Diagnostic dilemmas in biliary strictures mimicking cholangiocarcinoma.

BACKGROUND/AIMS: Bile duct strictures may be malignant or benign. In the absence of previous biliary surgery a precise preoperative diagnosis is often difficult, in particular when a tumor mass is absent in the preoperative radiologic findings. METHODOLOGY: A review of 179 patients observed between 1982 and 2001 by the same surgical team with a preoperative diagnosis of malignant stricture of the biliary tree. A surgical procedure was performed in 153 of these cases. RESULTS: The presence of a malignant stricture was confirmed by final pathologic examination in 32 of 38 cases (96%) in which a curative resection was performed. A final diagnosis of inflammatory stricture secondary to choledocholithiasis was made in 3 of the remaining 6 cases (4%), along with one case each of sclerosing cholangitis, granular cell tumor and Mirizzi's syndrome, respectively. CONCLUSIONS: Precise preoperative evaluation of biliary structures can be very difficult when a tumor mass is absent. Despite the use of invasive procedures and new techniques such as magnetic resonance cholangiopancreatography, a false-positive rate of 4% may be expected. However, whenever a malignancy is not definitely excluded, biliary strictures should be treated as a cholangiocarcinoma.

[Primary lymphoma of the breast. Three cases of non-Hodgkin lymphoma]. / Il linfoma primitivo della mammella. A proposito di 3 casi di linfoma non-Hodgkin.

Primary and sole breast lymphoma is a very rare disease. With the review of our series of 616 cases operated on for breast cancer, only 3 cases (0.48%) of primary breast non-Hodgkin lymphoma (LNH) have been observed. The authors outline the problems concerning diagnosis and therapy of this rare disease: pathological and immunohistochemical aspects are discussed. They stress the importance of staging in order to plan a correct multidisciplinary approach.

[Our experience in the surgical treatment of early breast cancer. Results of a prospective study of 204 cases]. / La nostra esperienza nel trattamento chirurgico del carcinoma mammario iniziale. Risultati di uno studio prospettico su 204 casi.

The authors report the results of a prospective study on 204 patients (1980-1993) affected by early infiltrating breast cancer (size pounds 2 cm) as a part of a surgical series of 608 cases. 53 cases who underwent QUART (25.9%) and 151 cases (74.1%) who underwent mastectomy modified according to Patey have been collected. 10 years actuarial survival has been respectively 79% after extensive surgery and 78% after conservative treatment. Local recurrences have been observed in 9 cases after meticulous follow-up (median 74.8 months, range 12-178): 3 (5.66%) patients after QUART and 6 (3.97%) after mastectomy; furthermore 1 patients after a conservative treatment (1.88%) has developed a second tumor at the same side probably dependent on the presence in the primary tumor of an extensive intraductal component. No correlations between histological features, grading, positive nodes, receptor status and local recurrences have been found. Only the age of patients looks significantly correlated with frequency of recurrences: 44.45% of local recurrences have been observed in patients less than 45 years old. Local recurrences after QUART have obliged, in all cases, to a radical mastectomy. Furthermore, frequency of distant metastases has been considered: after QUART percentage is lower (9.43%) than after radical mastectomy (13.9%). This consideration looks correlated with the longer follow-up of the later group. A multidisciplinary approach is advised but the most important role is played by surgery. In conclusion it is outlined that conservative surgery is addressed to selection and consenting patients.

[Natural history of breast cancer: lobular carcinoma versus ductal carcinoma in our experience]. / A proposito della storia naturale del cancro della mammella: carcinoma lobulare versus carcinoma duttale nella nostra esperienza.

Aim of the study is to evaluate the biology, the clinical evolution and the prognosis of lobular carcinoma of the breast. We retrospectively evaluated the patients treated in our institution during the last 13 years. 117 patients with lobular carcinoma of the breast and 117 patients, randomized out of 397 patients with 'classical' pattern of ductal carcinoma were compared. Age distribution, type of surgery, tumor size, TNM stage, axillary lymph node involvement, multifocality, multiple breast cancers, local and distant recurrences, overall survival and disease-free survival have been evaluated. There was not a significant difference in tumor size, lymph node involvement, stage distribution, estrogens and progesterone receptors status, local and distant recurrences. The only significant differences were found in multifocality and multiple breast cancers. The said difference does not seem to modify the overall survival and the disease-free survival that are the same in the two groups. Our research shows that tumor size and axillary lymph node status are the only elements that have to be considered in the choice of the surgical treatment and prognosis. It seems that the difference in distant metastatic pattern between lobular and ductal carcinoma is the distinctive feature in the follow-up of these patients.

Dissection of the esophagus after dilatation of a cervical diaphragm.

The authors report a case of a very large esophageal mucosal dissection observed during an esophagoscopy performed 7 days after dilatation of a cervical esophageal web. They treated this dissection by positioning an endoesophageal balloon which obtained the fast, overlapping closure of the torn mucosal layers and at the same time allowed both gastric drainage and enteral feeding via a pump.

[Monitoring esophageal pressure: comparison of various methods and a unique solution]. / Monitoraggio delle pressioni esofagee: confronto fra metodi differenti e proposta di una soluzione originale.

Ambulatory monitoring of intraesophageal pressure requires probes and techniques which are different from those used in the laboratory approach. In particular the perfusion system for the measurement of the pressure is not suitable and the development of alternative solutions is mandatory. In this perspective an accurate analysis of the theoretical basis of different methods is necessary in order to avoid incorrect results and difficulties in the subsequent phase of analysis. A prototype probe, which is based on inextensible thin plastic balloons filled with oil or saline, was tested in comparison with traditional (perfused) and microtransducer systems to outline the positive and negative aspects of the solution. The results were satisfactory as regards linear output and frequency response up to 5 Hz for the prototype probe and even superior, for instance, to the response of the perfused system to applied pressure, whose curves of the four open tips resulted different, and to the response of Millar transducer. The new prototype probe seems to be adequate to the clinical and research needs.

[Intraoperative esophageal manometry]. / La manometria esofagea intraoperatoria.

Intraoperative manometry has been proposed as a supportive procedure during the execution of anti-reflux operations and in the surgical treatment of achalasia. This procedure is not necessary in preparing anti-reflux plasty such as Belsey or Nissen, the outcome of which depends mostly on the correct execution of the surgical technique. Utilization of intra-operative manometry provides considerable benefits during the surgical treatment of achalasia, both when executing the extra-mucous myotomy and for the correct preparation of the anti-reflux plasty according to Dor, which is associated to it. Manometric control has made it possible to define the various anatomical components that, at both the esophageal and gastric levels, constitute the area which functionally corresponds to the lower esophageal sphincter and therefore a correct execution of the myotomy. As demonstrated by the follow-up study of our surgical patients, the intraoperative manometric measurement of the strain and of the length of the anti-reflux plasty is the determining factor affecting outcome over time. The pressure is apt to decrease even 5 year after surgery; maintaining given length and strain standards when executing the plasty can prevent delayed complications, such as esophagitis from gastro-esophageal reflux.