Adjuvant postoperative radiotherapy in rectal cancer: 148 cases treated at Florence University with 8 years median follow-up.

BACKGROUND AND PURPOSE: To analyse the outcome, the treatment related side effects, the prognostic significance of clinical parameters in a group of patients with rectal cancer receiving postoperative radiotherapy after radical resection. MATERIALS AND METHODS: From 1980 to 1990 148 consecutive patients with rectal carcinoma stage B2-B3 or C1-C2-C3 were treated with postoperative radiotherapy after radical surgery. All patients received 50 Gy in 25 sessions in 5 weeks. In 42 a "flash' dose of 5 Gy was also given within 24 h before surgery. Median follow up was 8.1 years. RESULTS: At 5 years the overall survival was 54%, the determined (cancer specific) survival 61%, the local recurrence-free survival 88%. The influence of stage, histotype, distance from anal margin, type of surgery, number of involved nodes and flash dose were analysed. Overall and determined survival and distant metastasis rate were significantly influenced (P < 0.005) by the pathological stage. Patients with more than 3 involved nodes presented a significantly lower determined survival (P < 0.001) and a higher distant relapse rate (P < 0.005) than those with 3 or less involved nodes. A higher determined survival (P < 0.01) was also found in patients receiving the preoperative "flash'; this group was however unbalanced in respect to the relative number of cases with 3 or less involved nodes. The incidence of major side effects requiring surgery or hospitalization for medical treatment was 35% before 1985 and 12% thereafter. The systematic use of small bowel visualization during simulation and the discontinuation of the flash dose were the main modifications introduced in the second period. As a consequence of the small bowel visualization the size of lateral fields was slightly reduced and some patients were excluded from the treatment. CONCLUSIONS: Value of postoperative radiotherapy to decrease the incidence of local recurrence was confirmed in this retrospective study; the incidence of side effects was however considerable and did not support the addition of chemotherapy as advised by the NIH consensus meeting. Our policy was therefore moved to preoperative irradiation whose combination with chemotherapy was recently reported to be better tolerated and highly effective.

Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma.

BACKGROUND: Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. METHODS: One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. RESULTS: Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). CONCLUSIONS: Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Preliminary experience in the treatment of rebel ascites from ovarian cancer with the peritoneo-venous shunt of Leveen.

4 cases of rebel ascites from advanced ovarian cancer, considered lost to chemotherapy, are treated with Leveen's peritoneo-venous shunt. Deterioration of general conditions for the ascites and progressive unaffectiveness of chemotherapy induced the authors to find better conditions of life for these patients. By the peritoneo-venous shunt life condition improved significantly; the patients were able to continue chemotherapy with good results; 2 patients are living more than 2 years after the shunt.

[A comparative study of 2 schedules of antibiotic prophylaxis using ceftazidime in the prevention of infections in elective surgery of the biliary surgery. Preliminary results]. / Studio di confronto fra due schemi di antibiotico profilassi con ceftazidime nella prevenzione delle infezioni nella chirurgia di elezione delle vie biliari. Risultati preliminari.

The authors compared short-term and ultrashort-term antibiotic prophylaxis with ceftazidime for the prevention of infections in selective biliary surgery. The multicenter (180 centers) study involved 1800 patients; at present data are available for 44 centers (392 patients, 129 males, 263 females, age range 18-87 years). Treatment schedule consisted of a single i.v. administration of 2 g ceftazidime concurrent with anesthesia induction (group 1) whereas short-term prophylaxis comprised administration of 1 g ceftazidime with preanesthesia, 30 min before the beginning of surgery and 6 and 12 hrs. after the first dose (group 2). The two groups (193 and 199 patients respectively) were similar for age, sex, concomitant pathology, presurgical diagnosis, risk factors (both as to incidence and type), biliary drainage. The difference in success rate between the two groups was 2.3% (92.2% in group 1; 94.5% in group 2) with a 90% confidence interval of 2.4 and 6.9%; this difference was not significant (p = 0.491). These preliminary findings indicate the administration of a single dose of ceftazidime as a valid alternative to short-term prophylaxis in view of its practical and economic advantages.

[Therapeutic trends in adrenal incidentaloma]. / Orientamento terapeutico nell'incidentaloma surrenalico.

The term incidentally discovered adrenal mass or incidentaloma includes several tumors, mainly benign, involving the adrenal space. From 1983 to 1990, at the 1st Surgical Department of the Careggi Hospital of Florence, 10 patients (8 females and 2 males), with age ranging from 31 to 66 years, were found to have an incidentaloma. The size of the mass ranged from 2 to 10 cms; the left side was interested in 2 cases and the right one in 8 cases. The first diagnostic approach was abdominal ultrasound scanning in 8 out of 10 patients, whereas computerized tomography was the first used in the remaining 2 patients. Overall, all patients underwent CT scanning, while abdominal ultrasound scanning was performed in 9, urography in 2, and MNR in 1. Fine needle aspiration was performed in one case of adrenal cyst both for diagnostic and therapeutic purposes. The Authors suggest a therapeutic-diagnostic program in which cytology, obtained through fine needle aspiration, may have a prominent role in reducing the need for surgical interventions, as it recently happened for thyroid disorders. Although technically more complex compared to thyroid fine needle aspiration, adrenal ultrasound-guided FNA may bring to a better classification of the different adrenal disorders reducing at the same time the need for surgery, which at present has a prevalent diagnostic intent.

[Splenic injuries: recent acquisitions concerning the treatment]. / Traumi splenici: recenti acquisizioni in tema di trattamento.

The Authors briefly review spleen functions and the consequences of splenectomy particularly for what the immune function is concerned. Data concerning postoperative infections following splenectomy for staging laparotomy in 92 patients with lymphoma are analysed. Data concerning immunological function of 17 pts. who underwent splenectomy in the last 5 yrs. compared to 17 normal controls, homogeneous for sex and age, are reported. Plasma IgM decrease in 3 cases, CMI anergic status in 3 cases and CD4+/CD8+ lymphocyte ratio increase in 8 cases were observed. This article also reviews surgical techniques and recent knowledge in relation to the best treatment for splenic traumas, emphasizing advantages and disadvantages of conservative treatment. The Authors conclude presenting their personal series of 42 pts. affected with traumatic lesions of the spleen treated in the last 10 yrs., also illustrating a treatment flow-chart.

Local effects of atherosclerotic plaque on arterial distensibility.

Hypertension, diabetes, and hypercholesterolemia are characterized by a reduction in arterial distensibility and by accelerated atherosclerosis. Whether arterial stiffening is an inherent feature of these conditions or just the consequence of the atherosclerotic clinical or subclinical lesions is not known, however. Our aim was to obtain information on this issue by directly measuring, in humans, arterial distensibility both at the site of an atherosclerotic lesion and at the proximal normal site. In 10 patients (8 men; mean+/-SEM age, 65.2+/-3.4 years) affected by monolateral hemodynamic significant internal carotid artery stenosis, we measured arterial distensibility (Wall Track System; PIE Medical) bilaterally, both at the internal carotid artery and at the common carotid artery level. In the common carotid artery, measurements were made 3 cm below the bifurcation. In the affected internal carotid artery, measurements were made at the plaque shoulder (wall thickness of 2 mm). Measurements were made in the contralateral internal carotid artery at a symmetrical level. Arterial wall thickness was measured in the same site of arterial distensibility. Arterial distensibility was less in the internal than in the common carotid artery, with a marked reduction at the plaque internal carotid artery level compared with the corresponding contralateral site (-45%, P<0.01). It was also less, however, in the common carotid artery branching into the atherosclerotic internal carotid artery than in the contralateral common carotid artery (-25%, P<0.05). Wall thickness was similar in the 2 common carotid arteries and obviously greater in the affected internal carotid artery than in the contralateral artery. Arterial distensibility was markedly less in the internal carotid artery where there was a plaque compared with the intact contralateral internal carotid artery; it was also less, however, in the common carotid artery of the affected side in comparison with the contralateral common carotid artery. This provides evidence that the effect of a plaque on arterial mechanical properties is not limited to the actual plaque site but rather extends to a considerable degree in a proximal direction.