Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma.

BACKGROUND: Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. METHODS: One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. RESULTS: Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). CONCLUSIONS: Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Surgery of the incidentally discovered mass of the adrenal gland (incidentaloma).

The authors present their experience about surgery in adrenal gland incidentaloma, during a period of 12 years (1982-1993), at the VI Division of General Surgery, University of Turin. In 17 patients, of 70 who underwent adrenalectomy, the adrenal neoplasm was located thanks to a diagnostic investigation (ECI or CT) executed for other reasons. In ten cases was diagnosed adenoma, in five cases carcinoma, in two cases cysts. In the diagnostic approach to adrenal incidentaloma we did not search for possible hormonal activity, since the patients had been previously selected from specialized endocrinological centres. At present, biological markers not being certain or absolute radiological significance so as to detect benignant from malignant forms. In accordance with international Literature the size of the neoplasm is the discriminant element for adrenalectomy. We have removed the incidentaloma in all cases, be it clinically or subclinically functional and the silent forms > 4 cm as we have observed a statistically significant difference (p < 0.0002) between the benign and malignant lesions, particularly those measuring more than 4 cm in diameter. We suggest a screening with CT scan every three months in lesions < 4 cm, silent and those > 4 cm in patients over sixty years with a morphological aspect of the bening form.

Primary hyperaldosteronism. Analysis of risk factors associated with persistent postoperative hypertension.

Between 1983 and 1992, 24 patients with primary hyperaldosteronism were operated at our division. Among these, 21 had adrenal adenoma and constituted the subjects of our study. The aim of this retrospective study was to determine risk factors that could potentially lead to persistent arterial hypertension (5 cases or 23.9%). The variables of the univariate and the multivariate analyses were: sex, age, diameter of the neoplasm, preoperative duration of the hypertension, and familial hypertension. The analysis demonstrated no statistically significant difference between the resolution of hypertension and the variables. Though not statistically significant, the only variable that approached statistical significance (p < 0.11) was familial hypertension.

Pudendal neuropathy in diabetic patients with faecal incontinence.

To investigate the pathophysiology of faecal incontinence in diabetes mellitus, two groups of diabetic patients were studied: 14 subjects (7 females and 7 males, mean age 57 +/- 9 years) with faecal incontinence (Group A) and 15 subjects (6 females and 9 males, mean age 54.7 +/- 8 years) without faecal incontinence but affected by somatic peripheral neuropathy. A third group (C) of 10 healthy volunteers was used as controls. All subjects underwent electroneurographic evaluation of peripheral neuropathy, pudendal nerve terminal motor latency, anorectal manometry and rectal sensitivity tests. All the patients of group A had somatic peripheral neuropathy. Maximum squeeze pressure was lower in A compared to C (P < 0.025) and sustained for a shorter period in A compared with B (P < 0.0005) and C (P < 0.0005). All rectal sensitivity thresholds were higher in A compared with B and C. Pudendal Nerve Terminal Motor Latency was prolonged in 93% of patients studied in group A and in 73% of patients in group B (A vs B P < 0.005), with a significant difference in comparison with C: A vs C P < 0.0005, B vs C P < 0.005. Our findings suggest that somatic neuropathy plays an important role in faecal incontinence in diabetic patients, combined with sensation threshold impairment as a feature of an autonomic involvement.

[Percutaneous transhepatic treatment of massive intrahepatic calculosis secondary to stenosis of a biliary-digestive anastomosis]. / Trattamento percutaneo transepatico esclusivo di calcolosi intraepatica massiva secondaria a stenosi di anastomosi bilio-digestiva.

The authors describe a successful technique for the percutaneous treatment of intrahepatic gallstones from a stenotic Rouxen-Y hepaticojejunostomy. A bilioplasty of the anastomosis with wash-out of the biliary tract has been achieved through two percutaneous external biliary drainage catheters, one inserted in the right biliary ducts and the other placed in the left biliary ducts by means of an anterior approach.