Surgical complications of carotid body tumors surgery: a review.

Carotid body tumor (CBT) is a rare neoplasm, although it represents about 65% of head and neck paragangliomas. Surgical excision is considered the appropriate therapy for CBTs. The aim of this study was to evaluate surgical outcomes on a large scale. We reviewed 19 studies between 2004 to 2014 with a total of 625 procedures. We observed a higher number of cases in women (62%). Only 3 (0,48%) deaths were reported as surgical complication. Total cranial nerve injuries were 302 (48,32%) of which 194 (31,04%) were transient and 108 (17,28%) were permanent. We found a total of 174 (27,84%) arterial injuries, most of which are external carotid artery (ECA) injuries. Cerebrovascular accident due to surgery were 15 (2,4%). We concluded that surgical resection remains the treatment of choice for these disease despite the related morbidity.

The use of intraoperative ultrasound for diagnosis and stadiation in pancreatic head neoformations.

UNLABELLED: The intraoperative staging of the pancreatic cancer is important to make a proper treatment. For this reason the intraoperative echography is playing an important role in the right treatment choice. The intraoperative echography, that can be performed with an open or laparoscopic probe, is used to confirm the preoperative diagnosis and assess the pancreatic cancer resecability. The intraoperative echography (IOUS) or laparoscopic intraoperative echography (LIOUS) are useful to identify the patients with a non resecable cancer and perform a faster neoadjuvant treatment. The LIOUS can also avoid an useless laparotomy. The aim of this study is to assess, both in our experience and in the cited literature, the concordance rate between the pancreatic cancer preoperative staging, performed with TC and MRI (when it is available), and intraoperative staging, performed with intraoperative laparotomic or laparoscopic echography. MATERIAL AND METHODS: We have analyzed the treatment management of 34 patients, who were candidate to major surgery for suspected pancreatic head cancer and who underwent to intraoperative LIOUS or IOUS staging from 2001 to 2012. RESULTS: LIOUS and IOUS have allowed to detect cases in which preoperative diagnosis, proved by CT and MRI, was not agreeing with intraoperative diagnosis (22 patients on 34, 64% discordance rate), avoiding the execution of a demolitive and uneseful surgery in order to guarantee the surveillance and life's quality of patients. CONCLUSION: We suggest to perform in every patients undergone to pancreatic surgery an intraoperative ultrasound exam, to detect unresecable and unpredicted lesions.

Long-term survival after curative resection for pancreatic ductal adenocarcinoma--Surgical treatment.

INTRODUCTION: Recent reports have demonstrated improvement in the 5-years serviva with resecate ductal adenocarcinoma. The aim of study is to determinate the factor influencing long-term survival after DCP. MATERIALS AND METHODS: We have critically reviewed a group of 85 patients how were admitted to our department with diagnosis of ductal adenocarcinoma of the head of pancreas between January 1974 and January 1998. RESULTS: Patients were stratified according to stage using TNM classification; in stage I 31 patients with 5 T1aN0M0 disease, 11 patients with T1bN0M0 and 15 patients T2N0M0 disease. By contrast, in stage III 54 patients with 48 patients T2N1M0 and 6 patients with T3N1M0. Tumour size was recorded for 72 patients with a median of 3.8 cm. The R1 dissection was performed in 67 patients. The R2 resection was performed in 18 patients. In our series we verified and analysed the histopathologic features of 5 patients with 15-years survival (5.8%). The features regard age, male or female, tumours size, stage and positive lymph node resection. DISCUSSION: We found a specifically subset of patients where the combination of prognostic factors, in particular, negative surgical margins R0, tumour size ≤ 30 mm and the absence of lymph node metastasis independently reduced the mortality indicating that earlier tumour detection and histologically curative resection are important factors contributing to long term survival and healing of ductal adenocarcinoma of the head of the pancreas.

The first case of acinic cell carcinoma of the breast within a fibroadenoma: case report.

A case of acinic cell carcinoma of the breast is reported in a 26-year-old woman. She presented a lump in her right breast, that seemed to be a fibroadenoma. The open biopsy revealed a well-bordered fibroadenoma, together with a proliferation of cells characterized by serous acinar differentiation and eosinophilic cytoplasmic granules. Tumor cells stained for amylase, lysozyme, α-1-antichymotripsin, epithelial membrane antigen, S-100 protein, pan-cytokeratin, cytokeratin 7 and E-cadherin. Estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 overexpression, CD10, P63, smooth muscle actin, cytokeratin 5/6 were negative. The sentinel node was negative. 8 months after surgery she is in good clinical conditions without recurrence or metastases.

Acinic cell carcinoma of the breast: review of the literature.

INTRODUCTION: The breast and salivary gland tissue share embryologic and thus pathological similarities. Acinic cell carcinoma (ACC) is a typical tumor in salivary glands, but rarely arises in breast too. We reviewed 38 cases of mammary ACC reported in literature and our case, the first ACC born within a fibroadenoma. MATERIALS AND METHODS: Data were collected by a research for the key words acinic cell carcinoma breast on Pubmed in March 2014, including a case treated in our department. All reviewed cases were compared for clinical approach and histological pattern. RESULTS: To date 23 articles presenting cases of ACC of the breast are reported in literature. We included in our review 38 cases previously described and one new case. The histological pattern was predominantly solid with a microglandular structure. All the tumor cells were cytologically characterized by monotonous round cells with a finely granular, weakly eosinophilic, or clearly vacuolated cytoplasm. The most of the cells were intensely stained with anti-lysozime, anti-amylase, anti-α1-chimotripsin, anti-EMA and anti-S100 protein antisera. Immunohistochemistry was also performed to point out: estrogen receptor (ER), progesterone receptor (PR), androgen receptors (AR), human epidermal growth factor receptor 2 overexpression (HER2/neu), E-cadherin (E-cad), cytokeratin-7 (CK7), gross cystic disease fluid protein 15 (GCDFP15), smooth muscle actin (SMA). CONCLUSION: ACC of the breast is a rare tumor, showing similarities with the salivary gland counterpart, above all in terms of good prognosis, and differences from the ordinary invasive breast carcinoma. Further investigations are needed to elucidate the true histogenesis and the correct treatment.

A case of infectious esophagitis caused by human papilloma virus.

Esophageal infections may be caused by diverse pathogens that alter the mucosal lining and produce mild symptoms or sometimes critical clinical diseases with a high risk of mortality, particularly among the immunocompromised. The most common causes of infectious esophagitis are: herpes virus, candida, cytomegalovirus (CMV), and human immunodeficiency virus (HIV); human papilloma virus (HPV) infections are rare in Western countries. Endoscopic features of infectious esophagitis are specific for different agents; nonetheless, differential diagnosis is difficult and requires biopsy, cultures and brushing. We present the clinical case of a young woman admitted to the Department of General Surgery of A.O.U. Federico II, Naples, for a large, deep ulcerative lesion of the esophagus caused by HPV infection.

Laparoscopic antireflux surgery: indications, preoperative evaluation, techniques, and outcomes.

BACKGROUND/AIMS: During the past decade, the development of mini-invasive surgery has determined a resurgence in popularity of the antireflux surgery. The purpose of this study is to examine indications, preoperative evaluation, surgical techniques, and outcomes after mini-invasive surgery. METHODOLOGY: From 1996 to 2000, 25 patients with gastroesophageal reflux disease associated to hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24h-pH monitoring, endoscopic evidence of esophagitis, and defective lower esophageal sphincter. Nissen fundoplication was performed in 16 patients with normal esophageal body motility, and 270 degrees posterior fundoplication in 9 patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 130 minutes and mean postoperative hospital stay 5 days. Twenty-four (96%) patients were completely cured of reflux symptoms off all medications. Transient, mild postoperative dysphagia occurred in 3 patients (12%). There was a significant improvement of the results in postoperative esophageal manometry and 24h-pH monitoring. CONCLUSIONS: Despite the fact that few patients were treated by using laparoscopic approach, results are encouraging with less morbidity and great advantages for patients. Precise selection of patients and surgical techniques are essential.

[Cystic echinococcosis in humans: our clinic experience]. / Idatidosi cistica: una nostra esperienza clinica.

Echinococcosis in humans is a zoonotic infection caused by larval stages of cestode species of the Echinococcus genus. In cystic echinococcosis (CE), caused by Echinococcus granulosus, the liver is the first and the more frequent involved organ, followed by the lung. Heart, spleen, kidney and brain are usually less involved. The finding of a cyst in course of echinococcosis is usually fortuitous, during ultrasound examination, X-ray or CT. The Authors report 4 cases of human CE admitted to the Department of Infectious Diseases University of Naples "Federico II". Each case is peculiar both for the organ involved by the cysts and for the symptomatolgy. The abdominal pain, in case 1 caused by gallstones, allowed, by the ultrasound examination, to find several hydatid cysts in the liver, never symptomatic until then. The woman, in case 2, was operated for cysts in the lung, without receiving pharmacological prophylaxis. The same occurred in case 4, in which the lack of prophylaxis caused very serious relapses. In case 3, the young woman underwent an ultrasound examination because of an abdominal pain. A unique large cyst extended only in the spleen. The specific serology for immunoglobulin anti-E. granulosus resulted positive 1:61 (n.v. < 50). The Albendazole therapy caused the disappareance of pain, quickly. Later, the patient was splenectomized. It's not clear why only the spleen was involved and why the anti-E. granulosus serum levels of were increased only a little. The man, in case 4, was admitted with chest pain and electrocardiographic findings of myocardial anterior ischemia. He underwent surgical treatment of three hepatic cysts by E. granulosus, during the previous year. Two-dimensional echocardiography, transesophageal echocardiography, and cardiac magnetic resonance revealed a round cystic mass, 6 x 6 mm, located in the middle interventricular septum. The cardiac isoenzymes were in the normal ranges, but the anti-E. granulosus immunoglobulins were positive 1:5120 (n.v. < 64). The patient was treated with Albendazole. This caused the almost simultaneous disappearance of the circular cystic and clinical and electrocardiographic findings of myocardial ischemia. A cardiac hydatid cyst is an uncommon lesion, occurring in about 0.4-2% of patients with echinococcosis. In conclusion, Cystic echinococcosis is a problem in Mediterranean regions because of the high population of stray dogs, favourable conditions created by man and, above all, the illegal slaughtering.

[Techniques and outcomes of laparoscopic surgery in gastroesophageal reflux disease]. / Tecniche e risultati della chirurgia laparoscopica nella malattia da reflusso gastroesofageo.

BACKGROUND: The purpose of this study is to report personal experience in laparoscopic antireflux surgery and to analyze the clinical and functional outcomes of this procedure, also in relation to the different techniques used. METHODS: From 1996 to 2000, 20 patients with gastroesophageal reflux disease associated with hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24 hrs-pH monitoring, endoscopic evidence of esophagitis and hiatal hernia, and defective lower esophageal sphincter. A Nissen fundoplication was performed in 13 patients with normal esophageal body motility, and a 270 degrees posterior fundoplication in seven patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 135 min and mean postoperative hospital stay 5 days. Operative morbidity was 15%. All the patients were completely cured of reflux symptoms; transient mild postoperative dysphagia occurred in two patients (10%). There was a significantly improvement of the results in postoperative esophageal manometry and 24 hrs-pH monitoring. CONCLUSIONS: This preliminary experience suggests that laparoscopic surgery represents a safe and effective procedure for the treatment of gastroesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.

Phase I dose escalation study of gemcitabine and paclitaxel plus colony-stimulating factors in previously treated patients with advanced breast and ovarian cancer.

Gemcitabine and paclitaxel (PTX) are among the most active new drugs in advanced breast and ovarian cancer. In this Phase I study, we used fixed doses of gemcitabine administered on days 1 and 8 and escalating doses of paclitaxel on day 1 of a 21-day cycle in patients with pretreated metastatic breast or ovarian cancer. The dose of gemcitabine was fixed at 1,000 mg/m2; PTX was commenced in the first small patient group at a dose of 90 mg/m2, which was then escalated in subsequent groups by 30 mg/m2 per step. From the third dose level onwards, all patients received granulocyte colony-stimulating factor 300 microg by subcutaneous injection on days 5 and 6, and granulocyte macrophage colony-stimulating factor on days 15-18. Cohorts of at least 3 patients were treated at each dose level. Dose escalation was stopped if at least a third of the patients in a given cohort had dose-limiting toxicity (DLT), which was defined as grade 4 neutropenia or thrombocytopenia, or grade 3-4 non-haematological toxicity. The maximum tolerated dose (MTD) was defined as the dose level immediately below that causing DLT in one-third of the patients or more. Evaluation of the tumour response was performed every three cycles. Forty-five patients (31 with breast cancer, 14 with ovarian cancer) were treated at seven different dose levels. Only at the seventh PTX dose level was DLT observed after the first course of therapy: three grade 4 neutropenia, one grade 4 thrombocytopenia, and one grade 4 anaemia. DLT occurred in 5/6 patients at at PTX dose of 270 mg/m2; therefore dose escalation was stopped at that level and the dose immediately before it (PTX 240 mg/m2) was considered as the MTD and recommended for further studies. No toxic deaths occurred. Grade 3-4 uncomplicated neutropenia was observed in four patients. Three had uncomplicated grade 3-4 thrombocytopenia. One patient had grade 3 and one grade 4 anaemia. Nonhaematological side effects were generally mild. Among 30 evaluable patients with metastatic breast cancer, four complete responses (CR) (13%) and 12 partial responses (PR) (40%) were observed, for an overall response rate of 53% (95% confidence interval (CI) 34-72). The median duration of response was 31 weeks. Among 13 evaluable patients with advanced ovarian cancer, one CR (8%) and five PRs (38%) were observed, for an overall response rate of 46% (95% CI 19-78). The median duration of response was 32 weeks. Our study shows that gemcitabine and PTX can be administered in combination in patients with breast and ovarian cancer without unexpected toxicities and with encouraging therapeutic results.

Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas.

Recent reports have demonstrated an improvement in 5-year actuarial survival of patients with resected ductal adenocarcinoma. The purpose of this study was to determine the factors favoring long-term survival after pancreaticoduodenectomy. Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. The overall postoperative mortality rate was 5.3% and morbidity was 24%. Median survival following resection was 17 months. The estimated 1-, 2- and 5-year survival rates were 68%, 46.7% and 18.7%, respectively. Five-year survival was significantly greater for node-negative versus node-positive patients (41.7% vs 7.8%, P < 0.001), for smaller (< 3 cm) versus larger tumours (33.3% vs 8.8%, P < 0.006), and for negative versus positive resection margins (23.3% vs 0, P < 0.001). Other factors, including gender, age, and blood transfusion had no significant effect on survival. The multivariate analysis was done using the Cox proportional hazards model to determine independent prognostic determinants of survival. The presence of positive resection margins was the strongest independent predictor of decreased survival. Lymph node metastasis, tumour size > 3 cm, and poor histologic differentiation were also independent predictors of poor survival. The most favorable subset consisted in 17 patients who had negative resection margins, negative lymph nodes, and tumor size < 3 cm. Their 5-year survival rate was 52.9%.

Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas.

BACKGROUND AND OBJECTIVES: Recent reports have demonstrated improvement in the 5-year actuarial survival for patients with resected ductal adenocarcinoma. The purpose of this study is to determine the factors favoring long-term survival after pancreaticoduodenectomy. METHODS: Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. RESULTS: Overall postoperative mortality rate was 5. 3% and morbidity was 24%. Median survival following resection was 17 months. Estimated 1-, 2-, and 5-year survival rates were 68%, 46.7%, and 18.7%, respectively. Five-year survival was greater for node-negative than for node-positive patients (41.7% vs. 7.8%, P < 0. 001) and for smaller (<3 cm) than for larger tumors (33.3% vs. 8.8%, P < 0.006). The 5-year survival in patients with negative margins (n = 60) was 23.3%, whereas no patient with positive margins (n = 15) survived at 13 months (P < 0.001). Multivariate analysis, performed by the Cox proportional hazards model, indicated that margin status, lymph node metastasis, tumor size, and poor histological differentiation were independent predictors of poor survival. CONCLUSIONS: Five-year survival for patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas was 18.7%. Survival was greater in the group of patients with negative lymph nodes, tumor size <3 cm, and negative margin status.

Significance of lymph node metastases in the surgical management of pancreatic head carcinoma.

Recent reports have demonstrated a reduction in the morbidity and mortality of pancreatic resections and improvement in the 5-actuarial survival for patients with resected ductal adenocarcinoma. However, the prognosis for patients with lymph node metastases remains uncertain. The purpose of this study is to determine if the presence of lymph node metastases influences the survival in patients with otherwise potentially curable pancreatic head carcinoma. Between January 1974 and December 1995, 340 patients with pancreatic carcinoma, including 238 patients with pancreatic head tumours, were evaluated and treated in our Department. Seventy-seven (32.3%) patients with pancreatic head carcinoma underwent pancreaticoduodenectomy. Ages ranged from 40 to 76 years, with a mean age of 61 years. Fifty patients were male, twenty-seven were female. The overall postoperative mortality rate was 5.2% (4 patients) and morbidity was 23.4%. Median survival following resection was 17 months (range 0 to 79). The estimated 1-, 2-, 3- and 5-year survival were 68.8%, 48.1%, 23.4% and 18.2%, respectively. There were 14 five-year survivors. Of the 77 patients, 25 (32.5%) had negative lymph nodes. The median and 5-year survival in these node-negative patients were 33 months (range 5 to 79) and 40%, respectively. Whereas the median survival and 5-year survival in 52 patients with lymph nodes metastases were 14 months (range 0 to 61) and 7.7%, respectively (P<0.0001). There were 4 five-year survivors in the group of patients with lymph node metastases; in 2 patients was performed extensive lymph node dissection (R2) and in other 2 patients R1 procedure. In the patients with lymph node metastases undergoing R1 resection (n = 39), the 1-, 2- and 5-year survival rates were 48.7%, 23.1% and 5.1%, respectively. Whereas in the patients with positive lymph nodes undergoing R2 resection (n = 14), the 1-, 2- and 5-year survival rates were 92.9%, 64.3% and 14.3%, respectively (P<0.02). As expected, tumour size and margin status in specimen proved to be two significant factors predicting survival. Pancreatoduodenectomy can be performed with low operative mortality. Lymph nodes metastases are found in 67.5% of patient undergoing resection. Pancreaticoduodenectomy offers good palliation for patients with lymph nodes metastases and encouraging long-term survival rates as well as a chance for cure in patients with negative lymph nodes and negative margins of resection.

Phase I/II study of paclitaxel and vinorelbine in metastatic breast cancer.

Paclitaxel and vinorelbine are among the most active new agents in metastatic breast cancer. Both in vitro and in vivo studies have shown that the combined administration of these two microtubule-targeting agents is feasible and worthwhile. Based on the promising preclinical data, patients with metastatic breast cancer no longer amenable to conventional treatment were entered into a phase I/II study in which the vinorelbine dose was fixed at 30 mg/sqm and paclitaxel was started at 90 mg/sqm and then subsequently escalated by 30 mg/sqm per step. Cycles were repeated every 21 days. Hematopoietic growth factor support was provided from the 4th dose level onwards. Grade III neutropenia was observed only in 2 patients treated at the 5th dose level. Thrombocytopenia never reached grade 3. Neurotoxicity was considered dose-limiting, since grade 3 peripheral neuropathy occurred in all three patients treated at the 6th dose level. Other toxicities were mild. Paclitaxel 210 mg/sqm and vinorelbine 30 mg/sqm was the selected combination for phase II. Overall response rate in 34 evaluable patients was 38% (95% confidence interval (C.I.), 22% to 54%). In particular, 3 complete responses (9%) and 10 partial responses (29%) were observed. The observed level of antitumor activity, with an overall response rate of 38% and a median duration of response of 12 months, is of interest, since the study was targeted only to anthracycline-pretreated patients, most of whom had adverse prognostic features. The evaluation of a combination of vinorelbine and paclitaxel as first-line therapy in metastatic breast cancer seems worthwhile and is currently undergoing.

Neoadjuvant chemotherapy in locally advanced gastric-cancer - preliminary-results of a phase-ii trial with a modified famtx combination.

Twenty-two patients with locally advanced inoperable gastric cancer received neoadjuvant chemotherapy with a modified 5-fluorouracil, doxorubicin, methotrexate (FAMTX) regimen. The patients who achieved at least a stable disease were considered eligible for surgery with curative intent, which was performed in 19 cases. 16 patients (all responsive to neoadjuvant chemotherapy) were rendered disease-free by the combined approach. No treatment-related deaths occurred; grade III leukopenia was observed in only 3 cases. The preliminary results of this study indicate the feasibility of our treatment approach; randomized trials are awaited to properly evaluate the role of neoadjuvant chemotherapy in locally advanced gastric cancer.

Second look in colorectal surgery.

PURPOSE: Follow-up should identify metachronous colonic neoplasms and precancers, suture line recurrences, and isolated liver or pulmonary metastases. For some sites of failure the surgical re-resection and multimodal approaches increase disease-free survival and quality of life. The aim of our study was to evaluate the role of the different follow-up plans and the carcinoembryonic antigen directed second-look surgery. METHODS: One hundred-sixty patients radically resected for Dukes B or C colorectal cancer were evaluated by a follow-up plan (plasma carcinoembryonic antigen every 2 months; echography every 6 months; chest x-ray every 12 months; and colonoscopy at 1 year and then every 3-5 years). RESULTS: Eighty-nine recurrences were detected (55.6 percent). In 72 recurrences plasma carcinoembryonic antigen elevation was present. Eight carcinoembryonic antigen directed second-look surgeries were performed: in four patients surgical evidence of recurrence was found (two isolated liver metastases were radically resected); two patients with no surgical evidence of recurrence developed a surrenalic isolated metastases and pelvic and hepatic recurrences; two patients had a five-year disease-free survival. In the 17 symptomatic patients with no carcinoembryonic antigen elevation diffuse disease was present, not resectable for cure. Four solitary liver metastases, one metachronous colonic neoplasm, and one suture line recurrence presented a five-year survival. CONCLUSIONS: The authors emphasize that carcinoembryonic antigen-directed second-look surgery is not acceptable for elevated costs. Intensive follow-up plans are superflous, while the monitoring of the carcinoembryonic antigen and instrumental restaging as an indicator of solitary liver metastases and mucosal lesions are very useful.