[The surgery of pulmonary metastases. The surgical indications and technical aspects of lung resections for metastases]. / La chirurgia delle metastasi polmonari. Indicazioni operatorie e aspetti tecnici delle resezioni polmonari per metastasi.

Surgery for pulmonary metastases is an accepted method of treatment for many kinds of malignant neoplasms, because of favorable results in five-year and ten-year survival. At present several technical aspects are being debate (operative indications, method of thoracic access, procedure of lung resection, approach of bilateral lesions), with the aim of improving the number of patients undergoing radical excision of all pulmonary metastatic foci. The present paper summarizes a recent experience (1989-1992) in the treatment of pulmonary metastases in 55 patients, with special reference to tactical and technical problems related to metastasectomies. The primary tumor was an osteogenic sarcoma in 28 cases (51%), other musculoskeletal and soft tissue sarcoma in 20 (36%), and epithelial neoplasms in 7 (13%). In 47 patients (85%) the discovery of pulmonary metastases was metachronous regarding primary malignancy, with a range of between 3 months and 17 years; in the other 8, lung disease was simultaneous with diagnosis of neoplasm. All patients underwent preoperative standard chest X-ray, thoracic computerized tomography and lung function assessment; the radical control of primary neoplasm and the absence of any extrapulmonary metastases were required for thoracotomy. Pulmonary nodules were single in 21 patients (38%), multiple ipsilateral in 16 (29) and bilateral in 18 (33%). The thoracic approach was a muscle-sparing thoracotomy (axillary vertical thoracotomy) in 51 patients, other thoracotomies in 3 and a median sternotomy in 1 patient. The operative procedures were 19 single wedge resections (35%), 27 multiple wedge resections (49%), 1 lobectomy (2%), 1 lingulectomy (2%) and finally 7 exploratory thoracotomies (12%) for different reasons. In patients with bilateral disease, a bilateral synchronous thoracotomy and multiple wedge resection was performed 13 times, while staged thoracotomy was necessary in 2 and a median sternotomy was preferred in 1 case; 2 patients received a monolateral axillary exploratory thoracotomy. A total of 186 lung nodules were excised, but only in 161 (86%) the histologic examination confirm the metastasis. There was no operative mortality and the postoperative complications were few. Based on this experience, the authors believe that every neoplastic patient with pulmonary metastases, certain or suspected, should be considered for thoracotomy, since metastasectomy is a very safe procedure today.(ABSTRACT TRUNCATED AT 400 WORDS)

[Axillary thoracotomy: a simple and conservative approach to the thoracic cavity]. / La toracotomia ascellare: un accesso semplice e conservativo al cavo toracico.

Morelli and Di Paola's thoracotomy allows to approach the pleural space with the only osteo-muscular sparing without any section of chest wall structures. With this kind of approach that we have been employing since twenty years, we report our experience about 82 cases recently operated on for both pulmonary and mediastinal disease. Unlike who don't consider this approach to allow adequate exposure of all endothoracic anatomic structures, it is our opinion that this thoracotomy not only allows every kind of operation in thoracic surgery, but is easy to perform and fast to repair. Moreover, postoperative pain is decreased, functional recovery is improved and patient can frequently be discharged earlier from the hospital with a very satisfactory aesthetic result.

[Adenocarcinoma of the distal ileal loop: a rare disease at the typical site for Crohn's disease]. / L'adenocarcinoma dell'ultima ansa ileale: una malattia rara nella sede tipica del morbo di Crohn.

The authors report their recent experience in the treatment of two patients respectively affected by Crohn's disease and adenocarcinoma of the terminal ileum. Although with some differences, they presented with radiological, pathological and gross morphological findings quite similar so that the authors concluded for a different clinical stage of Crohn's disease in both cases. Frozen-section examination carried out in one of the two cases, established the correct diagnosis and indicated a wide resection instead of a very limited one. An extremely rare case of primitive adenocarcinoma of the terminal ileum is presented and the literature is reviewed. Features which could help the differential diagnosis between malignant lesions and regional enteritis are therefore focused.

Critical value of laparotomy with splenectomy in stage III Hodgkin's disease as restaging procedure after chemotherapy.

38 patients with stage III Hodgkin's disease underwent laparotomy with splenectomy as restaging procedure after first line chemotherapy which included MOPP, ABVD, or both. 28 patients were judged to be in clinical complete remission (CR) and 10 were resistant or had relapsed. Among patients in CR, 27 (96%) were confirmed to be in pathological CR; among patients resistant or relapsed, 9 (90%) were confirmed to have disease in the abdomen or retroperitoneum. The therapy for patients in clinical remission before laparotomy consisted of TNI or sTNI in 19 patients, mediastinal radiation in 6 patients and no further therapy in the remaining 3 patients. No significant differences were seen in survival and relapse-free survival between those patients treated by extensive and those treated by local radiotherapy or no further therapy. Instead, among those patients who received extensive radiotherapy 3 developed acute non-lymphoid leukemia (ANLL). The therapy for this group of patients consisted of further chemotherapy in 7 who had concomitant liver involvement and TNI in the remaining 3 who had the disease confined to the spleen and/or lymph nodes. Among these patients, only 3 obtained CR; 2 with radiation and 1 who was resistant to MOPP, with ABVD. This study leads us to re-consider the role of laparotomy in stage III HD which should be used as non-routine procedure only in selected patients without poor prognostic factors who may be cured by radiotherapy alone. In patients resistant to chemotherapy, an early evaluation of disease in the abdomen may be useful for a better salvage treatment.

Surgical treatment of chronic idiopathic thrombocytopenic purpura: results in 107 cases.

Between 1972 and 1985, 107 patients with chronic Idiopathic Thrombocytopenic Purpura underwent splenectomy. Platelet life span and sites of sequestration were studied with labelled platelets and external scanning. Medical treatment was always of scarce and transient effectiveness and had considerable side effects. Splenectomy had minimal complications and mortality and caused no hazard of overwhelming sepsis in adults. The results of splenectomy were very satisfying, especially when platelet sequestration was mainly splenic (remission in about 90% of patients). Surgical treatment is at present the most effective in patients with chronic ITP.

[Fuso-cellular carcinoma of the esophagus with aspects of microcytoma (oat cell)]. / Carcinoma fuso-cellulato dell'esofago con aspetti di microcitoma (oat cell).

A case of polypoid carcinoma of the lower oesophagus in a 52 yr old man is reported. The tumour presented the histological features of spindle-cell squamous carcinoma and oat-cell carcinoma. The histogenesis of these tumours is considered.

[Gastrointestinal localizations of malignant lymphomas]. / Le localizzazioni gastrointestinali dei linfomi maligni.

Lymphoma of the alimentary canal is somewhat rare. It has no unusual features and few characteristics, with the result that its clinical, radiological and endoscopic diagnosis is problematic, since its lesions may readily be confused by other neoplastic or inflammatory forms. The difficulty is, of course, primarily felt in the case of primary sites, since the co-existence of other lymphomatous tissues facilitates diagnosis. It is suggested that surgeons should be aware of the existence and treatment of these forms. 13 cases collected from 25 laparosplenectomies for staging since 1971 are presented. Four patients had primary lesions, whereas generalised lymphoma was present in the remainder. Nine patients are still alive after treatment.

[Laparosplenectomy in 104 cases of Hodgkin's disease]. / La laparosplenectomia in 104 casi di morbo di Hodgkin

A series of 104 laparosplenectomies for Hodgkin's disease was carried out over a period of 4 years. Splenectomy was considered indicated in all cases observed, independently of the clinical situation; preference was, however, reserved to patients in whom the disease was just at the beginning and not yet treated. In such patients, the purpose of the intervention was to pinpoint the degree of development of the disease which would then dictate the chemo-radiological therapeutic protocol. The theoretical bases of the method are illustrated along with its aims and the simple technical features of the surgery. Intraoperative findings are discussed and compared with previous clinical and radiological data, and immediate results are reported.