[Locally advanced breast cancer in elderly patients: treatment standardised or tailored to individual needs?]. / Cancro della mammella localmente avanzato nell'età senile: trattamento standardizzabile o modulato?

Breast cancer in elderly patients occurs frequently and is often inadequately managed. Furthermore, for organizational and social reasons, the incidence of locally advanced neoplasms is higher in this age group than in the younger population. The aim of the study was to assess our experience in this specific pathology and review the international literature on this topic. From 2001 to 2005 116 cases of breast cancer in elderly women (70-95 years old) were observed by our surgical units. Of these, 38 were at a locally advanced stage (10--26.3%--stage IIIA, 28--73.7%--stage IIIB). Comorbidity (two or more diseases) existed in 32 patients. A Madden modified radical mastectomy was carried out in all cases. Resection was extended to the chest-wall tissues in cases of local infiltration. Surgical mortality was 10% (4 cases). Eight of the 34 patients discharged died within 24 months (2 of disease progression). Adjuvant chemotherapy was never offered. On the other hand, all patients received hormone therapy (tamoxifen). 10 of the 26 patients (38.4%) surviving over 2 years underwent redo surgery for local relapse of disease. Our conclusions are: 1) breast cancer in elderly patients is often underestimated and undertreated; 2) disease management cannot be standardized, but must be tailored to the single patient; 3) short- and medium-term results are satisfactory; 4) comorbidity must be carefully assessed.

The role of laparoscopy in pancreatic surgery.

Carcinoma of the pancreas is extremely common, with a five-year mortality rate of about 95-99%. Radical surgery requires good technical skill and can cause complications and operative mortality, but should be avoided in patients with extrapancreatic involvement. Advances in dynamic spiral CT-scan have decreased the number of unnecessary laparotomies. VLS is indicated in cases of pancreatic mass deemed resectable or "doubtful" by CT-scan. Direct laparoscopic visualization can be combined with intraoperative laparoscopic ultrasonography (LUS), which has shown a positive predictive value of resectability of 91%. Laparoscopic pancreatoduodenectomy (LPD) shows a high rate of complications and should be performed by very well-trained surgeons. Laparoscopic distal pancreatectomy (LDP) with an "en bloc" splenectomy and spleen preservation should be performed.

Efficacy of magnetic resonance cholangiopancreatography in detecting common bile duct lithiasis: our experience.

It has been shown that magnetic resonance cholangiopancreatography (MRCP) has a diagnostic accuracy comparable to that of ERCP. The aim of this study was to compare the diagnostic accuracy of MRCP in patients with suspected choledocholithiasis, but with negative ultrasonography findings. Among 404 patients undergoing videolaparocholecystectomy for cholelithiasis, 48 with risk factors for coledocholithiasis were evaluated. All the patients with risk factors underwent preoperative hepatobiliary ultrasonography and MRCP. Patients were assigned to one of 2 main groups: A) patients with common bile duct stones at ultrasonography (15/48: 31%) and B) patients without evidence of common bile duct stones on ultrasonography (33/48: 69%), with B comprising two subgroups: B1) MRCP-positive for stones (7/33:21%) and B2) negative US and MRCP (26/33:79%). MRCP showed 100% sensitivity and 100% specificity. The high sensitivity of MRCP allows us to recommend a greater use of the procedure with avoidance of unnecessary ERCP, which should be reserved for therapeutic purposes only.