Everolimus is an active agent in medullary thyroid cancer: a clinical and in vitro study.

Everolimus, an mTOR inhibitor, which has been demonstrated to induce anti-tumour effects in different types of neuroendocrine tumours, has never been evaluated in patients with medullary thyroid cancer (MTC). The aim of this study was to evaluate the in vitro and in vivo effects of everolimus in combination with octreotide in MTC. Two patients with progressive metastatic MTC and high calcitonin levels were treated with everolimus 5-10 mg/day. Both patients were under treatment with octreotide LAR at the study entry. An in vitro study was also performed to assess everolimus effects on MTC cell lines (TT and MZ-CRC-1 cells). A tumour response was observed in both patients. Serum calcitonin decreased by 86% in patient 1 and by 42% in patient 2. In TT and MZ-CRC-1 cells, everolimus induced a significant dose-dependent inhibition in cell proliferation. This effect seems to be related to a cell cycle arrest in G(0) /G(1) phase in both cell lines and to the induction of cellular senescence in TT cells. Everolimus in combination with octreotide may be active as anti-tumour therapy in patients with progressive metastatic MTC, suggesting to further evaluate this agent in MTC patients in a large prospective study.

Surgical treatment of differentiated thyroid carcinoma: a retrospective study.

INTRODUCTION: We carried out a retrospective analysis of our experience in the management of Differentiated Thyroid Carcinoma (DTC), in order to better define prognostic factors (age, gender, histological type, stage) and outline a standard procedure, where it's possible, for surgical treatment. PATIENTS AND METHODS: Patient population consisted of 432 cases, operated from 1978 to 2003. We carried out 285 operations of total thyroidectomy of which 39 associated to some kind of lymphadenectomy, 66 totalization (21 pts had been operated in other institutes), 60 subtotal thyroidectomies and 21 lobo-isthmectomies. Survival and mortality curves for age, sex, histological type, grading and staging have been calculated. Kaplan-Meyer statistical elaboration for disease-free interval and Mann-Whitney test for the comparison of different clinical and pathological data have been employed. RESULTS: The statistical analysis puts in evidence that on 432 cases examined, with a follow-up from 1 to 25 ys (median = 6.33 ys) and with a drop-out of 60 cases (13.8 %), total mortality for cancer has been of 24 cases (6,4%), with a median interval free by disease of 4.2 ys (range 5 months to 25 ys), and a probability to stay free by disease at 12 and 24 months respectively of 95.1% and 91.6%. The median survival is resulted of 5.8 ys (range 1 to 25 ys) with a probability of survival at 24 and 48 months respectively of 97.5% and 94.3%. The multivariate analysis evidences the most important variables, i.e. age > 45 ys, tumor of intermediate malignancy, with size 1.5 cm, operative M+, significantly condition the prognosis, noticeably getting worse it, independently by the kind of carried out operation. CONCLUSION: Our present therapeutic choices are: 1. total thyroidectomy in the treatment of the apparently benign pathology when bilaterally with spread; the checking at the final histological exam of a cancer makes however think adequate the carried out operation; 2. lobo-isthmectomy in the treatment of unilateral benign pathology or with suspect FNAB for follicular neoplasm; the histological checking of a cancer makes think the operation adequate only in presence of favourable prognostic parameters, but in presence even of just one unfavourable variable, we consider necessary the totalization; 3. total thyroidectomy in presence of a certain or strongly suspected preoperative diagnosis of cancer.

[Is extrauterine endometriosis confined to the gynecological sphere? A critical review of the experience in a general surgery unit]. / Endometriosi esterna: patologia di esclusivo interesse ginecologico? Il punto di vista del chirurgo generale.

Extrauterine or external endometriosis (e.e.) describes ectopic localization of functional endometrial tissue, a finding whose incidence is increasing due to the diffusion of laparoscopic procedures. The clinical presentation of such disease is often non-specific, even in those cases with a definite surgical indication, depending on the site and pathology of the lesions. Surgical planning is therefore difficult at times, specifically regarding the extent of resection in patients--as young women--willing to maintain fertility. The Authors report on 7 cases observed in their own experience (inguinal endometriosis--1 case, umbilical endometriosis--1 case, abdominal wall endometriosis--3 cases, intestinal endometriosis--1 case, diaphragmatic endometriosis associated with pneumothorax--1 case), representing the wide range of clinical settings related to e.e. Based on literature data, an analysis of clinical and diagnostic issues is carried out. Specifically, the problems related to extent of surgical resection in multifocal cases, possible malignant degeneration and localization on abdominal wall scars are discussed.

[Surgical treatment of sinus pilonidalis by Dufourmentel's flap technique]. / Il trattamento chirurgico del sinus pilonidalis con trasposizione di lembo secondo Dufourmentel.

The present study reports the results of surgical treatment of 175 consecutive chronic pilonidalis sinus cases by excision alone, excision and primary closure, excision and Dufourmentel's flap technique. The analysis of hospital stay , average recovery time, patient compliance and percentages of failures and recurrences enables us to state that Dufourmentel's technique is the best choice, allowing fast recovery with minimal discomfort and lower rate of recurrence. Moreover the good compliance of the technique and the use of recently introduced more effective local anaesthetics have allowed us to plan the treatment in a day-surgery setting with good clinical results.

Surgical treatment with Ligasure Precise of schwannoma of brachial plexus: case report.

English version We present a case of bulky schwannoma arising from the brachial plexus treated by a new surgical device. A 38-year-old man presented with a slow-growing left-sided supraclavicular mass and complained paresthesia of the third and forth fingers of the hand and forearm weakness. Physical examination revealed Tinel's sign. A CT-scan revealed a solid mass situated in the left profound supraclavicular fossa. The tumour was resected with the utilization of bipolar vessel sealing system (Ligasure Precise). This device is very useful in sutureless removal of masses localized in deep supraclavicular fossa. During the operation, care was taken to preserve the nerve function.

[Thyroid microcarcinoma: our experience]. / Microcarcinoma tiroideo: nostra esperienza.

Differentiated thyroid cancer had an excellent prognosis; the diagnosis of sub-centimetric differentiated cancer (microcarcinoma) is more and more frequently. Clinical evolution of microcarcinoma could be various: microcarcinoma can represent an autoptic finding or can evolve with locoregional lymph node involvement or metastasis. Various clinical and genetic factors have been considered to predict the aggressiveness of this neoplasm. From 2001 to 2004, 74 patients with diagnosis of thyroid microcarcinoma underwent surgical treatment. By a retrospective survey we evaluated risk factors and the choice of surgical treatment. The aggressiveness appear to be related mainly to multifocality and size. Our therapeutic strategy is to perform total thyroidectomy for benign pathologies, total thyroidectomy with lymphadenectomy in cases with preoperative diagnosis of microcarcinoma.

Breast surgery and sentinel node biopsy. Our experience.

Massive campaigns of screening of breast pathologies improved early diagnosis of breast cancers. Most of these cancers are small-sized (T1) and seldom show intraoperative nodal involvement. Sentinel node biopsy is the elective choice in the above mentioned cases because, if negative, it avoids axillary dissection. International literature reports rates of false negative sentinel node biopsy ranging among 4.5 and 12%; results in our experience account for almost 6%. As a consequence, there is the definite risk of potentially positive axilla that will not be dissected with subsequent risk of axillary recurrence within 24 months. The reason of that could be related to the fact that in Referral Centers this technique is performed in strictly selected patients, so as to gain a diagnostic accuracy of 98%. The rate of axillary recurrences does not justify the routine axillary dissection, since this is just a staging, not a therapeutic procedure. In case of doubt, it can be recommended a close and careful follow-up of the axilla.

[Male breast cancer. Five years experience and literature review]. / Il cancro della mammella maschile. La nostra esperienza di 5 anni e confronto con la letteratura internazionale.

Male breast cancer is an uncommon disease and its aetiology, clinical behaviour and treatment is not well-known . Retrospective studies show that age and stage-matched breast cancer in men and women are compared. Nevertheless, the poor mammary tissue in man allow a rapid local infiltration, late diagnosis and poor survival rate. The Authors report their five years experience and with a short literature review they summarise what is currently known about this uncommon neoplasm in terms of prognostic factors, therapy and survival.

Gastrointestinal tumours in elderly.

The Authors report their experience concerning 129 cases of gastrointestinal neoplasms (gastric, colonic, anorectal), recorded during the last years among patients aged between 70 and 81 years, who underwent radical surgery. The main issues evaluated were: anaesthesiological risk, stage, post-operative mortality and morbidity. Elderly seems not to be a contraindication, nor a limit for surgery if the patient is correctly and strictly managed pre and post-operatively.

Which therapy to prevent post-thyroidectomy hypocalcemia?

Hypocalcemia is one of the most frequent complications after total extracapsular thyroidectomy (TET). In most of cases it is a transient phenomenon. The aim of this study is to evaluate if and how the oral administration of calcium or calcium combined with D-vitamin could effectively prevent post-thyroidectomy hypocalcemia. A randomized prospective study was performed, recruiting 120 patients who underwent total thyroidectomy. The patients in our series were randomly assigned to one of two groups: group A--patients who received calcium lactogluconate/calcium carbonate (mg 300 per day); group B--patients who received calcium carbonate/cholecalciferol therapy (calcium carbonate: 1500 mg per day; cholecalciferol 400 UI per day). The groups were well matched for age, sex and pathologies. Patients of both A and B groups were divided in two subgroups: those operated on for benign thyroid diseases (A1 and B1) and those operated on for malignancy (A2, B2). Serum calcium assays, performed 24, 48 and 72 hours after surgery, showed mean values of calcemia higher in patients of the B1 and B2 group. Statistical analysis was performed using a Student's t test. Mean serum calcium concentrations on post-operative day one, two and three were higher in patients of the group B (p<<0.01). Early and combined oral administration of both calcium and vitamin D seemed to prove major efficacy in preventing and treating post-operative hypocalcemia, showing mean serum calcium levels higher than those of patients who received only oral calcium administration. Nevertheless, further studies are necessary to validate these data.

Major complications in thyroid surgery: utility of bipolar vessel sealing (Ligasure Precise).

In the present study the Authors tried and assess the advantages of the standard sutureless thyroidectomy performed by the Ligasure Vessel Sealing System, thanks to the use of the dedicated Precise handle. The Authors compared the efficacy of haemostasis and the economical impact of the device, in terms of drug administration and costs. The Authors comparatively analyzed 120 total extracapsular thyroidectomies (TET) performed by the standard operative technique (Group A, control) and 70 TET achieved by the "sutureless technique" (Group B, case). There was a statistically significant decrease of transient postoperative hypocalcemia (5.71% vs 7.5%) and also of mean operative time (about 20 minutes) in patients of the group B. Non significant decrease of other kind of complications (postoperative hemorrhage, transient and permanent inferior laryngeal palsy, stupor of the superior laryngeal nerve, seromas) were also observed. The use of the Ligasure Precise resulted easy, safe and efficient in the Authors' experience. It allowed the decrease of postoperative haemorrhages and mean operative time.

[Bile leakage after laparoscopic cholecystectomy: report of three cases in our experience]. / Coleperitoneo dopo colecistectomia laparoscopica: descrizione di tre casi nella nostra esperienza.

Laparoscopic cholecystectomy (LC) is associated with an higher incidence of bile duct injury than open cholecystectomy. There has been concern and the reason why bile leakages are more frequent with LC is yet unclear. Bile collections can occurr because of major about (75%) or minor (about 25%) injuries. Anyway, external biliary decompression is a key factor in the treatment, in order to avoid an emergency intervention. The Authors report their experience concerning 3 cases of bile leakages among a series of 458 LC. Only in one of the three cases the subhepatic space was not drained and an emergency laparotomy was performed. The Authors, on the basis of their own experience and of the data reported in literature, suggest the routinary intraoperative placement of a drainage into the subhepatic space, to be removed, if no complications occur, one day after surgery.

[Interstitial laser photocoagulation in liver tumours: our experience]. / Laserterapia interstiziale nell'epatocarcinoma su cirrosi: nostra esperienza.

Interstitial lasertherapy (ILT) is one of the percutaneous thermal procedures allowing the ablation of primary or secondary hepatic lesions. This technique can be performed without general anaesthesia, since the patient is completely painless, in spite of the high temperatures reached, because there are no sensitive fibers around the lesion. This study includes patients with small hepatocarcinomas (< 2 cm) non peripherically sited, far from the gallbladder and the hepatic hilum. Twenty patients suffering from 24 cirrhotic hepatocarcinomas (two patients showed two nodules) have been enrolled for the present study. Mean diameter of lesions was 1.8 cm (1.3-2 cm). One or more 21 G (length 20 cm) Chiba's needles were inserted under sonographic view into the lesions. The laser energy was switched on at 4 Watts for 4-6 minutes, until an amount of energy of 900-1800 Joule was reached. All the patients were discharged 48 hours after the procedure. Triphasic CT-scan with contrast were performed 7 to 14 days after ILT, in order to check its efficacy. CT-scan showed complete necrosis in all the nodules ranging from 1.5 to 3 cm. All the patients received only one IL T session, whose longest duration was 20 minutes. No major complications occurred. ILT of small hepatocarcinomas is a safe, efficient procedure, also feasible without anaesthesia. Differently from percutaneous radiofrequency, in fact, it shows the advantage of less pain, that can avoid the need for general anaesthesia.

Laparoscopic pancreatectomy: Did the indications change? A review from literature.

Pancreatic Cancer (PC) is the fourth cause of death for tumors in Western countries. Symptoms are not specific, and can vary according to the tumor size and place. Diagnostic workup includes CA 19-9, CT and MRI. Surgery is the only treatment for PC, associated to radio-chemo therapy. Laparoscopic approaches are actually used for PC treatment in few specialized centers, and could be an alternative to laparotomic surgery. The aim of our study is to evaluate the efficacy of laparoscopy for PC treatment compared to laparotomy. We reviewed 19 articles in literature to assess the feasibility and efficacy of Laparoscopic Distal Pancreatectomy (LDP) and Laparoscopic Pancreaticoduodenectomy (LPD). The results have shown that LDP is nowadays a safe technique, and the outcomes are comparable to laparotomic surgery. Regarding to LPD instead, results are controversial and the data are still not sufficient to consider this technique as a valid alternative to laparotomic surgery.

[Efficacy of somatostatin analogs in the treatment of neuroendocrine tumours and paraneoplastic syndromes]. / Efficacia degli analoghi della somatostatina nel trattamento dei tumori neuroendocrini e delle sindromi paraneoplastiche.

BACKGROUND: The authors report their experience with octreotide LAR in the adjuvant treatment of 10 patients suffering from neuroendocrine tumours and paraneoplastic syndromes. METHODS: All patients were studied preoperatively using traditional radiology and scintigraphy using octreoscan. RESULTS: Octreoscan was positive in all cases for somatostatin receptors. All patients with neuroendocrine tumours underwent surgery of the primary neoplasm; treatment with somatostatin was commenced at a later stage. CONCLUSIONS: The authors' experience with octreotide LAR proved to be an efficacious means of controlling symptoms and stabilising disease without collateral effects. They conclude by affirming that octreotide LAR represents a valid therapeutic choice in the symptomatic treatment of neuroendocrine tumours.

[Carotid glomus tumours. Personal experience in the surgical treatment of chemodectoma]. / Tumori dei glomi carotidei. Nostra esperienza nel trattamento chirurgico dei chemodectomi.

The authors present 6 cases of carotid glomus tumours referred to their attention over the past 10 years. Their experience shows that colour ultrasonography (using both morphological and functional evaluation) is the diagnostic key for defining the treatment of paraganglioma. More recent experience highlights the role of 111In Pentreotride using a multidisciplinary therapeutic approach.

[Total implantable venous systems in day surgery]. / Sistemi venosi totalmente impiantabili in day surgery.

UNLABELLED: Total implantable venous system (port-cath)in day surgery. AIMS: Most of patients underwent to a total implantable venous system (port-cath) can be treated in day surgery. METHODS: Since January 2000 to March 2003 we have implanted 31 port-a-cath, preferring access in subclavia v. We've treated all patients in day surgery and we've performed a Rx-control with a medium follow up of two hour. RESULTS: We have not reported any early complication, only 3 late complications: a device malfunction, a "kinking" reservoir and an infection of the subcutaneous pocket. The last two complications have required the explantation of the device. In difficult catheterizations can be helpful to use a pediatric kit. The rules of an aseptic and antiseptic operative procedure and the utilization of a short term antibiotic prophylaxis can avoid infective complications. We have proposed, after the device implantation, cardioaspirina like preventive therapy of septic and no septic thrombosis. In the thrombotic occlusion of the catheter we propose the use of activase. In malfunction's prevention we propose a lateral placement (to the skin incision) of the subcutaneous pocket and a 45 degrees reservoir rotation. CONCLUSIONS: The total venous system (port-cath) implantation can be mostly performed in day surgery, improving the compliance of the patients with a low cost procedure.

[Controlled clinical evaluation of 2 hypnotic triazole benzodiazepines, estazolam and triazolam, used the night before surgical interventions]. / Valutazione clinica controllata di due benzodiazepine ipnoinducenti triazoliche, estazolam e triazolam, nell'impiego alla vigilia di interventi chirurgici.

In order to study the efficacy of estazolam versus triazolam in preoperative patients, two groups of 49 patients each were treated with 2 mg estazolam and 0.5 mg triazolam in a single dose, the night before surgery. This controlled study was designed to evaluate sleep patterns, emotional status on awakening and side effects, by the administration of a questionnaire either in the morning of the day before (baseline) or on the morning of surgery. The results show better sleep patterns after estazolam excepting the duration of sleep that was the same for the two drugs. The better emotional status upon awakening in the morning before surgery and the lower incidence of side effects in the patients treated with estazolam, lead to the conclusion that estazolam is clearly better than triazolam in the treatment of preoperative patients.

[Cancer risk in breast lesions: diagnostic and therapeutic strategy]. / Lesioni a rischio della mammella: protocollo diagnostico-terapeutico.

BACKGROUND: The classification, diagnostic recognition and surgical treatment of breast lesions at risk of neoplastic transformation represent some of the most important objectives in breast research. Attention has been focused on lesions at risk of neoplastic transformation in breast pathology, such as: atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), multiple intraductal papilloma and sclerosing adenosis. METHODS: Our experience regards activity carried out from 1996 to 2001; the diagnostic approach included routine performance of echotomographic examination, mammography screening indicated in women >40 and, in selected cases, in women <40; FNAB was carried out in all lesions containing suspicious cells. In the case of non-palpable lesions we carried out a CT-guided FNAB using the stereotaxic technique. In cases of secreting breast, galactography proved useful. As regard clinically suspect nipple secretions, cytology was useful in the diagnosis of intraductal papillomatous lesions. Surgery was indicated for: mammographically negative nodular lesions with cytological finding of suspect lesions. Continuous, spontaneous mono-orificial, serous, sero-hematic or hematic secretion of the nipple also in the presence of negative and/or inconclusive galactographic and cytological findings. From a nosological viewpoint we have distinguished 3 groups: A) 49 women (average age 47.3 years) with suspect lesions subjected to biopsy. On the basis of the cytological response we carried out: 37 quadrantectomies with extemporary examination, 4 excisional biopsies, 5 radical ductectomies and 3 microductectomies. B) 26 patients (36.7 years) subjected to mammary biopsy for non-suspect lesions; in 24 cases excisional biopsy of the lesion and in 2 cases radical ductectomy. C) Control group consisting of 141 women (average age 44.5 years) suffering from benign pathology not suspected of lesions at risk and not subjected to surgery. RESULTS: The final histological examination evidenced: Group A: 7 cases of T1aN0M0 carcinoma (14.3%); 20 lesions at risk (40.8%); 22 lesions not at risk; Group B: 25 (96.1%) lesions not considered at risk, in 1 case (3.9%) area of sclerosing adenosis with ductal proliferation and slight atypias; Group C: in 4 cases (3.1%) the onset at follow-up of lesions at risk made it necessary to remove the lesion. Histology did not confirm the presence of cancer in any case. CONCLUSIONS: The diagnostic and therapeutic protocol proposed enables us to identify and radically treat high risk patients (Group A) and follow them up closely. On the contrary, Group B evidenced a very low incidence of lesions at risk which escaped preoperative diagnosis and in confirmation of this in Group C, during follow-up, the onset of only 4 lesions at risk was identified in which histological examination however excluded the presence of cancer.

Repair of complex giant ventral hernias with polypropylene and omentoplasty.

The Authors in this report describe their experience with complex giant ventral hernias repaired by omentoplasty and polypropylene meshes. They explain their own technique of using the omentum when there is a lack of tissue and the need of an autologous tissue to place between the viscera and the above-lying polypropylene mesh. Among the 5 patients repaired, 4 had a giant sub-umbilical midline ventral hernia and one had a giant border ventral hernia. In all patients, the omentum was placed between the viscera and the mesh, which was fixed by interrupted sutures to the above-lying musculoaponeurotic plane. No complications, signs of bowel obstruction, or recurrences occurred. The Authors stress the omentum as an ideal tissue because of its biocompatibility and prevention of adhesions and fistulas allowing the use of a rigid and efficient prosthesis such as polypropylene. Thus, on the basis of their own short- and long-term good results, they suggest, whenever possible and necessary, the use of omentoplasty to repair complex giant ventral hernias.