Preoperative staging of resectability of colon cancer using virtual colonoscopy: correlation with surgical results. Our experience

PURPOSE

To evaluate the clinical usefulness of preoperative computed tomography colonography (CTC) in locoregional staging in patients with abdominal pain secondary toocclusive colorectal cancer (CRC).

MATERIALS AND METHODS

80 patients with abdominal pain underwent CTC initially without contrast and after diagnosis with contrast. 47 patients had distal CRC and 33 had proximal CRC. CTimages were analyzed independently by two radiologists, using MPR reconstruction and VR images. Depending on the anatomical depth of wall invasion primary tumor (T) was classified ≤ T2, T3 and T4. The definition of node disease (N) was based on the number of involved regional lymph nodes. Metastases (M) were characterized by the presence and location of distant disease. Pre treatment stage (cT cN) was compared with pathologic stage (pT pN). Accuracy of CTC was also evaluated.

RESULTS

The overall accuracy values for T staging of reviewer 1, reviewer 2 and consensus reading were 91.6%, 86.2% and 92.8% respectively; 92.2%, 79.8% and 92.5% for T2; 88.1%, 85.5%, and 89.7% for T3; and 94.5%, 93.5% and 96.2% for T4. The accuracy values for N staging and M staging were 81,.8%, 94.0% for reviewer 1; 78.2% and 88.1% for reviewer 2; 81.8% and 94.0% for consensus reading, respectively.

CONCLUSION

In our experience CTC is not only useful in the evaluation of the proximal bowel, but can also provide surgeons with accurate information about staging and tumor localization. CTC is recommended for better evaluation of preoperative staging.

KEY WORDS

CT colonography, Colorectal cancer, Extracolonic findings, Staging.

Recurrence of paratesticular liposarcoma: a case report and review of the literature

Paratesticular liposarcomas are rare tumors that typically affect adult. Diagnosis is very difficult and inadequate surgical excision leads to a high rate of recurrence.We report a case of local recurrence of paratesticular liposarcoma diagnosed six months following surgery.Since there is low response to adjuvant treatments, extensive surgery remains the only curative approach, as shown by the case described here and the following review of the literature.

Analysis of variables predictive of severity in biliary peritonitis

OBJECTIVE

To analyze clinical and laboratory findings in order to find variables predictive of severity of Biliary Peritonitis (BP).

METHODS

Physical findings, course of illness, imaging and laboratory data were evaluated in 22 patients with BP, and statistically analysed to assess their prognostic significance.

RESULTS

Serious illness and worse outcome were associated with: age > 60 years (P= 0.034), long time between onset of symptoms and treatment (P= 0.025), fever > 38°C (P= 0.009), WBC count > 17.000 cell/mm3 (P=0.043), diffuse abdominal pain (P= 0.034), and infected bile (P= 0.048).

CONCLUSIONS

Most patients become severely ill due to supervening infection, while early bile drainage avoids serious complications. In addition, abdominal pain, fever and WBC count are also predictive of severity of BP.

Severity in biliary peritonitis

OBJECTIVE

To analyze clinical and laboratory findings in order to find variables predictive of severity of Biliary Peritonitis (BP). Patients and methods. Physical findings, course of illness, imaging and laboratory data were evaluated in 42 patients with BP, and statistically analysed to assess their prognostic significance.

RESULTS

Serious illness and worse outcome were associated with: age ≥ 60 years (P=0.034), long time between onset of symptoms and treatment (P=0.025), fever > 38°C (P=0.009), WBC count > 17,000 cell/mm³ (P=0.043), diffuse abdominal pain (P=0.034), and infected bile (P=0.048).

CONCLUSIONS

Most patients become severely ill due to supervening infection, while early bile drainage avoids serious complications. In addition, abdominal pain, fever and WBC count are also predictive of severity of BP.

Primary testicular plasmocytoma

A case of Primary Testicular Plasmocytoma (PTP) in an 81-year-old man with a painless nodule in the left testis is reported. All possible pre-operative investigations were carried out, but the diagnosis of PTP was possible only after microscopic examination of the resected testis.

Analysis of variables predictive of severity in biliary peritonitis

OBJECTIVE

To analyze clinical and laboratory findings in order to find variables predictive of severity of Biliary Peritonitis (BP). Patients and methods. Physical findings, course of illness, imaging and laboratory data were evaluated in 22 patients with BP, and statistically analysed to assess their prognostic significance.

RESULTS

Serious illness and worse outcome were associated with: age > 60 years (P=0.034), long time between onset of symptoms and treatment (P=0.025), fever > 38°C (P=0.009), WBC count > 17.000 cell/mm³ (P=0.043), diffuse abdominal pain (P=0.034), and infected bile (P=0.048).

CONCLUSIONS

Most patients become severely ill due to supervening infection, while early bile drainage avoids serious complications. In addition, abdominal pain, fever and WBC count are also predictive of severity of BP.

Cesarean section and hernia repair: simultaneous approach

AIM

Hernias of the abdominal wall occurring during pregnancy are usually treated a few weeks after delivery. The aim of this study was to retrospectively evaluate the clinical outcome of inguinal or umbilical hernioplasty performed at the time of the cesarean section, and to compare the outcome of this group with a control population, who received a cesarean section alone.

MATERIAL & METHODS

We reviewed 28 women who developed an inguinal or umbilical hernia during pregnancy from January 1, 2000 to December 31, 2007 and who received a combined cesarean section and hernia repair, and we compared this group with 100 women (controls) who only received a cesarean section.

RESULTS

In the group of women who received a combined cesarean section and inguinal or umbilical hernia repair, median age was 23.8 years and hospital stay ranged from 3 to 5 days (versus 3-4 days for cesarean sections alone). The time employed for the combined surgical procedure was of 50 ± 7 min and 70 ± 4 min, respectively, for umbilical and inguinal hernia (versus 37.4 ± 12.6 min for cesarean sections alone). No complication was recorded during the perinatal and follow-up periods, and no recurrences were observed.

CONCLUSION

Our analysis suggests that cesarean section and hernia repair, performed in one session, avoids need for readmission to hospital, is safe, effective, and well accepted. It neither increases the complication rate nor prolongs the hospital stay, with clear advantages for both the patients and the hospital budget.

Stromal tumors of the small bowel causing unexplained melena: report of two cases

Gastrointestinal stromal tumors (GISTs) of the small bowel are relatively rare and, therefore, both difficult to diagnose and treat. The authors present two cases of such tumors and review the various options for diagnosis and treatment.

Stromal Tumors of the Small Bowel Causing Unexplained Melena: Report of Two Cases

Gastrointestinal stromal tumors (GISTs) of the small bowel are relatively rare and, therefore, both difficult to diagnose and treat. The authors present two cases of such tumors and review the various options for diagnosis and treatment.

[Results of surgical treatment of varicocele in male infertility]

To evaluate the results of surgical treatment of varicocele on infertile men, especially regarding sperm count, 245 patients, surgically treated from 1993 to 2003, were evaluated. Patients underwent to ligature and section of the pampiniform plexus, through the subinguinal approach and local anaesthesia. At the follow-up (3-6-12 months) an improvement of sperm count was relieved in 79.5% of patients and the incidence of complications and relapses was of 3.7% and 1.2%, respectively. The Authors stress the efficacy of surgical treatment of varicocele in male infertility and hold the subinguinal approach as an effective treatment, minimally invasive and low cost.

Umbilical metastases: current viewpoint

Background

Umbilical metastases from a malignant neoplasm, also termed Sister Mary Joseph's nodule, are not commonly reported in the English literature, and they have usually been considered as a sign of a poor prognosis for the patient. The present article reports on the current view point on umbilical metastasis besides discussing the epidemiology, clinical presentation, pathophysiology and treatment.

Method

A search of Pubmed was carried out using the term 'umblic*' and 'metastases' or metastasis' revealed no references. Another search was made using the term "Sister Joseph's nodule" or sister Joseph nodule" that revealed 99 references. Of these there were 14 review articles, however when the search was limited to English language it yielded only 20 articles. Articles selected from these form the basis of this report along with cross references.

Results

The primary lesions usually arise from gastrointestinal or genitourinary tract malignancies and may be the presenting symptom or sign of a primary tumour in an unknown site.

Conclusion

A careful evaluation of all umbilical lesions, including an early biopsy if appropriate, is recommended. Recent studies suggest an aggressive surgical approach combined with chemotherapy for such patients may improve survival.

Umbilical metastases: current viewpoint

BACKGROUND: Umbilical metastases from a malignant neoplasm, also termed Sister Mary Joseph's nodule, are not commonly reported in the English literature, and they have usually been considered as a sign of a poor prognosis for the patient. The present article reports on the current view point on umbilical metastasis besides discussing the epidemiology, clinical presentation, pathophysiology and treatment. METHOD: A search of Pubmed was carried out using the term 'umblic*' and 'metastases' or metastasis' revealed no references. Another search was made using the term "Sister Joseph's nodule" or sister Joseph nodule" that revealed 99 references. Of these there were 14 review articles, however when the search was limited to English language it yielded only 20 articles. Articles selected from these form the basis of this report along with cross references. RESULTS: The primary lesions usually arise from gastrointestinal or genitourinary tract malignancies and may be the presenting symptom or sign of a primary tumour in an unknown site. CONCLUSION: A careful evaluation of all umbilical lesions, including an early biopsy if appropriate, is recommended. Recent studies suggest an aggressive surgical approach combined with chemotherapy for such patients may improve survival.

The role of Echo Colour/Power Doppler and magnetic resonance in expansive parotid lesions

The purpose of this research was to evaluate the role of Echo Colour/Power Doppler and Magnetic Resonance Imaging (MRI) in the diagnosis of expansive parotid lesions, and to establish criteria for differential diagnosis between benign and malignant forms. Forty nine patients (23 males and 26 females), aging from 30 to 85 years, with an expansive pathology of parotid gland were enrolled in our study from February 1999 through August 2004. Each patient was carefully assessed employing both ultrasonography integrated with Color/Power Doppler and MRI. Eventually, all patients received echo-guided needle-biopsy and surgical excision of the parotid lesion. Preliminary ultrasound assessed site, size, echoic appearance and margins of the lesion. In order to assess blood supply by means of Colour/Power Doppler, we divided the patients in four groups. Our MRI diagnostic criteria included site, size, intensity of signal, behaviour of the lesion after i.v. contrast, relationship with facial nerve and retromandibular vein, detection of margins and proximity to adjacent structures. On the basis of our results, the Authors concluded that both Echo Colour/Power Doppler and MRI play a very important role in the diagnosis and surgical planning of parotid gland lesions.

Thyroid cancer in patients with hyperthyroidism

OBJECTIVE

The coexistence of hyperthyroidism and thyroid cancer is considered a rare event. With the aim of assessing the clinical relevance of this association, we have retrospectively analyzed the incidence of thyroid cancer in 425 hyperthyroid patients seen and treated by surgery in our institutions.

METHODS

Among these hyperthyroid patients, we observed 241 (56.7%) cases of multinodular toxic goiter, 120 (28.3%) of uninodular toxic goiter and 64 (15%) cases of Graves' disease.

RESULTS

Thyroid cancer was diagnosed in 7 (1.65%) hyperthyroid patients. Histological examination revealed the presence of papillary carcinoma in 5 cases and follicular carcinoma in 2 cases. Neoplasia was detected in 4 patients with nodular toxic goiter and in 3 with uninodular toxic goiter. None of the patients with Graves' disease had thyroid cancer. During the follow-up of 74 months (range 4-154), there were no deaths or any recurrences.

CONCLUSION

Although the occurrence of thyroid cancer in hyperthyroid patients is a rare event, the presence of a 'cold' nodule in a hyperfunctioning thyroid should be carefully evaluated to exclude the presence of concurrent malignancy.

[Clinical-therapeutic features of gynecomastia]

This study reports 36 cases of gynaecomastia surgically treated. The median age was 25-years old (range 14-65 years). In 27 patients (75%) gynaecomastia was bilateral, in the others only one breast was interested. According to Simon's classification; 12 patients with stage 1, 18 stage 2a, 3 stage 2b and 3 stage 3 were observed. A specific cause was discovered in 12 cases: 2 Klinefelter syndrome and 10 adipomastia. Other 24 cases had an idiopathic origin. Subcutaneous mastectomy, through inferior periareolar approach was performed to all patients while submammary approach was reserved in selected patients (stage 3).

[Phyllodes tumor of the breast. Personal contribution of 21 cases]

The study is based on the observation of 21 cases of phyllodes tumour of the breast. The mean age of patients was 43 years (range 18-60 years). In all the cases the tumour was monolateral, more common in the right breast (66.7% vs. 33.3%) and in external quadrants. Clinical features and diagnostic investigations were able to make a preoperative diagnosis in 6 out of 21 cases, while frozen sections and histological examination allowed to diagnose in the others. FNAB was not performed in any case. In this way 18 benign and 3 "borderline" tumours were discovered. No malignant lesion was observed. Local recurrence rate was 14.6%. Local recurrence was not associated with age of patients, tumor size and histological type. In neither case axillary nodal involvement was found. The study and the review of the literature suggest that wide local excision is the treatment of choice and adjuvant therapies have no place in the routine management of phyllodes tumours.

[Benign schwannoma of the pelvic retroperitoneum. Report of a case and review of the literature]

Benign schwannoma is a tumor arising from Schwann cells (forming the neural sheath of peripheral nerves). The retroperitoneal location is unusual (0.5-5% of cases). Most common locations are cranial nerves (especially the 8th pair) and, in peripheral nerve system the neck, mediastinum and extremities. To this date the known cases of benign retroperitoneal schwannoma are about 60, of which less than 20 in the pelvis. The low frequency of this tumor and the lack of specific instrumental signs and objective symptoms (since it develops in a deep and broad region as retroperitoneum) make presurgical diagnosis very difficult. It can be confirmed only during surgery and definitive histological examination. The information provided by ultrasonography, CT and MR help to limit diagnostic hypothesis, but they don't show any pathognomonic images. The resection of this tumor is the appropriate treatment, even though it is really a complex one. Prognosis is quite good since post-surgical recurrences are unusual. If they appear is probably because excision wasn't radical. Complete resection is the best treatment for retroperitoneal pelvic schwannoma and today it can be performed also by laparoscopy. Partial resection can be used when the mass is strongly connected to essential organs in order to prevent iatrogenic harms (neural deficit, vessel lesions); this may occur in 10% of cases. This paper describes a benign schwannoma with pelvic retroperitoneal location, incidentally discovered during a routine gynecological check up. The purpose of this study is to review current therapeutic and diagnostic techniques in retroperitoneal pelvic schwannoma (including a review of current literature) and to identify th problems that can be encountered in the differential diagnosis of this unusual disease from other neoplasms occurring in the same place.

[Primary carcinoma of the cystic duct: a case report and review of the literature]

The Authors, after a short introduction concerning the primary carcinoma of the cystic duct and the exact definition according to Farrar's criteria, report a case occurred to their observation, the 35th case of international literature. In particular the importance of some hemato-clinical parameters and instrumental investigation (ERCP, angio-CT) to underlined in order to surgical indication. In the case here reported cholecystectomy uses informed with partial resection of the hepato-choledochus and excision of some periductal and pericholedochus lymph nodes. Finally, the Authors discuss about clinical data and diagnostic and therapeutic trends, on the case of their experience and literature review.

[Adrenal cysts: therapeutic indications]

Adrenal cysts are relatively rare and usually discovered only if large and associated with clinical manifestations. Asymptomatic cysts are diagnosed with increasing frequency because of their incidental finding on ultrasonography or computed tomography, but surgical treatment is indicated when the cysts are large, symptomatic or rapidly expanding. A case of adrenal cyst is reported. The clinical, pathologic and therapeutic implications of this disease are briefly discussed.

[Total thyroidectomy in the treatment of multinodular toxic goiter]

The Authors report their experience in the management of 201 patients with multinodular toxic goiter (MTG): 122 (60.7%) underwent subtotal thyroidectomy (STT), while 79 (39.3%) underwent total thyroidectomy (TT). Through a retrospective study the patients were stratified into two groups according to the type of operation (TT or STT). Overall, neither operative mortality nor recurrent nerve damage were encountered. Permanent hypocalcemia was observed in 7 patients (5.7%) who underwent STT and in 6 patients (7.5%) who underwent TT (p=N.S.), while transitory hypocalcemia was observed in 12 cases (9.8%) in group I and 11 cases (13.9%) in group II (p=N.S.). All patients were followed every 4 months for the first year and every 6 months thereafter. Average and median follow-up period were, respectively, 72 and 74 months. The Authors conclude that total thyroidectomy is the surgical treatment of choice in multinodular toxic goiter (MTG). A thorough anatomical-surgical evaluation is essential in order to prevent the complications characteristic of this type of surgery (inferior laryngeal nerve injury and hypoparathyroidism).

[Lateral cysts and fistulas of the neck. Diagnosis and treatment]

Lateral neck cysts and fistulae are considered to be a well-defined clinical entity which needs a precise knowledge of the development of the branchial system to have an appropriate and subsequent successful treatment. According to the recent classification cysts of I and II type and fistulae of I, II and III type can be recognized. In the former ultrasonography and Computerized Tomography represent the most appropriate diagnostic tools, while in the latter fistulography is preferred. An elective surgical excision seem to be resolutive in the majority of cases: on the contrary emergency surgery is related to a certain relapse of this pathology. 45 cases of branchial pathology are reported; diagnostic and therapeutic choices are then discussed.

[Clinical and therapeutic features of MEN II]

Multiple Endocrine Neoplasia type 2 is a genetically transmitted poliendocrinopathy, in which pheochromocytoma (PCC), medullary thyroid carcinoma (MTC) and parathyroid disease may occur and coexist with different rates. Although the clinical behaviour of each component is well known and usually predictable, controversies still exist on the most appropriate therapeutical strategy when patients exhibit synchronous lesions; many elements may influence this choice: the evidence of bilateral (PCC) or multicentric (MTC) lesions, the evaluation of their malignancy, the adoption of therapies other than surgery (alpha receptor blockers in PCC). In this paper the Authors report their experience in diagnosing and treating MEN 2; it is based on 5 patients operated from 1972 to 1993 and on the screening of their relatives for thyroid and/or adrenal lesions. The individual manifestations of the disease, with regard to time and extent of organ involvement, are considerably variable; however, an aggressive approach of MTC, even in presence of a synchronous PCC, as well as a unilateral adrenalectomy (with a close follow up of the patient) when surgical exploration does not show an involvement of the remaining gland, is suggested.

[Hürthle cell tumors: personal experience]

Hürthle cell tumors of the thyroid gland are uncommon lesions (3% of all well differentiated tumors). Histological diagnosis is often difficult: according to recent criteria only those tumors with almost 75% of oxyphil cells are well recognized as Hürthle cell neoplasms. Extracapsular and blood-vessels invasion, capsular penetration, DNA patterns and tumoral necrosis are indicative for malignancy. The Authors report their experience in the management of 46 patients who underwent thyroid surgery for Hürthle cell neoplasms. Histological findings, surgical approach and post-operative follow up are discussed.