[Surgical repair of pectus excavatum by internal metal strut fixation. Clinical experience in 51 cases]. / Riparazione chirurgica del petto escavato mediante fissazione interna con barre metalliche. Esperienza clinica su 51 casi.

BACKGROUND: Broad is the spectrum of congenital chest wall deformities. Fortunately the severe life-threatening deformities (i.e. ectopia cordis and Jeune's disease) are rarer than the more frequent pectus excavatum and carinatum. Funnel chest is the most common anterior chest wall deformity, it results from posterior depression of the sternum and cartilages, from the third to the eighth; it occurs more frequently in boys than in girls (4:1 ratio). While the deformity may be recognizable at birth, especially during crying spells, it progressively worsens during childhood, producing, sometimes, respiratory and cardiac impairment. METHODS: The authors report their experience, from April 1970 to December 1998, in correction of Pectus Excavatum using a single surgical technique, at the Borgo Roma Hospital of Verona. During this period 51 patients (mean age 14 years) affected by this deformity, were treated performing a sterno-chondroplasty with internal fixation. Most of the patients (94%) required operation for the esthetic and psychological reasons only. The grade of funnel chest (according to the Chin Classification) was: type I in 59.6% of patients, type II in 31.4% and type III in 11.7%. The surgical technique consisted in the modification of the Ravitch's technique (subperichondrial cartilage resection, transverse osteotomy with internal stainless steel strut fixation). We considered the intervention advisable to correct an existing defect or to prevent its progression. We don't think, in fact, that spontaneous recession of the deformity may occur. RESULTS: The follow-up varied from 4 to 18 years. The result was classified according to the classification of Humphreys and it was excellent in 64.7%, good in 17.7%, fair in 9.8% and poor in 7.8%. CONCLUSIONS: This technique proved to be safe and effective, it can be performed with no mortality, very low complication rate and satisfactory results.

The Italian trial of endovascular AAA exclusion using the Parodi endograft.

PURPOSE: To report the outcome of the prospective 11-center Italian Parodi Trial using straight and tapered endografts for the endovascular exclusion of abdominal aortic aneurysms (AAA). METHODS: From April 1994 to July 1995, 27 patients were evaluated and selected for endovascular AAA exclusion. The Parodi devices were delivered through femoral arteriotomies using 18 to 22F introducers and deployed by balloon expansion of the terminal stents. RESULTS: Of 27 cases attempted, 24 endografts (15 tube, 9 aortomonoiliac) were implanted (1 deployment and 2 access failures [11.1%] were converted). Three endoleaks (12.5%) were treated intraoperatively with covered stents, two successfully, and the third sealed within 30 days. Three (12.5%) of the 24 treated patients died in-hospital of device-(n = 2) and procedure-related (n = 1) causes; the remaining 21 patients were discharged within 8 days. Of the 8 aortomonoiliac grafts in follow-up, only 1 (12.5%) failed in the mean 23-month (range 18 to 30) follow-up: however, 4 (31%) of 13 tube graft patients were converted to surgery within 18 months. Of the 16 (66.7%) surviving endografts at 2 years, 6 (38%) showed no change in the AAA diameter, while 10 (62%) had shrunk. CONCLUSIONS: The tube graft was applicable in only about 5% of cases, and accurate endograft sizing and distal fixation were problematic. The aortomonoiliac design was not appealing to surgeons but fared better in the long term. Given the advent of newer endograft models, the Italian Parodi Trial has been terminated.

Radioiodinated meta-iodobenzylguanidine in the diagnosis of childhood neuroblastoma.

In a group of 97 patients aged from 6 months to 12 years, all with suspected or proven neural crest tumours, metaiodobenzylguanidine (MIBG) scintigraphy was performed at the time of diagnosis and, in some instances, after induction chemotherapy. All the patients underwent a tumour biopsy with cytological and histological analysis, in addition to imaging examinations such as X-rays, ultrasound, computed tomography and magnetic resonance, within a short period before or after scintigraphy. In 82 of 97 cases MIBG was effective in detecting the primary tumour, hence the technique's sensitivity was 84%. A significant different of sensitivity between [131I]MIBG and [123I]MIBG was not demonstrated. As regards metastatic locations, MIBG scans revealed one or more bone metastases in 12 cases, bone marrow involvement (assumed to be present when diffuse and symmetric uptake in the spine, pelvis and possibly other skeletal sites were visualized) in 9 cases, and focal liver metastases or hepatomegaly in 4 cases. Probably owing to the restrictive diagnostic criterion adopted or to the early phase of the bone marrow involvement, the last was found by biopsy but missed by MIBG in 25 cases. The overall sensitivity in detecting metastases was low (48%), but it was much higher if only bone metastases were considered (81%). Twenty-nine patients who had positive scans at diagnosis were checked following 1-2 courses of induction chemotherapy (IC). MIBG scans remained positive in 22 primary tumours, while 7 primary masses were no longer detected. Out of 12 cases showing metastases at diagnosis, two cases with liver lesions became normal and in one case some, but not all, of the bone lesions were not detectable; 4 cases remained abnormal, while in 5 cases bone marrow involvement was not confirmed. Three cases were confirmed to be true negatives; in 4 other cases bone marrow involved not showing at diagnosis was revealed and confirmed by biopsy; 3 cases in which bone marrow involvement was not revealed by MIBG at diagnosis, had normal MIBG and biopsy results after IC; finally, 2 false negative bone marrow cases and 5 true negative cases at diagnosis remained unchanged, but were not checked by biopsy. Performing total body MIBG scintigraphy in childhood neuroblastoma at diagnosis is useful: 1) to predict the nature of the masses detected by other imaging techniques, when biopsy has not yet been performed; 2) for more accurate tumour staging, in addition to standard imaging investigations, MDP scintigraphy and bone marrow aspiration biopsy, thanks to its ability to detect metastatic lesions; 3) to anticipate the decrease in sensitivity of the technique in detecting both the primary mass and the metastases following induction chemotherapy.

Place of meta-[131I]iodobenzylguanidine in the treatment of neuroblastoma: the Genoa experience.

The aim of this paper is to focus on our previous experience with the treatment of Group 3 and 4 neuroblastoma patients and on the therapeutic use of [131I]MIBG, to better define the role of this radioactive drug in the treatment of neuroblastoma (NB). Analysis of the studies on Group 3 patients treated with chemotherapy and surgery showed that the progression-free survival (PFS) increased from 45% for patients treated before 1985 to 63% for patients treated in the period of 1985-1989 and to 78% for patients treated after 1989. [131I]MIBG administered in 17 Group 3 patients who did not achieve a radical excision of the primary resulted in 7 partial response (PR) and 5 minor response (MR), with 10 cases of long term survival. Results in Group 4 patients confirmed the good prognosis in the subset of children aged 6-12 months at diagnosis (PFS 86% at 5 years). In patients aged > 12 months at diagnosis intensive induction chemotherapy induced a higher response rate of 69% and PFS was 26% at 5 years. [131I]MIBG administered in advanced stage 4 patients induced a response in 50% of the cases (2 complete response [CR], 13 PR and 2 MR out of 34 children) and 8 children treated for residual primary (4 cases) or residual bone metastases (4 cases) are long term survivors. We conclude that [131I]MIBG is the treatment of choice in Group 3 patient with a residual primary tumor and could contribute to consolidate the response obtained in Group 4 patients.

Semiquantitative evaluation of regional cerebral flow by means of SPECT with 99mTc-hexamethyl-propylene amine oxime in hypertensive patients under treatment.

Cerebral SPECT with 99mTc-HM-PAO allows a semiquantitative evaluation of regional cerebral blood flow (rCBF). Using this method we studied 25 patients affected by slight-to-moderate degree hypertension, in effective pharmacological treatment, and a control group of normotensives. On the cross-sections symmetrical ROIs were traced at the level of the cerebral lobes and the cerebellum. From the counts obtained on the ROIs the rCBF values were calculated in percentage units with Lassen's algorithm. We found no significant differences between the rCBF values of the two groups. In 5 hypertensive patients, however, focal areas of hypoperfusion were evidenced. These patients did not differ from the other hypertensives by pressure levels or other risk factors. Neurological, tomographic and flowmeter examinations of the supraaortic arteries proved to be normal. It is possible that SPECT with 99mTc-HM-PAO identifies a subgroup of hypertensives at risk of future cerebrovascular pathology despite the setting up of an effective antihypertensive therapy.