[Is it possible to improve survival in patients with Klatskin tumors?]. / E possibile migliorare la sopravvivenza dei pazienti con tumore di Klatskin?

BACKGROUND: This retrospective study was undertaken to evaluate if a high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer. METHODS: Between 1985 and 2001, 50 patients (34 males and 16 females) with proximal bile duct cancer were treated. The tumor site were classified according to Bismuth-Corlette's classification: 9 lesions (18%) were Bismuth type I, 23 lesions (46%) type II, 12 lesions (24%) Type IIIa, 5 lesions (10%) type IIIb and only 1 resected tumor (2%) was type IV. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent non surgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-enY cholangiojejunostomy with two or three divided segmental hepatic ducts; in ten, the cholangiojejunostomy was performed with 4 or 5 divided segmental hepatic ducts. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins. RESULTS: There was no operative mortality. Overall 1-year, 3-year and 5-year survival of the entire surgical group was 61%, 22.5% and 9% respectively. In the 19 patients treated with curative intent the survival at 1,3, and 5 years was 66%, 30% and 15%, respectively, while in the palliative group it was 45%, 15% and 0%, respectively. CONCLUSION: Only margins free from tumor may guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better 5-year survival.

[Palliative treatment of esophageal and cardial carcinoma]. / La palliazione del carcinoma esofageo e cardiale.

Recent series reported increasing incidence of esophageal and cardial cancers with prognosis still severe in spite of surgical progress. The late diagnosis reduces the chance of radical surgery; on the other hand about 80-90% of patients develop local or distant recurrence. Therefore the treatment of esophageal and cardial cancer is often palliative: surgical resection is reserved only to selected cases. Endoscopic palliation was the treatment of choice in a total of 265 patients 174 of which received laser therapy and 91 prosthesis intubation. The results it good in about 80% of cases.

Endoscopic palliation of esophageal and cardial cancer: neodymium-yttrium aluminum garnet laser therapy.

The aim of this study was to evaluate the impact of laser palliation on symptoms such as dysphagia and bleeding in patients with esophageal and cardial carcinomas. From November 1992 to October 1997, 174 patients with unresectable esophageal and cardial carcinomas were treated with neodymium-yttrium aluminum garnet laser therapy. The indications for palliative treatment were advanced tumor in 96 patients and high surgical risk in 78. The tumor involved the esophagus and cardia in 107 and 67 patients respectively. The mean length of the tumors was 6 cm. Two laser sessions (range 1-4) were necessary for recanalization. During the follow-up, the average interval between the laser sessions was 2 months. Overall, no early and late complications or hospital mortality occurred. The quality of palliation was excellent or good in 82%, of the patients. The mean survival time was 6 months, and mortality was not related to the procedure. Endoscopic laser therapy in patients with vegetant or hemorrhagic carcinomas may represent the best therapy, with acceptable morbidity and mortality rates and satisfactory functional results.

[Lithiasic, congenital, choledochal dilatation: problems of diagnosis and therapy]. / Dilatazione coledocica congenita litiasica: problemi di diagnosi e di terapia.

We report a case of a 30-year old female with congenital lithiasic choledochal dilatation which was not diagnosed at the ultrasonographic examination. Congenital biliary dilatation abnormalities are rare and may clinically present with episodic biliary colics or more rarely with recurrent pancreatis. Ultrasound, CT-scanning and ERCP usually make these anatomic alterations evident but in some cases there may be some doubt despite the vast range of radiological techniques available (PTC, Tc99m-Isida scinti-scan). The best results from a diagnostic point of view are obtained from the ERCP that may in fact visualize an anomalous pancreatico-biliary junction, rule out carcinoma, accurately define the cyst dimensions or show the intrahepatic ductal radicals. Furthermore, the extraction of intracystic stones or the treatment of choledochocele through a papillostomy may be performed. However the ERCP may cause traumatic pancreatitis, above all in youngster as was verified in our patient. During surgical exploration, the definitive diagnosis can be achieved via intraoperative cholangiography. We emphasize that in patients with congenital choledochal dilatation, the dilated choledochus should be excised even in young children to avoid the risk of malignancy which may occur also following cyso-duodeno- or cystojejunostomy treatment. In our patient an hepatiocojejunostomy on a Roux-en-Y limb was performed. This single case has been oresented along with a review of the literature to recall such anomalies in differential diagnosis of biliary colics and to stress that the choice treatment is surgical resection.

[Timing in disorders associated to tracheo-pulmonary pathology]. / Timing nelle affezioni in associazione a patologie tracheo-polmonari.

Although a wide variety of extrathoracic pathologies may be associated to tracheo-pulmonary lesions, this paper draws attention to tumour pathologies due to their frequency and the difficulties involved in their treatment in relation to the question of "whether to carry out treatment" as well as the importance of timing. This dual nature is particular true of malignant conditions, since the lung may be the site of primary tumours and metastasis. The most frequent associations reported in the literature are tumours of the upper airways-digestive tract and colon carcinoma. Although tumours of the upper airways-digestive tract and lung cancer are both primary and primary tumour must be given priority treatment and only when oncologically satisfactory results have been obtained and there is no evidence of metastasis in other sites, are lung metastases. As far as concerns tracheal pathologies, this often takes the form of a locoregional extension of tumours from nearby organs such as the thyroid gland. In these cases, it is preferable to carry out total thyroidectomy and tracheal resection using T-T anastomosis.

Current situation in the treatment of gallbladder cancer. Considerations on the utility of an extended resection.

Twenty-two of the 25 patients with carcinoma of the gallbladder seen during the last 9 years have been analyzed for survival in relation to treatment and disease stage. All patients were classified according to Nevin's staging scheme, and a correct preoperative diagnosis was made in 31.8% of cases. The median survival of the 8 stage V patients who had no surgery or alternatively underwent only limited excision of the tumor was 16.5 days (for the two patients receiving explorative laparotomy); 2 months for a patient undergoing a debulking operation and 5 months for the 5 patients receiving nonoperative biliary drainage. Survival in patients undergoing cholecystectomy, whether associated with biliary drainage or not has proved to be adversely affected by the stage of the malignancy, the stage I patient being alive and well at 2 years whereas the stage II patient died after 5 and a half months, the stage III patient survived 1 year and the stage IV patient 1 year and 6 months. Stage V patients receiving simple cholecystectomy (1 case) or associated with biliary drainage (5 cases) died 16.5 days and 4.5 months following surgery, respectively. More radical operations have been performed in 4 other stage V patients, who had resection of segments IV and V (2 patients, one of them survived 3 months and the other is still alive and well at 5 months), resection of segment IV (survival was 15 days), and right hepatectomy (survival 7 months). In view of our limited experience no statistically significant conclusions can be drawn.(ABSTRACT TRUNCATED AT 250 WORDS)

Parathyroid localization in primary hyperparathyroidism: double-tracer scintigraphy and venous sampling techniques combined. A first evaluation.

The authors report their first experience with two techniques for preoperative localization of hyperfunctioning parathyroid glands: double-tracer (99mTc-201Tl) scintigraphy and venous sampling from thyroid veins. Nineteen patients affected by primary hyperparathyroidism were examined by both methods and subsequently submitted to surgery. Scintigraphy showed a sensitivity of 77.3% while the positivity of sampling was 63.6%; with the two techniques combined a correct localization was obtained in 90.9% of all cases. The authors emphasize the usefulness of both methods combined for locating enlarged hyperfunctioning parathyroids.