Still a role for surgery as first-line therapy of splenic marginal zone lymphoma? Results of a prospective observational study.

AIM: Assessment of hematologic improvement, survival and peri-operative morbidity after first-line splenectomy for splenic marginal zone lymphoma (SMZL). METHODS: Forty-three patients undergoing open splenectomy were prospectively analyzed. Perioperative clinical course, overall and progression-free survival (OS-PFS) were evaluated. Risk factors analyzed were gender, age, ASA-grade, ECOG performance status, presence of B-symptoms, body mass index, steroidal treatment, serum albumin concentration, IIL-score, operative time, spleen size and weight. RESULTS: The median follow-up was 31 months (IQR 15-76; range 24-154). Anemia and thrombocytopenia resolved in 80% of patients at 6 months; in 60% at 2 years. The 5-year and 10-year PFS were 35% and 13% respectively, with a median of 35 months (shorter in patients with ECOG performance status ≥2 and B-symptoms). Nineteen cases (44.2%) had a progression of disease within 2 years. Of these, 14 (32.6%) received adjuvant chemotherapy (mainly R-FC or R-CVP). Progression was attributed to high-grade B lymphoma in 7 (16.3%) patients. The median time between diagnosis and progression to aggressive lymphoma was 25.5 months (range 18.8-81.8). The median time to next treatment was 83.5 months (95% CI 49-118). The 5-year and 10-year OS were 75% and 53% respectively. Mortality was due to disease progression and histological transformation in high-grade B lymphoma in 50% of cases, myelodisplastic syndrome in 15%, recurrence of hemolytic anemia in 15%, Hodgkin lymphoma in 7% and to infections (mainly pulmonary) in the remaining 13% of cases. Post-operative morbidity was 2.3% (1 patient with grade-3 complication). Overall grade ≥2 complication rate was 32.5% (mainly hemorrhagic and pulmonary complications). Spleen weight was the only independent risk factor for morbidity. Mortality was nil. CONCLUSION: Splenectomy is safe and effective as regards cytopenia resolution and OS, although disease progression is frequently observed at follow-up. Such results are strictly linked to accurate pre- and post-operative clinical management and optimal anesthesiologic approach.

Additional Cavity Shaving at the Time of Breast-Conserving Surgery Enhances Accuracy of Margin Status Examination.

PURPOSE: We addressed the impact of separate cavity margin excision (shaving) during breast-conserving surgery (BCS) for breast cancer on specimen volume, tumor margin clearance, re-excision rate, local recurrence and survival. METHODS: A retrospective case-matched study was performed on 298 women with stage 0-III breast cancer; 179 patients received shaving (shaving + lumpectomy group; SLG) and 119 patients did not (lumpectomy group; LG). RESULTS: The two groups had similar baseline characteristics. The median volume of surgical specimen was 131.9 cc in the SLG versus 134.8 cc in the LG (p = 0.81), and surgical margins were tumor-free in 90.7 % of cases in the LG versus 92.7 % in the SLG (87.1 % before shaving) (p = 0.69). The re-excision rate was 14.3 % in the LG versus 10.6 % in the SLG (p = 0.44). In the SLG, shaving spared 10 (5.6 %) patients from reoperation (positive lumpectomy margins but tumor-free shaving margins) (p = 0.11), and only 2/19 (10.5 %) patients in the SLG had tumor-free response at histological examination of re-excised margins compared with 10/17 (58.8 %) cases in the LG (p = 0.004). Tumor in shavings was found in 44/156 (28.2 %) patients having tumor-free lumpectomy margins. At multivariate analysis, distance of tumor from lumpectomy margins, tumor multifocality, receptor status, and tumor size were related to tumor persistence in shavings. Median follow-up was 27 months (range 23-35), and two patients had tumor relapse in the SLG versus none in the LG (p = 0.16). Overall survival was 100 % in both groups. CONCLUSIONS: Shaving does not significantly decrease the re-excision rate but provides wider clear margins in most procedures. It ensures more accurate margin examination and decreases false-positive margin rate, without any increase in removed breast-tissue volume.

Hepatoblastoma of the adult with pericardial metastasis: A case report.

BACKGROUND: Hepatoblastoma is the most frequent liver tumor in children, but very rare in the adult and associated with an unfavorable prognosis. The diagnosis is always postoperative or post mortem and biopsy is not useful. Surgery is the only accepted treatment. CASE PRESENTATION: Our patient underwent surgery in the suspect of liver metastasis from a previous gastric cancer. Surgery consisted in left lobectomy with partial diaphragm resection and partial pericardiectomy for a pericardial lesion, found after the opening of the thorax. The diaphragm defect was corrected with a biological mesh. RESULTS: The histopathological examination indicated hepatoblastoma of the adult with pericardial metastases. The patient was asymptomatic and without recurrence after 21 months of follow up. CONCLUSION: The hepatoblastoma of the adult is related to a poor prognosis with median survival time less than 5 months. Surgery is the only curative treatment, but in many cases tumor resection requires complex operations. Vascular and thoracic expertise could be useful in the management of hepatoblastoma.

Refractory hepatic lymphorrhea after total pancreatectomy. Case report and literature review of this uncommon complication.

INTRODUCTION: After extended abdominal lymphoadenectomy, lymphatic vessel injury may cause lymphorrhea that usually disappears spontaneously. However, intractable ascites sometimes develops. Although there are many reports describing persistent chylous ascites from intestinal lymphorrhea, little is known about hepatic lymphorrhea, not containing chyle. It is caused by injury of the lymphatic vessels during hepatoduodenal ligament lymphadenectomy. We present a case of massive ascites due to hepatic lymphorrhea after total pancreatectomy and extended lymhoadenectomy for Ampullar adenocarcinoma. We successfully treated it with prolonged medical therapy after surgical relaparotomy. PRESENTATION OF CASE: A 65-year old man underwent total pancreatectomy with extended nodal dissection. Massive clear-colored ascites (2000-9000mL per day) developed since the second postoperative day and persisted despite conservative therapy. At re-laparotomy no lymphatic leakage was found. Similarly lymphangiography was showed no contrast spreading. We treated this hepatic lymphorrea with intermittent opening of the abdominal drainage until spontaneous resolution. DISCUSSION: The standard treatment of hepatic lymphorrhea is an aggressive medical treatment. After such approach the most effective therapy seems to be surgical exploration. Other option are peritoneovenous shunt or intraperitoneal administration of OK-432. CONCLUSION: In our experience the intermittent abdominal drainage until spontaneous resolution is an useful approach to hepatic lymphorrhea.

Management of pancreatic intraductal papillary mucinous neoplasm in an academic hospital (2005-2010): what follow-up for unoperated patients?

OBJECTIVES: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed frequently in asymptomatic patients. It is still not clear what follow-up is indicated for patients not undergoing surgical resection. METHODS: Review of all reports of magnetic resonance cholangiopancreatography (MRCP) from June 2005 to June 2010, identifying all patients diagnosed with IPMN; subsequent reconstruction of the initial therapeutic decision, indications for and adherence to scheduled follow-up, and IPMN evolution by morphology and by biology. RESULTS: Overall, 4943 MRCP reports were analyzed, identifying 234 patients with IPMN. Although 143 (61.1%) of these were comprised in Sendai criteria for resection, surgical resection was considered in only 42 (17.9%) patients. Of the remainder, 52 were not subjected to any control, 58 to a single short time check, 77 to MRCP-based regular annual follow-up, and 5 were treated for associated ductal adenocarcinoma. With a median follow-up of 39.5 months (range, 12-72), 37.6% of 125 patients in follow-up had a morphological evolution, but only 2.4% has developed a malignant IPMN. No deaths were recorded, directly related to IPMN, in all 187 conservatively managed patients. CONCLUSIONS: In the analyzed series, fewer patients than expected underwent surgical resection, and only 67.2% undergo regular follow-up, but no more than 2.4% developed malignancy.

Lesson learned from 10 years' experience in laparoscopic appendectomy in a community hospital.

The debate between open and laparoscopic appendectomy is now overtook by the need of a standardized technique, as laparoscopy, in the elective and emergency setting, is widely disseminated thorough surgical practices. A retrospective review of a 10 years' case history (838 laparoscopic appendectomies) is analyzed, and the last 5 years experience (300 cases) compared to the previous experience after the adoption of a standardized technique, which comprehends an all-comers policy without patients' selection prior to explorative laparoscopy. No post-operative infections have been recorded, neither intra-abdominal abscesses nor wound infections, in the laparoscopic group. Significant differences (p < 0.05) have been found between the rate of peritonitis and male sex, elderly patients, and the use of stapler for the treatment of the appendiceal stump. Also conversion to laparotomy has been associated with complicated appendicitis, while associated diseases are found more frequently in fertile women. No differences in the operating time have been evidenced between laparoscopic, open or converted appendectomy. We sustain that every patient with a suspect of appendicitis should have a laparoscopic chance, indeed maintaining a low threshold for conversion; and that surgical indication should be anticipated for male and elderly patients, in order to lower the rate of complicated appendicitis.

Endovascular treatment of an internal carotid artery thrombus using reversal of flow: a case report.

A case of a symptomatic free-floating thrombus of the internal carotid artery is described. A 51-year-old woman presented with a transient ischemic attack and was placed on anticoagulation after diagnosis with angiography. After medical therapy failed, she underwent suction embolectomy using reversal of flow with the Parodi Anti-Embolism System. Balloon angioplasty was performed, and a stent was placed. The patient tolerated the procedure well. A follow-up carotid ultrasound scan showed resolution of the thrombus.

The environmental fate of heavy metals arising from a MSW incineration plant.

Pollutant fluxes from municipal solid waste (MSW) incinerators are of a certain concern, especially gaseous emissions from the stack, which constitute the major effluent from the plant. In this work, heavy metals in soil and vegetation sampled in different sites around the plant are compared with those found in the gaseous emissions from an incinerator: the suspected source and environmental matrices are observed together, in order to detect a possible relationship of cause and effect, using statistical methods. The incinerator examined, regarding dimension and technology, can be considered a typical Italian one. Heavy metal concentrations in soil and vegetation show a clear dependence on sampling year; similar behaviour can be found in emission fluxes referring to the same years. A dependence on the distance from the incinerator is also apparent. This study supplies a methodological approach that can be easily extended and applied to other suspected contamination sources.