Metaplastic squamous cell breast cancer: A case report and treatment strategy during covid-19 pandemic.

INTRODUCTION: Squamous carcinoma is a very rare breast cancer resulting from a differentiated squamous metaplasia. Its diagnosis is late due to the absence of specific clinical and radiological features. PRESENTATION OF CASE: The authors present the case of a 39-year-old patient with the clinical onset of an inflammatory cyst diagnosed with mammography and cytological examination. After segmentectomy, on histological examination was defined as: "squamous keratinizing aspect". In light of this report she was subjected to quadrantectomy with lymphadenectomy. She did not undergo radiotherapy treatment, which was delayed due to the ongoing pandemic. After a few months developed a local recurrence and underwent a mastectomy with multidisciplinary treatment. DISCUSSION: Squamously-differentiated metaplastic carcinoma of the breast is one of the rarest forms of breast cancer. Its etiopathogenesis is still unclear but some authors suggest that it originates from a squamous metaplasia deriving from the epithelium of cysts. This is a very aggressive and fast-growing tumour especially in young women, in fact the patient had a recurrence after a few months. She came to our attention 6 months after the initial surgery with a relapse at a local-regional level for which she was subjected to radical treatment and with a metastatic spread for which she was given the first-line chemotherapy treatment. CONCLUSION: There are no well-defined guidelines for the treatment of this rare form of cancer. The case illustrates how the rapid aggressiveness of the disease requires adequate and immediate multidisciplinary treatment from the very beginning.

Preoperative fasting - "nihil per os" a difficult myth to break down: a randomized controlled study.

INTRODUCTION: For several years the scientific anaesthesia societies declared a preoperative fast of 6 hours for solid foods and 2 hours for clear liquids before elective surgical interventions to be sufficient. The aim of this study is to identify the extent of the gap that exists between the preoperative fasting time required and that actually encountered in operating rooms. PATIENTS AND METHODS: The safety and clinical applicability of a reduction of the preoperative fasting time was investigated through the use of oral solutions enriched with maltodextrin and their effects on the pre- and postoperative well-being that this may have on patients who are candidates for elective abdominal surgery. The study was conducted in two successive phases (I and II) and patients divided into two groups (A and B). DISCUSSION: Clinical practice is slow to change, in fact, in our study the duration of fasting was an average of 19 hours for solids and 13 hours for liquids. The duration of the fasting did not show differences in the various surgical departments, demonstrating that it is a transversal practice and is not only limited to abdominal surgery in which the utility of fasting would theoretically be greater. Among Group patients A, the fasting time for liquids was about 9 hours. This shows that the time is certainly shorter but not much different when compared to the fasting time for liquids in group B which was on average 14 hours. It is important how difficult it is to achieve good compliance from patients when trying to reduce the time of preoperative fasting based on scientific evidence that is now well established. CONCLUSION: The use of carbohydrate-enriched drinks up to 2 hours after induction of anaesthesia appears to be a safe procedure. The use of these solutions reduces the catabolic response to surgery and contributes to maintaining a pre-operative state of well-being by reducing feelings of hunger and thirst and the state of preoperative anxiety.

Complicated duodenal-jejunal diverticulosis: case report.

BACKGROUND: Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur. CASE REPORT: An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump. CONCLUSION: Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.

Primitive squamous cell carcinoma of the breast (SCCB): case report of an uncommon variant of metaplastic carcinoma.

INTRODUCTION: Metaplastic carcinoma of the breast includes a heterogeneous group of neoplasms characterized by admixture of adenocarcinoma with area of squamous, chondroid and osseous differentiation. If the tumor shows pure squamous differentiation, it is designated as squamous carcinoma. SCCB accounts for less than 1% of all invasive breast carcinoma. It can present as cystic lesions and simulate a breast abscess. CASE REPORT: A 75-year old woman was visited at our General Surgery Unit for a palpable lump, about 5 cm in size, at the lower inner quadrant of right breast. Mammography revealed 3cm oval opacity with micro calcifications and US appearance as isoechogenic lump with lesion solid-cystic appearance; cytology deposes for cystic inflammatory lesion(C2) to be monitored. A subsequent ultrasound check one year later confirmed an increase of volume, so micro histology sampling was made with suspect malignancy(B4). After biopsy, the patient underwent excision of cyst. Final histological examination showed SCCB with diffuse positivity for Cytokeratin 34beta-E12 and p63; negative reactions to ER and PR; monoclonal antibody Ki67 > 40%; HER2/neu with score 2+ and FISH examination negative. Subsequently, the patient underwent radical Madden mastectomy which confirmed the histological diagnosis and the negativity of the lymph nodes. DISCUSSION: In literature, prognosis and therapy are still discussed; SCCB has shown very little responsiveness to common chemotherapy. CONCLUSION: A quadrantectomy or a radical mastectomy with lymph node dissection must be considered the best treatment for this rare neoplasia.

Ingestion of foreign bodies among prisoners: a ten years retrospective study at University Hospital of Southern Italy.

INTRODUCTION: We studied 21 episodes of ingestion of foreign bodies (IFO) among 15 prisoners. PATIENTS AND METHODS: Rectrospective research in pts admitted to emergency from June 2005 to May 2105. Ingestion, management and pts outcome were analyzed. Prisoners with previous esophagogastroduodenal disease were excluded. RESULTS: All pts were males and ingestions were intentional. Esophagogastroduoduenoscopy (EGDS) was performed in 10pts (8 cases with successful removal, 1 case we did not find anything e 1 of unsuccessful EGDS, that required emergency surgey. 9 pts rejected EGDS: in 2 pts were not necessary.Among the 9 pts that rejected EGDS, 5 discharged voluntary. No mortality neither morbidity. Only 1 pt required surgery.The IFO were 34 (23 sharp, 6 flat,5 indefined). We did not observe any food bolus impaction. Multiple ingestion was found in 11 pts. Recurrent episodes were found in 4 pts. DISCUSSION: Almost all episodes can be treated conservatively with observation and endoscopy but the management of this pts has a financial impact on healthcare cost and on security costs. Prevention strategies are important to predict patient group at high risk for recurrent IFO.

TSC but not PTEN loss in starving cones of retinitis pigmentosa mice leads to an autophagy defect and mTORC1 dissociation from the lysosome.

Understanding the mechanisms that contribute to secondary cone photoreceptor loss in retinitis pigmentosa (RP) is critical to devise strategies to prolong vision in this neurodegenerative disease. We previously showed that constitutive activation of the mammalian target of rapamycin complex 1 (mTORC1), by loss of its negative regulator the tuberous sclerosis complex protein 1 (Tsc1; also known as Hamartin), was sufficient to promote robust survival of nutrient-stressed cones in two mouse models of RP by improving glucose uptake and utilization. However, while cone protection remained initially stable for several weeks, eventually cone loss resumed. Here we show that loss of Tsc1 in the cones of RP mice causes a defect in autophagy, leading to the accumulation of ubiquitinated aggregates. We demonstrate that this defect was not due to an inhibition of autophagy initiation, but due to an accumulation of autolysosomes, suggesting a defect in the end-stage of the process causing an amino-acid shortage in cones, thereby hampering long-term cone survival. Because cells with TSC loss fail to completely inhibit mTORC1 and properly activate autophagy in the absence of amino acids, we sporadically administered the mTORC1 inhibitor rapamycin, which was sufficient to correct the defects seen in cones, further enhancing the efficiency of cone survival mediated by Tsc1 loss. Concordantly, activation of mTORC1 by loss of the phosphatase and tensin homolog (Pten) did not affect autophagy and amino-acid metabolism, leading to a more sustained long-term protection of cones. As loss of Pten, which in cones results in less robust mTORC1 activation when compared with loss of Tsc1, still affords long-term cone survival, therapeutic interventions with mTORC1 activators or gene therapy with selected mTORC1 targets that improve glucose metabolism are potential strategies to delay vision loss in patients with RP.

Long lasting postoperative ileus after surgery for intestinal obstruction due to left paraduodenal hernia (LPDH). Case report.

Left paraduodenal hernia is a rare congenital anomaly which arises from an error of rotation of the midgut; sometimes can be responsible for intestinal occlusion, that require surgery. In many cases of literature a prompt diagnosis and therapy reduced morbidity and mortality and almost all patients were discharged on 4th or 5th postoperative day (POD). We report a case of a 59 years old patient who underwent surgery for intestinal obstruction due to a massive left paraduodeneal hernia, that had a very long period (20 days) of postoperative ileus.

[Gardner syndrome: clinical and epidemiologic up to date]. / Attualità cliniche nella sindrome di Gardner: contributo casistico.

In 1950 EJ Gardner first described a new syndrome characterized by (1) familial colonic polyposis, (2) multiple osteomas, (3) soft tissues cysts and (4) fibrous lesions. Thereafter, in 1975 Watne and coll. have demonstrated the occurence, in patients affected by Gardner syndrome, of the early onset of osteomas and dental inclusions in maxillary bones. Gardner syndrome is actually considered a severe life treathening condition due to the poor quality of life and the evolutive pattern of colonic polyps to colon cancer in 100% of cases. The aim of this paper is the review of the pathophysiologic and clinical aspects of Gardner syndrome, with report of institutional clinical data about epidemiology and clinical presentation of such condition, attempting to elaborate a clinical protocol for early detection of that.

[Hepatic hydatidosis in Puglia: analysis of the hospital discharge cards in the years 1996-2000]. / L'echinococcosi epatica in Puglia: analisi delle schede di dimissione ospedaliera (S.D.O.) negli anni 1996-2000.

The authors valueted the distribution of Hepatic Hydatidosis in the Region Puglia (Italy) by hospital dimission cards (schede di dimissione ospedaliera). At present, the SDO represent the most important information tool to monitor hospital activity. The authors examined 468 cases of hepatic Hydatidosis admitted in regional hospital during 1996-2000. 54% were men and 46% women, 75% of whom aged between 40-60 anni. The median hospitalization time was of 12 days and 80% were surgical departments. All the cases examined were uniformedly distributed in surgical hospitals. No hospital acts as a pole of attraction. The periodal prevalence was 6.4/100.000. 40% of cases had surgical DRG with quadriennal sanitary cost of 4 miliardi liras. The Surgical procedure was 53% hepatic lesion demolition, 14% partial epatectomy, 7.2% lobectomy, 5.2% marsupializzazione, 2.6% hepatectomy, and 19% others procedures. At present, due to physiopathological considerations, radical surgery is preferred to conservative surgery. Hepatic hydatidosis is considered a public health problem whose epidemiologic monitoring and precautionary measures could be oriented to control the related sanitary costs.

The eyeless homeodomain is dispensable for eye development in Drosophila.

Pax-6 genes, known to be essential for eye development, encode an evolutionarily conserved transcription factor with two DNA-binding domains. To corroborate the contribution of each DNA-binding domain to eye formation, we generated truncated forms of the Drosophila Pax-6 gene eyeless and tested their capacity to rescue the ey(2) mutant. Surprisingly, EY deleted of the homeodomain rescued the ey(2) mutant and triggered ectopic eyes morphogenesis. In contrast, EY lacking the paired domain failed to rescue the ey(2) mutant, led to truncation of appendages, and repressed Distal-less when misexpressed. This result suggests distinct functions mediated differentially by the two DNA-binding domains of eyeless.

[Rare neoplasms of the breast: our experience concerning nonepithelial malignant breast tumors]. / Neoplasie rare della mammella: la nostra esperienza dei tumori maligni mammari non epiteliali.

The Authors report their experience about some clinical cases of uncommon breast neoplasms observed at the Division of Surgical Pathology, referring particularly on non epithelial malignant tumors. Signalled more meaningful anatomopathologic elements, they describe diagnostic difficulties and therapeutic of such neoplasias; for their rarity they would deserve a study more deepened finalized to the formulation of diagnostic and therapeutic guidelines as so as in the most common breast carcinoma.

[Immune evaluations in cancer patients after colorectal resection]. / Valutazioni immunitarie in pazienti neoplastici dopo resezione colo-rettale.

The authors report a protocol of immunomodulation and monitoring of the intestinal function in coloresected patients using fermented milk (yoghurt). Intestinal immunity was evaluated with respect to CD4+ cells armed with secretory intestine-derived IgA, and to CD8+ cells armed with IgG aiming to an additional effect in the host protection against Gram-negative strains, such as Salmonella typhi, whose particularly high incidence in Apulia accounts for an increased immunitary activity. Ten patients (six females, four males), age ranging from 44 to 85 years, who underwent surgery between 1989 and 1992, each of whom had been prescribed a daily ration of 500 gr skimmed yoghurt for one month, were observed. The authors suggest that yoghurt may determine a higher release of gamma-IFN with activation of CD4+ and CD8+ cells. The Lactobacillus stimulation of the B lymphocytes of the Peyer plates seems to induce an increased production of secretory IgA that bind to the CD4+ surface, and of IgG (as an anamnestic response to challenge with yoghurt lactobacilli). Coloresected patients show an immunitary deficiency related to the Gram+ bacterial flora reduction and consequently a decrease in the physiological stimuli. Although these date concern a limited sample, the authors stress the importance of the restoration of bacterial flora in coloresected patients.

Nuclear shape and axillary metastases in breast cancer. Analytic morphometry of aspiration smears.

The aim of this work was to seek quantitative parameters other than dimensions to describe nuclear shape and, by this means, to determine the sum of contour irregularities and large asymmetries and seek a connection with the biologic behavior of the tumor. Nuclei of the cells obtained from 57 aspiration smears of breast cancers were studied. Dimensional parameters (area, perimeter, maximum diameter and roundness factor) and analytic parameters were computed by the Shape Analytical Morphometry software system to evaluate both contour irregularities and asymmetry of nuclear shape. All the tumors were subdivided according to their diameters into two groups: T1 tumors, the maximum diameter of which was < 2 cm (18 cases), and T2 tumors, the maximum diameter of which was > 2 cm and < 5 cm (39 cases). Among T1 tumors, both dimensional and analytic parameters were highly significant (P < .001) in distinguishing tumors with (N+) and tumors without (N-) axillary metastases, while among larger tumors (T2) only the analytic parameters showed degrees of significance, albeit variable. It could be inferred that in smaller tumors, aggressiveness is related to an increase in nuclear dimensions and shape distortions more so than in larger tumors.

[Report of a case of malignant atrophic papulosis or Degos disease]. / Su un caso di papulosi atrofica maligna (P.A.M.) o malattia di Degos.

The Authors report an exceptional case of Atrophic Malignant Papulosis (P.A.M.) or Degos disease, presenting as acute abdomen with ileal and multiple colic perforations. The disease is due to an occlusive, progressive, thrombotic vascular pathology affecting different parts of the body and may bring to death. Usually this rare disease presents with typical multiple papulous skin lesions, followed by a systemic involvement of the digestive, nervous, and visive tracts. Peritonitis and cerebral infarction are the most frequent causes of death.

[Cystosarcoma phyllodes of the breast: clinical cases]. / II cistosarcoma filloide della mammella: contributo clinico.

The authors report their experience in the management of 8 cases of cystosarcoma phylloides of the breast observed between January 1979 and December 1986 in the Surgical Department of the University of Bari. This uncommon breast pathology, which stands halfway between benign (adenofibromas) and malignant (carcinomas) tumors presents considerable difficulties in terms of diagnosis particularly problematic for the small-sized lesions. The authors stress the need of a surgical treatment which takes into account women aesthetic desire assuring at the same time a complete exeresis. The latter includes the sacrifice of at least 1 cm thick normal breast tissue to prevent the frequent local relapses.