Long-term results after proactive management for locoregional control in patients with colonic cancer at high risk of peritoneal metastases.

PURPOSE: A major problem in treating patients with peritoneal spread from colorectal cancer is that at diagnosis wide peritoneal involvement often precludes all curative attempts. A possible solution is to identify those patients at risk for peritoneal metastases and intervene early to prevent locoregional disease spread before it develops and, thus, to improve outcome. METHODS: We analyzed long-term results from a previous study and compared outcomes in 25 patients with advanced colon cancer considered at high risk for peritoneal spread (pT3/pT4 and mucinous or signet ring cell histology) prospectively included and managed with a proactive surgical approach including target organ resection for peritoneal spread plus hyperthermic intraperitoneal chemotherapy (HIPEC) and in 50 retrospectively well-matched controls who underwent standard surgical resection during the same period and in the same hospital by different surgical teams. RESULTS: At 48 months after the study closed, peritoneal metastases and local recurrence developed significantly less often in proactively managed patients than in controls (4 vs 28%) (p < 0.03). Patients in the proactive group also survived longer than control patients (median overall survival 59.5 vs 52 months). Despite similar morbidity, Kaplan-Meier survival curves disclosed significantly longer disease-free and overall survival in the proactive than in the control group (p < 0.05 and <0.04). CONCLUSIONS: In patients with advanced colon cancer at risk for peritoneal recurrence, the proactive surgical approach plus HIPEC seems to achieve good locoregional control preventing peritoneal spread thus improving outcome without increasing morbidity. These advantages merit investigation in a multicentric randomized trial.

Weekly combination of non-pegylated liposomal doxorubicin and taxane in first-line breast cancer: wALT trial (phase I-II).

BACKGROUND: Through different pharmacodynamic-kinetic interactions, weekly administration of proved efficacy agents can overcome resistance with lower toxicity and greater benefit. Based on this assumption, we designed a phase I-II trial with weekly non-pegylated liposomal anthracycline and taxane in first-line breast cancer patients. PATIENTS AND METHODS: We enrolled 56 previously untreated metastatic breast cancer patients; they were randomly assigned to receive paclitaxel (Taxol) (50 mg/mq) or docetaxel (Taxotere) (30 mg/mq) combined with non-pegylated liposomal anthracycline (25 mg/mq) on days 1, 8 and 15 every 4 weeks. The primary end points were the clinical benefit and treatment-related toxic effects assessment. Secondary end points were time-to-disease progression (TTP) and overall survival (OS). RESULTS: The overall clinical benefit was 87.04%. World Health Organization G3-4 toxic effects included neutropenia (45%), anemia (44%), complete alopecia (83%), severe onycholysis and neuropathy. The 24% of patients developed left ventricular ejection fraction reduction but none >10% with recover after treatment completion. The median absolute decrease from baseline was 1%. Median TTP was 11 months and median OS was 23 months. CONCLUSIONS: Combined weekly administration of taxane and non-pegylated liposomal anthracycline is well tolerated and clinical benefit data encourage phase III study design.

Surgical removal of a ruptured, detached angioplasty balloon after popliteal stenting.

Balloon catheter entrapment after stent implantation is a potential interventional complication. However, angioplasty balloon disconnection from the catheter shaft and in-stent entrapment is a very uncommon event that could have serious thrombotic or embolic consequences. The management of this event may be interventional or surgical, depending on the patient's status and the position of the balloon inside the vessel. We describe a case of acute lower limb ischemia after popliteal self-expandable stenting, due to loss of the balloon along with a portion of its shaft. Surgical retrieval was accomplished without any further complications.

Fatal complication after thrombin injection for post-catheterization femoral pseudoaneurysm.

Femoral artery pseudoaneurysm (FAP) is one of the most common vascular complications after cardiac and peripheral angiographic procedures. Ultrasound-guided thrombin injection is the standard procedure for the treatment of FAP. Complications such as thrombotic events with leg ischemia after thrombin leakage into the femoral artery or immunogenic consequences are rare. Our experience indicates the need for caution when treating FAP, as severe complications can occur after thrombin injection in a femoral pseudoaneurysm, leading to a fatal event.

Pulmonary emboli due to venous aneurysm of extremities.

Venous aneurysms are uncommon but they can have devastating consequences, including pulmonary embolism, other thromboembolic events and death. We report six cases of venous aneurysm of the extremities, in which the first sign of presence was acute pulmonary embolism. Surgical resection is recommended whenever possible. Our experience suggests that prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for extremity deep and superficial venous aneurysms for their potential risk of developing thromboembolic complications despite adequate anticoagulation. Other venous aneurysms should be excised only if they are symptomatic or enlarging.

Open and endovascular combined procedures in lower limb arterial reconstructions.

INTRODUCTION: The association of open and endovascular procedures in patients with obstructive disease of the lower limbs gives the opportunity to treat in a single step multi-segmental lesions which were currently treated in the past by more demanding open procedures. PATIENTS AND METHODS: From January 2003 to May 2009, 52 patients with peripheral occlusive chronic arterial disease of the lower limbs were submitted to combined open and endovascular procedures. In 37 patients (71.2%) a femoro-popliteal/pedidial bypass was carried out after Percutaneous Transublimal Arterio (PTA)/stenting of the iliac/femoral arteries, while in the remaining 15 patients (28.8%) the endovascular procedures were performed following open approach, that consisted in a femoro-popliteal bypass. Iliac stenting interested the common iliac artery in 19 patients (51.3%), the common and external iliac artery in 11 patients (29.7%) and the external artery in 7 (19%). In this same group a fem-pop bypass below knee was carried out in 28 (75.6), a fem-pop above knee in 6 (16.2%), a fem-pop and jump on the posterior tibial in 2 (5.4%) and a superficial femoral-pedal in the last one (2.8%). In the other group the fem-pop bypass below knee was followed by a PTA of the tibial vessel in 12 cases (80%) and by a stenting in only 3 cases (20%). RESULTS: Three patient was lost to follow-up. Three (8.1%) iliac stents became occluded and the sudden onset of an acute ischemia of the limb required in all cases an aorto-femoral bypass. The occlusion of tibial stent in 2 patient (13.3%) was no clinical relevant, and the failure of the PTA procedure in other 4 patients with the reocclusion of the tibial arteries was followed by thight amputation. Occlusion of the femoro-popliteal bypass occurred in 9 of 37 patients (24.3%) submitted to iliac stenting and in 4 of 15 (26.6%) patients with PTA of the tibial vessels. The overall patency rate was 69.2%. Limb salvage was 77.5% CONCLUSIONS: Combination of the open and endovascular procedures to treat lesions of the lower limbs is effective and durable in terms of patency and complication rate. For validation this new approach needs the recruitment of much more patients and prospective protocol studies.

[Renal artery aneurysm. Treatment by ex-vivo reconstruction and autotransplantation: three cases and literature review]. / Autotrapianto renale ex vivo negli aneurismi delle arterie renali. Analisi di tre casi e revisione della letteratura.

Renal artery aneurysms (RAAs) is a rare clinical entity: the prevalence is approximately 0.01%-1% in the general population. Complex aneurysms of the first ramification of the main renal artery often require nephrectomy for adequate excision. From December 2002 to July 2007, we treated 3 patients with complex RAA. All the patients were treated with ex vivo reconstruction of the renal artery followed by autotransplantation of the kidney into the ipsilateral iliac fossa. Observation is suggested for asymptomatic complex renal artery aneurysms measuring less than 2 cm in diameter. Surgical treatment by aneurysmectomy and reconstruction in vivo or ex vivo technique is indicated for RAA causing renovascular hypertension, dissection, embolization, local expansion and for those in women of childbearing age with a potential for pregnancy, or asymptomatic more than 2 cm in diameter. Ex vivo repair and renal autotransplantation is a safe and effective treatment for the management of complex renal artery aneurysms.

Thrombin injection and compression with removable guidewire in the treatment of postcatheterization femoral pseudoaneurysm.

AIM:The purpose of our study was to determine the efficacy of percutaneous thrombin treatment for iatrogenic femoral artery pseudoaneurysms (FAP) and to identify those criteria that may help to predict increased treatment failure risk and complications. METHODS: A number of 32 iatrogenic femoral pseudoaneurysms were treated with US-guided thrombin injection (group A), while four elderly patient with complex femoral pseudoaneurysm underwent compression assisted by removable "guidewire" (group B). Twenty-five were classified as simple (single lobe) and 11 as complex (at least two lobes with a single neck to the native vessel). Pseudoaneurysm volume, classification, thrombin dose, anticoagulation therapy status, and sheath size were considered independent prognostic factors. RESULTS: All the 36 patients (pts) had initial complete femoral pseudoaneurysms thrombosis. The aneurysm was thrombosed on a Doppler ultrasound (US) follow-up in all the cases but four (group A), those who required the additional thrombin injection. A fatal complication occurred in one patient with complex FAP (group A). CONCLUSION: Preliminary data suggest that US-guided percutaneous thrombin injection is a safe and effective method to treat iatrogenic pseudoaneurysms. Simple iatrogenic femoral pseudoaneurysms benefit a single injection of up to 500 units of topical thrombin. We recommend more caution in complex pseudoaneurysms treatment; it is preferable to perform thrombin injection first into the lobe which is not directly joined to the femoral artery. A longer bed rest and closer observation are mandatory during the subsequent 24 hours. If the lobe communicating with the femoral artery is still patent, it can be retreated. Alternatively, we propose a new strategy approach through compression assisted removable "guidewire".