Parathyroid cancer as rare cause of primary hyperparathyroidism. Case report and review of the literature.

Primary hyperparathyroidism (PHPT) due to parathyroid carcinoma is rare, and affects more frequently women in their 4th-5th decades of life. Parathyroid cancer (PC) accounts for 0.5% up to 5% of the patients with primary hyperparathyroidism (PHPT). Diagnosis of PC is not easy, and a lot of patients with PHPT receive no pre-operative or intra-operative diagnosis of malignancy. Most of PC are hyperfunctioning, with marked serum PTH levels, and symptoms occurs more frequently than in benign disease. We report the case of a 52 years old woman that underwent a single parathyroidectomy for hyperfunctioning gland. Histological examination revealed carcinoma. Parathyroid carcinoma is rare and surgery represent the only curative approach, although there can be a local recurrence of the disease. A pre-operative diagnosis is not easy, and many features that suggest the diagnosis of malignancy are controversial. According to the literature, we think that the cure of the parathyroid cancer is difficult to achieve. After two years of follow- up, our patient is in good conditions and has no evidence of disease. A careful follow up is of primary importance to diagnose the local recurrence of disease and perform a second surgical treatment, to achieve the control of hypercalcemia, which causes severe metabolic alterations and visceral lesions until the death.

[Subareolar injection for sentinel lymph node biopsy in multiple breast cancer]. / L'iniezione subareolare per la biopsia del linfonodo sentinella nei tumori multipli della mammella

In this study we performed subdermal injection of 99mTc-labeled albumin combined with subareolar (SA) injection of blue dye to axillary lymphatic mapping and sentinel lymph node biopsy (SNLB) in patients with multifocal and multicentric breast cancer (MC) to evaluate the feasibility and accuracy of this technique. We compared the results with a group of patients with unifocal breast cancer. From January 1999 to March 2006 axillary lymph node mapping and SLNB was performed on 250 patients followed by a complete axillary lymph node dissection. Retrospective analysis showed that 32 (12.8%) of these patients have MC on final histopathologic examination and 218 (87.2%) have unifocal cancer. In statistical analysis tumor size shows a significant difference (p=.01) with largest lesions in MC. In MC often histological type is invasive lobular with or without in situ cancer (p= .001). Metastatic lymph node involvement was significantly higher in the MC group compared to unifocal cancer group (p=.001). False negative (FN) rate was 5.8% in MC and 9.6% in unifocal cancers. The overall accuracy of lymphatic mapping was 96.8% in MC and 97.6% in unifocal cancers. Sensitivity was 94.4% in MC and 91.2% in unifocal cancers. In this study we provide further evidence that lymphatic mapping may be reliable even in patients with MC. SA injection technique demonstrates a high sentinel lymph node identification rate and low FN rate; therefore this technique should been recommended to SLNB in patients with MC of the breast.

Prognostic factors in breast cancer: the predictive value of the Nottingham Prognostic Index in patients with a long-term follow-up that were treated in a single institution.

The Nottingham Prognostic Index (NPI) is an index, derived from a retrospective multivariate study, that is able to predict survival in patients with breast cancer. The index is based on tumour size, lymph node stage and histological grade and allows the stratification of patients into three different prognostic groups. The aim of this study was to verify, according to our experience with a long-term follow-up, the effect of some prognostic variables on survival and to establish the independent influence of each of them by means of a survival regression analysis. Then we applied the NPI to the same group of patients in order to assess the predictive power and reproducibility of the index. 402 patients treated from January 1979 to December 1987 were evaluated. In multivariate analysis (Cox proportional hazard model), only size, lymph node involvement and histological grade remained independent prognostic factors. The survival curves obtained after applying the NPI are similar to those for the factors with independent prognostic significance derived from our multivariate analysis. Our improved survival rates may be attributed to the administration of adjuvant therapies to a larger number of patients. The NPI allow us to accurately predict prognosis and we advocate its more common use.

Initial experience with sentinel lymph node mapping and biopsy in breast cancer. Preliminary results on 80 consecutive patients.

Sentinel node biopsy, in breast cancer, is a promising surgical technique for predicting histological findings in the remaining axillary lymph nodes, especially in patients with clinically node-negative breast cancer. 80 patients with breast cancer were evaluated for enrollment in this study. For mapping procedure 32 patients underwent lymphoscintigraphy in combination with an injection of vital blue dye, while 48 utilized only vital dye. In all patients, after sentinel node (SLN) biopsy, a complete axillary dissection was performed. The mapping procedure was possible in 79 cases (98.7%). The SLNs were positive in 27 (34.1%), in 52 patients SLNs were negative and in 50 of these all axillary nodes were negative. There was concordance in 77/79 cases (97.4%). The false negative rate was 3.8% (2/52). The overall sensitivity of the SNL biopsy was 93.1% (27/29), with a negative predictive value of 96.1% (50/52). This study demonstrates that accurate SLN identification was obtained combining lymphoscintigraphy and blue dye. Moreover, each method requires a suitable learning curve. Further studies are needed to define an accurate patient selection and the most speedy and precise method for intraoperative histological examination of SLNs.

Quantitative morphometrical investigation of basal cell layer in laryngeal premalignant lesions.

Histological diagnosis of laryngeal dysplasia is quite subjective. Since morphometry is highly reproducible, this method was applied to compare shape and size variations of the basal nuclei of the laryngeal epithelium in normal, laryngeal intraepithelium neoplasia (LIN) and invasive carcinoma to assess the reliability of light microscopic criteria used in grading dysplasia according to Friedman classification. Morphometrical analysis was carried out by Shape Analytical Morphometry (S.A.M) system. The logical architecture assumes that each irregular shape contains elements of two distinct logical domains: gross distortions that interest the contour and its local perturbations. These features were investigated separately by analytical procedures to acquire independent parameters both on the logical level and the numerical one. The nuclear area significantly increased from normal to carcinoma (p<.001). The increasing of the nuclear area was evident also in LIN I. Nuclear distortions were present in LIN II and LIN III. The highest nuclear contour irregularities were found in LIN III. Multivariate analysis showed a difficulty in discriminating various grades of dysplasia, especially between LIN I and LIN II (31% of error). In conclusion, our results indicate that nuclear pleomorphism of the basal cells layer, using a unique evaluator, is an unsatisfying criterion to distinguish moderate dysplasia.

Pure ductal carcinoma in situ and in situ component of ductal invasive carcinoma of the breast. A preliminary morphometric study.

Nuclear pleomorphism is a fundamental feature in evaluating the aggressiveness of ductal carcinoma in situ (DCIS) of the breast. In this study, pure DCIS and the in situ component (IS-comp) of invasive duct carcinoma (IDC) are compared in order to verify if these are two different entities or the same process observed at different times during its evolution. Five cases of pure DCIS and nine of IDC with extensive in situ component were selected. They were moderately and poorly differentiated. 30 nuclei for each DCIS, and 30 nuclei for both the in situ and invasive component of each IDC were studied; thus, a total of 720 nuclei were submitted to the SAM (Shape Analytical Morphometry) analysis, which enables a numerical expression not only of dimensions (area, perimeter, diameter) but also of nuclear contour irregularities and nuclear shape distortions. Univariate statistical comparisons were carried out between the nuclei of: (1) DCIS and in situ component of invasive duct carcinoma, (2) DCIS and the invasive component of infiltrating carcinoma and (3) between the in situ and invasive component of infiltrating carcinoma. Multivariate analysis was utilized to compare nuclei of DCIS with the in situ component of IDC. The in situ features of each tumor were also evaluated with the mitotic index (MI). Nuclei of pure DCIS resulted significantly larger (p < 0.001) and with a more regular shape (p < 0.001) than those of the in situ component of IDC. No differences were observed between the nuclei of the in situ and the invasive component of infiltrating carcinomas. Multivariate statistical analysis discriminated 77% of nuclei of in situ proliferation when both G2 and G3 tumors were considered, and 80% when only G3 tumors were considered. In conclusions morphological differences exist between pure DCIS and the in situ component of IDC, which may be an expression of their biological behavior; moreover, these morphological differences seem to have a better discriminating power within the same histological grade.

Tc-99m sestamibi and In-111 DTPA octreotide uptake in breast carcinoma with neurendocrine differentiation.

Some breast tumors are classified as primary neuroendocrine carcinomas because of argyrophilia and positivity for neuroendocrine markers (chromogranins A and B and neuron-specific enolase), regardless of their cellular rest and cord structures. Tc-99m sestamibi has been widely used to identify epithelial breast carcinoma and lymph node metastases, whereas In-111 DTPA-octreotide has been used to identify primary and secondary neuroendocrine neoplasms specifically. The use of In-111 DTPA-octreotide and Tc-99m sestamibi scintigraphy in a woman with neuroendocrine differentiated cancer of the left breast is reported. Uptake of these radiopharmaceuticals only in the breast tumor permitted identification of a primary breast carcinoma, whereas absence of In-111 DTPA-octreotide uptake in other sites helped to exclude the presence of other neuroendocrine neoplasms in other organs.

[Rectal prolapse: etiopathogenetic and therapeutic problems in psychiatric patients]. / Il prolasso del retto: problematiche etiopatogenetiche e terapeutiche nel paziente psichiatrico.

Rectum prolapse is a pathological condition which has long been considered as rare but whose occurrence has been progressively increasing in the past decades. There still exists a degree of uncertainty as to the disease etiopathology: moreover the exact relationship between rectum prolapse and psychic disorders which have been found in up to 50% of the patients with prolapse has not been clarified. Neither on the therapeutic level is there a common opinion as to the ideal surgical approach and over one hundred techniques have been suggested for the surgical correction of the prolapse. A study has been carried out on 10 patients suffering from psychiatric pathology of different kinds (oligophrenia, schizophrenic psychosis), hospitalized at Istituti Ospedalieri Opera Don Uva in Bisceglie. They suffered from complete rectum prolapse and underwent surgical intervention. In this study the etiopathogenetic problems of prolapse are investigated according to recent developments, with particular reference to the very peculiar implications they have in the psychiatric patient. Finally the surgical techniques correctly used and their possible application in the psychiatric patient are examined.

Factors affecting prognosis in patients with short bowel syndrome.

Aim of the study is to analyse physiopathological implications of massive intestinal resection and factors affecting prognosis in patients with short bowel syndrome. Twenty massive intestinal resections were performed. The causes of bowel resection were: intestinal infarction (11 cases), Crohn's disease (5 cases), small bowel volvulus (4 cases). All intestinal resections were more than 50-60% of the intestinal length. In eighteen patients intestinal anastomosis was performed immediately. In all the patients postoperative therapy with parenteral nutrition (PN) was performed. The operative morbidity and thirty-day mortality were respectively 30% (6 cases) and 35% (7 cases). The diarrhea was the dominant symptom. The average weight was 20% lower compared to the initial weight. The length of residual small bowel and type of anastomosis strongly affect survival of patients underwent massive intestinal resections. Parenteral nutrition (PN) has great importance in postoperative treatment. A useful treatment, in severe short bowel syndrome, can be small bowel transplantation.

Sentinel lymph node biopsy for sparing axillary dissection in selected patients with breast cancer.

Axillary lymph nodal status in breast cancer remains one of the more important prognostic factors. In early breast cancer axillary lymph node metastasis are found only in 10-18%. It can be deduced that in all these patients a complete axillary dissection is an overtreatment. The concept of sentinel lymph node (SN) was applied to breast cancer. Of course if SN examination gives negative findings, the patient will avoid axillary lymphadenectomy. 134 patients with localized breast cancer were evaluated for enrollment into the study. In 40 (29.8%) patients lymphoscintigraphy was performed together with an injection of vital dye to identify the SN, in 94 (70.1%) only vital dye was utilized. The mapping procedure was successful in 129 cases (96.2%). In our study there was concordance between SNs and axillary nodes in 120 out off 124 cases (96.7%). The false-negative rate was 4.8% (4/83). The overall sensitivity of the SN biopsy was 91.1% (41/45), with a negative predictive value of 95.1% (79/83). Five patients had SN negative and they decided do not undergo axillary lymphadenectomy. This study demonstrates that accurate SN identification was obtained combining lymphoscintigraphy and blue dye. Moreover, each method requires a suitable learning curve. After an accurate training, complete axillary lymphadenectomy can be avoided in selected patients.

[Acute ileitis due to Ascaris lumbricoides]. / Ileite acuta da "Ascaris lumbricoides".

The authors report their experience of two cases of acute ileitis with an obstructive complication due to "Ascaris lumbricoides". The distinctive features were, in the first case, the pathogenic mechanism responsible of the occlusion, and in the second one, the need of a long term follow-up. The latter, especially in the "aspecific forms", often allows an etiological diagnosis difficult even at laparotomy. Indicating the most frequent causes of surgical complications found in ileitis, which is a medical disease easily curable by medical and dietetic means, the authors confirm the difficulties of an etiological diagnosis and surgical treatment, increased by the rarity of the disease.

[Cystosarcoma phyllodes of the breast: clinical cases]. / II cistosarcoma filloide della mammella: contributo clinico.

The authors report their experience in the management of 8 cases of cystosarcoma phylloides of the breast observed between January 1979 and December 1986 in the Surgical Department of the University of Bari. This uncommon breast pathology, which stands halfway between benign (adenofibromas) and malignant (carcinomas) tumors presents considerable difficulties in terms of diagnosis particularly problematic for the small-sized lesions. The authors stress the need of a surgical treatment which takes into account women aesthetic desire assuring at the same time a complete exeresis. The latter includes the sacrifice of at least 1 cm thick normal breast tissue to prevent the frequent local relapses.

[Rare neoplasms of the breast: our experience concerning nonepithelial malignant breast tumors]. / Neoplasie rare della mammella: la nostra esperienza dei tumori maligni mammari non epiteliali.

The Authors report their experience about some clinical cases of uncommon breast neoplasms observed at the Division of Surgical Pathology, referring particularly on non epithelial malignant tumors. Signalled more meaningful anatomopathologic elements, they describe diagnostic difficulties and therapeutic of such neoplasias; for their rarity they would deserve a study more deepened finalized to the formulation of diagnostic and therapeutic guidelines as so as in the most common breast carcinoma.

[Pica in psychotic patients: an unusual cause of acute abdomen]. / Il picacismo nei pazienti psicotici: una inconsueta causa di addome acuto.

Pica is a pathologic craving for substances not commonly regarded as foods. In this study the authors report their experience about five cases presented with an acute abdomen following foreign bodies ingestion by patients mentally handicapped. Therapeutic treatment was emergency laparatomy with postoperative morbidity of 40% and mortality of 40%. It is hoped that specific drug therapy with more aggressive surgical treatment will reduce the mortality significantly.

[Immune evaluations in cancer patients after colorectal resection]. / Valutazioni immunitarie in pazienti neoplastici dopo resezione colo-rettale.

The authors report a protocol of immunomodulation and monitoring of the intestinal function in coloresected patients using fermented milk (yoghurt). Intestinal immunity was evaluated with respect to CD4+ cells armed with secretory intestine-derived IgA, and to CD8+ cells armed with IgG aiming to an additional effect in the host protection against Gram-negative strains, such as Salmonella typhi, whose particularly high incidence in Apulia accounts for an increased immunitary activity. Ten patients (six females, four males), age ranging from 44 to 85 years, who underwent surgery between 1989 and 1992, each of whom had been prescribed a daily ration of 500 gr skimmed yoghurt for one month, were observed. The authors suggest that yoghurt may determine a higher release of gamma-IFN with activation of CD4+ and CD8+ cells. The Lactobacillus stimulation of the B lymphocytes of the Peyer plates seems to induce an increased production of secretory IgA that bind to the CD4+ surface, and of IgG (as an anamnestic response to challenge with yoghurt lactobacilli). Coloresected patients show an immunitary deficiency related to the Gram+ bacterial flora reduction and consequently a decrease in the physiological stimuli. Although these date concern a limited sample, the authors stress the importance of the restoration of bacterial flora in coloresected patients.

A survival regression analysis of prognostic factors in colorectal cancer.

BACKGROUND: Many prognostic factors of colorectal cancer are known but their actual clinical validity is still uncertain. The aim of the present study was to verify, on the basis of our experience, the prognostic validy of variables for survival by using survival regression analysis. METHODS: From January 1978 to December 1986 the prognostic factors for 192 patients were analysed. These patients had undergone surgical resection for colorectal cancer. The follow up was completed in every patient by the end of December 1992, with a median follow up of 10 years (range 6-14 years). The prognostic factors considered in the statistical analysis were age, sex, size of tumour, site, grade, direct spread, node involvement and stage (according to Astler-Coller and pTNM). RESULTS: Of the prognostic factors, sex was the only one not to show any prognostic significance. In the survival regression analysis we have used an accelerated failure time model (equivalent to the Cox proportional hazard model); age, grade and stage were significant covariables. CONCLUSIONS: Although clinical pathological staging (pTNM) appears as a pre-eminent prognostic factor, and as our analysis shows, it needs a further variable (grading), which has been shown to affect the prognosis in a significant way.

Nuclear morphometry in node-negative breast carcinoma.

OBJECTIVE: To determine whether nuclear morphometry can confirm or add useful information to classic clinicopathological prognosticators to identify the subpopulation of breast carcinoma patients with node-negative (N-) disease, at high risk of disease relapse. STUDY DESIGN: On the basis of results obtained by clinicopathologic evaluation of a group of patients with N- breast cancer, on a test group of 56 cases (32 patients disease free and 24 with relapse), we performed a morphometric analytical study of nuclei using the Shape Analytical Morphometry (SAM) software system; 20 nuclei for each case and 17 morphometric parameters for each nucleus were analyzed. RESULTS: The SAM system allowed us to quantify shape differences in nuclei in terms of contour irregularities and asymmetries along with evaluation of nuclear dimensions. Dimensional and analytic parameters were subjected to univariate (Student's t test) and multivariate (Hotelling's test) analysis. Multivariate discriminant analysis showed that an exact forecast of disease relapse could be made in 77% of patients with N- breast cancer by using a set of six both analytic and dimensional parameters. CONCLUSION: These results confirm that nuclear pleomorphism is the result of both contour irregularities and shape asymmetries and that even though they should be considered preliminary results, they stress the importance of quantitative shape evaluation.