[Predictive scores used during the anesthetic preoperative visit. Part 2. Assessment of perioperative risk]. / Scores prédictifs employés lors de la consultation d'anesthésie. Partie 2: évaluation des risques peropératoires.

Anesthesia remains a high-risk specialty, even though the discipline has evolved considerably over the last few decades. Independently of postoperative complications, some risks are inherent to the perioperative period itself. In this narrative review of the literature, we describe these risks and the predictive scores, allowing an assessment of these complications. All these scores are designed to detect high-risk patients and to promote personalized medicine and individualized anesthesia. They also increase the objectivity of the preoperative assessment. Finally, using these scores, the practitioner can more accurately respond to the patient who presents anxiety regarding the perioperative period.

L'anesthésie-réanimation reste une spécialité à risque, même si la discipline a fortement évolué au cours des dernières décennies. Indépendamment des complications postopératoires, il existe des risques inhérents à la période peropératoire en elle-même. Dans cette revue narrative de la littérature, nous décrivons quels sont ces risques et quels sont les scores prédictifs permettant d'appréhender au maximum ces complications. Tous ces scores ont pour finalité de dépister les patients à haut risque et de tendre vers une médecine personnalisée, une anesthésie individualisée. Ils augmentent également le caractère objectif de l'évaluation préopératoire. Finalement, ils offrent au praticien la possibilité de répondre plus précisément au patient qui présente une anxiété face à la période périopératoire.

[Predictive scores used during the anesthetic preoperative visit. Part 1. Assessment of postoperative complications]. / Scores prédictifs employés lors de la consultation d'Anesthésie. Partie 1. Evaluation des complications postopératoires.

Anesthesia is changing, moving from an intraoperative medicine to a transversal perioperative medicine. The evolution of the preoperative anesthetic consultation is part of this evolution. Recently, anesthesiologists attempt to categorize their patients to detect as early as possible those at risk of short, medium, and long-term complications. In that way, a personalized (individualized) anesthesia could be performed considering the patient's comorbidities as well as the type of surgery. Respect for the guidelines is easier to achieve with such personalized medicine. For this purpose, anesthesiologists can use predictive scores. In the last few years, there was an increase in the availability of these validated scores. A shared feature of these scores is to provide objectivity but also efficiency in their ability to be predictive while being easy and quick to apply in clinical practice. Thereby, anesthesiologists can inform the patient with more accurate information concerning their perioperative risks. Finally, these scores are part of a public health care policy that aims to reduce expenses by optimizing patient management and preoperative testing. These scores provide a global vision of the patient, which can be shared and understandable by the different practitioners.

L'anesthésie-réanimation est en pleine mutation, évoluant d'une médecine peropératoire à une médecine transversale périopératoire. L'évolution de la consultation d'anesthésie préopératoire s'inscrit dans ce cadre. L'anesthésiste-réanimateur cherche ainsi à sérier les patients afin de dépister, le plus précocement, les patients à risque de complications à court comme à moyen et long termes. De la sorte, il est possible de pratiquer une anesthésie personnalisée, individualisée, indépendante de critères démographiques et prenant en compte les comorbidités spécifiques de chacun ainsi que le type de procédure envisagée. Pour ce faire, l'anesthésiste dispose de scores prédictifs validés dont le nombre tend à croître ces dernières années. Ces scores ont pour dénominateur commun d'apporter de l'objectivité, d'être performants et efficients dans leur caractère prédictif, tout en étant d'application aisée et rapide en pratique clinique courante. Ils permettent, en outre, à l'anesthésiste de fournir au patient une information plus éclairée quant aux risques encourus. Enfin, ils s'inscrivent dans une logique de réduction des coûts en santé publique, en permettant d'optimaliser la prise en charge des patients, de rationaliser la prescription d'examens complémentaires et en offrant une vision du patient pris dans sa globalité. Cette vision est lisible par les différentes lignes de soins.

[Usefulness of gallium 67 in research into the need for radical cervical lymph node dissection in patients with head and neck carcinomas]. / Utilità del gallio 67 nella ricerca della radicalità delle dissezioni linfonodali del collo nei pazienti affetti da carcinoma del capo e del collo.

Fifty-nine patients with head and neck carcinoma were examined with 67Ga scintigraphy. All patients had undergone lymph node dissection of the neck. They were followed for a minimum of 2 years after the examination. The primary tumor, treated prior/contemporaneously to the lymph node dissection, did not evolve in this interval. Metastatic involvement of the lymph node capsule was observed in all 44 cases with metastatic lymph nodes; macroscopic radicality was surgically obtained since involvement of the capsule was only microscopic. Nevertheless, complementary radiotherapy was given. The whole of 17 recurrences in the soft tissues of the neck were found, within 2 years, in the group of 26 patients who had undergone dissection of lymph nodes with metastatic capsular involvement and whose postoperative 67Ga scintigraphy was positive. On the contrary, no recurrences in the soft tissues of the neck were observed in the group of 18 patients who had undergone dissection of lymph nodes with metastatic capsular involvement and whose scintigraphy was negative. This result proves (P less than 0.001) 67Ga capable of evidencing eventual microscopic diffusion. Such a possibility has not yet been realized in vivo with any other investigation technique. Scintigraphy was negative in a control group of 15 patients who had undergone lymph node dissection, and with nonmetastatic lymph nodes. This finding leads us to exclude that the use of 67Ga might result in misinterpreted findings in the exploration of relatively superficial tissues. In fact, the eventual accumulation of radioisotope in nonneoplastic pathologies is quite easily recognizable in the neck. We can therefore conclude that in those 9 cases with positive scintigraphy and in whom no recurrence was found, microscopic diffusion was probably present, but local recurrence of the disease was prevented by complementary radiotherapy.

Lack of efficacy of lymphoscintigraphy in detecting axillary lymph node metastases from breast cancer.

Preoperative detection of metastases in regional lymph nodes should constitute a fundamental step towards a better management of breast cancer. The National Cancer Institute of Milan has traditionally been engaged in this particular problem, that is, the search for a new imaging technique for detecting lymph nodal metastases from breast cancer. In 1984 axillary lymphoscintigraphy was performed on 26 patients with operable breast cancer by periareolar injection of 100 mu Ci of 99mTc sulphur microcolloid. The regional lymph nodes were identified as spot areas and a comparison was made between the number of primary draining axillary lymph nodes and their pathological examination. In only 2 of the 26 patients have more than 3 spot areas been revealed by axillary scintiscan, but this finding did not correspond to metastatic invasion. The lymphoscintigraphy pattern of the other 24 patients did not suggest any pathological condition. From our experience the method does not appear to help either a precise diagnosis of breast disease or the definition of the extent of mammary cancer.

Transient left homonymous hemianopsia during treatment of testicular carcinoma with cisplatinum, vinblastine, and bleomycin.

This is the third case, reported in the literature, of transient cortical blindness that occurred during treatment of testicular carcinoma with cisplatinum, vinblastine and bleomycin. The presence of transiently pathological computerized tomography and brain scan suggests that this alarming event may not only be a toxic side effect of chemotherapy, but also a symptom related to eradicable subclinical metastases.

[Radiographic semeiotics of bone metastasis in thyroid carcinoma]. / Semeiotica radiografica delle metastasi ossee da carcinoma tiroideo.

It's well-known that thyroid malignant cancer often metastatizes to skeletal structures. Analysing a wide casuistry of the National Cancer Institute of Milan, we thought right not only consider most common iconographic findings of these bone metastases, but rarest too. Therefore, we studied many radiological symptoms: osteolysis and its shape; extension in the next soft tissues; absence of the periosteal reaction; some resemblances with other primitive cancer or secondary too and dysplasic focus; the changes after therapy usually give a not univocal interpretation of the pictures regarding these peculiar alterations.

Laser oncology in Italy: experimental research and clinical applications at the National Cancer Institute, Milan.

CO2, Nd:YAG, and argon lasers have been used for 5 years for experimental and clinical procedures at the National Cancer Institute of Milan under the auspices of the National Research Council. Experimental data regarding tumor cell spread through lymphatic and hematic channels and cell viability in the fumes after CO2 laser irradiation are reported. New advantages in the combined treatment modalities have been demonstrated, since the synergism between the low power argon laser beam and chemotherapeutic agents (anthracyclines) was assessed on cell cultures and the least toxic and the most effective doses of the drugs were identified. Due to the optical properties of the laser beam, physical measurements of the delivered energy and mathematical calculation of the energy per tissue volume unit to be ablated increase the precision in microsurgery especially when conservative managements are indicated. Main applications in surgical oncology, and comparison versus conventional methods, both with vaporization and excisional techniques, according to specific therapeutic protocols, in general surgery, otolaryngology, gynecology, and endoscopy, even on an outpatient basis, are finally illustrated in a series of 600 cases.

Association of CEA test and liver scan in detection of hepatic metastases of gastrointestinal carcinoma.

The authors evaluate the combined use of liver scan and the CEA test in the diagnosis of hepatic metastases of carcinoma of the gastrointestinal tract. Association of the two tests is justified by the fact that the liver scan is very specific but not very sensitive, whereas the CEA test is more sensitive and not very specific. The sensitivity of the CEA test, on the other hand, can be increased by increasing the threshold of normality. However, the associated diagnostic use of the liver scan and the CEA test gives a loss of specificity with respect to the use of the liver scan alone. The present study, carried out on a series of 376 patients affected by gastrointestinal tumors of which 79 were of the stomach (9 with hepatic metastases), 133 of the colon and higher sigmoid (25 with hepatic metastases), and 164 of the lower sigmoid and rectum (29 with hepatic metastases), proposed to establish by use of a statistical method the optimal threshold of the CEA test that would give the best diagnostic specificity of the combined CEA test and liver scan without any relevant loss of sensitivity. A threshold of 26 ng/ml of the CEA test and gave a specificity of 92%, a sensitivity of 80%, and an accuracy of 90%. The authors think that in the detection of liver metastases of gastrointestinal tumors, the combined test can be more helpful the less the probability, for a given patient, for other metastatic localizations.

Microsphere angiography in hepatic artery infusion for cancer.

99mTc-human albumin microspheres were injected at a slow rate into the hepatic arteries of 24 patients before starting intraarterial chemotherapy for liver cancer. The distribution patterns of radiolabeled microspheres were significantly different from those obtained in contrast angiography in 13 of 22 patients. Liver uptake of slowly injected microspheres was greater than 75% in 16 of 24 patients and less than 25% in 4 of 24 patients. A significantly increased arterial blood supply to intrahepatic neoplastic regions was demonstrated in 12 of 20 patients. Microsphere examination allowed an easy evaluation of the relative perfusion of the liver and of the intrahepatic distribution of arterial blood flow in all patients.

[Clinical examination and 131 Cs scanning in the diagnosis of cold nodules of the thyroid (author's transl)]. / L'esame clinico e lo studio con radiocesio (131 Cs) nella diagnosi di natura dei noduli freddi tiroidei

The usefulness of 131Cs scanning in preoperative diagnosis of 131I cold nodules of the thyroid that present no clear clinical sign of malignancy is discussed. The results of clinical examination of 283 thyroid nodules, associated in 139 cases with 131Cs scanning, are correlated with the histologic nature. In nodules that were classifided as cold, warm or hot in the 131Cs scan, the incidence of malignancy was 2.6, 12.3 and 25%, respectively. In the nodules that, on the basis of clinical examination, were classified as probably benign, dubious or suspected for malignancy, the incidence of cancer was, respectively, 3.6, 26.3 and 72.7%. Malignancy ocurred in 16 of 144 patients that were selected for surgical treatment only on the basis of clinical data and in 17 of 139 patients that were selected on the basis of clinical examination associated with 131Cs scanning. The accuracy of clinical preoperative diagnosis of thyroid cold nodules does not seem to be significantly improved by association of 131Cs scanning.

Double-tracer scintigraphy with 67Ga-citrate and 99mTc-sulfur colloid in the diagnosis of hepatic tumors.

A method of liver scanning based on a subtraction technique with simultaneous use of two tracers, 67Ga-citrate and 99mTc-sulfur colloid, is described. The subtraction technique isolates radiogallium uptake by the space-occupying hepatic lesions by subtracting interference due to tracer uptake by healthy hepatic tissue. In 82 patients, the method yielded a correct result in 94.7% of the positive scans and in 97.7% of the negatives. Two false positives and one false negative occurred. Very poor results were obtained in the same patients using conventional technetium and gallium scans: only 20.7% of these interpretations were correct. The method proved very helpful in differentiating malignant from benign lesions.

[Possibilities and limitations of the direct radioimmunological method with double guinea-pig antibody in the detection of serum Australia antigen]. / Possibilitá e limiti del metodo radioimmunologico diretto con doppio anticorpo di cavia per la ricerca dell'antigene Australia nel siero

The results obtained with the direct radioimmunological method and electrosyneresis in the search for Australia antigen were compared in 3100 donor sera. In a limited number of sera, the positivity of radioimmunological examination was tested by neutralization tests with human antibody and with the serum of normal guinea-pigs. Electrosyneresis proved positive in 4% of cases, while radioimmunological examination produced a clearly positive result in 6.7% of cases and a faintly positive or doubtful result in 1.8%. The presence of doubtful results is due to the fact that the distribution of values obtained shows some overlapping between normal population and population of subjects carrying the antigen. The neutralization tests have shown a high incidence (45%) of aspecific positivity between the sera proving positive at radioimmunological examination and negative at electrosyneresis. This inconvenience should be resolved by the recent introduction of a radioimmunological method which provides for use of labelled antibody of human origin.