Colon cancer adrenal metastasis: case report and review of the literature.

The authors report a case of alone right adrenal metastasis from colon carcinoma discovered incidentally by CT scan imaging 4 years after colon resection in a 74-year-old man. The presence of metastasis in the adrenal glands represents the second most frequent cause of "adrenal incidentaloma", following cortical-adrenal adenomas. The most common primary tumors responsible for adrenal metastasis are carcinoma of the lung, breast and kidney. Alone adrenal metastases due to colon or rectal carcinoma is very rare. Due to their rarity, at present there are not randomised studies supporting the effectiveness of surgery. Nevertheless, on the basis of international Literature and our experience of adrenalectomy could represent the current "gold-standard" therapeutic approach.

Local injection of infliximab in severe fistulating perianal Crohn's disease: an open uncontrolled study.

BACKGROUND: Perianal fistulas are frequent complications of Crohn's disease. Intravenous infliximab can control perianal disease and promote perianal fistula closure. Perifistular infliximab injections have been proposed for patients who are intolerant or unresponsive to intravenous therapy. The aim of this study was to assess the long-term efficacy of surgical treatment combined with local infliximab therapy. METHODS: A prospective cohort study was designed. Twelve patients with Crohn's disease and high/complex transphincteric and intrasphincteric perianal fistulas refractory to other treatment were submitted to core-out fistulectomies, plus perifistular injections of infliximab (20-25 mg in 15-20 ml of 5% glucose) every 4-6 weeks. The main outcome measure was the clinical closure of all perianal fistulas. A 95% confidence interval was calculated for short- and long-term fistula closure rates. RESULTS: None of the procedures were associated with local or systemic adverse effects. Four patients did not complete treatment, two because of relapse of intestinal symptoms, which required intravenous infliximab. In one case, treatment with intravenous infliximab was complicated by a hypersensitivity reaction. Eight patients continued treatment until all perianal fistulas were closed and setons were removed (median: 5 sessions). Persistent closure was observed in seven (87.5%, 95% CI: 47.4-99.6) of the eight patients 12 months after completion of treatment and in five (62.5%; 95% CI: 24.5-91.5) of eight at the end of follow-up (range: 19-43 months, median: 35 months). CONCLUSIONS: The cohort we examined is small, but fistulectomy combined with repeated perifistular injections of infliximab appears to be safe and may help in fistula healing. However, in most patients, permanent closure of all fistulas is not achieved.

[Ultraconservative treatment in stage I and II breast carcinoma. Results of a long-term follow-up on 500 operated breasts]. / Trattamento ultraconservativo nel carcinoma della mammella in stadio I e II. Risultati di un follow-up a lungo termine su 500 mammelle operate.

AIM: Several randomized trials on conservative surgery compared with mastectomy in early-stage breast cancer have validated this technique in terms of local and distant relapse and survival of patients. Standard conservative approach includes surgical removal of the cancer with adequate cancer-free margins, axillary dissection, postoperative breast irradiation and adjuvant treatments when required. METHODS: From 1987 to 2003, 500 early stage breast carcinoma were treated on 494 patients with conservative surgery and postoperative radiotherapy. Surgery consisted in a wide tumorectomy, with intraoperative control of R0 margins. The total postoperative radiation dosage was 50 Gy on the whole breast, associated with a boost of 10 Gy on tumor bed (20 Gy in T2 neoplasms). Before 1997 node-positive patients were treated with axillary irradiation with 50 Gy. Postoperative chemotherapy and/or hormonal therapy were administered to patients according with node-involvement, age and menopausal status. AJCC-stage was T1N0 in 44%, T2N0 in 15%, T1N1 in 19% and T2N1 in 22% of the patients. RESULTS: In a postoperative setting, we observed 9% of axillary seromas or hematomas and 7% of oedema of the arm. At a median follow-up of 150 months (range 48-248 months), actuarial local recurrence rates were 7% at 5 years and 14% at 10 years. The actuarial rates of distant metastases were 18% at 5 years and 33% at 10 years. Ten-year overall and disease-free survival rates were 81% and 60%, respectively. Cosmetic results were good/excellent in 80%, satisfactory in 10% and poor in 10% of patients. CONCLUSION: Recurrence and survival rates in breast-conserving surgery are consistent with indexed literature on conservative treatment of early breast cancer. Women eligible for conservative treatment should be offered the choice of either wide tumorectomy or quadrantectomy with axillary lymph nodes removal and postoperative radiotherapy, or modified radical mastectomy.

[Pancreaticoduodenectomy for adenocarcinoma of the pancreatic head and papilla of Vater]. / Duodenocefalopancreatectomia per adenocarcinoma della testa del pancreas e della papilla di Vater.

AIM: The authors report their consecutive experience in the surgical management of adenocarcinoma (ADC) of head of pancreas and papilla of Vater, in order to review the available literature. METHODS: One hundred and seventy cases (131 in the head of pancreas and 39 in the papilla of Vater) were operated upon for ADC by radical pancreaticoduodenectomy in the period 1972-2005. The stomach was resected in 81 patients (47.7%) and the pylorus was preserved in 89 (52.3%). Follow-up was completed in all patients. RESULTS: Postoperative morbidity was reported in 66 patients (38.8%) and pancreatic fistulae were observed in 39 patients (22.9%). Postoperative mortality was 9.4% (16 patients), but in the last 10 years it was reduced to 4.1% (4/97 patients). Five-year survival for pancreatic ADC was 75% in stage IA, 43.9% in stage IB and IIA, 3.2% in stage IIB. In ADC of the papilla of Vater, for the same stages, the 5-year survival rates were 54.4%, 51.4%, 0% and 37.5%, respectively. None of the III-staged patients survived at a 5-year follow-up in both groups. CONCLUSIONS: Preoperative studies should include laparoscopy with cytological examination of peritoneal lavage, while preoperative biliary drainage is rarely indicated in case of obstructive jaundice. The Wirsung duct has to be anastomosed directly to the jejunum and the pancreatic section needs to be checked. Extended lymphadenectomy, in addition to the standard peripancreatic excision, is seldom indicated, there is no controindication to pylorus preservation and Wirsung drainage is not necessary. This operation should be performed in Centres with substantial experience.

Quality of life and psychological problems of patients with oral mucosal disease in dermatological practice.

BACKGROUND: Dermatologists see patients with oral mucosal conditions. OBJECTIVES: To evaluate oral health-related quality of life (OHRQoL) and the burden of disease of dermatological patients with oral mucosal diseases. METHODS: All consecutive patients (April 2005 to November 2006) coming to the oral health care unit of the IDI-IRCCS in Rome were asked to complete oral health-specific (14-item Oral Health Impact Profile, OHIP-14), generic health status (12-item Short Form of Medical Outcome Study, SF-12) and general psychological (12-item General Health Questionnaire, GHQ-12) questionnaires. Physicians and patients gave a global assessment of severity of disease on a 5-point scale. RESULTS: 206 patients participated. Recurrent aphthous stomatitis (RAS) had the highest impact on OHRQoL. Women had poorer OHRQoL both on physical and mental scales of the SF-12. 33.7% of patients were GHQ-positive with women showing a much higher prevalence than men (39.7 vs. 20.3%). OHIP-14 high scores were observed in RAS, followed by oral lichen planus and burning mouth syndrome. Patients whose condition was 'underestimated' by the physicians had the worst OHRQoL and psychological status. CONCLUSIONS: Administration of specific and generic questionnaires provides a detailed picture of the impact of oral diseases on patients, which adds information that may be useful in clinical practice. The possible contribution of such tools should be assessed in a randomized controlled trial.

A randomized controlled trial to evaluate short-term treatment with eosin vs. topical steroids in psoriasis.

BACKGROUND: The therapeutic effects of some histological staining agents on psoriasis have been reported in the past. One of these agents is eosin, which is still currently used in routine treatment, although it has never been formally tested in a randomized controlled trial. Aim. To compare treatment with eosin in patients with moderate to severe psoriasis vs. short-course topical steroid, a well-defined, evidence-based treatment. METHODS: A randomized trial was designed and conducted. The Skindex-29 and General Health Questionnaire (GHQ)-12 questionnaires, and Psoriasis Activity and Disease Index (PASI) were used before treatment in 43 patients. Five days after treatment, PASI was measured again. RESULTS: Five days after treatment, a significant mean reduction of PASI was observed in both groups: 6.8 (95% CI 5.5-8) for eosin, and 5.2 (3.2-7.1) for steroids. The difference between the two groups was not significant (P = 0.161). CONCLUSIONS: Eosin has a short-term effect similar to topical steroids. The low cost of eosin treatment and its limited collateral effects suggest that eosin could be an effective steroid-sparing agent in the initial phase of psoriasis treatment.

Identification of categories at risk for high quality of life impairment in patients with vitiligo.

BACKGROUND: Quality of life (QoL) in patients with vitiligo is strongly impaired. Therefore, it seems inadequate to describe the severity of the disease using only physical indicators. OBJECTIVES: To investigate the QoL of patients with vitiligo, identifying categories at risk for high impairment, also analysing single questions from a QoL instrument. METHODS: The Skindex-29 questionnaire, a QoL dermatology-specific instrument, was completed by 181 consecutive patients with vitiligo. Answers to the Skindex-29 items were given on a five-point scale, from 'never' to 'all the time'. Results The QoL problems more frequently experienced 'often' or 'all the time' were: worry of the disease getting worse (60%), anger (37%), embarrassment (34%), depression (31%), having social life affected (28%), and shame (28%). The prevalence of patients with probable depression or anxiety, evaluated using the 12-item General Health Questionnaire, was 39%, and the prevalence of patients with alexithymia, evaluated using the 20-item Toronto Alexithymia Scale, was 24%. The association of QoL impairment with psychological problems was very strong for all the items, and remained significant also when taking into account simultaneously gender, age, clinical severity, family history, and localization of vitiligo. CONCLUSIONS: Detailed information on QoL in patients with vitiligo may lead dermatologists to pay particular attention to patient categories at risk for a high QoL impairment.

[Cystic pancreatic tumors. Review of literature and proposal of a diagnostic-therapeutic pathway]. / I tumori cistici del pancreas. Revisione della letteratura e proposta di un percorso diagnostico-terapeutico.

In this paper the Authors consider the epidemiological, clinical, pathological, instrumental, chemical and physical findings of every type of pancreatic cystic lesions. They perform a critical examination of each of them. In this way, they can identify the most important features of every single class. A pathway consisting in four main groups of instrumental and chemical tests (abdominal ultrasonography / EUS, CT, MR, FNA / biopsy/ assay of tumoral markers and amylase of cystic fluid) was chosen to know all these informations according to careful principles of specificity, sensitivity and diagnostic accuracy taken from international scientific literature. In each subgroup of cystic pancreatic tumor, at last, the most reliable therapeutic project is suggested according to the common international scientific agreement.

Control of matrix metalloproteinase production in human intestinal fibroblasts by interleukin 21.

BACKGROUND: T cell-mediated immunity plays a central part in the pathogenesis of tissue damage in inflammatory bowel disease (IBD). The mechanism by which T cells mediate tissue damage during IBD remains unclear, but evidence indicates that T cell-derived cytokines stimulate fibroblasts to synthesise matrix metalloproteinases (MMPs), which then mediate mucosal degradation. We have previously shown that, in IBD, there is high production of interleukin (IL) 21, a T cell-derived cytokine, which enhances Th1 activity. AIM: To investigate whether IL21 controls MMP production by intestinal fibroblasts. METHODS: IL21 receptor (IL21R) was evaluated in intestinal fibroblasts by reverse transcriptase-polymerase chain reaction (RT-PCR) and western blotting. Fibroblasts were stimulated with IL21 and MMPs were evaluated by RT-PCR and western blotting. The effect of a neutralising IL21R fusion protein (IL21R/Fc) on the induction of MMPs in fibroblasts stimulated with IBD lamina propria mononuclear cell (LPMC) supernatants was also evaluated. RESULTS: Intestinal fibroblasts constitutively express both IL21R and the common gamma chain receptor, which are necessary for IL21-driven signalling. IL21 enhances fibroblast production of MMP-1, MMP-2, MMP-3 and MMP-9, but not tissue inhibitors of MMP-1 and MMP-2. Moreover, IL21 synergises with tumour necrosis factor alpha to increase synthesis of MMP synthesis. IL21 enhances MMP secretion without affecting gene transcription and protein synthesis. IBD LPMC supernatants stimulate MMP secretion by intestinal fibroblasts, and this effect is partly inhibited by IL21R/Fc. CONCLUSIONS: These results suggest that fibroblasts are a potential target of IL21 in the gut and that IL21 controls MMP secretion by fibroblasts.

[The surgical treatment of gastric carcinoma. Evolution in surgical technique and staging in a series of 194 patients]. / Trattamento chirurgico del carcinoma dello stomaco. Evoluzione della tecnica chirurgica e della stadiazione in una serie di 194 pazienti.

AIM: Surgery is, at present, the only potentially curative treatment for gastric carcinoma. The curability depends upon the extension and localization of the tumor and, particularly, the lymphatic involvement and the presence of distant metastases. The aim of this paper is to describe the personal experience during the last 2 decades and analyze the results of the surgical approach which has changed over the time. METHODS: One-hundred and ninety-four consecutive patients have been reported (127 male and 67 female, with a median age of 65.8 years), affected by gastric carcinoma and subjected to surgical procedures from 1987 to 2000. Because of the wide period of time which it refers to, this study is overlapped by a radical change in the staging rules of gastric carcinoma, according to the publication, in 1997, of the 5th edition of the TNM. This has made necessary to divide the series into 2 different groups. The 1st group is composed of 123 patients (63.4%), staged according to TNM-1987; the 2(nd) group is composed of 71 patients (36.6%) staged according to the TNM-1997. A D1 lymphadenectomy was used as treatment protocol until 1995. Subsequently, a D2 lymphadenectomy was performed in the most part of potentially curable patients. The reconstruction after total gastrectomy was carried out in all cases with Roux technique. In distal gastrectomies a Billroth 2 technique was performed in 89.3% of the cases and a Billroth 1 technique in 10.7% of the cases. RESULTS: The operative mortality observed on the total of patients was 1.5% (3 cases). With a median follow-up of 83 months (minimal 24, maximum 180 months), 134 patients were died, 50 are alive and 10 have been lost. The total median survival, in the 2 groups, was 24 months. We have observed a trend to improvement of survival for patients with carcinoma in stage II and III operated after 1997. CONCLUSION: The treatment of unresectable gastric cancer, i.e. palliative surgery, is the best choice when possible in comparison to other surgical procedures (gastroenteronastomosis, jejunostomy), endoscopic procedures (dilatation, endoprosthesis, laser, percutaneous endoscopic gastrostomy) and medical therapies. In order to choose the best palliative treatment, a careful evaluation of the non-curability signs is necessary to avoid high risk surgical interventions in patients with a low expectation of life.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome.

BACKGROUND: Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC). METHODS: In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B). RESULTS: In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups. CONCLUSIONS: The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

[Conservative surgery for ductal carcinoma in situ of the breast]. / Presentazione di un caso clinico di mielolipoma surrenalico gigante e revisione della letteratura.

BACKGROUND: The conservative surgery is considered currently the treatment of choice for the carcinoma of the breast in the initial stage. METHODS: From 1993 to the 2000, 46 patients (median age 52 years) affected by intraductal carcinoma of the breast, have been submitted to surgical intervention. In 10 cases (21,7%) a palpable mass was observed (mean dimension of 1.3 cm). In 36 cases (78.3%) non palpable lesions were identified by mammography (26 microcalcifications and 10 non palpable masses). All patients have been treated after stereotactic preoperatory mammographic localization of the lesions. 15 simple mastectomies, 11 mammary resections without radiotherapy and 20 mammary resections followed by radiotherapy have been performed. No patient was submitted to axillary dissection. The radiotherapy has been administered with a boost of 50 Gy on the breast. RESULTS: At a 36 months median follow-up all the patients are alive and no local recurrence or distant metastases has been observed. CONCLUSIONS: The treatment of choice is the local resection of neoplasm followed by radiotherapy.

[Anoplasty with House advancement flap for anal stenosis after hemorrhoidectomy. Report of a clinical case]. / Plastica anale con lembo di scorrimento tipo "house flap" per stenosi anale post emorroidectomia. Presentazione di un caso clinico.

Anorectal strictures may occur after anorectal surgery and in particular after surgical haemorrhoidectomy. Anal examination under general anaesthesia was recommended to evaluate the stricture and to choose the appropriate technique. The house advancement flap has been recently proposed for postsurgical anal stenosis repair. The house flap receives its blood supply through unnamed vessels extending through a fatty pedicle from the underlying external sphincter muscle and not from a skin or mucosal bridge like the other common flaps (Y-V and mucosal advancement flap). The aims of this study were firstly to report a case of post-haemorrhoidectomy anal stenosis in a 68-year-old man treated in our institution by house advancement anoplasty and secondly to evaluate the efficacy and safety of this new technique. The technique was totally successful in alleviating anal stenosis and maintaining faecal continence. House advancement anoplasty should be part of the armamentarium of colon and rectal surgeons for treating severe anal stenosis.

[Complex duodenopancreatic injuries]. / I traumi complessi del blocco duodenopancreatico.

Injuries of the duodenopancreatic region are rare and difficult to diagnose and treat. The related high mortality is mainly due to the presence of associated lesions. Complex traumas (AAST grade IV and V lesions) require difficult surgical treatment with high postoperative morbidity and mortality rates. In a review of 200 pancreaticoduodenectomies performed for pancreatic head traumas the postoperative mortality was 31%. The authors present 6 cases of complex duodenopancreatic traumas, treated from 1995 to 1999. The aetiology was blunt trauma in 5 cases (83%) and a shotgun wound in 1 case (17%). In 3 cases, with a grade V lesion of the pancreatic head, a pancreaticoduodenectomy was performed. A case of a grade IV lesion of the tail of the pancreas was treated with distal splenopancreatectomy. Two cases of grade IV lesions of the third part of the duodenum were submitted to duodenal resection with direct anastomosis. One postoperative death was observed in a patient treated with duodenal resection. The overall mortality was 16%. A pancreatic fistula, which healed spontaneously, was observed in a case of pancreaticoduodenectomy.

[Treatment of perianal Crohn's disease]. / Il trattamento del morbo di Crohn perianale.

Perianal Crohn's disease (PACD) is defined as the presence of persistent lesions in the anal canal and perianal region in patients with Crohn's disease. The relative incidence of PACD in Crohn's disease patients ranges from 15 to 80% in the literature, depending on the accuracy of the clinical investigations and the clinical importance attributed to the lesions in the various study populations. The incidence is significantly higher if the intestinal disease is located in the colon-rectum rather than in the small bowel. We reviewed our experience in 105 patients with PACD, 32 of whom presenting rectal localisation of the primary disease. We observed 2 stenoses, 3 perirectal abscesses, 3 rectal ulcerations, 5 skin tags, 10 fissures and 77 fistulas. Two dilatations under narcosis, 2 intrarectal drainages of abscesses, 19 fistulotomies, 7 partial fistulotomies and insertion of loose setons, 47 loose setons and 4 anoperineal diversions were performed. The remaining patients received medical and topical treatments. After a median follow-up of 30 months, 90 patients (86%) showed a good response with improvement in functional scores, while 15 (14%) showed no improvement or a worsening requiring proctectomy in 13 cases. All patients submitted to proctectomy had rectal localization of the disease.

A pilot study of concomitant protracted venous infusion 5-fluorouracil and hyperfractionated radiotherapy in rectal tumors.

It has recently been shown that postoperative radiotherapy combined with 5-fluorouracil (5FU) resulted in an increase of survival and local control in patients with rectal cancer. However, hematological and intestinal toxicity were also increased. Experimental and clinical studies showed an increased radiation effect with an acceptable toxicity by delivering 5FU via a continuous intravenous infusion. From July 1988, 38 patients radically operated on for stages B2-C rectal cancer were irradiated in our hospital with 3 fractions per day of 100 cGY to a total dose of 5,600 cGY. Of these 38 patients, 13 underwent postoperative radiotherapy alone, and 25 received postoperative radiotherapy combined with concomitant protracted infusion of 5FU at doses of 250 and 300 mg/m2 per day. In addition, 14 patients with inoperable, locally advanced tumors or postoperative recurrences, were treated with the same combination schedule of 5FU and radiotherapy to a total radiation dose of 6,500 cGy. After a median follow-up of 43 months, the actuarial 3-year overall and disease-free survival rates in the postoperative group of patients were 68% and 68%, respectively, in the combined modality group, as compared to 51% and 36%, respectively, in the radiation alone group. Patients with inoperable tumors exhibited 3-year overall and disease-free survival rates of 24% and 32%, respectively. The main toxicity was rectal tenesmus, diarrhea, dysuria, and, less frequently, leukopenia. These symptoms were responsible for a treatment delay of more than 5 days in 2 of 6 and in 7 of 33 patients who received 5FU doses of 300 and 250 mg/m2 per day, respectively, as compared to 2 of 13 patients treated with radiotherapy alone.

[Adrenal myelolipoma. A case report and review of the literature]. / Mielolipoma del surrene. Presentazione di un caso e revisione della letteratura.

Myelolipoma is a rare benign neoplasm of the adrenal gland, histologically characterized by the presence of mature fat cells and bone marrow elements. In the international literature were reported 126 cases of adrenal myelolipoma surgically treated. The indications to surgical removal of this tumor are the presence of large symptomatic tumours, high risk of spontaneous haemorrhage, and suspicion of malignant neoplasms. The authors present a case of adrenal myelolipoma, preoperatively identified with an abdominal MNR, and surgically removed.

[Leiomyoma associated with esophageal diverticulosis]. / Leiomioma associato a diverticolo esofageo.

The Authors report a case of leiomyoma located in an epi-phrenic diverticulum. The development of the leiomyoma may have weakened the esophageal wall and caused the diverticulum to appear. Surgical treatment consisted of diverticulectomy with myotomy and a Belsey MK IV antireflux procedure.