year. Patient concerns were about new research into their illness (64%), medical treatments (58%), risks and complications (51%) and genetics (42%). Preferred sources of information were paper bulletin (76%), electronic media (30%) and international organization (79%). Diagnosis (ulcerative colitis or Crohn's disease), gender, education level and country impacted significantly on patients' choices. CONCLUSIONS: In providing health care information to patients with IBD their individual attitudes and preferences must be considered. There should be greater roles for IBD patients' associations and international IBD-research organizations, and an increasing use of electronic media.

[Is extrauterine endometriosis confined to the gynecological sphere? A critical review of the experience in a general surgery unit]. / Endometriosi esterna: patologia di esclusivo interesse ginecologico? Il punto di vista del chirurgo generale.

Extrauterine or external endometriosis (e.e.) describes ectopic localization of functional endometrial tissue, a finding whose incidence is increasing due to the diffusion of laparoscopic procedures. The clinical presentation of such disease is often non-specific, even in those cases with a definite surgical indication, depending on the site and pathology of the lesions. Surgical planning is therefore difficult at times, specifically regarding the extent of resection in patients--as young women--willing to maintain fertility. The Authors report on 7 cases observed in their own experience (inguinal endometriosis--1 case, umbilical endometriosis--1 case, abdominal wall endometriosis--3 cases, intestinal endometriosis--1 case, diaphragmatic endometriosis associated with pneumothorax--1 case), representing the wide range of clinical settings related to e.e. Based on literature data, an analysis of clinical and diagnostic issues is carried out. Specifically, the problems related to extent of surgical resection in multifocal cases, possible malignant degeneration and localization on abdominal wall scars are discussed.

[Surgical treatment of sinus pilonidalis by Dufourmentel's flap technique]. / Il trattamento chirurgico del sinus pilonidalis con trasposizione di lembo secondo Dufourmentel.

The present study reports the results of surgical treatment of 175 consecutive chronic pilonidalis sinus cases by excision alone, excision and primary closure, excision and Dufourmentel's flap technique. The analysis of hospital stay , average recovery time, patient compliance and percentages of failures and recurrences enables us to state that Dufourmentel's technique is the best choice, allowing fast recovery with minimal discomfort and lower rate of recurrence. Moreover the good compliance of the technique and the use of recently introduced more effective local anaesthetics have allowed us to plan the treatment in a day-surgery setting with good clinical results.

Surgical treatment with Ligasure Precise of schwannoma of brachial plexus: case report.

English version We present a case of bulky schwannoma arising from the brachial plexus treated by a new surgical device. A 38-year-old man presented with a slow-growing left-sided supraclavicular mass and complained paresthesia of the third and forth fingers of the hand and forearm weakness. Physical examination revealed Tinel's sign. A CT-scan revealed a solid mass situated in the left profound supraclavicular fossa. The tumour was resected with the utilization of bipolar vessel sealing system (Ligasure Precise). This device is very useful in sutureless removal of masses localized in deep supraclavicular fossa. During the operation, care was taken to preserve the nerve function.

[Prenatal medicine: from the obstetric stethoscope to the computerized telecardiotocography]. / La medicina dell'età prenatale: dallo stetoscopio ostetrico alla telecardiotocografia computerizzata.

The aim of this article is to illustrate the history of fetal auscultation from the 19(th) century, when the fetus was considered as an object and the obstetrician as a ''mechanic of the birth'', to the present age, when the fetus is a subject and the obstetricians have at their disposal all the means they need to confirm his well-being and to early diagnose his pathologies, even using prenatal telemedicine.

Modulation of apelin and APJ receptor in normal and preeclampsia-complicated placentas.

Apelin is an endogenous ligand of the human orphan receptor APJ. This peptide is produced through processing from the C-terminal portion in the pre-pro-protein consisting of 77 amino acid residues and exists in multiple molecular forms. Although the main physiological functions of apelin have not yet been clarified, it is known that apelin is involved in the regulation of blood pressure, blood flow and central control of body fluid homeostasis in different organs. Since human placenta is a tissue where vasculogenesis, blood pressure and flow are dramatically important to allow a normal embryonic and fetal growth and development, the aim of the present study was to investigate the immunohistochemical distribution of apelin and APJ in normal placentas throughout pregnancy and in preeclampsia-complicated placentas. Specifically, we observed that in normal placentas the expression levels of apelin decreased from the first to the third trimester of gestation in both cytotrophoblast and syncytiotrophoblast cells and in the stroma of placental villi, in contrast with increased expression levels of APJ in the cytoplasm of cytotrophoblast cells and in the cytoplasm of endothelial cells of normal placenta samples. In contrast, in preeclampsia-complicated pregnancies, we observed a very strong increase of expression levels of both apelin and APJ receptor in all the placental compartments, cytotrophoblast, syncytiotrophoblast and stroma with a particular increase in endothelial cells inside preeclamptic placental villi. Our data seem to indicate an important role of apelin and APJ in the regulation of fetal development through a correct regulation of human placenta formation during pregnancy. Moreover, the strong expression levels of apelin and APJ in preeclamptic placentas, suggest their possible involvement in the onset of this pathology.

Expression and distribution of notch protein members in human placenta throughout pregnancy.

Notch signaling is an evolutionarily conserved mechanism used by invertebrates and vertebrates to control cell fates through close-range cell interactions. Four Notch receptors have been identified in vertebrates and different ligands, divided into Delta-like and Serrate-like (Jagged). Several studies have demonstrated that Notch signaling is involved in different branches of the cell fate decision tree: differentiation, proliferation and apoptosis. These three processes are finely regulated in human placenta in order to allow a successful pregnancy and a correct fetal growth. Moreover, Notch and its ligands participate in the vascular remodelling and stabilization, other two processes much important and ticklish in human placenta. So, we decided to investigate the pattern of expression of Notch-1, Notch-4 and Jagged-1, together with two members related to Notch pathway and involved in angiogenesis: VEGF and p21, in human placenta during gestation by immunoblotting and immunohistochemistry. We showed a modulation of Notch proteins throughout the pregnancy; in particular we showed a slight decrease of Notch-1 throughout pregnancy, with a decreased cytoplasmic staining from the first to the third trimester of gestation in cytotrophoblast and syncytiotrophoblast. In contrast Jagged-1 showed an increase throughout pregnancy especially in syncytiotrophoblast and stroma during the third trimester of gestation. In addition, we found by immunoblotting an increase of VEGF expression from the first to the third trimester and an intense VEGF expression inside endothelial cells throughout the gestation as also confirmed by immunohistochemistry. We also showed a decrease of p21 expression during the pregnancy both through immunoblotting and immunohistochemistry assays. Moreover, we observed Notch localization in extravillous trophoblast cells that are able to invade the decidualized endometrium. Our results suggest an involvement of Notch signaling in regulation of placental cell fate decision and in angiogenesis that are dramatically important to maintain a normal physiology of this organ during pregnancy.

[GnRH agonists and antagonists in the preoperative therapy of uterine fibroids: literature review]. / Agonisti e antagonisti del GnRH nella terapia pre-chirurgica della fibromiomatosi uterina.

Uterine leiomyomas are the most frequent gynecological benign tumors. Their growth is regulated by ovarian steroids, therefore a hypoestrogenic state, like menopause or pharmacologically induced pseudo-menopause by GnRH-agonists or GnRH-antagonists, is associated with the decrease of their volume. This volume reduction allows a less invasive surgical procedure and may reduce the amount of blood loss during surgery. Therefore, GnRH-agonists and antagonists are used in presurgical treatment of uterine fibromatosis. This review analyses the effects of GnRH-agonists and GnRH-antagonists therapies. GnRH-agonists produce a down-regulation of GnRH receptor, while GnRH-antagonists compete with endogenous GnRH for pituitary binding sites. Due to the lack of any intrinsic activity of GnRH-antagonists, the characteristic initial flare-up observed with GnRH-agonist treatment is absent. So, GnRH-antagonists rapidly suppress gonadotropin release within 4-8 h, while GnRH-agonists show clinical effects after 2 or 3 weeks of treatment. GnRH-antagonist activity is dose-dependent so it is possible to adjust the dose to obtain the proper levels of inhibition. The GnRH-agonist presurgical treatment usually is a short-term therapy (3-6 months), because it causes side-effects like menopause symptoms. GnRH-antagonist clinical effects can be achieved with a short-time therapy too. Their side-effects include flushes and head-ache. After stopping therapy with both drugs, leiomyomas rapidly achieve their original size while side-effects disappear. Further studies are necessary to establish the use of GnRH-antagonists in leiomyomas therapy, but in Italy this is not possible because their use is not approved.

[Male breast cancer. Five years experience and literature review]. / Il cancro della mammella maschile. La nostra esperienza di 5 anni e confronto con la letteratura internazionale.

Male breast cancer is an uncommon disease and its aetiology, clinical behaviour and treatment is not well-known . Retrospective studies show that age and stage-matched breast cancer in men and women are compared. Nevertheless, the poor mammary tissue in man allow a rapid local infiltration, late diagnosis and poor survival rate. The Authors report their five years experience and with a short literature review they summarise what is currently known about this uncommon neoplasm in terms of prognostic factors, therapy and survival.

Involvement of cdks and cyclins in muscle differentiation.

Myocyte differentiation is due to transcription of genes that characterize the phenotypic and biochemical identity of differentiated muscle cells. These are the myogenic regulatory factors (MRFs) MyoD, Myf5, myogenin and MRF4. Overexpression of cdk/cyclins has been reported to inhibit the activity of MyoD and prevent myogenic differentiation by different modalities. Unlike other cdk/cyclin complexes, overexpression of cdk9/cyclin T2a, enhances MyoD function and promotes myogenic differentiation. In addition, cyclin T2a interacting with a novel partner, PKN alpha, is able to strongly enhance the expression of myogenic differentiation markers, such as myogenin and Myosin Heavy Chain. So, cyclin T2a could stimulate myogenic differentiation interacting with different kinase partners Cdk9 or PKN alpha in a synergistic or antagonistic way.

[Granulomatous mastitis: diagnostic and therapeutic problems. Case report and review of the literature]. / Mastite granulomatosa: problemi di diagnosi e terapia. Presentazione di un caso e revisione della letteratura

The granulomatous mastitis is uncommon inflammatory disease of the breast of unknown etiology. The diagnosis is obtained only through hystopathology. We report a case of woman, 41 years old, showing lesions of the breast, that caused strong pain with ulcerations sero-haematic secretion and axillary omolateral lymphadenopathy. The diagnostic workup (sonography, mammography, multiples FNAB of single lesions, the culture of cells and hormonal profile) showed an inflammatory aspecific lesions with presence of atipic cells in nipple's secretion and in FNAB of periareola lesion. We performed an excisional biopsy. The hystopathologic diagnosis showed a granulomatous mastitis, confirming the validity of our diagnostic and therapeutic choices. The excisional biopsy has allowed to avoid an overtreatment and obtain a good aesthetic result.

Major complications in thyroid surgery: utility of bipolar vessel sealing (Ligasure Precise).

In the present study the Authors tried and assess the advantages of the standard sutureless thyroidectomy performed by the Ligasure Vessel Sealing System, thanks to the use of the dedicated Precise handle. The Authors compared the efficacy of haemostasis and the economical impact of the device, in terms of drug administration and costs. The Authors comparatively analyzed 120 total extracapsular thyroidectomies (TET) performed by the standard operative technique (Group A, control) and 70 TET achieved by the "sutureless technique" (Group B, case). There was a statistically significant decrease of transient postoperative hypocalcemia (5.71% vs 7.5%) and also of mean operative time (about 20 minutes) in patients of the group B. Non significant decrease of other kind of complications (postoperative hemorrhage, transient and permanent inferior laryngeal palsy, stupor of the superior laryngeal nerve, seromas) were also observed. The use of the Ligasure Precise resulted easy, safe and efficient in the Authors' experience. It allowed the decrease of postoperative haemorrhages and mean operative time.

[Interstitial laser photocoagulation in liver tumours: our experience]. / Laserterapia interstiziale nell'epatocarcinoma su cirrosi: nostra esperienza.

Interstitial lasertherapy (ILT) is one of the percutaneous thermal procedures allowing the ablation of primary or secondary hepatic lesions. This technique can be performed without general anaesthesia, since the patient is completely painless, in spite of the high temperatures reached, because there are no sensitive fibers around the lesion. This study includes patients with small hepatocarcinomas (< 2 cm) non peripherically sited, far from the gallbladder and the hepatic hilum. Twenty patients suffering from 24 cirrhotic hepatocarcinomas (two patients showed two nodules) have been enrolled for the present study. Mean diameter of lesions was 1.8 cm (1.3-2 cm). One or more 21 G (length 20 cm) Chiba's needles were inserted under sonographic view into the lesions. The laser energy was switched on at 4 Watts for 4-6 minutes, until an amount of energy of 900-1800 Joule was reached. All the patients were discharged 48 hours after the procedure. Triphasic CT-scan with contrast were performed 7 to 14 days after ILT, in order to check its efficacy. CT-scan showed complete necrosis in all the nodules ranging from 1.5 to 3 cm. All the patients received only one IL T session, whose longest duration was 20 minutes. No major complications occurred. ILT of small hepatocarcinomas is a safe, efficient procedure, also feasible without anaesthesia. Differently from percutaneous radiofrequency, in fact, it shows the advantage of less pain, that can avoid the need for general anaesthesia.

Helicobacter pylori and gastric epithelial cells: from gastritis to cancer.

Helicobacter pylori is a spiral, gram-negative rod-shaped pathogen that attaches to gastric epithelial cells in the human stomach and is a causative agent of chronic active gastritis, peptic ulcer and neoplasia. H. pylori is one of the most common pathogens afflicting humans and is the major environmental factor in the development of gastric cancer increasing from 4 to 6 folds the risk of its development. Several specific virulence factors are implicated in the mechanism of H. pylori infection like the bacterial motility; the secretion of large amounts of urease; specific adhesins for the interaction between H. pylori and the gastric surface epithelium; the traslocation into gastric ephitelial cells of the cytotoxin-associated gene A (CagA), the vacuolating cytotoxin A (VacA) and the heat shock protein HspB. Adherence of H. pylori to the gastric epithelium and secretion of interleukins are believed to be an important step in the induction of active inflammation of the mucosal layer. Several studies have demonstrated that H. pylori infection induces gastric epithelial cell proliferation activating ERK and MAPK pathways and increase of mitosis and mutations. Therefore, H. pylori infection seems to increase apoptosis, implying increased gastric epithelial cell turnover. Recently, it has been shown that H. pylori-induced apoptosis in gastric epithelial cells is mediated via the CD95-receptor/ ligand system but that TRAIL also plays an important role in this regulation.

Apoptosis and human placenta: expression of proteins belonging to different apoptotic pathways during pregnancy.

Apoptosis occurs during normal development and it is important for the right balance between the loss of old, non-functional cells and the formation of new cells in different organs and tissues. Apoptosis is triggered by different cell-type-specific signals which involve several pathways, such as mitochondrial and receptor-mediated pathways, resulting in caspase cascade activation. Several studies have suggested that apoptosis plays an important role in the normal development, remodelling and aging of the placenta. Moreover, it has been demonstrated that apoptosis increases as pregnancy progresses suggesting that it is a normal physiological phenomenon throughout gestation. In the last years, it has been hypothesized that the process known as syncytial fusion is directly or indirectly related to apoptotic events. In particular, it has been suggested that cytotrophoblast cells early express most important apoptotic proteins that translocate in the syncytiotrophoblast with the fusion. This suggests that apoptosis has a central role in the villous trophoblast turnover. Recently, another important involvement of apoptotic processes in human placenta has been demonstrated. In particular, the apoptosis, mainly through Fas-FasL or TRAIL-R-TRAIL signalling, may be a defence mechanism against rejection of the fetal allograft by maternal immune system. The whole data suggest that regulation of apoptotic events is important to allow a correct development, differentiation and function of the placenta throughout pregnancy and that an unbalance of this process leads to severe pathologies such as pre-eclampsia and intrauterine growth retardation. Therefore, due to its extensive proliferation and invasive properties, the placenta mimics a malignant tumor and represents an interesting model to evaluate those processes leading to carcinogenesis.