Duodeno-pancreatic neuroendocrine tumours.

Duodeno-pancreatic neuroendocrine tumours (DP-ETs) are increasingly diagnosed today due to the widespread use of modern imaging methods. Duodeno-pancreatic endocrine tumours should be treated by radical surgical resection, which offers a high chance for cure when the disease is localized. A high index of suspicion is required in these patients for the presence of a multiple endocrine neoplasia type syndrome. We present four patients with DP-ET surgically treated at our department between 2000 and 2004. Histological/immunohistochemical diagnosis was somatostatin-producing tumour in the first patient, oncocytic endocrine tumour positive for neurone-specific enolase and focally for chromogranin in the second patient, glucagonoma and pancreatic polypeptide-producing endocrine pancreatic tumour in the third patient, and gastrin, somatostatin, calcitonin, insulin and adrenocorticotropic hormone (ACTH)-producing tumour in the fourth. The second patient died 6.5 years following surgery due to disseminated disease.

Early (mucosal) gastric cancer with synchronous osteosclerotic bone metastases: a case report.

Early gastric cancer (EGC) is defined as an adenocarcinoma confined to the gastric mucosa or submucosa, regardless of the presence of lymph node metastases. Early gastric cancer carries an excellent prognosis, with a 5-year survival rate at least 85% in most series. However, there are rare cases where distant metastases exist. Bone metastases are rare in gastric cancer; osteoblastic bone metastases are even rarer. We report a patient with EGC (mucosal) and synchronous osteosclerotic bone metastasis. To our knowledge, this is the first reported case of submucosal EGC with synchronous bone metastases. The patient was operated and he received adjuvant chemotherapy and radiotherapy. He died 18 months after gastric surgery from generalized disease.

Breast cancer surgery: an historical narrative. Part II. 18th and 19th centuries.

During the 18th and 19th centuries, management of breast cancer was greatly improved. The humoral theory of Galen, which dominated for centuries, was fallen into disfavour. Axillary nodal involvement was recognised as an adverse prognostic factor, while LeDran, in the middle of the 18th century, proposed the theory of lymphatic spread of breast cancer; he also favoured the idea that breast cancer at its earliest stage was a local disease, which could be effectively treated by surgery. The need to excise enlarged axillary lymph nodes was recognised by other surgeons of the 18th century, including Petit, who proposed a procedure very similar to radical mastectomy. During the 19th century, significant advances were noted, including the development of anaesthesia and antisepsis, a better understanding of the biology of cancer and the introduction of microscopic examination. Radical mastectomy was widely used in clinical practice by Halsted. However, this radical procedure was used by other surgeons of that time, including Meyer. Halsted was able to report a very low local recurrence rates (approximately 6%), a very important achievement given the advanced stages of the breast cancer when diagnosed in women at that time.

Breast cancer surgery: an historical narrative. Part III. From the sunset of the 19th to the dawn of the 21st century.

The 20th century is marked by significant advances regarding the management of breast cancer. A clear trend towards less aggressive surgical operation was constantly noted. Modified radical mastectomy gradually replaced radical mastectomy during the second half of the 20th century, while during the last two decades breast-conservation therapy became the treatment of choice for the treatment of breast cancer. This type of therapy includes segmental mastectomy (either quadrantectomy or lumpectomy) with axillary lymph node dissection, followed by postoperative irradiation. Other significant advances during the 20th century include the introduction of systemic therapy (chemotherapy, hormonal therapy) and radiation therapy. Better patient follow-up, statistical analysis, development of staging systems and the introduction of frozen section, the development and wide use of mammography (including screening mammography), breast reconstruction following mastectomy and the development of newer diagnostic methods [including breast magnetic resonance imaging and the advanced breast biopsy instrumentation (ABBI)] are other advances that contributed to a better management of breast cancer patients. Sentinel lymph node biopsy has been introduced during the 1990 s in an attempt to reduce morbidity due to axillary lymph node dissection. Despite these advances, breast cancer remains a significant problem and represents a field of active and intense research.

Obstructing sigmoid cancer in a patient with a large, tender, non-reducible inguinal hernia: the obvious diagnosis is not always the correct one.

We present a 85-year-old patient with intestinal obstruction and a large, tender, non-reducible right inguinal hernia. He was operated with the presumed diagnosis of strangulated inguinal hernia. At surgery, a perforated obstructing sigmoid colon was diagnosed. A sigmoidectomy (Hartman procedure) and hernia repair (Bassini technique) was performed.

Sentinel lymph node biopsy in breast cancer: what a physician should know, a decade after its introduction in clinical practice.

In the era of breast conservation surgery, sentinel lymph node biopsy is increasingly used. Sentinel lymph node biopsy can be performed by using the blue dye technique, lymphoscintigraphy and the combined method. Sentinel lymph node biopsy is a minimally invasive technique which has many advantages over the classical axillary (level I and II) lymph node dissection. However, false negative results - albeit rare in experienced hands - may be a serious limitation. The physician should be familiar with this new technique. This will allow him or her to be more actively involved in the management of breast cancer patients and to understand the available management options for these patients.

Microscopic papillary thyroid cancer as an incidental finding in patients treated surgically for presumably benign thyroid disease.

BACKGROUND: Papillary thyroid microcarcinoma (PTMC) is a relatively common entity in the general population. AIM: To present our experience with papillary thyroid microcarcinoma of the thyroid as an incidental finding in patients treated surgically for presumably benign thyroid disease. SETTINGS AND DESIGN: Histology reports of patients treated surgically with a preoperative diagnosis of benign thyroid disease were reviewed to identify patients with PTMC. Patients with a preoperative diagnosis of thyroid cancer were excluded from this study. MATERIALS AND METHODS: The files of 380 patients who underwent surgery for presumably benign thyroid disease in our hospital from 1990 to 2002 were reviewed. Data regarding patient's demographics, pathology findings, management and outcomes, were retrieved. STATISTICAL ANALYSIS USED: The findings are expressed as absolute numbers and as percentages (with reference to the total number of patients of this study). RESULTS: Twenty-seven patients with PTMC diagnosed incidentally following thyroid surgery for presumably benign thyroid disease (27/380 or 7.1%) (multinodular goiter = 20 patients, follicular adenoma = 6 patients, diffuse hyperplasia of the thyroid = 1 patient) are presented. Mean diameter of PTMC was 4.4 mm. In 11 patients (40.7%) the tumor was multifocal and in about half of them tumor foci were found in both thyroid lobes. In two patients the tumor infiltrated the thyroid capsule. Total/near-total thyroidectomy was performed in all these patients (in three as completion thyroidectomy). All patients received suppression therapy and 20 of them underwent adjuvant radioiodine therapy. Follow-up (mean 4.56 years, range 1-12 years) was completed in 25 patients; all these patients were alive and disease-free. CONCLUSIONS: PTMC is not an uncommon incidental finding after surgery for presumably benign thyroid disease (7.1% in our series). The possibility of an underlying PTMC should be taken into account in the management of patients with nodular thyroid disease; total/near total thyroidectomy should be considered, at least in selected patients with presumably benign nodular thyroid disease.

Squamous cell carcinoma of the rectum: a case report and review of the literature.

Squamous cell carcinoma of the colon and rectum are extremely rare neoplasms. Many questions regarding their histogenesis and biological behaviour remain unanswered. Surgery is the most effective therapy, and adjuvant chemotherapy and radiotherapy should be considered, especially for node-positive patients. We present a patient with squamous cell carcinoma of the middle rectum who underwent abdominoperineal resection and postoperative adjuvant chemotherapy. The pertinent literature is reviewed.

New legislative regulations, problems, and future perspectives, with a particular emphasis on surgical education.

Major changes in the residency-training systems are currently under way worldwide. New laws regulating the maximum number of work-hours per week are already enforced in the USA and are soon to be enforced in the European Union (EU); they apply to residents in training, as well as to practising specialists in the USA. These changes are expected to influence training imparted to resident doctors, quality of care given to hospitalised patients and functioning of hospitals, in general. The implications of the new regulations are likely to be magnified by the gradual decrease in the number of young people willing to take up Medicine as a career and even more so by the decrease in the number of medical graduates who choose to take up Surgery as their specialty. This communication describes the new situation that has developed (especially in general surgery) with the recent regulations and intends to suggest possible solution to the important problems that are likely to arise.

Lateral cervical cyst with unsuspected metastasis from an occult tonsillar carcinoma.

Lateral cervical cysts containing squamous cell carcinoma is a diagnostic and therapeutic challenge for the clinician since they usually represent a cystic metastasis from an occult carcinoma. Various imaging modalities or even blind biopsies will help identify the primary tumour. If the primary tumour is identified, an appropriate treatment decision can be made that incorporates both the primary tumour and the cervical node. If the primary remains unidentified, the neck is treated with a modified or radical neck dissection, depending on the extent of metastatic disease, and radiation therapy is administered to Waldeyer's ring and both necks. We present in this paper, a case with a large cervical cyst where histology showed the presence of a poorly differentiated squamous cell carcinoma in the wall of the cyst. A diagnostic evaluation of the patient was negative. Blind biopsies of the right tonsil revealed occult squamous cell carcinoma. The patient was treated by combined chemo/radiotherapy and she is doing well nine months following excision of the mass. The relevant literature is briefly reviewed.

The clinical significance of axillary lymph node micrometastases in breast cancer.

OBJECTIVE: To evaluate the clinical significancer of axillary lymph-node micrometastases, in the era of sentinel lymph node (SLN) biopsy. DATA SOURCES: Searches of MEDLINE (1966-2003) and an extensive manual review of journals were performed using the key search terms breast cancer, axillary lymph-node micrometastases, micrometastatic disease, and SLN biopsy. STUDY SELECTION: All articles identified from the data sources were evaluated and all information deemed relevant was included for this review. CONCLUSIONS: Axillary lymph-node micrometastases can be detected by serial sectioning, immunohistochemistry, or reverse transcriptase-polymerase chain reaction (RT-PCR). The presence of axillary SLN micrometastases is generally associated with a worse prognosis and is an indication for axillary lymph node dissection (ALND) and adjuvant therapy. The clinical significance of micrometastases identified by RT-PCR remains unknown and further research with longer follow-up is needed to ascertain the clinical implications of a positive result.

Management of septic shock: current concepts, with a particular emphasis on the role of source control, and future perspectives.

Sepsis is an infection-induced syndrome characterized by a generalized inflammatory state. The normal reaction to infection involves a series of complex immunological processes. A potent, complex immunological cascade ensures a prompt protective response to microbial invasion in human beings. Although activation of the immune system during microbial invasion is generally protective, septic shock develops in a number of patients as a consequence of excessive or poorly regulated immune response to the offending organism. This unbalanced reaction may harm the host through a maladaptive release of endogenously generated inflammatory compounds. Early recognition of the syndrome is of key importance to promptly start appropriate management. Timely, aggressive resuscitation to preserve organ function remains a fundamental principle in the care of septic patients. The specific treatment is directed at identifying and treating the underlying disorder. The physician should investigate diligently for the presence of active infection using modern imaging methods and other diagnostic studies to localize the site of infection and to obtain adequate culture specimens from potential infective sources. Early administration of appropriate, effective antibiotic therapy is important in the management of septic patients. Infected fluid collections and/or infected necrotic tissues should be drained or debrided without delay. Adequate nutritional support is indicated in the management of the septic patient. A number of adjuvant therapies, aimed at blunting/downregulating the host immune response to bacterial infection are currently under intensive investigation; however, the complexity of immunological defences and the potential for complementary interaction of the different components of the inflammatory cascade make the development of these pharmacological interventions difficult.

A case of gallstone ileus with an unusual impaction site and spontaneous evacuation.

Gallstone ileus is an unusual cause of colonic obstruction. The formation of a fistula between the gall bladder and the bowel wall may allow a gallstone to enter the intestinal tract. Plain abdominal films, abdominal ultrasound and abdominal computed tomography aid in the diagnosis. Although surgery is the treatment of choice in cases of colonic gallstone ileus, colonoscopic removal of the impacted stone should be attempted. We describe the case of an 85-year-old man who presented with symptoms and signs of large bowel obstruction. Diagnostic evaluation revealed a large gallstone impacted in the sigmoid colon, which is a rather unusual impaction site. Despite our efforts we could not extract the stone endoscopically, mainly due to its large size. Yet, despite its large size, the stone was spontaneously evacuated a few hours later.

Combined carcinoid-adenocarcinoma tumour of the anal canal.

The concurrence of carcinoid admixed with adenocarcinoma in the gastrointestinal tract is an unusual phenomenon that has been reported in the oesophagus, stomach, small intestine, appendix, colon and rectum. These mixed or 'composite' tumours seem to be derived from a multipotential stem cell capable of bidirectional differentiation and have a worse prognosis than ordinary adenocarcinoma. Chromogranin-A staining has increased the diagnostic yield for detecting these tumours and provides information for perioperative management and long-term prognosis. We describe a patient who presented to our department due to painful defecation. Sigmoidoscopy demonstrated a mass in the anal canal. Histology revealed that the tumour was a mixed carcinoid-adenocarcinoma neoplasm. To our knowledge, this is the first report in the English literature of a composite tumour of the anal canal.

Hepatitis caused by occupational chronic exposure to trichloroethylene.

Trichloroethylene (TCE) is an organic solvent used in a variety of industries for more than 60 years. Several adverse events following acute or chronic exposure to trichloroethylene have been reported. However, TCE-induced hepatitis is very rare. We present the case of a 55-year old male who was presented with anorexia, fatigue and upper abdominal discomfort. Routine laboratory examination revealed marked elevation of liver enzyme values. All possible causes of hepatitis were ruled out. The patient has been working as a shoemaker, in a small room of a basement, with insufficient air-exchange; during the last 5 years he used daily a glue containing 1,1,1 trichloroethylene. The diagnosis of hepatitis was confirmed by liver biopsy. The offending agent was withdrawn. Three months later, he was "feeling well" and liver enzyme values had returned to normal. Six months after the initial biopsy, a second liver biopsy was performed and histology was markedly improved. Workers exposed to hazardous chemicals, such as trichloroethylene, must have periodic follow-up examinations. Good work practices are very important when using toxic substances. In patients whose initial diagnostic workout is negative for common causes of acute or chronic hepatitis, toxic causes should be considered, with emphasis on patient's job and working conditions.