Oxygen-ozone autohemotherapy in breast cancer patients suffering from fatigue and musculoskeletal pain upon aromatase inhibitors treatment: a case-series study.

OBJECTIVE: In patients with breast cancer and positive hormone receptors, aromatase inhibitors are effective in reducing the risk of recurrences and are active in progressing the disease in this setting. On the other hand, fatigue and painful musculoskeletal side effects can significantly reduce treatment compliance. With no further treatment options to control these symptoms, non-pharmaceutical interventions, such as oxygen-ozone therapy, may play a role in managing rheumatologic symptomatology inasmuch. We have previously reported evidence on the effectiveness of oxygen-ozone in the treatment of pain and fatigue in chronic fatigue syndrome and fibromyalgia patients and in oncological patients as well. PATIENTS AND METHODS: In this study, we reported 6 cases of patients (mean age 64 yrs, all Caucasian females) with breast cancer upon treatment with anastrozole (Arimidex®), suffering from musculoskeletal pain, weakness and fatigue, and therefore treated with oxygen-ozone major autohemotherapy according to the Italian Scientific Society of Oxygen Ozone Therapy (SIOOT) protocol. Pain was measured with a 10-item Numerical Rating Scale (NRS) and fatigue with a 7-item Fatigue Scoring Scale (FSS). RESULTS: A reduction of at least 66% of pain (from 9.43 ±0.54 SD to 2.36 ±1.32 SD, p<0.001) and 66.26% of fatigue were obtained for all the cases. Pain and fatigue disappeared within one month from ozone therapy, and a healthy painless state lasted for many months following the oxygen-ozone therapy. CONCLUSIONS: The oxygen-ozone therapy is a sound opportunity for breast cancer patients to reduce anti-aromatase-induced pain, fatigue, and musculoskeletal symptoms.

Kaposi's sarcoma in HIV-infected patients in the era of new antiretrovirals.

Kaposi's Sarcoma (KS) is a multicentric angioproliferative cancer of endothelial cells (ECs) caused by Human Herpesvirus 8 (HHV8) characterized by clinical heterogeneity depending on the host immune conditions. Despite its incidence has dramatically decreased in developed countries after the introduction of Highly Active Antiretroviral Therapy (HAART), KS remains the most frequent tumor in HIV-infected patients worldwide. Clinical presentation varies from an indolent slowly progressive behavior, generally limited to the skin, to an aggressive and rapidly progressing disease. In more than 50% of cases, the skin lesions are often associated with a more or less important visceral involvement, particularly to the oral cavity and the gastrointestinal tract that are involved in 35% and 40% of cases respectively. A large number of treatments can be used both as local and as systemic therapy. Particularly, HAART represents the first treatment in patients with moderate lesions limited to skin, and it can be sufficient to reduce significantly the size of lesions and, often, the complete disappear in 35% of cases after 3-9 months of treatment. In case of a rapidly progressive disease with extensive cutaneous and/or visceral involvement systemic drugs are used such as the liposomal anthracyclines pegylated liposomal doxorubicin (PLD) and daunorubicin citrate liposome (DNX), the combined treatment adriamycin-bleomycin-vincristine (ABV) and bleomycin-vincristine (BV), Paclitaxel and Interferon-alfa. In patients with limited skin localization, the local treatment can play an important role. Local medical therapy is based on the use of alitretinoin, antineoplastic drugs vincristine, vinblastine and bleomycin and Sodium Tetradecyl Sulfate (STS). In addition to medical therapy, physical treatment, such as cryotherapy and radiotherapy, are also commonly used.

Multimodal approach of advanced gastric cancer: based therapeutic algorithm.

Gastric cancer (GC) is the third leading cause of cancer death in both sexes worldwide, with the highest estimated mortality rates in Eastern Asia and the lowest in Northern America. However, the availability of modern treatment has improved the survival and the prognosis is often poor due to biological characteristics of the disease. In oncology, we are living in the "Era" of target treatment and, to know biological aspects, prognostic factors and predictive response informations to therapy in GC is mandatory to apply the best strategy of treatment.The purpose of this review, according to the recently published English literature, is to summarize existing data on prognostic aspects and predictive factors to response to therapy in GC and to analyze also others therapeutic approaches (surgery and radiotherapy) in locally, locally advanced and advanced GC. Moreover, the multidisciplinary approach (chemotherapy, surgery and radiotherapy) can improve the prognosis of GC. The purpose of this review, according to the recently published English literature, is to summarize existing data on prognostic aspects and predictive factors to response to therapy in GC and to analyze also others therapeutic approaches (surgery and radiotherapy) in locally, locally advanced and advanced GC. Moreover, the multidisciplinary approach (chemotherapy, surgery and radiotherapy) can improve the prognosis of GC.

Lymph node evaluation in gallbladder cancer: which role in the prognostic and therapeutic aspects. Update of the literature.

OBJECTIVE: The widespread use of laparoscopy has changed the outcome of gallbladder cancer as a consequence of increasing referral and incidental discovering of earlier stages cancer. Nevertheless, GBC is still associated with a poor prognosis and lymphnodal involvement is a main prognostic factor, important both for staging and for evaluating surgery quality. No consensus exists about the extension of lymphadenectomy to be performed nor about contraindications to extensive resection. A review of literature was so designed to identify the actual role, extension and limits of lymphadenectomy. MATERIALS AND METHODS: A search on Pubmed and Scopus has been performed using the following keywords: gallbladder cancer, gallbladder neoplasm, surgery, laparoscopy, lymphadenectomy to evaluate the prognostic and the therapeutic role of the lymphadenectomy in gallbladder cancer. The retrieved articles were analyzed aimed to evaluate the impact of lymphectomy and of its extension on overall and disease free survival. RESULTS:  Although no consensus still exists over the extension of ideal lymphadenectomy, some points are already clearly established: a part from T1a neoplasms, that do not require further surgery, and T1b for which a regional lymphectomy (N1) is safe and mandatory, more advanced stages require a more aggressive surgery but the fate of paraortic nodal station is still under evaluation. In fact some Authors still believe that the involvement of these nodes determine a so poor prognosis to make uselessly risky their surgical aggression. Other Authors conversely, show that there is not any difference in survival, among node positive patients, between paraortic node positive and no paraortic node positive patients. CONCLUSIONS: The prognosis of gallbladder cancer remains poor because in most patients the diagnosis is made at an advanced stage. Complete surgical resection provides the only curative treatment option in this disease. In order to improve long-term outcome, several surgeons have advocated aggressive surgical resection, including major hepatectomy, pancreatoduodenectomy and extended lymphadenectomy. Even a para-aortic nodal disease shouldn't discourage from pursuing this objective.

Laparoscopic cholecystectomy: ultrasonic energy versus monopolar electrosurgical energy.

OBJECTIVE: Nowadays, laparoscopic cholecystectomy (LC) is undoubtedly considered the "gold standard" in the surgical treatment of symptomatic gallstones, gallbladder adenomas and acute cholecystitis. Among the alternative energy sources proposed (monopolar, bipolar electric scalpel, radiofrequency sealers) with the aim to dissect and/or seal, the ultrasonic energy has been frequently adopted, however without a widespread acceptance among surgeons for routine or emergency laparoscopic cholecystectomy. This study investigates the possible beneficial aspects of ultrasonic dissection and its efficacy in the closure of the cystic artery and duct. PATIENTS AND METHODS: Patients were retrospectively divided into 2 groups according to the instruments used for division of the cystic artery and duct as well as for dissection of the liver bed: 121 patients in whom dissection and coagulation were performed using monopolar coagulation and 43 patients who were all treated with the ultrasonically activated scalpel harmonic ACE (Ethicon Endo-Surgery) as the sole instrument used in the whole procedure. RESULTS: The mean operative time, was significantly shorter in the harmonic group than in the traditional group (35.36 + 10.15 min vs. 55.6+12.10 vs. respectively; p < 0.0001). The rate of gallbladder perforation was significantly higher in the traditional group than in the harmonic group 20.66% (25 patients) vs. 6.98% (3 patients), respectively; p < 0.05). Intraoperative volume blood loss was significantly more in the traditional group than in the HS group (29.32+14.21 vs. 12.41+8.22; p < 0.0001). The mean amount of postoperative drainage was not significantly different among the two group (18.41+6.54 vs. 15.96+8.69 ml, p > 0.05). No considerable visceral injury has been recorded in either group. The postoperative parameters observed included postoperative hospital stay and morbidity for each group. The hospital stay was not significantly shorter in harmonic group (48.15+4.29 vs. 49.06+2.94 h, p > 0.05). The overall morbidity rate was 14.02 % (not significant). CONCLUSIONS: The use of the harmonic scalpel shows some statistically significant advantages limited to a few intraoperative parameters. We conclude that a wider use of harmonic scalpel not offers such advantages to make it the reference technique.

Cystic pancreatic neoplasms: diagnosis and management emphasizing their imaging features.

The incidence of cystic pancreatic neoplasms increased in the past decade, due to the recent advances in multidetector computed tomography and magnetic resonance imaging; several pancreatic cysts are incidentally encountered during diagnostic exams performed for non-pancreatic diseases. Indeed, cystic pancreatic tumors are currently considered relatively rare, accounting for approximately 10% of all pancreatic neoplasms. Serous cystadenoma, mucinous cystadenoma, intraductal papillary mucinous neoplasms and solid-pseudopapillary tumor represent about 90% of all pancreatic primary cystic tumours. The non-optimal diagnostic preoperative accuracy in distinguishing benign from malignant cystic lesions ensures that up till now there are no well-defined guidelines regarding the management of cystic pancreatic neoplasms. Imaging findings often do not allow the diagnosis, because there is a considerable overlap among the cystic lesions; the best pre-operative characterization is obtained by the association of all diagnostic procedures available. For their different histology and behavior, cystic pancreatic neoplasms need to be managed according to various factors. In this review, the main elements necessary for their management are assessed--radiological features, tumour dimensions, patients' characteristics, the mode of clinical presentation and the associated oncologic markers. A multidisciplinary approach--including gastroenterologists, radiologists and surgeons--should be adopted in order to perform a differential diagnosis and a correct management.

Elderly gastrointestinal cancer patients and radiochemotherapy: a review.

Gastrointestinal cancers are among the most frequently occurring cancer worldwide. Elderly patients represent a large proportion of patients diagnosed with gastrointestinal cancers. Despite this, elderly patients are generally under-represented in clinical trials, therefore a general consensus on how to treat elderly patients is still far from being achieved. In oesophageal cancer, radiochemotherapy can be administered successfully and effectively but should be administered with close monitoring because of potential toxicities especially hematological. In gastric and rectal cancer, there is no clear trade-off between efficacy and side effects and some patients may not gain a survival benefit from combined treatment. Instead, the treatment of elderly pancreatic cancer patients with a good performance status should be no different than the treatment of younger patients. Radiochemotherapy maintains its activity and feasibility in elderly gastrointestinal cancer patients. Finally, it is very important to assess co-morbidity with its severity in order to aid in the development of plans for treatment.

Feasibility of intraperitoneal Trastuzumab treatment in a patient with peritoneal carcinomatosis from gastric cancer.

OBJECTIVES: This case report evaluates the feasibility and efficacy of intraperitoneal (IP) trastuzumab administration in gastric cancer (GC) patients with peritoneal carcinomatoses. METHODS: Peritoneal metastasis is a common sign of advanced tumor stage, tumor progression or disease recurrence in patients with GC. Recently, the role of HER2 overexpression in GC, occurring in about 20% of cases, is correlated with a worse prognosis. We report the case of 61-years old female, admitted to our Hospital after curative surgery for GC with over-expression of HER2. Seven months after the start of first line chemotherapy treatment a pleuro-peritoneal disease progression occurred, documented by cytological exam; according to HER2 status, we decided to treat the patient with IP trastuzumab administration. RESULTS: Between September and October 2012, the patient (ECOG performance status was 0), underwent to 6 cycles of IP trastuzumab. Trastuzumab was administered weekly at a dose of 150 mg for each cycle after paracentesis. The safety was good, no local complications (e.g. abdominal pain, peritonitis) occurred. The clinical revaluation evidenced a stable peritoneal disease. CONCLUSIONS: To our knowledge this is the first report on Trastuzumab use to treat IP metastases from GC, with acceptable toxicity and local disease control.

Dissemination metastasis after laparoscopic colorectal surgery versus conventional open surgery for colorectal cancer: a metanalysis.

PURPOSE: The purpose of this systematic review is to evaluate and compare the risk of dissemination metastasis (wound, port-side metastases and peritoneal seeding) after laparoscopic colorectal surgery and conventional open surgery for colorectal cancer. MATERIALS AND METHODS: The Authors searched relevant randomized controlled trials between January 1998 and July 2012. RESULTS: Wound, port-site metastases and peritoneal seeding were rare and no significant differences occurred between the two groups. The port-site and extraction site recurrence were likely to be the results of suboptimal surgical techniques and occurred in the early phase of the learning curve. The authors also found no significant differences in overall, local and distant recurrences. No significant differences between laparoscopic and open surgery were found in cancer-related mortality during the follow up period of the study (7 RCTs, 3525 patients, 12.8% vs. 14.00%; OR (fixed) 0.83, 95% CI 0.68-1.02), with no significant heterogeneity (p = 0.35). CONCLUSIONS: The literature supports the implementation of laparoscopic surgery into daily practice. Laparoscopic surgery can be used for safe and radical resection of cancer in the right, left, sigmoid colon and rectum. However further studies should address whether laparoscopic surgery is superior to open surgery in this setting.

Vitamin D deficiency in HIV infection: an underestimated and undertreated epidemic.

Hypovitaminosis D is a very common disorder, regarding both Western and developing countries. A growing amount of data over the last years have shown vitamin D deficiency to be high prevalent among HIV-positive subjects. In addition to "classic" risk factors, such as female sex, low dietary intake, dark skin pigmentation and low sun exposure, HIV-related factors, including immune activation and antiretroviral adverse effects, may affect vitamin D status. Even if both protease inhibitors and non-nucleoside reverse transcriptase inhibitors have been associated with low vitamin D levels, available evidences have failed to univocally associate hypovitaminosis D with specific antiretroviral class effects. Low vitamin D is known to have a negative impact not only on bone health, but also on neurocognitive, metabolic, cardiovascular and immune functions. Similarly to the general population, several studies conducted on HIV-infected subjects have associated hypovitaminosis D with a greater risk of developing osteopenia/osteoporosis and fragility fractures. Analogously, vitamin D deficiency has been described as an independent risk factor for cardiovascular disease and metabolic disorders, such as insulin resistance and type 2 diabetes mellitus. Last EACS guidelines suggest to screen for hypovitaminosis D every HIV-positive subject having a history of bone disease, chronic kidney disease or other known risk factors for vitamin D deficiency. Vitamin D repletion is recommended when 25-hydroxyvitamin D levels are below 10 ng/ml. Furthermore, it may be indicated in presence of 25OHD values between 10 and 30 ng/ml, if associated with osteoporosis, osteomalacia or increased parathyroid hormone levels. The optimal repletion and maintenance dosing regimens remain to be established, as well as the impact of vitamin D supplementation in preventing comorbidities.

Comorbidity assessment and radiotherapy in elderly cancer patients.

More than 60% of all cancer patients in Europe and the USA are older than 65 years at the time of diagnosis. Despite this, elderly patients are generally under-represented in clinical trials. There is a lack of clinical trials to drive evidence-based decision making in the elderly cancer patients. In this review, we address the most important issue surrounding the treatment of older cancer patients: comorbidity assessment.