An interpretation of optic nerve tortuosity. A case report.

Magnetic resonance imaging disclosed both optic nerve tortuosity and kinking in a 64-year-old man with orbital pain and monolateral abducens nerve palsy. The association between optic nerve tortuosity and abducens nerve palsy is often described in literature reports of idiopathic intracranial hypertension. However the diagnosis of idiopathic intracranial hypertension was excluded in our patient because of the absence of other signs such as papilledema (universally present in the cases of idiopathic intracranial hypertension), visual loss, headache and flattening of the posterior sclera. Other possible diagnoses to be considered when looking at a case of optic nerve tortuosity are neurofibromatosis and/or optic nerve glioma. Tortuosity of both optic nerves seems to be isolated in our patient and not associated with other diseases or disorders. We suggest that in some patients optic nerve tortuosity could be correlated with an aberrant anatomical development of the optic nerve. Further studies are necessary to confirm this hypothesis which currently remains conjectural.

Osteoblastoma of the orbit. A case report and review of the literature.

We describe a case of benign orbital tumour involving the frontal sinus and ethmoidal cells. CT findings were typical of "bone tumour of the orbit", histological analysis yielded a diagnosis of benign osteoblastoma. A review of the literature disclosed only 13 well documented cases. We compared out radiological findings with the features described in these reports. CT patterns were similar in most cases. The lesion generally appears as a heterogeneous mass where it is possible to appreciate both high density portions and low density areas. On MRI osteoblastoma shows an iso- low signal both in T1 and in T2 sequences. Less frequently the lesion may yield a high signal in T2 images. The orbit is rarely involved by bone tumours, but all bone tumours may theoretically involve the orbit, often making it difficult to establish the right differential diagnosis by imaging. Thirteen cases are insufficient to describe general radiological criteria to improve the specificity in detection of this disease and a broader outlook is essential. For this reason we also examined the radiological signs of bone tumours involving other portions of the body. Even though many literature reports suggest CT is the landmark in bone tumour diagnosis, we think it should always be accompanied by MRI. MRI is known to overestimate local staging, but its contribution to differential diagnosis among various tumours may be decisive.

[Surgical treatment of breast cancer in the elderly]. / Trattamento chirurgico del carcinoma della mammella in età avanzata.

AIM: The aim of this study is to evaluate the prognosis and survival of patients aged over 70 years and affected by breast cancer. METHODS: From January 1994 through December 2000, 56 patients with breast cancer aged 70 years or older were submitted to surgical treatment. Associated diseases were present in 24 patients, while no patient showed distant metastases at the time of hospital admission. All patients underwent breast preserving surgery regardless the tumour size and in 31 subjects out of 56, the surgical procedure was performed under local anesthesia. An axillary lymphectomy was associated in 46 patients. According to the TNM staging system, tumours were classified as follows: 10 T1Nx, 18 T1N0, 9 T1N1, 7 T2N0, 10 T2N1 and 2 T3N1. RESULTS: There was no postoperative mortality and in 6 cases an axillary seroma was observed. Radiotherapy and tamoxifen treatment followed surgery in all cases. The median follow-up was 44 months. Nineteen patients (34%) died during the follow-up: 6 patients of cancer progression with a specific cancer-death of 10.7% while 13 patients (23.2%) died because of concurrent diseases. A local relapse (1.8%) was observed in a single patient 2 years after the primary surgical treatment and, at 3 years, 37 patients (66%) are alive and disease-free. Long-term survival was significantly related to the stage of disease at the time of surgery, while our data do not allow any conclusions concerning the impact of axillary dissection on long-term outcome. CONCLUSIONS: In conclusion, results for breast cancer therapy are comparable in old and young patients and therefore strategies and treatment protocols should be similar, breast preserving surgery followed by radiotherapy and ormonal treatment being ''the gold standard''.

Pre-operative assessment of extramural invasion and sphincteral involvement in rectal cancer by magnetic resonance imaging with phased-array coil.

OBJECTIVE: Pre-operative staging of rectal cancer should identify patients with extrarectal spread, who might benefit from pre-operative radiotherapy, and patients with minimal sphincteral involvement, who can avoid permanent colostomy. The aim of this study was to assess the accuracy of Magnetic Resonance Imaging (MRI) to predict tumour stage and sphincter status. PATIENTS AND METHODS: Thirty-three patients with a rectal tumour were pre-operatively assessed by MRI with a phased-array coil. Imaging results were correlated with the final pathological findings. RESULTS: The overall accuracy of pre-operative staging with MRI was 88% (k = 0.75) for extramural tumour invasion and 59% (k = 0.26) for lymph node metastases. MRI correctly evaluated the infiltration of the anal sphincters in 87% of patients (7 of 8 patients with low rectal tumour). CONCLUSION: MRI provides the surgeon with valuable information regarding extramural tumour spread and sphincteral involvement, enabling appropriate selection of patients for pre-operative adjuvant therapy or sphincter-saving surgery.

[Transverse minilaparotomy as an access route in right colon disease: a valid alternative to midline laparotomy]. / La minilaparotomia trasversale come via di accesso nella patologia del colon destro: una valida alternativa alla laparotomia mediana.

AIMS OF THE STUDY: 1. To evaluate the feasibility and appropriateness of transverse right minilaparotomy for right colectomy and lymphadenectomy. 2. To identify the clinical advantages, if any, of this access route compared to the more traditional midline incision. PATIENTS: 44 patients with right colon adenocarcinoma undergoing colonic resection via a transverse or midline laparotomy. METHODS: The transverse incision starts 1 cm above the umbilicus, running from the midline to the anterior axillary line. RESULTS: 17 (39%) transverse minilaparotomies and 27 (51%) midline laparotomies were performed, respectively. The mean operative time was 107 min for patients with the transverse incision and 157 min. for those with midline laparotomy. Twelve out of 17 patients (70%) with the transverse incision experienced no or only mild pain as against 11 out of 27 patients (41%) with midline laparotomy. Bowel function was slightly faster in the first group of patients, though the difference was not statistically significant. Forty-seven percent of patients with transverse minilaparotomy were discharged within 8 days postoperatively as against 4% with midline laparotomy (P = 0.001). No major complications occurred in the first group, while 2 patients (7%) operated on via the midline laparotomy experienced complications (haemorrhage, deep venous thrombosis). CONCLUSION: Although this is a preliminary study in only 44 patients, our results support the idea that transverse minilaparotomy is a less traumatic access route to the right colon, in addition to offering an adequate exposure of the operative field, faster postoperative recovery and a shorter hospital stay. We believe it to be a good alternative to midline laparotomy for right colon surgery.

[Intestinal occlusion due to a giant lipoma of the cecum]. / Occlusione intestinale da lipoma gigante del cieco.

Lipomas of the colon are localised in 90% of cases at submucous level, they are usually solitary and may be sessile or pedunculated. They are almost always asymptomatic; only when they are of a certain size they become manifest, causing alterations of the alveus, rectorrhagia, abdominal pain or intestinal transit alteration. They are often discovered by chance during endoscopic or radiological examination.

[Colorectal neoplasms in patients with ulcerative rectocolitis. Their surgical treatment and follow-up]. / Le neoplasie del colon retto in pazienti affetti da rettocolite ulcerosa. Trattamento chirurgico e follow-up.

Patients with ulcerative colitis (UC), especially those with a long-term standing or severe disease, show a higher incidence of colorectal neoplasms. Dysplasia represents the most important risk-factor for malignancy in patients with UC. From 1989 to 1999, 71 patients with UC, were surgically treated at our Institution. Indications for surgery were: non responding disease or refractory bleeding in 61; pathologic evidence of severe dysplasia during endoscopic surveillance in 5 patients, evidence of a neoplasm in the remaining 5 patients. Operative mortality was 1.4%. Infections of the surgical wound has been the most common postoperative complication. In 4 cases pouchitis has been reported. In 7 patients because of progression of the proctitis a second surgical treatment has been made. When surgical treatment is indicated in the course of ulcerative colitis, several operations may be performed. In the large majority of patients, total colectomy, mucosectomy and ileal pouch-anal anastomosis is the procedure of choice.