A rare case of extraskeletal osteosarcoma of the esophagus: an example of difficult diagnosis.

Sarcomatous lesions of the esophagus are rare. We describe a controversial case of a malignant aggressive tumor of the aesophagus, with a very poor prognosis and rapid outcome for the patient. A 74-year-old man underwent endoscopic examination for recurrent thoracic pain and dysphagia. A 8 cm mass was found in the cervical esophagus. A sarcomatous tumor with osteoid aspects was observed on the histopathological examination, without any carcinomatous component.

Acute abdomen in the elderly. A peripheral general hospital experience.

We reviewed our experience on 291 consecutive patients aged over 65 years who were operated on for acute abdomen during the period 2003-2007 at "Santo Spirito" Hospital of Casale Monferrato, a peripheral hospital in the Piedmont region. The mean age of the patients was 78 years and the male/female ratio was 149/142. A total of 126 patients (43%) had one or more associated disease. The most common causes for an emergency operation were mechanical bowel obstruction (45%), hollow viscus perforation (18%) and strangulated hernia (18%). 234 patients (80%) recovered and were free from major complications. The remaining 57 (20%) developed at least one major complication (including death). The 30-days postoperative deaths were 33 (11%). Nonlethal major complications were 24 (8%). The commonest complications were cardio-respiratory. Septic complications were 15. Total reoperations for surgical complications were 5. Mesenteric ischaemia and secondary peritonitis were the most important causes of fatal outcome (respectively 42 and 17% of mortality). We also reported high mortality among patients with peritoneal carcinomatosis (24%). Emergency surgery was relatively safe for the remaining groups of patients, with a complexive mortality ratio of 5.3%. We conclude that "acute abdomen" is still an appreciably frequent cause of death in the older age group. A high level of vigilance and early attention is therefore advocated. Anyway, excluding some severe conditions, the overall success of surgical interventions for abdominal emergency is satisfactory in the majority of older people. About the debated role of peripheral hospitals in the health care system, we conclude that the surgical treatment of the acute abdomen in the elderly is safe and feasible in the peripheral hospitals, and that these hospitals play a determining role in the management of old patients, especially in emergency.

Sporadic flat ileal adenocarcinoma: an intriguing challenge in the comprehension of a rare neoplasia and its genesis. Case report and review of literature.

Small bowel adenocarcinoma is a rare tumor, with a still not well studied tumorigenesis process, usually presenting in an advanced stage. The clinical diagnosis is often difficult; surgery is the treatment of choice when feasible, while the chemotherapeutic approach is still not well standardized. We describe the case of a 71-yr-old male patient, presenting with an acute right abdomen. At laparotomy the terminal ileum appeared chronically inflamed and thickened. An ileocecal resection with latero-lateral ileocolic anastomosis was performed. The gross appearance resembled an inflammatory bowel disease, but microscopic examination revealed the extensive presence of an infiltrating ileal adenocarcinoma. Literature about small bowel adenocarcinoma has been reviewed for better understanding its pathogenesis.

[Surgical treatment of Graves' disease: results in 108 patients]. / Trattamento chirurgico del morbo di basedow: risultati in 108 pazienti.

AIM OF THE STUDY: To evaluate morbidity and functional results of surgical treatment in patients with Graves' disease. METHODS: A retrospective study was performed in 108 patients operated on during 1993-2003. Main indications for surgery were failure of treatment with antithyroid drugs (80.6%), large goiter (46.3%) and/or severe ophthalmopathy (23.1%). Surgical procedures were extensive subtotal thyroidectomy (EST; n = 33; uni- or bilateral remnant of <2 g) or total thyroidectomy (TT; n=75). Functional results were established in 89 patients (27 EST patients and 62 TT patients) after a mean follow-up of 5.9 years. RESULTS: Operative mortality was zero. There were 4 (3.7%) transient unilateral recurrent laryngeal nerve (RLN) palsies and no cases of permanent RLN palsy. Temporary hypocalcemia occurred in 15 patients (13.9%) and permanent hypoparathyroidism resulted in two (1.9%). Four patients (3.7%) developed a postoperative hematoma that required reoperation. There was no significant difference in the rate of complications between EST and TT, although temporary hypocalcemia was more common following TT than EST (17.3% vs. 6.1%) and permanent hypoparathyroidism affected only TT patients. None of the patients developed recurrent hyperthyroidism; all patients are maintained on levothyroxine. CONCLUSIONS: Surgery is an effective therapy for selected cases of Graves' disease. When performed by experienced surgeons, it can be carried out with no mortality and minimal morbidity. EST (with uni- or bilateral remnant of <2 g) and TT are both effective in order to achieve a definitive cure of hyperthyroidism.

[Post-thyroidectomy cervical hematoma]. / L'ematoma cervicale postoperatorio nella chirurgia tiroidea.

AIM: Postoperative hematoma is a complications of thyroid surgery uncommon but potentially life threatening. It has implications for the trend toward outpatient procedures. METHODS: Retrospective review of 1.221 thyroidectomies performed at our institution over a 6-years period, to identify patients with hematomas requiring reoperation. Symptoms, treatment and findings at reoperation were evaluated. A control group (n=120) was compared for perioperative risk factors and outcome. RESULTS: Eighteen patients (1.5%) developed a postoperative hematoma. Symptoms included neck pain/pressure in 10 patients, respiratory distress in 9, wound drainage in 2, dysphagia in 1, agitation and sweating in 1. Mean time to symptom onset was 12 hours (range: 1.3-40 hours). Six hematomas presented between 7 and 24 hours, and 3 beyond 24 hours. Six patients required bedside hematoma evacuation. The bleeding source was identified in 15 patients. All patients recovered well, but one required a temporary tracheostomy. Case/controls comparison yielded in the study group a higher prevalence of hyperthyroidism (55.6% vs 25.8%, P=0.022) and intrathoracic goiter (50% vs 22.5%, P=0.029), and a longer mean hospital stay (5.22 vs 4.1, P=0.012); morbidity was not increased. CONCLUSIONS: Postoperative hematoma is an uncommon complication of thyroid surgery. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the hematoma development needs to be considered when establishing outpatient practice guidelines.

[Integration of B-mode and color Doppler ultrasonography in the preoperative diagnosis of thyroid lesions. Preliminary experience in 91 cases]. / Integrazione ecografica B-mode e color-Doppler nella diagnosi preoperatoria di lesioni tiroidee. Esperienza preliminare in 91 casi.

Ninety-one patients affected with thyroid diseases (97 lesions) were examined with conventional B-mode and color-Doppler US. To verify if color-Doppler is able to provide additional elements in the US diagnosis, for each lesion were expressed two diagnosis: the first found on conventional US patterns and the second on color-Doppler patterns. US diagnosis was compared with histologic findings that identify 73 benign lesions and 24 malignant lesions. With conventional B-mode US the diagnosis was correctly expressed in 62/73 benign lesions (85%) and in 18/24 malignant lesions (75%) while it misdiagnosed as positives 11/73 case (15%) and as negatives 6/24 cases (25%). If we completed the conventional US diagnosis with color-Doppler patterns, the false negative reduced to 4% and false positive to 6.8%. On the whole, although any correlation between color-Doppler patterns and different histological types was found, the color-Doppler had a high predictive value of benignity in patterns I, II, and IV while pattern III is not peculiar because it includes either malignant or benign lesions.

Primary hyperparathyroidism sustained by a giant adenoma of the parathyroid gland.

A case of primary hyperparathyroidism sustained by an unusually large parathyroid adenoma is presented. The tumor affected a 45-year-old woman with a 15-year history of nephrolithiasis and presented as a palpable neck mass. On the basis of clinical findings and ultrasound examination, it was initially misdiagnosed as a thyroid nodule. CT scan and transesophageal endosonography gave a correct definition of the tumor, which was located behind the left thyroid lobe and expanded posterior to the pharynx and the esophagus in the prevertebral space. At surgery a parathyroid tumor measuring 8 x 7 x 3 cm and weighing 90 g was successfully removed. No signs of malignancy were observed by both morphological and cell kinetic analyses.

Ectopic aldosteronoma associated to another adrenocortical adenoma in the adrenal gland of the same side.

The occurrence of tumors originating from aberrant adrenocortical tissue in ectopic site is very rare. Up to now only two cases of ectopic aldosterone-producing adenoma have been described. We have observed another case of ectopic aldosteronoma, located in the retrocaval region, laterally to the body of the 12th thoracic vertebra. This ectopic tumor was associated to another adrenocortical adenoma, in the adrenal gland of the same side. The diagnostic implications of this observation are discussed.

[Prognostic value of nuclear morphology in colorectal neoplasms]. / Valore prognostico della morfologia nucleare nelle neoplasie del colonretto.

Cytomorphometry measures the main geometric parameters of the cell nucleus (area, min. and max. diameter, circunference) on ordinary histological preparations. It has been employed to asses the prognosis of breast and ovary tumours. The possibility that cytomorphometry, when allied with other parameters, such as age, sex, Duke's stage, bleeding etc., can be used in the prognosis of tumours of the large intestine is examined through a study of intraoperative biopsies from 44 patients followed after surgery. Univariate analysis showed that the Duke's stage and tumour site were significantly related to prognosis. The standard deviation of the maximum diameter and circunference were also related to survival with a negative correlation. Multivariate analysis confirmed the significance of the maximum diameter and the Duke's stage. These parameters were then used to calculate the relative risk. If due account is taken of the reservation expressed in the literature concerning the reproducibility of the data offered by cytomorphometry and its heavy dependence on the skill of the operator, it can be used to advantage in the prognosis of the colorectal tumours.

[Prognostic value of nuclear morphometry in follicular carcinoma of the thyroid gland]. / Valore prognostico della morfometria nucleare nel carcinoma follicolare della tiroide.

Histological material from 60 cases of follicular carcinoma of the thyroid operated between 1962 and 1987 was examined morphometrically to see whether this would produce data that could be correlated with survival. Nuclear parameters (area, perimeter, minimum and maximum diameter and their ratio, form factor) and the mitotic index were investigated. At the same time, account was taken of certain clinical parameters (sex, age, degree of differentiation, size of the primary lesion, extension of the tumour) potentially correlated with prognosis. Survival in relation to all these variables was examined by means of an actuarial method and subjected to both uni- and multivariate analysis. The results, although suggesting the existence of a relationship between nuclear size and the aggressiveness of this type of tumour, failed to demonstrate a significant correlation between these morphometric parameters and survival after treatment. By contrast, survival was significantly influenced by some of the clinical variables, particularly loco-regional extension of the disease and the patient's age. The prognostic significance of nuclear size was recently demonstrated in breast cancer and in a series of thyroid carcinomas including tumours with different morphologies and progression patterns. In follicular thyroid carcinoma the degree of cellular pleomorphism is usually low. So, morphometry does not seem able to provide information regarding prognosis more valuable than those obtained by the clinical data.

[Precedents of benign thyroid pathology in carcinoma of the thyroid]. / Precedenti di patologia tiroidea benigna nel carcinoma della tiroide.

The clinical history of 125 thyroid cancer (99 women and 26 men) operated on between 1985 and 1992 is reviewed. Previous benign thyroid disease is recorded in 52% of all cancers; this was generally goitre or a thyroid nodule, and in few cases hyperthyroidism. Previous disease is observed in 75% of insular, in 68% of follicular, in 51.5% of papillary, in 35% of anaplastic carcinomas. It is supposed that previous thyroid disease is a risk factor in the development of cancer.

[Poorly differentiated "insular" carcinoma of the thyroid: long-term survival]. / Il carcinoma scarsamente differenziato "insulare" della tiroide: sopravvivenza a distanza.

Poorly differentiated "insular" thyroid carcinoma is a rare, aggressive and often lethal variant of thyroid cancer. Thirty-one cases of this entity were encountered over a 18-yr period. In most of them surgical therapy consisted of total or near-total thyroidectomy. Six patients had distant metastases and/or mediastinal or tracheal infiltration at presentation. Fifteen out of 25 apparently cured after surgery (60%) developed recurrence in the neck and/or distant sites. Radioiodine was employed to destroy thyroid remnants (22 cases) and subsequently to treat persistent/recurrent disease (17 cases). Thirteen patients showed radioiodine uptake in neoplastic lesions and in 3 cases complete resolution was observed. After a mean follow-up of 4.5 years (range 1-16) 6 patients had died of their tumor, 12 are alive with persistent/recurrent disease, 13 do not show any evidence of disease. This experience confirms that "insular" carcinoma tends to have an aggressive behavior, but therapy can be effective. Recognition of this entity is therefore important for planning adequate surgical approach and subsequent patient management.

[Parathyroid transplantation and cryopreservation techniques]. / Trapianto di paratiroidi e techniche di crioconservazione.

This report reviews several aspects of parathyroid transplantation, including some technical aspects of cryopreservation. The problems concerning the control of autograft are also presented, with a little review of the more recent references. These results lead to the recommendation that total parathyroidectomy and autotransplantation should be considered as the method of choice in the treatment of secondary hyperparathyroidism.

[Ischemic colitis manifested as Crohn's disease. A case report]. / Colite ischemica manifestatasi quale morbo di Crohn. Case report.

Ischaemic colitis has many and different clinical features as it is often linked to the severity of ischaemic injury. In this paper two patients with clinical features of Crohn's disease are reported. In both patients the diagnosis has been confirmed with endoscopy and biopsy. They have been treated with specific therapy until they developed bowel obstruction in one case and peritonitis in the other. Both patients underwent laparotomy and the histological specimen showed a picture of ischaemic colitis. In one case a Dixon's resection was done, in the other Hartmann's operation.

[Diagnostic approach to extra-renal pheochromocytoma]. / Approccio diagnostico ai feocromocitomi extra-surrenalici.

Stress is laid on certain principles of diagnostic research in the event of extra-suprarenal pheochromocytomas. The importance of CT is recalled, specifying the usefulness of complementary examinations such as selective venous catheterism and above all of scintigraphy with 131I MIBG.

Multifactorial study of prognostic factors in differentiated thyroid carcinoma.

Using survival corrected for intercurrent deaths as an endpoint, the prognostic significance of age, sex, histology, clinical extent of disease, size of primary tumor, type and result of treatment, was assessed in a series of 133 patients with differentiated thyroid carcinomas treated over a 16-year period. The following parameters were shown to be unfavourably related to survival: old age, follicular moderately-differentiated histological type, extrathyroid growth of the primary tumor and/or presence of distant metastases at diagnosis. In patients not cured after surgery, postoperative radioiodine therapy was correlated with, better survival rates. A multivariate statistical analysis (Cox model) showed that tumor stage and age at diagnosis were the major determinants of prognosis. Based on this data a risk index was worked out and three low/intermediate/high risk subgroups, characterized by significantly different survival rates, were identified in the study population.

[Solitary ulcer of the rectum. Description of a case]. / L'ulcera solitaria del retto. Descrizione di un caso.

A case of solitary rectal ulcer is presented. Different views on the pathogenesis are discussed. Symptoms were nonspecific: anal pain, rectal tenesmus and bleeding. On sigmoidoscopy, the lesion has a characteristic appearance, but the definitive diagnosis of benignity must depend upon the recognition of specific histopathologic features in rectal biopsy specimens from ulcer margins. In this case, the surgical treatment was satisfactory, but frequently neither medical nor surgical treatment achieve relief of symptoms or healing of the lesion.

[Bandage of the common femoral artery after intervention of disobliteration or aneurysmectomy (considerations on surgical technic apropos of 4 cases)]. / Bendaggio dell'arteria femorale comune dopo interventi di disobliterazione o di aneurismectomia (considerazioni di tecnica chirurgica a proposito di 4 casi).

The Authors refer their surgical experience in those particular cases in which, after performing an aneurysmectomy or an endarterectomy of common femoral artery, the residual arterial wall appears too thin and weakened. In these not very rare cases, can be indicated, as an additional and prudent manoeuver in order to avoid a possible evolution towards suture disruption or pseudoaneurysm formation, the wrapping or banding of the endarterectomized tract of artery by the mean of dacron prosthesis, sutured around the artery longitudinally. This simple technique, performed in 4 patients, appears easy and safe to perform, offering the advantage to guarantee a biological arterial lumen.