Parathyroid carcinoma. A single Institution experience and a review of the international literature.

INTRODUCTION: Parathyroid carcinoma (PC) is a slow-growing and very rare malignancy, representing less than 0.005% of all cancers. The rarity of PC makes it hard to create large-scale published series of patients affected by this condition. MATERIALS AND METHODS: We present four cases of PC treated in our Institution and analyze the most salient aspects of this disease highlighted in recent international literature. DISCUSSION AND COMMENTS: In our experience, in 3/4 cases, the clinical presentation of PC was not different compared to adenoma; therefore, the diagnosis was a post-operative histopathological surprise. We noticed a clear, preoperative laboratory evidence of higher values of PTH and calcemia in patients with PC compared to adenoma. In our experience, a surgical approach consisting in parathyroidectomy associated with ipsilateral loboisthmectomy and central neck lymph node dissection offers the best prognostic chance. Moreover, surgery should be performed only in referral centers where an interdisciplinary management is guaranteed. We are confident in suggesting the surgical approach also in patients with poor clinical status due to high calcemia. If performed by experienced surgeons, the surgical risk of parathyroidectomy is low and we assisted to a progressive restoration of neurological function and an improvement in the patient's quality of life. Finally, even if our experience is limited, we observed an association between PC and thyroid cancer that deserves a validation through more comprehensive further studies. CONCLUSION: PC remains a complex disease in which a valid surgical approach represents the only curative treatment. KEY WORDS: Parathyroid, Parathyroid carcinoma, Parathyroidectomy, hormone, Surgical oncology.

Parathyroid carcinoma. A single Institution experience and a review of the international literature.

INTRODUCTION: Parathyroid carcinoma (PC) is a slow-growing and very rare malignancy, representing less than 0.005% of all cancers. The rarity of PC makes it hard to create large-scale published series of patients affected by this condition. MATERIALS AND METHODS: We present four cases of PC treated in our Institution and analyze the most salient aspects of this disease highlighted in recent international literature. DISCUSSION AND COMMENTS: In our experience, in 3/4 cases, the clinical presentation of PC was not different compared to adenoma; therefore, the diagnosis was a post-operative histopathological surprise. We noticed a clear, preoperative laboratory evidence of higher values of PTH and calcemia in patients with PC compared to adenoma. In our experience, a surgical approach consisting in parathyroidectomy associated with ipsilateral loboisthmectomy and central neck lymph node dissection offers the best prognostic chance. Moreover, surgery should be performed only in referral centers where an interdisciplinary management is guaranteed. We are confident in suggesting the surgical approach also in patients with poor clinical status due to high calcemia. If performed by experienced surgeons, the surgical risk of parathyroidectomy is low and we assisted to a progressive restoration of neurological function and an improvement in the patient's quality of life. Finally, even if our experience is limited, we observed an association between PC and thyroid cancer that deserves a validation through more comprehensive further studies. CONCLUSION: PC remains a complex disease in which a valid surgical approach represents the only curative treatment. KEY WORDS: Parathyroid, Parathyroid carcinoma, Parathyroidectomy, hormone, Surgical oncology.

A novel approach to inoperable or recurrent rectal cancer by chemoembolization: A new arrow in our quiver?

PURPOSE: Assess the feasibility, safety and efficacy of TACE with irinotecan loaded micro particles (debiri) for the treatment of locally advanced rectal cancer patients. RESULTS: We assessed the Edmonton Symptom Assessment System (ESAS). The tool is designed to assess nine common symptoms in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath. The ESAS score was 7 in 10/12 (83%) patients before treatment and 6 in 2/12 (16.5%) patients. After treatment in 6/12 (50%) patients the score dropped to 3; 3/12 (33%) reported 4, 1/12 (8%) reported 2. All patients experienced local control disease with a degree of citoreduction; in 4 cases (33%) we observed outstanding responses with a dramatic reduction in the tumors size which led us to surgical radical resections. MATERIALS AND METHODS: We run a prospective mono-institutional study where we recruited, 12 non- consecutive patients with histology confirmation of rectal cancer, inoperable and not treatable due to severe comorbidities, or pelvic recurrence/progression after curative treatment, chemotherapy, radiotherapy and/or surgery. Their performance status (PS) ECOG was 2-3 . Twelve patients (10 male and 2 female) with a median age 71 (range 56-89) were recruited in the study. CONCLUSIONS: The study has met the primary endpoint and showed encouraging activity. Debiri could be a possible option for locally advanced/inoperable or recurred rectal cancer patients. Further trials are warranted to validate this methodic in early stages.

Inferior mesenteric artery chemoembolization and chemotherapy for advanced rectal cancer: report of a clinical case.

Patients with advanced and incurable colorectal cancer have a very poor prognosis. Curative-intent resection was performed in 70%-90% of cases in reported series of colorectal cancer, sometimes after neoadjuvant chemotherapy and radiotherapy. The remaining 10%-30% of patients are treated with palliative intent, where treatment is aimed at relieving disease-related symptoms and improving quality of life. The provision of palliative care for these patients is complicated and outcomes are often disappointing. Although there are many available options including a variety of surgical and nonsurgical interventions, the best management remains controversial. Transarterial chemoembolization with irinotecan-loaded drug-eluting beads (DEBIRI) is an effective, minimally invasive procedure performed by interventional radiologists that allows intra-arterial drug delivery to stop vascular feeding and exert local cytotoxic effects. We here report on a patient treated with DEBIRI followed by systemic chemotherapy with the FOLFOX regimen for locally advanced, inoperable colorectal cancer.

Peritoneal lactate as a potential biomarker for predicting the need for reintervention after abdominal surgery.

BACKGROUND: Early diagnosis of complications after abdominal surgery is crucial to improve outcomes. This study aimed to evaluate the use of the peritoneal-serum lactate ratio and of peritoneal lactate levels applied alone for predicting the need for reintervention after abdominal surgery. METHODS: This prospective observational study included 88 patients who underwent abdominal surgery (48 emergency and 40 elective operations) and presented with fever, leukocytosis, late passage of flatus, and abdominal pain by the fourth postoperative day. The lactate levels were measured in the serum and peritoneal fluid. In total, 31 of 88 patients required reintervention. The receiver operator characteristic analysis was used to determine the best threshold value for the peritoneal-serum lactate ratio and for peritoneal lactate levels applied alone to identify patients who required reintervention. RESULTS: A peritoneal-serum lactate ratio greater than 4.5 (area under the curve, 0.865; 95% confidence interval, 0.773-0.957; p < 0.001) and a peritoneal lactate value greater than 9.1 mmol/L (area under the curve, 0.834; 95% confidence interval, 0.735-0.934; p < 0.0001) discriminated between patients who required reintervention with a sensitivity of 91.3%, a specificity of 81%, and a negative predictive value of 94.4% and a sensitivity of 81.9%, a specificity of 82%, and a positive predictive value of 89%, respectively. CONCLUSION: The results of our study support the hypothesis that the peritoneal-serum lactate ratio and the peritoneal lactate level applied alone could be safe, simple, inexpensive, noninvasive, and potentially valuable tools for the early identification of patients who require reintervention after elective or emergency abdominal surgery. LEVEL OF EVIDENCE: Diagnostic study, level III. Prognostic study, level III.

Small bowel obstruction in percutaneous fixation of traumatic pelvic fractures.

The use of external fixation for the initial treatment of unstable, complex pelvic injuries with hemodynamic instability remains an effective treatment for multiply injured patients. Bowel entrapment within a pelvic fracture is a rarely reported, potentially fatal complication. Here, we report a polytrauma patient with pelvic fractures who developed an intestinal obstruction after an external fixation. At an explorative laparotomy, we found an ileum segment trapped in the sacral fracture. Reported cases of bowel entrapment in pelvic fractures, especially in sacral fractures, are exceedingly rare. The diagnosis is often delayed due to difficulty distinguishing entrapment from the more common adynamic ileus. In conclusion, clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures treatment. To exclude bowel entrapment, patients with persistent ileus or sepsis should undergo early investigations.