Inhibin alpha-subunit and the inhibin coreceptor betaglycan are downregulated in endometrial carcinoma.

OBJECTIVE: In the present study we evaluated the protein distribution and mRNA levels of inhibin alpha-subunit and its coreceptor betaglycan in endometrial adenocarcinoma. DESIGN: Two groups of postmenopausal women were studied: the first group had recently diagnosed endometrial adenocarcinoma (n = 16; age range 61-79 years), and the second group (n = 12; age range 64-78 years) had undergone hysterectomy for uterine prolapse and served as control. METHODS: Inhibin alpha-subunit and betaglycan gene expression and tissue distribution were evaluated by semiquantitative RT-PCR and immunohistochemistry respectively. RESULTS: Inhibin alpha-subunit and betaglycan mRNAs were expressed by both healthy and tumoral endometria, but their expression was significantly lower in endometrial carcinoma (P < 0.001, based on Student's t test). Inhibin alpha-subunit expression was much weaker in the glands of tumours than in non-neoplastic specimens. Betaglycan protein was identified in the epithelial cells lining non-tumoral endometrium, and in endothelial cells of both normal and tumoral endometria. Well-differentiated neoplastic cells had a faint and scarce betaglycan staining, and poorly differentiated cells did not express betaglycan at all. CONCLUSIONS: The lower inhibin alpha and betaglycan expression in endometrial adenocarcinoma suggests that the inhibin action may be disrupted. However, the expression of betaglycan in the endothelia of the tumour vasculature suggests that a selective vascular response to inhibin may be possible in these tumours.

Spontaneous superior mesenteric vein thrombosis (SMVT) in primary protein S deficiency. A case report and review of the literature.

Superior mesenteric vein thrombosis (SMVT) is an uncommon but important clinical entity that can induce ischemia or infarction of the small and large bowel. It is rare and accounts for 5-15% of mesenteric vascular occlusions. Bowel infarction due to SMVT can present as an acute abdominal disease, requiring urgent laparotomy with resection of the intestinal segment affected. However, the clinical diagnosis of this event remains difficult and invariably requires specific imaging investigations in order to be able to treat the condition as soon as possible. SMVT without bowel infarction can present as persistent, non-specific abdominal pain and nausea with minimal clinical signs, affecting young individuals without any known predisposing disorder, where laparotomy is not an urgent indication. We report a case of a young adult man with SMVT due to a hypercoagulable state (protein S deficiency), in whom an early diagnosis and appropriate anticoagulant treatment prevented any further extension of the thrombotic process and limited the hemorrhagic infarction of the ileum, which simply required a segmental resection.

Aortic dissection type A versus type B: a different post-surgical death hazard?

OBJECTIVE: Patients with type B aortic dissection differ from patients with type A dissection in age, hypertension prevalence, indications and timing of surgical treatment, yet reported long-term results have been rather similar (see Doroghazi et al. J Am Coll Cardiol 1984;3:1026-1034). METHODS: With the aim of comparing the post-surgical history, we have reviewed our results in 288 dissections, 213 type A and 75 type B, operated consecutively between 1 January 1970 and 31 November 1994. Follow-up was 100% complete. Empirical survival of both groups was interpolated with a fully parametric method and the shape and scale of the hazard function was investigated. RESULTS: Survival was not significantly different between type A and type B. Parametric survival was, respectively, 0.52% (70% C.L.: 0.48-0.55) vs. 0.56% (0.51-0.62) at 5 years, 0.44% (0.40-0.47) vs. 0.28% (0.23-0.25) at 10 years, 0.37% (0.33-0.41) vs. 0.25% (0.19-0.32) at 15 years, and 0.31% (0.26-0.35) vs. 0.24% (0.18-0.31) at 20 years. Following the high perioperative risk phase in type A dissection, the intermediate and late risk remains constant at a rate of 0.0033 events/month (3.9% patient-years (pt.-years)). By contrast, the postoperative course of type B dissection shows an intermediate risk phase between 4 and 10 years with an average linearized risk of 9.3% pt.-years and a peak of 20%. This determined lower survival rates (24 vs. 31% at 20 years, P = NS). CONCLUSIONS: We conclude that patients with type B dissection have a steeper postoperative death hazard as compared to type A dissection patients. Age confounding or late entry do not explain the difference. This could be possibly related to a greater propensity for expansion, higher risk of malperfusion complications or to limitations of our current surgical treatment.

Intramural Myomectomy Using a Combination of Hysteroscopy and Laparoscopy

Thanks to advances in hysteroscopic surgery and improvements in instrumentation, hysteroscopy can now be performed for intramural myomas. Twelve women with submucous or intramural myomas with a diameter ranging from 3.5 to 5.8 cm received preoperative preparation with 5 months of gonadotropin-releasing hormone analogs. The uterine cavity was distended with sorbitol-mannitol solution infused by an electronic pump. Hysteroscopic resection was performed with a 26F resectoscope and electrosurgical monopolar unit under laparoscopic control in all patients. Four women required a second procedure to complete the resection of myoma. No major complications occurred.

Risks of Virus Transmission During Diagnostic Hysteroscopy

The high frequency of asymptomatic carriers of viral infections represents a major risk for transmission. Viral agents can be transmitted through blood or biologic fluids during diagnostic hysteroscopy. Routine disinfection methods to clean hysteroscopes cannot be considered adequate to prevent transmission. Hepatitis C and B viruses require 1-hour sterilization in glutaric aldehyde or gas sterilization (ethylene oxide) to be decontaminated. Human immunodeficiency virus decontamination of instruments is easier and safer. Blood test screening of patients positive for hepatitis B and C should be performed in all candidates for endoscopic gynecologic procedures to avoid the possibility of virus transmission.

[Hysteroscopic evaluation of the endometrium in 63 postmenopausal patients treated with tamoxifen for breast cancer]. / Valutazione isteroscopica dell'endometrio in 63 pazienti in post-menopausa trattate con tamoxifene per carcinoma della mammella.

This retrospective analysis intends to evaluate by histeroscopy the endometrial findings in a group of 63 patients in post-menopausal treated with tamoxifen for breast cancer. Our patients assumed tamoxifen for a different period between 6 and 120 months. Patients have been divided in two groups: I) patients undergoing hysteroscopy because of some clinical symptoms; II) patients who undergoing hysteroscopy as a routine examination. The most important observation of this work is the correlation between the presence of negative endometrium and low risk hyperplasia (LRH) associated to: symptomatology and duration of therapy. In the group of asymptomatic patients the LRH is found only after 3 years of treatment, while in the group of symptomatic patients, LRH is present within the first two years of treatment; beyond this period high risk hyperplasia (HRH) and endometrial carcinoma have been diagnosed. We also observed a higher incidence of endometrial polyps in this population than among the non treated group and among the symptomatic patients. From these data we conclude that hysteroscopy follow-up has to be performed in the group of patients treated with tamoxifen and that it would be necessary to have a hysteroscopy before the beginning of therapy and that this one has to be repeated once a year through the treatment. Obviously the symptomatic patients have to undergo hysteroscopy as soon as possible as a higher incidence of HRH and endometrial carcinoma has been detected in this group of patients.

Hemodynamic alterations during massive incisional hernioplasty.

BACKGROUND: The operative treatment of a large abdominal incisional hernia increases intra-abdominal pressure (IAP). This study was done to verify if this IAP elevation acts on the cardiocirculatory function. STUDY DESIGN: Hemodynamic measurements were performed in five patients who underwent massive incisional hernioplasty before and after abdominal wall closure. RESULTS: Reduction of a large abdominal hernia increases (+226 percent) IAP, which can produce serious hemodynamic alterations, manifested in two patients by a fall of cardiac output (-30 percent), without significant variations of heart rate and arterial pressure. Cardiac output is decreased secondary to decreased venous return, despite the increase in measured central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). CONCLUSIONS: During massive incisional hernioplasty, CVP cannot be used as an indicator of venous return to the heart as it reflects a composite of venous filling pressure, pleural pressure, and transmitted IAP. Transmural CVP and PCWP, and not directly measured CVP and PCWP, should be used as clinical indicators of venous return to the heart in this situation.

Aortic valve prosthesis and late survival of successfully repaired type A dissection.

Seventy-two operative survivors of acute type A dissection between 1973 and 1993 had a complete follow up with a 16 years actuarial survival of 57% and a reoperation free actuarial survival of 34%. Follow up was 100% complete and covered a total of 500.6 patients-years with a median of seven years. Distal tear location (proximal, medium or distal aortic arch) with retrograde dissection toward the aortic valve was the single most important predictor of late mortality with a relative risk of 4.4 (70%CL 2.4-8.2) (p = 0.016). Mortality rate of patients with an aortic valve prosthesis was 6.2%/patient-year vs. 1.7/patient-year without aortic valve prosthesis, with a relative risk of 3.4 (70%CL 2.0-5.8) (p = 0.02). This finding could be due to confounding of variables related both to death and need of aortic valve replacement. Therefore a multivariate proportional hazard analysis, with mandatory inclusion of possible confounders, was done. It showed that patients with aortic valvular prosthesis had eight times higher risk (70% CL 2.7-24.2); prosthetic aortic valves and conservative aortic root procedures had an unconfounded relative risk of 14 times higher (70%CL 3.4-58.7) (P = 0.06), whereas patients with a composite conduit had a six times higher risk (70%CL 2.0-19.9) (p = 0.11). These findings support the attitude favoring a selective approach to aortic root repair and oppose standardized use of aortic valve prosthesis or composite conduit in acute type A dissection.

Diabetic fibrous breast disease: a clinical entity that mimics cancer.

Three typical cases of fibrous mastopathy associated with diabetes mellitus are described. The histological change is a connective-tissue overgrowth with vasculitis and some proliferation of duct epithelium. The clinical changes are indistinguishable by physical or radiographic findings from malignancy. In young patients with long-standing diabetes the presence of one or more suspicious clinical and imaging findings can suggest the presence of this lesion but a surgical biopsy or, at least, a close follow-up is required.

Single-layered cervical esophageal anastomoses: a prospective study of two suturing techniques.

We carried out a prospective, randomized study over a 1-year period to compare the efficacy of a single layer of continuous absorbable monofilament (Maxon) with that of a single layer of interrupted Polyglactin sutures (Vicryl) in the performance of cervical esophagogastric anastomoses. Forty-two consecutive patients with carcinoma of the esophagus or cardia, in whom the stomach was transposed through the mediastinal route after esophagectomy, were enrolled in the study. There were 21 patients in each group. There was no hospital mortality. One asymptomatic anastomotic leak and two early anastomotic strictures requiring dilation occurred in patients in whom an interrupted technique was employed. The continuous technique required significantly less operative time (p < 0.0001), and the cost of the suture material was reduced markedly. We conclude that either a continuous or an interrupted monolayer esophagogastric anastomosis can give satisfactory results after esophagectomy for cancer, provided that the vascular supply to the gastric fundus is maintained adequately. The continuous technique has the advantages of being time-saving, cheaper, and easier to perform and to teach.

Preoperatory treatment with Triptorelin LA in hysteroscopic metroplastic.

Septate uterus is the intracavitary pathology which is most associated with infertility and/or preterm labor; therefore, it is primary indication for hysteroscopic metroplasty. By the introductio of the resectoscope in gynaecological endoscopy the surgical technique has been revolutioned. GnRHa therapy before surgery has showed some advantages related to surgical results, surgery time, intraoperative bleeding and endometrial detachment, and amount of fluids used for uterine cavity distention. The treatment before hysteroscopic metroplasty for partial septus has not influenced positive results, while for uterine septus that reached the inferior third of the cavity or moreover, it provided better condition for this procedure.

Discrete subaortic stenosis. Operative age and gradient as predictors of late aortic valve incompetence.

Between January 1969 and May 1990, 100 patients were operated on for discrete subaortic stenosis. Three patients died in the perioperative period. Patients with intrinsic lesions, prosthetic replacement, or extensive operative remodeling of the aortic valve were excluded from the analysis. The 67 remaining patients had a median follow-up of 62 months. Preoperatively, 8 patients had aortic valve competence, 51 had mild incompetence, and 8 patients moderate aortic valve incompetence. At follow-up mild incompetence persisted in 27 and moderate incompetence in 6 patients. In 1 patient it worsened from no incompetence to mild and in another patient from mild to moderate. The probability of aortic incompetence at follow-up was significantly and simultaneously related (multivariate ordinal logistic model) to (1) older age at operation (logarithm of months, p = 0.007), (2) higher preoperative gradient (third power of milligrams of mercury, p = 0.0004), (3) preoperative cardiomegaly (p = 0.04), and (4) surgical myectomy (p = 0.002). There was an interaction between age and gradient (p = 0.03). Two nomograms are proposed as a generalizable aid to decision making. The data support the policy of early repair of subaortic stenosis.

Push-through intubation: effective palliation in 409 patients with cancer of the esophagus and cardia.

Between 1980 and 1989, 355 patients with cancer of the esophagus and 54 with cancer of the cardia underwent push-through intubation because of advanced tumor stage or medical contraindications to tumor resection. In 36 other patients (8.1%), the attempt at transtumoral intubation failed. The hospital mortality rate after intubation was 3.4%. The following complications were observed: hemorrhage in 2.0% of the patients, esophageal perforation in 4.9%, tube dislodgment in 12.7%, and tube obstruction in 4.4%. Early resumption of semisolid oral feeding was possible in 80% of the discharged patients. The actuarial 1-year survival rate was 7.7% and the median survival, 3.9 months. In conclusion, push-through intubation represents a valid therapeutic choice, which is indicated mainly for patients with a long, infiltrating, and circumferential stricture of the thoracic esophagus or cardia that is inoperable and for patients with an esophagorespiratory or esophagomediastinal fistula.

[Cancer of the hypopharynx and cervical esophagus]. / Le cancer de l'hypopharynx et de l'oesophage cervical.

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arising after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a segmental laryngo-pharyngo-cervical esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent total laryngo-pharyngo esophagectomy and the gastrointestinal tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with a hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of carcinoma of the hypopharynx and cervical esophagus.

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 with a carcinoma of the cervical esophageal region that developed after laryngectomy for laryngeal cancer. The mean age of the patients was 57.5 years (range: 41-73). One hundred and sixty-seven patients underwent surgical exploration (operability rate 59.5%), and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a laryngopharyngo-cervical segmental esophagectomy with free intestinal loop transplantation was performed, with an operative mortality of 6.1%. One hundred and three patients underwent laryngo-pharyngo-total esophagectomy, and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus who refused laryngectomy, with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded in patients operated on for carcinoma of the hypopharynx than in patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs. 26% and 43% vs. 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)

[Critical analysis of the new TNM staging (UICC, 1987) of cancer of the cervical esophagus in relation to therapeutic decisions]. / Analisi critica della nuova stadiazione TNM (UICC, 1987) del cancro dell'esofago cervicale in relazione alle decisioni terapeutiche.

66 consecutive patients with a tumor confined to the cervical esophagus underwent surgical resection. The comparison between clinical and pathological TNM stage showed a clinical understaging in 30 patients. 25 of the 56 patients who had undergone curative resection had lymph node metastases: positive mediastinal and abdominal nodes were found in 8 (32%) and 0 cases, respectively. The mean survival after curative resection of the 10 evaluable patients with metastatic periesophageal, recurrent and/or paratracheal nodes was 22.4 months; of the 6 evaluable patients with positive mediastinal nodes it was 10.3 months; and of the 5 patients with positive deep latero-cervical nodes it was 5.8 months. The 2-year actuarial survival after curative resection (in the 53 operative survivors) was as follows (according to pathologic TNM staging): Stage I (n = 3) 100%, Stage IIA (n = 17) 30%, Stage IIB (n = 3) 33%, and Stage III (n = 30) 22%. The exact location of neoplastic recurrence after curative resection was documented in 13 cases; it was in the neck in 8 cases (61%); both neck and at a distance in 3 cases (23%) and only at a distance in 2 (16%). The clinical TNM staging of cervical esophageal cancer was not in agreement with the pathological findings in nearly 50% of the cases and is, therefore, inaccurate and unreliable both for therapeutic decision-making and for prognostic evaluations. Endoscopic ultrasound, which was not used in most of the patients studied here, may improve the accuracy of clinical TNM staging. The N classification, which defines only the cervical nodes as regional nodes, appears to be arbitrary since the pathological staging showed metastatic mediastinal nodes in 32% of the N + cases, with a survival comparable to that of patients with metastatic nodes only in the neck. The prognostic value of pathological TNM staging was not confirmed in the present study since only Stage I patients had a significantly better prognosis than patients in the other stages. This may be due to the small number of patients considered or to lymph node understaging caused by the fact that most patients did not undergo mediastinal lymphadenectomy through a thoracotomy or a sternum splitting.

[Cancer of the hypopharynx and cervical esophagus. Role and limits of the surgical treatment]. / Cancer de l'hypopharynx et de l'oesophage cervical. Rôle et limites du traitement chirurgical.

From 1975 to 1988, we observed 169 patients with a carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 with a carcinoma of the cervical esophagus occurring after laryngectomy for laryngeal carcinoma. The average age was 57.5 years (41-73). Exploration was surgical for 167 patients (operability ratio 59.5%), and the lesion was resected in 152 cases (resectability ratio 81.1%). Resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). A laryngopharyngoesophagectomy involving the cervical esophagus and requiring the transplantation of a free intestinal loop was performed in 33 cases, with an operative mortality rate of 6.1%. Pharyngolaryngectomy with total esophagectomy was performed in 101 patients, and the digestive tract was reconstructed by means of pharyngogastrostomy or pharyngocolostomy (respectively 85 and 16 cases) with an operative mortality rate of 12.9% and 18.3%, respectively. Complete esophagectomy without laryngectomy was performed for 18 patients with carcinoma of the distal cervical esophagus who refused laryngectomy, the hospital mortality rate being of 5.5%. The actuarial survival rate after 5 years (not including operative mortality) was 15.8%. Better results were achieved after complete resection for carcinoma of the hypopharynx than for carcinoma of the cerebral esophagus. The actuarial survival rates after 2 and 5 years were 59% vs. 26% and 43% vs. 17% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of carcinoma of the hypopharynx and cervical esophagus]. / Il trattamento chirurgico dei carcinomi dell'ipofaringe e dell'esofago cervicale.

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arose after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.9%) and palliative in 23 (14.1%). In 33 cases of laryngo-pharyngo-cervical segmentary esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent laryngo-pharyngo-total esophagectomy and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)

[Esophagectomy without thoracotomy as a treatment of esophageal cancer. Indications, technical features and results]. / L'oesophagectomie sans thoracotomie comme traitement du cancer de l'oesophage. Indications, points de technique opératoire et résultats.

Between 1980 and 1989, 229 patients with squamous cell carcinoma of the esophagus underwent esophagectomy without thoracotomy. The tumor was located in cervical and thoracic esophagus in 112 and 117 cases, respectively. Out the patient with a tumor of the thoracic esophagus, the mean age was 63 years (range 32-81). There were 90 males and 27 females. The locations inside the thoracic esophagus were as follows: upper thoracic 39, middle thoracic 40, lower thoracic 38 cases. A complete resection of the tumor was performed in 87 patients and in 30 cases the procedure was palliative. The digestive tract was reconstructed by means of esophago-gastrostomy in 101 patients, esophago-colostomy in 13, esophago-jejunostomy in 2, and pharyngo-colostomy in 1 patient, respectively. The post-operative morbidity was as follows: pulmonary complications 13.6%, anastomotic leak 17.1%, necrosis 5.1%, recurrent laryngeal nerve injuries 10.2%. The overall hospital mortality was 7.6%. Actuarial survival rates after curative and palliative resection were 82.4% and 47.1% at 7 year, 46.3% and 8.1% at 2 years, 39.0% and 0% at 3.5 and 6 years. In our experience, esophagectomy without thoracotomy is an excellent technique, with low morbidity but with oncologic limitations. Patients with carcinomas of the thoracic esophagus in whom thoracotomy is contraindicated can be resected with this technique with morbidity and mortality rates comparable to those of patients undergoing transthoracic esophagectomy.