Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors.

OBJECTIVE: To evaluate the prognostic significance of different clinico-pathological and molecular factors, and to compare survival after standard and extended pancreaticoduodenectomy (PD) in ampulla of Vater adenocarcinoma (AVAC). There are discordant data on factors affecting prognosis, and hence therapeutic choices, in AVAC. PATIENTS AND METHODS: Clinical-pathological factors were evaluated in 59 patients, subjected to PD for AVAC; in 42 subjects information on chromosome 17p and 18q allelic losses (LOH) and microsatellite instability (MSI) was also available. The association between survival and type of PD was investigated in the 25 patients operated between 1990 and 2001 (16 standard and nine extended). RESULTS: The overall 5- and 10-year tumor-related survival rates were 46% and 33%, respectively. Sixteen patients had T-stages 1-2, 14 T-stage 3, and 29 T-stage 4 cancers. Chromosome 17p and 18q LOH were detected in 23 (55%) and 15 cases (36%), respectively, and in 12 cases (29%) coexisted. Five cases were MSI-positive (12%). At univariate analysis, poor survival was associated with cancer ulceration (P = 0.051), poor differentiation (P = 0.008), T-stage 4 (P < 0.001), nodal metastases (P = 0.004), chromosome 17p (P < 0.001) and 18q LOH (P = 0.002), and absence of MSI (P = 0.009). At multivariate analysis, only T-stage (P = 0.002) and 17p LOH (P = 0.001) were independent predictors of survival. All patients with MSI-positive cancers were long-survivors (>12 yrs), whereas only 30% of MSI-negative cancer patients survived at 5 years. Extended pancreaticoduodenectomy was associated with a 3-year disease-related survival higher than standard resection (83% vs 31%; P = 0.018). CONCLUSION: MSI and chromosome 17p status allow to better define prognosis within ampullary cancers at the same stage. Surgery alone resulted curative in MSI-positive cancer patients, whereas it was inadequate in patients showing allelic losses, who might benefit from adjuvant therapy. In this observational study, extended PD was associated with increased survival compared to standard procedures.

[Mediastinoscopy for diagnosis of diseases of the chest and staging of lung cancer: our experience in 253 cases]. / La mediastinoscopia nella diagnostica delle malattie del torace e nella stadiazione del cancro del polmone: nostra esperienza di 253 casi.

The main indications for cervical mediastinoscopy are preoperative staging of lung cancer and diagnostic biopsy of mediastinal mass (lymphoma, sarcoidosis, tuberculosis etc.). We undertook a retrospective review of our experience of mediastinal exploration by cervical media-stinoscopy: 253 mediastinoscopies were performed on 252 patients (195 male and 57 female; mean age 53 years, range 14-88 years) between 1995 and June 2003. Four extended mediastinoscopies were performed and 1 patient had a re-mediastinoscopy following a non-diagnostic procedure. 319 lymph nodal stations were investigated in 253 procedures. We observed no mortality, while 2 patients had major bleeding (0.7%), with the need for open surgical treatment in order to achieve haemostasis. The median length of hospital-stay was one day, with discharge in the first postoperative day. 69 out of 170 patients, who eventually resulted to be affected by a histologically proven lung cancer, had a negative mediastinoscopy. Fifteen of them resulted N2 at the time of surgery: 8 patients with a false negativity in a biopsied station (4 in station 4R and 4 in station 7), while 7 cases showed infiltration in stations which were not sampled (5 in station 5, 1 in station 8 and 1 in station 7, the latter being the only one in which a standard cervical mediastincoscopy could have been able to stage it correctly). So, having observed 61 true negatives and 8 false-negatives in the sampled stations, in our experience the negative predictive value of cervical mediastinoscopy was 88.4%, with 78.2% of patients correctly staged without using other diagnostic tools. In conclusion, mediastinoscopy is an important procedure for the diagnostic biopsy of mediastinal mass and a useful tool in preoperative staging of lung cancer, especially if associated with chest CT-scan and Positron Emission Tomography (PET). In our experience, the spreading of PET does not lead to a reduction of cervical mediastinoscopies, both for the contemporary introduction of new chemotherapeutic preoperative protocols and, above all, for the not negligible incidence of false-positive results using PET, suggesting that media-stinoscopy should always be performed in patients affected by a PET-positive mediastinal growth.

Cushing's syndrome induced by bronchopulmonary carcinoid tumours: a review of 98 cases and our experience of two cases.

Bronchopulmonary carcinoids are one of the most common cause of ectopic secretion of corticotropin (ACTH) and account for approximately 1% of all the patients in whom Cushing's syndrome develops. We reviewed 98 cases described in the World Literature and we report on two new cases. A 60-year old woman affected by Cushing's syndrome underwent to surgical wedge resection of a peripheral pulmonary nodule and a 30-year old woman with similar clinical features underwent to middle lobectomy for a small hilar neoplasm. Histopathologic examination of the tumours defined them as typical bronchopulmonary carcinoids. The patients are asymptomatic and with no sign of recurrence 72 and 30 months after surgery. According to our review we found no clear evidence that bronchial carcinoids associated with Cushing's syndrome should be considered a more aggressive variant or subtype of the typical carcinoid. If Cushing's syndrome does not disappear after surgery, the presence of residual disease (often a nodal involvement) should be investigated. A long-term relapse of the syndrome requires a careful search for local or distant neoplastic recurrence.

[Surgical treatment of breast tumors in patients after mammography screening. Personal experience in the first 3 years of operation of the screening program in the province of Verona]. / Il trattamento chirurgico dei tumori della mammella nelle pazienti sottoposte a screening mammografico. Esperienza personale nei primi tre anni di attività del programma di screening nella provincia di Verona.

A mammographic screening program was started in 1999 in the Province of Verona and was offered to women aged 50-69. The purpose of this study was to analyse and compare our data, particularly the type of surgery and histotype, with the literature data where no screening program was implemented. During the first three years of the screening, 113 patients underwent surgical treatment in our Institute. The histology of the mammary lesions was benign neoplasia in 28 (24.7%) and breast cancer in 85 (75.3%) patients. Seventy-three women (85.9%) with malignant neoplasms were submitted to conservative treatment. Mastectomy was performed in 12 (14.1%) patients, 8 of whom with immediate breast reconstruction. Patients coming from screening programs benefit in a high percentage of cases from conservative treatment, which, together with the reduced aggressiveness of the cancers, permits alternative treatments for the axillary lymph nodes and a reduction in adjuvant chemotherapy.

Results of pancreaticoduodenectomy for pancreatic cancer: extended versus standard procedure.

In Western experience, the long-term survival benefit after extended pancreaticoduodenectomy (EPD) in patients with pancreatic ductal adenocarcinoma is still controversial. The aim of this work was to evaluate weather EPD for pancreatic ductal adenocarcinoma prolongs long-term survival compared to standard pancreaticoduodenectomy (SPD). From November 1992 to September 1996, we performed pancreatic resections in 30 patients affected by stage I-III pancreatic ductal adenocarcinoma: 13 patients underwent SPD and 17 patients underwent EPD, consecutively. The two groups of patients were similar for all the demographic, clinical, and pathological characteristics, and all the intraoperative factors considered except the number of resected lymph nodes (mean number per case = 34.2 +/- 15.5 in the EPD group versus 12.8 +/- 3.6 in the SPD group, p <0.001) and the operative time (median time per case = 375 minutes in the EPD group versus 270 minutes in the SPD group, p = 0.009). Patients in the two groups experienced a similar postoperative course. The estimated survival probability at 1 and 3 years after operation was 0.76 (95% confidence interval [CI]: 0.49 to 0.90) and 0.24 (95% CI: 0.07 to 0.45) in the EPD group; 0.31 (95% CI: 0.09 to 0.55) and 0.08 (95% CI: 0.00 to 0.29) in the SPD group (p = 0.014). According to a Cox model, the treatment was associated with R0 patients' long-term survival (SPD versus EPD: hazard ratio (HR) = 4.82, 95% CI: 1.66 to 14.00, p = 0.004). Grading of tumor differentiation was confirmed to be a relevant prognostic factor (poor versus moderate: HR = 4.33, 95% CI: 1.49 to 12.61, p = 0.007), whereas type of resection had no significant effect (pylorus-preserving versus hemigastrectomy: HR = 1.49, 95% CI: 0.56 to 3.95, p = 0.42). The proportion of R0 patients with local recurrence was lower in the EPD group (20.0% versus 70.0%, p = 0.034).