Surgical treatment of impending and pathological fractures of tibia.

Advances in adjuvant and neoadjuvant therapies have improved the prognosis of cancer patients leading to an increasing incidence of bone metastases and consequent long bone fractures. In the present study the authors consider the indications and the different surgical options of treatment of tibial pathological lesions. 13 patients (14 lesions, 6 pathological fractures), treated according to histotype and lesion localisation, were retrospectively evaluated. Using generic outcome instruments such as the Eastern Cooperative Oncology Group (ECOG) and Quality of life questionnaire of European Organization for Research and Treatment of Cancer (QLQ-C30) pain, mobility and use of analgesics were evaluated before and after surgery. In all patients, mechanical stabilisation of the osteolytic lesion was achieved. There were no pathological fractures, and no implant mechanical failure. All patients reported pain relief, with a relevant reduction in the amount of analgesics used. Surgical treatment of tibial metastases has to be decided taking into consideration the histotype, localisation of the metastases and life expectancy. The treatment has to be all-encompassing in a solitary lesion in patients with a good prognosis but less invasive in plurimetastatic patients with poor prognosis. Acquisition of good mechanical stability is crucial for a successful outcome.

Soft tissue metastases in lung cancer: a review of the literature.

BACKGROUND: In lung cancer patients, metastases to soft tissues (STs), including skeletal muscle, subcutaneous tissue and skin, are rarely reported. Besides, lung cancer, primary carcinomas of the kidney and colon are the most commonly associated with ST metastases. AIM: To determine the prevalence, clinical-pathological features and treatment options of ST metastases originating from lung carcinoma. MATERIALS AND METHODS: A literature search was performed using the following terms: lung cancer, ST metastasis, skeletal muscle metastasis, cutaneous metastasis, subcutaneous metastasis. RESULTS: Autopsy series have detected STs metastases in 0.75-9% of patients who died from metastatic lung carcinoma. Pain and the presence of a palpable mass are the most frequent clinical features. The biopsy is recommended after MRI for diagnosis. Due to the rarity of ST metastases, the differential diagnosis must be posed especially with primary ST sarcomas. The type of treatment depends on the patient's clinical status and prognosis, and includes observation, radiotherapy, chemotherapy and surgery. CONCLUSIONS: In lung cancer patients, ST metastases are rare, but not exceptional. Their presence should be suspected in the presence of a palpable mass either painful or asymptomatic. Radiological and histological examinations are required for the definite diagnosis. The choice of treatment should be based on considerations related to the stage of the primary tumor and the patient's global health status.

Skeletal modifications in mucopolysaccharidoses: an overview.

The mucopolysaccharidoses (MPS) are a group of rare diseases characterized by deficiencies in different enzymes required for degradation of complex carbohydrates. The enzymatic deficiencies lead to lysosomal accumulation of dermatan sulphate, heparan sulphate, and keratan sulphate in different tissue resulting in multi-system complications. Six different principal types are described. Most MPS types, with the exception of MPS III, are associated with widespread skeletal abnormalities and joint disease. Authors analyzed clinical pathological and radiographical features of mucopolysaccharidoses focusing on pelvic and spine pathologies that generally limit activity and normal life so they have to be treated at the beginning of their manifestations in order to avoid major complication and improve quality of life.

Angiogenesis in hand chondroma: an immunohistochemical study.

Hand chondroma is a particular cartilagineous tumour, being clinically benign, but morphologically malignant. This study investigates the expression of VEGF together with other growth factors and proliferation markers such as TGFß2, Ki-67, TNF, FGF1, P53 in 8 cases of hand chondroma treated with courettage, in order to define the ethiopathogenesis of this tumour and the clinical significance of the resulting immunohistochemical profile, with particular respect to angiogenesis. VEGF was expressed in all cases; 5 cases were positive for TFGß2 and 3 for PDGF. None of the other factors was expressed. On the basis of histologic results a specific model of tumour progression based on the indicators of angiogenesis could be related to hand tumours, in which VEGF expression should be the first stadium of the tumour aggressiveness, and the following PDGF, TGF 2 expression should be accompanied with a morphological outline worsening. Nevertheless the non constant expression of these indicators and the absent expression of proliferated indicators can explain the scant tendency to the relapse in presence of accurate curettage. It is important to remember that the cellular polymorphism typical of the cartilaginous tumours does not allow the application of an only oncogenesis model.

Zirconia toughened alumina (ZTA) powders: ultrastructural and histological analysis.

Ceramic materials, as Alumina and Zirconia, has made an improvement in the choice of new biomaterials for the load bearing application in dental and orthopaedic implants. These materials has shown mechanical resistance to high stress related to weight bearing and low debris in time. For this reason they are indicated on young patients implant, with high demanding activities and long life expectance. In literature however the risk of chronic inflammation due to chronic wear debris release and the possibility of carcinogenesis, is still to be definitively investigated. Another point to investigate is the acute reaction of the tissue in case of acute release of powders of these materials. The aim of this study was to investigate the possible local and systemic acute effects of ceramic precursors in form of powders of different size when released into articular joint. Powders of ZTA were implanted in the knee joint of twenty-four New Zealand white adult rabbits, that were sacrificed at 1,3,6, and 12 months. Radiographic, histological and immunoistochemestry analysis were conducted on periprosthetic tissue and peripheral organs, to verifying local host response and systemic toxic effects.

Histological and ultrastructural reaction to different materials for orthopaedic application.

Prosthetic joints loosening in absence of infection is the most common reason for revision surgery and is known as aseptic loosening. A significant role in the pathogenesis of implant failure undoubtedly played by the generation of wear debris, mainly from the load bearing joint surfaces, and the cellular reaction through the formation of tissue membrane around implants. This article analyzes histologic, immunohistochemical ad ultrastructural aspects of periprosthetic tissue membrane collected at time of surgical revision, paying attention on cell host response to different materials: metals, polyethylene and ceramics. Dimension of particles seems to be crucial in the activation of different cell population to wear debris.

An original method for the evaluation of in vivo controlled release of the ceramic materials.

In recent years, the use of ceramic materials in orthopaedics and dentistry is becoming increasingly popular. However, it is important to know their biological and mechanical properties to optimize their use. The aim of this study is to describe a specific method to assess in vivo the effects of chronic release of ceramic materials implanted, in relation also to the type of material, pellets or powders. This was achieved by implanting ceramic powders and pellets, formed by low cohesion grains, in the patellar tendon of 48 New Zealand adult rabbits (24 with powders and 24 with pellets). The motion of the joint allowed easily and progressively the release of grains, detached from surface of the pellets and released to the joint space. Animals were sacrificed at different intervals (1, 3, 6, 12 months). Retrieved knee joints underwent X-Ray, histological and ultrastructural analysis.

Jaw osteonecrosis related to bisphosphonate treatment of bone metastasis.

The efficacy of bisphosphonate in controlling skeletally-related event in cancer patients without a great number of adverse events has resulted in a widespread use of these medications in oncology. Zoledronic acid and pamidronate are the most common bisphosphonates intravenously administered as a preventive treatment of bone complications encountered in multiple myeloma, as well as a palliative treatment of bone metastases in a large variety of solid tumours including breast, prostate and lung cancers. However, in recent years a relationship has been established between these drugs and a new bone injury characterised by avascular necrosis of bone that was isolated to the jaws. This paper reviews the literature concerning the discovery of this disease, its clinical, radiological and histological manifestations; its pathogenesis, with a look at the treatment and future options in preventing this complication and in treating hypercalcemia and bone lytic lesions in solid tumours.

Infection following bone tumor resection and reconstruction with tumoral prostheses: a literature review.

Bone resection is the choice treatment of malignant bone tumors. Tumor prosthesis is one of the most common solutions of reconstruction following resection of bone tumor located to the metaphysis of long bones. Periprosthetic infections are a frequent complication of limb-salvage surgery which is largely due to prolonged and repeated surgeries, as well as to the immunocompromised condition of these patients due to neoplastic treatment. Furthermore, the large exposure of tissues during this type of surgery and the dissection across vascular distributions also contributes to the high risk of infection. The authors reviewed the literature discussing the incidence of infections of tumor prosthesis implanted following resection of bone tumors, taking into account the different sites of implantation. In the English literature, the highest risk of infection which led to limb amputation was observed after proximal tibia resection and this difference was considered to be due to the poor condition of soft tissue and also after pelvic resection due to huge dead space after sarcoma resection not filled by implant. Independent of the location, the management of infected prosthesis is similar. That is, after one or more attempts at debridement and antibiotic therapy, it consists of implant removal and insertion of a new implant in a one- or two-stage procedure, with a decreased risk of failure with the two-stage procedure.

[Conservative treatment of postoperative pancreatic fistula. Role of interventional radiology]. / Trattamento conservativo della fistola pancreatica postoperatoria. Ruolo della radiologia interventistica.

OBJECTIVE: To assess the role of interventional radiology in the conservative treatment of postoperative pancreatic fistula. CASE REPORT: A case of a high flow mixed entero-bilio-pancreatic fistula caused by dehiscence of pancreatic-jejunal anastomosis after duodenocephalopancreasectomy for endocrine neoplasm of the head of the pancreas, SETTING: General Surgery Division and Diagnostic Radiology. CONCLUSIONS: Conservative treatment represents at the time being, due to the current possibilities in assisting critical patients and in controlling pancreatic secretory activity, the first choice in pancreatic fistula treatment. The effectiveness of this treatment depends on the severity of inflammatory disease of the pancreas. Clinical (Ranson, Glasgow, APACHE II) and radiological (Balthazar, Vernacchia) parameter evaluation is a critical step in therapeutic choice. Surgery should be used in patients with severe pancreatitis. Conservative treatment represents the first choice in stable and critical patients with mild pancreatitis.

[Clinical value of spleen autograft]. / Considerazioni sul valore clinico dell'autoinnesto di milza.

A relaparotomy for cholecystectomy in a 21 year old patient, who received a spleen autograft after a traumatic injury four years before, allowed us to describe the long term morphological and functional follow-up of the autotransplanted spleen, with a histological evaluation of one of the grafts. We point out the technical aspects of the surgical procedure with a review of the experimental background. We underline the analogy of the functional features of the splenic autograft both in the experimental field and in the clinical setting. The histological study of the splenic fragment in our case showed the same structural pattern of the experimental studies. Thus we stress the hypothesis of an effective protection of the implanted splenic tissue against the overwhelming post-splenectomy sepsis in man.

[Intestinal occlusion in cocaine-packet ingestion]. / L'occlusione intestinale nella cocaine-packet ingestion.

During the last decade, the increase of drug traffic and close customs' control have led smugglers to attempt various methods to pass through customs undetected. One method is the ingestion of large numbers of drug-filled packets (usually containing cocaine), together with anticholinergics inhibiting intestinal peristalsis, by a smuggler, called "body-packer" or "mule". The up-to-date approach to cocaine-packet ingestion is conservative medical management during the spontaneous evacuation of the "ovules". Emergency surgical treatment should be reserved for the complications of cocaine-packet ingestion ("body packer syndrome"), which are bowel obstruction due to clustering of the containers and intraluminal rupture of the "ovules" with massive drug transmucous absorption (acute cocaine intoxication). We describe a case of cocaine-packet ingestion in a 19 year old man who was asymptomatic at admission and thus conservatively treated. During the spontaneous evacuation of ovules, clinical and radiological signs of bowel obstruction appeared and the patient underwent emergency laparotomy with removal of 21 containers, two of them clustered in the distal ileum, causing the occlusion. This case gave reasons for a discussion on the specific features of bowel obstruction in cocaine packet ingestion. The bowel obstruction of cocaine-packet ingestion should be carefully considered and promptly treated because of the potentially lethal consequences (death rate of 56% of cases) of transmucous absorption of cocaine contained in "ovules". In fact, while opioid intoxication can be fought with specific antagonists towards opioid receptors (naloxone), the lack of a specific antidote makes cocaine poisoning particularly dangerous.(ABSTRACT TRUNCATED AT 250 WORDS)

[Is the surgical treatment of spontaneous bacterial peritonitis still up-to-date?]. / Trattare chirurgicamente la peritonite batterica spontanea è ancora attuale?

We describe a case of spontaneous bacterial peritonitis in a 53 year old man affected by cryptogenic micro-macronodular cirrhosis, portal hypertention, splenomegaly and hypersplenism, who was admitted with hepatic failure and septic shock and successfully treated with antibiotics (combination of clindamycin and netilmycin), surgical abdominal drainage and splenectomy. This case gave reason for a literature review and an update on the therapeutic options in these high risk patients, especially concerning the role of surgery. Spontaneous Bacterial Peritonitis (SBP) is defined as a bacterial infection of ascitic fluid in the absence of any septic focus. It is a typical life-threatening complication of hepatic cirrhosis with ascites. Mortality is very high and ranges from 75% to 97% of patients, due to septic shock and hepatic failure (hepatorenal syndrome, hepatic encephalopathy, gastrointestinal bleeding). Infection with a single organism is found in most cases. Gram negative bacilli are present in about 70% of cases and E. coli (less frequently Klebsiella, Serratia, Pseudomonas) is principally found. Gram positive cocchi comprise an additional 30% of cases. Anaerobic and microaerophilic organisms seem to be rare causes of SBP (2.7-6%); this finding is probably due to the intrinsic bacteriostatic activity of ascites, which contains high oxygen tension (70 mmHg) and is an inhospitable environment for bacteroides and Clostridia. The prevalent isolation of enteric organism suggest that the gut is the most frequent source of infection, even if the pathogenetic mechanism is not yet well known. The right treatment depends on differentiating primary (SBP) from secondary peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)