Giant mature teratoma in thymic tissue removed with uniportal vats approach.

INTRODUCTION: Teratomas are tumours composed by different tissues derived from one or more of the three primitive germ cell layers. The frequency of mediastinal teratomas ranged from 1 to 5 %, in most cases with localization in the anterior/superior mediastinum. PRESENTATION OF CASE: We report a case report of a 29 years old male who presented an occasional and asymptomatic mediastinal mass. Computer Tomography (CT) scan showed a 6.8 × 4.5 cm mass in the anterior mediastino, located below the left brachio-cephalic vein, next to aortic arch and left pulmonary artery. Complete excision of the mass "en block" with anterior mediastinal adipose tissue was achieved, using uniportal VATS approach. The postoperative course was regular, without air leak or other pulmonary complication. DISCUSSION: VATS technique is minimally invasive and, moreover, it is characterized by a shorter recovery period, a minor blood loss and a shorter hospital stay. VATS has been advocated since 2010 for pulmonary resections, but today it is also performed for mediastinal intervention and a series of reports have demonstrated that it is feasible and safe. CONCLUSION: The report aims at pointing out the possibility of undergoing this kind of surgery not only in case of pulmonary mass (on which the previous literature has focused) but also when mediastinum lesions occur, as in our case.

Ectopic thoracic thyroid removed by uniportal VATS approach. A case report.

INTRODUCTION: We speak of "Ectopic thyroid gland" when a piece of thyroid tissue is placed at a certain distance from the second to fourth tracheal cartilages. PRESENTATION OF CASE: This case report focuses on a case of a hyperplastic cystic nodule of ectopic thyroid in a 30-year-old woman treated with uniportal video-assisted thoracic surgery (VATS). The patient, was admitted to Emergency Unit for abdominal pain and vomit, underwent a CT which highlighted a mass of significant dimension on the right side of the mediastinum, in contact with close structures. The lesion has been removed with an innovative mini-invasive technique, which is characterized, differently from traditional surgical approaches, by reduced loss of blood and time of hospitalization and, in addiction to that, an aesthetic small-dimensioned scar. DISCUSSION: VATS technique is minimally invasive and, moreover, it is characterized by a shorter recovery period, a minor blood loss and a shorter hospital stay. VATS has been advocated since 2010 for pulmonary resections, but today it is also performed for mediastinal intervention and a series of reports have demonstrated that it is feasible and safe. CONCLUSION: The report aims at pointing out the possibility of undergoing this kind of surgery not only in case of pulmonary mass (on which the previous literature has focused) but also when mediastinum lesions occur, as in our case.

Lung cancer screening with low dose CT: experience at Campus Bio-Medico of Rome on 1500 patients.

AIM: The main purpose of our project was to evaluate the prevalence of lung cancer in high risk, asymptomatic individuals in addition to quantifying the rate of surgically resectable tumors, and evaluating the role of lung cancer with low dose computed tomography (LDCT) as a tool for lung cancer screening. METHODS: Between June 2011 and March 2014, 1500 volunteers at high risk for lung cancer were enrolled in our study and underwent LDCT in our institution. The subsequent diagnostic and therapeutic steps were planned in relation to the results emerging from LDCT. To evaluate speed and type of growth, solid nodules ≤4 mm were reassessed with annual LDCT, those >4-6 mm or >6-8 mm were reassessed with LDCT in 6 or 3 months while nodules suspicious for malignancy were investigated with PET-CT or biopsy according to NCCN guidelines. RESULTS: Non-calcified nodules were detected in 525 subjects (35% of population): among these 42% had a diameter ≤4 mm, 43% had a diameter >5 mm but <10 mm, 3% appeared as "ground glass" lesions, and 63 (12% of detected nodules) had malignant characteristics (irregular margins, retraction of the surrounding parenchyma, diameter >10 mm). Among the 63 patients who underwent PET-CT or biopsy, 25 cases resulted positive for lung cancer (1.7% of population). These patients underwent surgical treatment with histological detection of tumors in stages IA, IB or IIB. CONCLUSION: Our study confirmed the emerging data on the use of LDCT as a screening tool for lung neoplasm in individuals at risk. Due to the LDCT low rate of specificity complementary biomarkers are required to properly define patients at risk and to reduce the number of further radiological examinations.

Promyelocytic leukemia (PML) gene expression is a prognostic factor in ampullary cancer patients.

BACKGROUND: Promyelocytic leukemia (PML) tumor suppressor gene plays a key role in acute PML pathogenesis but its involvement in pathogenesis and prognosis of solid cancers has not been defined yet. PATIENTS AND METHODS: In all, 62 ampullary adenocarcinoma patients who underwent curative surgery between 1996 and 2005 were included. Expression analysis of PML was carried out by immunohistochemical staining and correlated with disease-free survival (DFS) and overall survival (OS). RESULTS: In 24 tumor specimens (38.7%), PML was classified as absent, in 16 (25.8%) as focally expressed and in 22 (35.5%) as diffusely expressed. By univariate analysis, DFS was significantly influenced by pathological T stage (P=0.03), lymph nodal involvement (P=0.002), and PML expression (P=0.001). DFS in patients without PML expression was 28.0 months versus 45.1 and 75.5 for patients with focal and diffuse expression, respectively. OS in the group of patients without PML expression, with focal expression, and with diffuse expression was 40, 48, and 77 months, respectively (P=0.002). By a multivariate analysis, PML expression was the strongest prognostic factor for DFS (P=0.003) and the only statically significant prognostic factor for OS (P=0.009). CONCLUSIONS: Our preliminary data suggest PML as a novel prognostic tool for ampullary cancer patients.

[Signet-ring cell carcinoma of the Vater's ampulla: report of a clinical case]. / Carcinoma a cellule ad anello con castone dell'ampolla di vater: osservazione di un caso clinico.

We report the case of a sixty-six year-old man admitted at our hospital with a suspected malignant tumor of the ampulla of Vater. The patient underwent a Pylorus-preserving pancreatico-duodenectomy. Histology showed a signet-ring cell carcinoma of the ampulla of Vater. This case is the 13th report in the literature of a signet-ring cell carcinoma of the ampulla of Vater.

Primary closure of complicated perineal wounds with myocutaneous and fasciocutaneous flaps after proctectomy for Crohn's disease.

BACKGROUND: The purpose of this study is to detail the use of advanced tissue transfer techniques to achieve primary closure of the perineal wound after proctectomy for Crohn's disease. METHODS: Between October 1984 and March 2000, we performed proctectomy with permanent intestinal stoma in 97 patients with Crohn's disease. Twelve of these patients (12.4%) required at least 1 myocutaneous flap to achieve primary closure of the perineal wound. Details of each patient's perioperative course were recorded prospectively. RESULTS: All 12 patients had fistulizing perineal Crohn's disease combined with Crohn's proctitis. Two patients had a simultaneous anal adenocarcinoma. Indications for flap closure included management of large perineal skin defects (n = 11), reconstruction of the posterior vaginal wall (n = 2), and the need to fill a large pelvic dead space (n = 3). (Three patients had a combination of the previous indications). In total, 6 rectus abdominis, 5 gluteus maximus, 1 posterior thigh, 3 chimeric posterior thigh, and 1 latissimus dorsi flaps were performed. Six patients required more than 1 flap. Three patients had complications develop related to the flaps (2 wound hematomas and 1 seroma). Complete perineal healing was achieved in all patients. CONCLUSIONS: Complex tissue flap closure of the perineal wound after proctectomy for perineal complications of Crohn's disease should be considered when simple closure is not possible or when reconstruction of the posterior wall of the vagina is necessary.

Primary retroperitoneal soft tissue sarcomas: results of aggressive surgical treatment.

A retrospective study was undertaken to evaluate the results of surgical treatment in a series of patients with primary retroperitoneal sarcomas consecutively treated by the same surgical team. The hospital records of 42 patients with primary retroperitoneal sarcomas who underwent surgical exploration at our unit from 1984 to 1995 were reviewed. A univariate analysis was used to identify the main clinical, pathologic, and treatment-related factors affecting long-term survival. Twenty-five patients (59.6%) underwent radical surgery. The 5-year survival and 5-year disease-free survival after radical resection were 48.1% and 38.8%, respectively. According to the univariate analysis of survival tumor classification (T), stage and gross surgical margins significantly affected prognosis. The study indicates that even though there are predetermined and unmodifiable tumor-related factors, such as tumor classification (T) and stage, that influence survival in patients with retroperitoneal sarcomas, wide surgical excision offers a concrete chance for long-term survival.

Survival in early gastric cancer: multivariate analysis on 72 consecutive cases.

BACKGROUND/AIMS: Few reports from the Western hemisphere have investigated the impact of pathological features and surgical modalities on the prognosis of patients affected by early gastric cancer (EGC). In particular, the extent of lymphadenectomy (limited vs. extended) and the type of gastric resection (subtotal vs. total) remain controversial issues in the management of EGC. The aim of this study was to identify factors influencing prognosis in patients affected by EGC. METHODOLOGY: Hospital records and pathological specimens of 72 patients with EGC undergoing resective surgery during the period 1981-1995 were retrospectively reviewed. Patient status was determined by follow-up examination or by telephone contact. Univariate and multivariate analysis was used to calculate the 5-year survival probabilities with respect to the following variables: age (< or = 65, > 65), sex, depth of invasion (mucosal, submucosal) tumor location (upper, middle and lower third), gross appearance (type I, type II and type III), size (< or = 1.5 cm, > 1.5 cm), presence or absence of lymph node metastasis, histological type (intestinal, diffuse), extent of lymphadenectomy (limited or extended), and type of gastrectomy (total or distal subtotal). Survival was the outcome variable studied. RESULTS: Multivariate logistic regression analysis showed that age, nodal involvement and depth of invasion were independently associated with poor survival. CONCLUSIONS: Results showed a significant dominance of host- and tumor-related factors over the type of surgical procedure on prognosis of EGC patients.

Structured versus long-chain triglycerides: a safety, tolerance, and efficacy randomized study in colorectal surgical patients.

BACKGROUND: After trauma or surgery, researchers have suggested that medium-chain triglycerides have metabolic advantages, although they are toxic in large doses. To try to reduce this potential toxicity, structured lipids, which provide a higher oxidation rate, faster clearance from blood, improved nitrogen balance, and less accumulation in the reticuloendothelial system, could be used. Therefore, we evaluated, through a blind randomized study, the safety, tolerance, and efficacy of structured triglycerides, compared with long-chain triglycerides (LCT), in patients undergoing colorectal surgery. METHODS: Nineteen patients were randomized to receive long-chain or structured triglycerides as a lipid source. They received the same amount of calories (27.2/kg/d), glucose (4 g/kg/d), protein (0.2 g/kg/d), and lipids (11.2 kcal/kg/d). Patients were evaluated during and after the treatment for clinical and laboratory variables, daily and cumulative nitrogen balance, urinary excretion of 3-methyl-histidine, and urinary 3-methylhistidine/creatinine ratio. RESULTS: No adverse effect that required the interruption of the treatment was observed. Triglyceride levels and clinical and laboratory variables were similar in the two groups. A predominantly positive nitrogen balance was observed from day 2 until day 5 in the LCT group and from day 1 until day 4 in the structured triglycerides group. The cumulative nitrogen balance (in grams) for days 1 to 3 was 9.7+/-5.2 in the experimental group and 4.4+/-11.8 in the control group (p = .2). For days 1 to 5 it was 10.7+/-10.5 and 6.5+/-17.9 (p = .05), respectively. The excretion of 3-methylhistidine was higher in the control group but decreased in the following days and was similar to the experimental group on day 5. CONCLUSIONS: This study represents the first report in which structured triglycerides are administered in postoperative patients to evaluate safety, tolerance, and efficacy. It suggests that Fe73403 is safe, well tolerated, and efficacious in terms of nitrogen balance when compared with LCT emulsion.

Bacteriophage phi29 early protein p17 is conditionally required for the first rounds of viral DNA replication.

The gene 17 of the Bacillus subtilis phage phi29 is known to be involved in the viral DNA replication in vivo. In this paper, we show that the presence of protein p17 is required when phage infection occurs at a low multiplicity of infection (moi), which is probably the natural condition for infection, but is dispensable at a high moi. Gene 17 has been cloned in an Escherichia coli expression vector and protein p17 purified. A stimulatory effect of protein p17 was demonstrated under in vitro conditions required to amplify phi29 DNA, starting with a low amount of input DNA. We propose that p17, which is synthesized early after infection, is required at the very beginning of the phage amplification, conditions in which a low number of viral DNA molecules enter the host cell, possibly to recruit the limiting amount of initiation factors at the replication origins. Once the infection process is established and the other replication proteins reach optimal concentration, p17 becomes dispensable.

[Surgical treatment of gastric carcinoma: lymphadenectomy]. / Trattamento chirurgico del carcinoma gastrico: la linfoadenectomia.

The review of the literature shows the improvement of outcome of patients with gastric cancer after resection and extended lymphadenectomy. Lymphadenectomy D2/D3 was performed in 206 out of 639 patients with gastric cancer: 5-year survival was 66.3% versus 41.5% of the 121 patients that underwent D1 resection (p < 0.0001). Univariate and multivariate analyses show that proximal location of the cancer, advanced stage and lymphadenectomy limited to perigastric stations are negative prognostic factors. Although there are still different opinions regarding D2 or D3 lymphadenectomies for the operative risks, pancreatic resection (preferring pancreas sparing techniques) and splenectomy is subtotal gastrectomy for antral carcinoma, extended lymphadenectomy remains an important point to improve survival.

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.

Risk factors and prevention of venous thromboembolism.

In the last 20 years within the clinical research on venous thromboembolism a major objective was to identify and develop increasingly effective and safe methods of prevention. This trend is justified by the high incidence of thromboembolism as well as by the relevant mortality for acute pulmonary embolism and postphlebitic sequels of difficult treatment. A significant contribution to the rational application of methods of prevention was given by the knowledge of risk factors. Together with acquired risks, as surgery, age, malignant tumors, in the last 30 years some conditions of thrombophilia were identified. They are caused by deficiencies in coagulation inhibitors (antithrombin III, protein C, protein S) or other alteration of the anticoagulation system as resistance to activated protein C or antiphospholipid antibodies. The primary prophylaxis of venous thromboembolism is aimed at the prevention of thrombosis by pharmacologic methods able to oppose the procoagulant alterations while avoiding hemorrhagic complications. The physical methods tend to reduce the stasis in the veins of the lower extremities. Subcutaneous calcium heparin at the dose of 5000 U twice or three times a day is the most common pharmacologic method used. It was shown to be safe and effective especially in postoperative prophylaxis of venous thromboembolism in general surgery. More recently, low molecular weight heparin fractions have been introduced. As compared to standard heparin they have the advantage of a single daily dose and a better efficacy in some groups of patients, as those undergoing hip replacement. Among the substances under clinical experimentation, dermatan sulfate seems promising. Most common physical prevention methods consist in the use of elastic graduated compression stockings and systems of intermittent pneumatic calf compression. The former can be used also in presence of a hemorrhagic risk as in neurosurgery. The latter have shown a good efficacy in increasing flow velocity and probably also in enhancing the fibrinolytic activity. The combination of physical and pharmacologic methods seems to be able of enhancing the efficacy of prophylaxis.

[Aorto-iliac aneurysms and associated gastrointestinal neoplasms. Treatment problems]. / Aneurismi aorto-iliaci e neoplasie gastrointestinali associate. Problemi di trattamento.

In patients affected by aortoiliac aneurysm the concurrent presence of a gastrointestinal tumor is a not infrequent occurrence which poses problems of therapeutic approach (one step operation or prior treatment of one of the two diseases; in the latter case definition of timing and sequence of the surgical treatment). Three cases are reported where an eclectic therapeutic approach has enabled satisfactory results. A patient with an isolated aneurysm of right hypogastric artery associated with rectal cancer was treated with percutaneous embolization of the aneurysm and subsequent excision of the tumor. In a patient with a neoplasm of the left colon and aortic aneurysm, the aneurysm was treated first and after about a month the tumor was resected. In a patient with gastric cancer and aortic aneurysm subtotal gastrectomy was first performed and subsequently, after about 3 months, the aneurysm was treated by extraperitoneal route. Even if an unidirectional approach cannot be defined, it is thought that the two-step treatment of the associated diseases is preferable. In the presence of non stenosed non bleeding colorectal tumors it seems more suitable to treat the aneurysm first (increased postoperative risk for rupture of the aneurysm; more difficult preparation of subrenal aorta in the presence of cicatricial outcomes of colonic surgery; persistence of perianastomotic infections after colonic resection). Gastric tumors should be treated first for their higher biological aggressiveness and unfeasible correct preoperative staging. In particular cases (single unilateral aneurysm of a hypogastric artery associated with gastrointestinal cancer), non surgical treatment of the vascular lesion (embolization during angiography) is the treatment of choice.

The Italian Registry for Adrenal Cortical Carcinoma: analysis of a multiinstitutional series of 129 patients. The ACC Italian Registry Study Group.

BACKGROUND: Adrenal cortical carcinoma is an uncommon tumor with a poor prognosis. The low incidence of this tumor makes it difficult to achieve reliable data on clinical manifestations, natural history, and the impact of therapies. The purpose of this study was to evaluate such aspects in a large series. METHODS: A retrospective series of 129 cases (55 men and 74 women, mean age of 49 years) was collected from 18 surgical institutions. At the time of diagnosis 45.7% of patients had endocrine symptoms. One hundred twenty-four patients underwent surgery, which was considered curative in 91 cases and palliative in 33. Sixty-three patients had local disease, 48 had regional disease, and 43 had distant metastases. RESULTS: This study confirmed a higher incidence in the 40- to 50-year-old population with a female prevalence; hormonal hyperincretion was more common in women, but it was not caused by advanced disease. The overall 5-year survival rate was 35%. Tumor stage and curative resection affected prognosis significantly. The influence of gender, side, age, and hormonal function has not been confirmed. Adjuvant therapies were ineffective in prolonging survival. Reoperated patients experienced better survival (mean, 41.5 months) than nonreoperated cases (mean, 15.6 months). CONCLUSIONS: The poor prognosis of adrenal cortical carcinoma may be improved by early diagnosis and complete resection. Radical surgery is the sole effective therapy, particularly in early stages. Surgical treatment of recurrence seems to improve survival and should be attempted systematically. Adjuvant therapies obtained contrasting results, and their role should be evaluated in prospective multicentric trials.

Colorectal cancer. Epidemiology, etiology, pathogenesis and prevention.

Colorectal cancer (CRC) is a neoplasm with a steadily growing incidence in Western countries. Moreover the age of 50 and over is a critical risk factor. The relationship between dietary, environmental factors and CRC has been evaluated. At present, a number of genetic risk factors such as the genetic susceptibility, tumor suppressor genes and oncogenes are thought to play a major role. The correlation of CRC with adenomatous polyps and chronic inflammatory disease, ulcerative colitis in particular, has been evaluated. Prevention of CRC is mainly based on a rational diet and in the adoption of mass screening programmes.

[Results of endoscopic biliary drainage in primary tumors of the common bile duct (cholangiocarcinoma)]. / Risultati del drenaggio biliare endoscopico nei tumori primitivi della via biliare principale (colangiocarcinomi).

Endoscopic drainage is an effective therapy for palliation of patients with bile duct carcinoma. From November 1987 to November 1994 112 patients with cholangiocarcinoma were observed. The success rate of the procedure was 94.5%. The biliary drainage was successful in 99% of patients (in 4% of patients the complete biliary drainage was obtained with the aid of a transhepatically inserted guide-wire with the "rendez-vous" procedure). In 15 patients an intraluminal radiation therapy with Iridium-192 was associated. The morbility was 13% and the 30-days mortality 11%. A surgical operation was performed in 26% of patients with radical intent. The mean survival time in patients treated only endoscopically was 208 days for patients with lesions of the distal and middle third of the bile duct and 281 days for patients with hilar cholangiocarcinoma. In patients with intraluminal radiation therapy the mean survival time was 357 days, with a significative difference with the only endoscopically treated group (357 vs 238 days, p < 0.05). We conclude that endoscopic drainage is a safe and effective management for patients with cholangiocarcinoma and it does not preclude definitive surgical treatment in appropriate candidate.

Open vs closed treatment of secondary pancreatic infections. A review of 42 cases.

OBJECTIVE: To compare the results of closed treatment (CT) with the results of open treatment (OT) that uses laparostomy and marsupialization of the lesser sac in patients affected by secondary pancreatic infections. DESIGN: Retrospective cohort study. SETTING: Both primary and referral hospital care. PATIENTS: Forty-two patients undergoing emergency operations for unequivocal secondary pancreatic infections (infected pancreatic necrosis [n = 26] and pancreatic abscess [n = 14]) were retrospectively divided into two treatment groups on the basis of the operative treatment: conventional CT (n = 24) (1981 through 1986) and OT by laparostomy and marsupialization of the lesser sac (n = 18) (1987 through 1991). The OT and CT groups were homogeneous regarding demographic characteristics, mean APACHE (Acute Physiology and Chronic Health Evaluation) II score (17.1 +/- 6.0 vs 17.9 +/- 7.2, respectively; P value was not significant), and distribution of patients according to the type of pancreatic infection (infected pancreatic necrosis [13 vs 15, respectively] and pancreatic abscess [five vs nine, respectively]). The use of medical supportive care, including total parenteral nutrition and heavy doses of broad-spectrum antibiotics, was similar in both groups. MAIN OUTCOME MEASURES: Surgical complications; recurrent or persistent sepsis; postoperative death. RESULTS: The incidence of major surgical complications was 55.5% and 8.3% in OT and CT groups, respectively (P = .001). In OT and CT groups, signs of recurrent or persistent sepsis were observed in 5.6% vs 41.7% of the patients, respectively (P = .008): 7.7% vs 46.7% in patients with infected pancreatic necrosis (P = .02) and 0% vs 33.3% in patients with pancreatic abscess (P value was not significant). Overall mortality rates were 22.2% and 28.5% in the OT and CT groups, respectively (P value was not significant). The mortality rates due to recurrent or persistent sepsis in the OT and CT groups were 5.5% and 29.1%, respectively (P = .03). CONCLUSIONS: Although the frequency of major surgical complications after OT is significantly higher than that observed after CT, open drainage by means of laparostomy and marsupialization of the lesser sac controls pancreatic infection better, thus reducing mortality rate due to persistent or recurrent sepsis.