[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.

Recombinant growth hormone (GH) therapy in GH-deficient adults: a long-term controlled study on daily versus thrice weekly injections

Currently, replacement recombinant GH (rGH) therapy in GH-deficient (GHD) adults is performed in daily injections. This modality of treatment is not complied with by the totality of GHD patients, who are supposed to receive life-long replacement. The aim of our study was to compare daily vs. thrice weekly (TIW) rGH injection effects on lipid profile, body composition, bone metabolism, and bone density in 34 GHD patients (13 women and 21 men; median age, 39 yr; range, 30-55 yr) randomly assigned to different therapeutic regimens. Group A included 18 patients receiving daily rGH injections, and group B included 16 patients receiving TIW injections of rGH. The starting dose of rGH was 10 microg/kg x day in both groups. Subsequently, the dose was adjusted to maintain serum insulin-like growth factor I (IGF-I) concentrations in the normal age-adjusted range. IGF-I levels were assessed before and after 1, 3, 6, and 12 months of rGH treatment, and lipid profile, body composition, bone metabolism, and bone density were evaluated before and after 6 and 12 months of treatment. Thirty-four healthy subjects served as controls. In the basal condition, lipid profile, body composition, bone metabolism, and bone density were significantly different in patients compared to controls. Conversely, patients included in groups A and B had similar serum IGF-I levels, lipid profile, body composition, bone metabolism, and bone density. After 3 months of rGH treatment, IGF-I levels were normalized in 15 of 18 patients (83.3%) in group A and in 7 of 16 patients (43.7%) in group B (chi2 = 4.21; P = 0.04). At this time point, serum IGF-I levels in patients in group A (202+/-57.5 microg/L) were significantly higher than those in patients in group B (155+/-45.1 microg/L; P = 0.001). After 6 months of therapy, serum IGF-I levels were normalized in all patients and were similar in both groups (223+/-35.2 vs. 212+/-41.4 microg/L, A vs. B, respectively). IGF-I levels remained normal until the 12-month follow-up. After 6 months of rGH replacement, total cholesterol, low density lipoprotein cholesterol, triglycerides, bioelectrical impedance, and body fat mass were significantly reduced, whereas high density lipoprotein cholesterol levels and lean body mass were significantly increased in both groups of patients, without any difference between them. No further change in lipid profile and body composition was observed after 12 months of treatment. Serum bone GLA protein and procollagen III levels were significantly increased after 6 months, and a downward trend was observed after 12 months of rGH replacement. However, a slight, but significant, increase in bone mineral density was observed in both groups only after 12 months (P = 0.0001). All patients in group B had good compliance to the TIW treatment, whereas 5 patients in group A had poor compliance to the treatment (chi2 = 3.2; P = 0.07). In conclusion, our randomized, prospective, and controlled study confirmed that rGH therapy with TIW injection regimen is effective in normalizing IGF-I levels and improving lipid profile, body composition, bone metabolism, and bone density. It also demonstrated that this efficacy is comparable to that observed in patients treated with daily rhGH therapy, with few side-effects and good compliance.

Minimally invasive video-assisted surgery of the thyroid: a preliminary report

BACKGROUND

Endoscopic thyroidectomy has not yet met the favor of most endocrine surgeons. We evaluated the technical feasibility of a video-assisted approach to thyroid surgery.

PATIENTS AND METHODS

The study group comprised 22 females and 5 males, all with a single thyroid nodule. The nodule was "hot" in 4 patients, microfollicular in 17 and with Hürthle cell cytology in 6. A 15-mm skin incision was made above the sternal notch. The midline was opened and a 12-mm trocar inserted into the thyro-tracheal groove. It was inflated with CO2 for 3 min. The trocar was then removed and the procedure performed using external retractors and needlescopic instruments. The upper pedicle was dissected. Identification of recurrent nerve and parathyroid glands was facilitated by endoscopic magnification. The upper gland portion was then retracted out of the operative cavity; inferior veins were ligated and the lobe entirely extracted and dissected. Frozen section was obtained for "cold" nodules.

RESULTS

Video-assisted hemithyroidectomy was accomplished in 24 patients; 1 underwent video-assisted total thyroidectomy (positive frozen section). Cervicotomy was required once to achieve hemostasis and once to perform total thyroidectomy (positive frozen section). Mean operative time was 82 min (range 60-120 min). No complications were registered. The cosmetic result was excellent.

CONCLUSIONS

Video-assisted thyroid surgery is feasible and may improve cosmetic outcome; total thyroidectomy can be accomplished through the same access point.

Local and distant failures after limited surgery with positive margins and radiotherapy for node-negative breast cancer

PURPOSE

To determine the outcome of patients with positive margins after lumpectomy for breast cancer and to address the issue of the relationship between local recurrences and distant metastasis in the absence of chemotherapy.

METHODS AND MATERIALS

Among 3697 patients with primary breast cancer, we retrospectively analyzed 152 patients who had undergone conservative surgery with axillary dissection, had infiltrating carcinomas with positive margins, were node-negative, and received radiotherapy without chemotherapy. One-third received hormonal therapy. Endpoints were local failure and distant metastasis. Median follow-up was 72 months.

RESULTS

Five- and 10-year recurrence-free survival were 0.80 and 0.71 respectively for local recurrences, and 0.85 and 0.73 respectively for metastasis. Infiltrating carcinoma on the margins was associated with early local relapse as opposed to intraductal carcinoma. Local and distant recurrences had similar patterns of yearly-event probabilities. Hazard of relapsing from metastasis was 2.5 times higher after a local recurrence. In the multivariate analysis, negative estrogen receptors (ER-)(p = 0.0012), histologic multifocality (p = 0.0028), and no hormonal therapy (p = 0.017) predicted local relapses, while ER- (p = 0.004) and pathologic grade (p = 0.009) predicted metastasis. Hormonal therapy did not prevent early local recurrences.

CONCLUSION

In this population, reexcision is advisable for local purposes and because the data support the hypothesis that local and distant recurrences are tightly connected.

Minimally invasive surgery for thyroid small nodules: preliminary report

Cytological assessment of cold thyroid nodules cannot exclude malignancy in case of follicular tumors. Many follicular nodules undergo surgery although most of them later on prove to be benign. We report a new minimally invasive video-assisted approach (MIVA) for the treatment of thyroid lesions with a diameter minor than 3 cm. Ten females and 2 males (mean age: 37 yr) with a cold thyroid nodule and a cytological diagnosis of microfollicular tumor were selected for MIVA hemythyroidectomy. The procedure was carried out through a 15 mm incision with needlescopic instruments and a 30 infinity 5-mm endoscope. Mean operative time was 87 min (range 60-120). No complications were registered. Cosmetical result was excellent in all patients. MIVA hemythyroidectomy is safe and effective; indications and limits of this new procedure require further studies.

[Video-assisted parathyroidectomy: a series of 85 cases]

AIM OF THE STUDY

To verify the feasibility of video-assisted parathyroidectomy, set up the indications and report the results in a series of 85 patients.

MATERIAL AND METHODS

From 1997 to 1999, 85 patients affected by primary hyperparathyroidism due to single gland disease, with an adenoma smaller than 35 mm as demonstrated by preoperative imaging, were referred for video-assisted parathyroidectomy. There were 62 females and 23 males. Mean age was 53 years, (range 23-82). Video-assisted parathyroidectomy was associated with intra-operative PTH quick-assay. Calcium testing was controlled before leaving the hospital, 1 month and 3 months later, and postoperative laryngoscopy was performed in all patients.

RESULTS

There were five conversions to open cervicotomy: three due to a contra-lateral second adenoma, two because of an intrathyroidal adenoma. The mean operative time for video-assisted procedure was 59 minutes (range: 25-180). Circulating PTH levels 10 minutes after the removal of the affected gland(s) always dropped significantly, and pathological report confirmed the parathyroid nature of the specimens (mean diameter 13 mm, range 7-35). Morbidity consisted of five cases of transient hypocalcemia and one permanent laryngeal nerve paralysis. We registered no persistent or recurrent disease (mean follow-up 12.8 months, range 1-28).

CONCLUSIONS

Video-assisted parathyroidectomy is feasible, and its results are similar to those of traditional procedure, while it seems superior as regards postoperative course and aesthetic results. It also allows different strategical decisions even during operation (i.e. bilateral exploration or thyroid lobectomy) by the same approach.

Neuroblastoma in two siblings supports the role of 1p36 deletion in tumor development

Familial neuroblastoma occurs rarely. We studied a family with three children; one of them has a disseminated (stage 4) and another has a localized (stage 2) neuroblastoma. We observed subtelomeric locus D1Z2 (1p36) deletion in both tumors by using double-color fluorescence in situ hybridization. The MYNC gene was found in single copy in both tumors. Loss of heterozygosity (LOH) and restriction fragment length polymorphism analyses were performed by using DNA from frozen tumor cells and from microdissected tumor areas excised from paraffin-embedded sections. We detected somatic LOH at locus D1S468 (1p36) in a tumor-cell population with a trisomy 1 of the stage-2 patient. Neuroblastoma cells of the stage-4 patient were diploid and showed allelic loss at the following loci: D1S172, D1S80, D1S94, D1S243, D1S468, D1S214, D1S241, and D1S164. Haplotype study showed that the siblings inherited the same paternal 1p36-->pter chromosome region by homologous recombination and that, in the two tumors, arm 1p of different chromosomes of maternal origin was damaged. Our results suggest that the siblings inherited the predisposition to neuroblastoma associated with paternal 1p36 region and that tumors developed as a consequence of somatic loss of the maternal 1p36 allele.

Ultrasound-guided fine needle aspiration of ovarian cysts during pregnancy

OBJECTIVE

To evaluate the safety and efficacy of ultrasound-guided fine needle aspiration in the treatment of ovarian cysts during pregnancy.

STUDY DESIGN

Nine out of twenty-nine patients between the 6th and the 16th week of gestation with unilateral ovarian cysts ranging between 65 and 540 cm3 in volume were selected for sonographically-guided fine needle aspiration.

RESULTS

No complications were observed at either short or long-term follow-up; all patients delivered healthy infants at term. Clinical and sonographic post-partum follow-up was uneventful in all cases. In three cases it was necessary to repeat the procedure once and in one case twice during pregnancy. In one case a recurrent serous cyst was excised at operative laparoscopy performed 3 months after delivery.

CONCLUSIONS

Ultrasound-guided fine needle aspiration was safely performed in nine patients as an alternative treatment to surgery when persistent monolateral and unilocular ovarian cysts with regular borders and completely anechoic structure are detected during pregnancy.

Interstitial and large chromosome 1p deletion occurs in localized and disseminated neuroblastomas and predicts an unfavourable outcome

We studied chromosome 1p loss of heterozygosity (1p-LOH) in 53 neuroblastomas (NBs) using 15 (CA)n repeat loci, which covered a region of 90 cM. We also assessed chromosome 1p36 deletion by fluorescence in situ hybridization (FISH) on interphase nuclei. 1p-LOH was found in 19 (36%, 95% confidence interval (CI) 23-50%) NBs. We detected interstitial and large deletion in both localized and disseminated tumours and in one tumour of a patient at stage 4S. Allelic loss was frequently observed in 1p36 and 1p32 regions. In patients older than 1 year of age (53 versus 13%, P < 0.002) we detected significant chromosome 1p deletion and it was associated with MYCN amplification (P = 0.001). Overall survival (OS) analysis showed that 1p-LOH is predictive of a poor outcome (odds ratio 16.5, 95% CI 5.4-50.9%); therefore, 1p-LOH should be regarded as an additional tumour progression marker in neuroblastoma.

Endoscopic parathyroidectomy by a gasless approach

Endoscopic approach for the treatment of primary hyperparathyroidism is one of the new fields of interest for minimally invasive surgery. The removal of the parathyroid gland can be achieved either by a gas or gasless technique. Massive carbon dioxide (CO2) diffusion and absorption has been reported to occur during the gas procedure. Endoscopic techniques that do not rely on CO2 insufflation have still to be set. We have developed a new procedure that was offered to 20 selected patients with a localized parathyroid adenoma. A 3-minute CO2 insufflation (12 mm Hg) through a conventional trocar inserted under the strap muscles is used just to anatomically dissect the virtual thyrotracheal groove. Actually, the working space is maintained by means of skin retractors so as to allow needlescopic instruments to perform a parathyroid adenomectomy with the gasless procedure. In all cases the parathyroid adenoma was removed through a 1.5-cm skin incision. Quick parathyroid hormone assays always confirmed the removal of all pathologic glands and permitted unilateral cervical exploration. Mean operative time was 71.7 +/- 35.5 minutes. No complication was registered. At follow-up, all patients were normocalcemic. This new endoscopic approach to the neck seems to be safe, effective, and cosmetically satisfactory.

Benefits of granulocyte-colony-stimulating factor after stem cell transfusion in intensive sequential chemotherapy for breast cancer

The aim of this study was to evaluate the clinical and economic benefit of filgrastim given with intensive sequential chemotherapy. Women with poor-prognosis breast cancer received four cycles of high-dose cyclophosphamide (3 g/m2) and doxorubicin (75 mg/m2), followed by filgrastim 5 microg/kg/dy, stem cell collection after the cycle 1, and stem cell infusion after cycle 3 and cycle 4. The first cohort received filgrastim after the fourth cycle but the second cohort did not.Thirty three patients were included in the first cohort and 13 in the second. The results indicate that the duration of grade IV neutropenia was shorter in the group given filgrastim as was the median time to recover an absolute neutrophil count (ANC) > 1.0 x 10(9)/L. The rate and duration of the rehospitalizations were higher in the group not receiving filgrastim. We found that costs such as drugs and hospitalizations were significantly higher (p = 0.032 and p = 0.049) in the non-filgrastim-treated group. Using ANC > 1.0 x 10(9)/L as an intermediary efficiency criterion it was more cost effective to give filgrastim. It can be concluded from this study that filgrastim can decrease the duration of grade IV neutropenia in patients receiving intensive sequential chemotherapy. This, in turn, reduces the cost of hospitalization. However, in our study, this reduction of neutropenia did not have any impact on further therapy.

Effect of steroid and high-dose immunoglobulin therapy on opsoclonus-myoclonus syndrome occurring in neuroblastoma

The authors describe a case of an 8-month-old boy with opsoclonus-myoclonus syndrome (OMS) and coincident unresectable neuroblastoma (NB). He achieved a complete remission for NB after 6 courses of standard-dose chemotherapy without significant neurological improvement despite the use of steroids and high-dose immunoglobulin (HIG), administered separately. Only the combined treatment withthese two drugs induced a complete disappearance of neurological symptoms. On the basis of this experience, the authors suggest the association of steroids plus HIG for the treatment of OMS in patients not responsive to conventional first line therapy with steroids.

Bronchioloalveolar carcinoma arising in congenital cystic adenomatoid malformation in a child: a case report and review on malignancies originating in congenital cystic adenomatoid malformation

A type I congenital cystic adenomatoid malformation (CCAM) in the left lower lobe was removed from a 11-year-old boy with a 3-month history of recurrent pneumonia. As incidental finding, a bronchioloalveolar carcinoma (BAC) was found in the lung parenchyma adjacent to the cyst. A left lower lobectomy was performed. At 18 months after surgery the patient is well and free of neoplastic disease. To the best of our knowledge, this association has not been reported previously in a pediatric patient. Malignancies complicating CCAM are rarely seen, but have been reported in adults. Including our case, eight cases of BAC and five cases of rhabdomyosarcoma (RMS) in association with CCAM have been reported so far. As CCAM can host metaplastic mucous cells, primitive mesenchymal cells and differentiated but poorly organized striated muscle fibers, it has been proposed that CCAM may act as a predisposing condition for oncogenesis. Our experience adds further support that CCAM can act as a premalignant lesion. Previous reports of both BAC and RMS in asymptomatic CCAM suggest prompt resection shortly after diagnosis.

Activated protein C resistance due to a factor V mutation associated with familial ischemic stroke

Recent findings have indicated the association between activated protein C (APC)-resistance and cerebrovascular disease. These reports prompted us to investigate whether resistance to APC could be found in patients suffering from transient ischaemic attacks or stroke. Therefore, we studied APC-resistance in 14 young adults belonging to three different families with a history of transient ischemic attacks (TIAs) and stroke. Nine out of fourteen subjects showed APC-resistance but no deficiencies in the anticoagulant proteins AT III, PC and PS. The family history demonstrated a distribution of APC-resistance compatible with dominant autosomal inheritance. A rapid screening method to detect factor V R506Q (Leiden) mutation without sequencing or restriction enzyme digestion has been set-up after biochemical analyses. DNA analysis showed a guanine to adenine transition at nucleotide 1,691 in patients and their relatives with poor response to activated protein C detected by APTT tests. Of 14 investigated subjects and their family members, 5 were normals, 6 were heterozygotes and 3 were homozygotes for factor V mutation. The mutation, in heterozygous form, was also found in 1.3% of our normal population (n = 75). Our findings indicate a possible involvement of APC-resistance in the pathogenesis of arterial thrombosis in young adults.

Loss of heterozygosity for chromosome 1p in familial neuroblastoma

Loss of heterozygosity (LOH) and deletion of chromosome 1p are very often found in sporadic neuroblastoma. Nevertheless, very few data are available concerning 1p LOH in familial neuroblastoma. Families with recurrent neuroblastoma are rare and analysis of chromosome 1p in these families might give useful information for identifying the putative neuroblastoma suppressor gene. We used combined cytogenetic and molecular techniques to study 1p LOH in two neuroblastoma families. Family M has 2 out of 3 children with neuroblastoma and family C has 2 children, 1 of whom has neuroblastoma and type 1 neurofibromatosis (NF1). All patients of both families showed tumour cells with chromosome 1p deletion (1pdel), but only the patient from family C also had MYCN gene amplification. In all cases the deleted chromosome 1 was of maternal origin.

[Intensive chemotherapy with autologous stem cell transplantation in ovarian cancers: analysis of 67 patients treated at the Paoli-Calmettes Institute and a review of the literature]

Despite important initial chemosensitivity, advanced ovarian cancer has a bad prognosis with a median survival of 20 to 30 months. These results might be better with intensive chemotherapy. We analysed 67 patients treated by intensive chemotherapy with autologous stem cell transplantation for advanced ovarian cancer at Institute Paoli-Calmettes between 1980 and 1994. Population was divided in two groups: salvage group (n = 30) for initial chemotherapy-refractory patients and consolidation group (n = 37) for sensitive patients. Several successive conditioning regimens were used, all based on alkylating agents. Principal toxicities were severe aplasia and mucositis. Four patients died from toxicity related to infection during strong immunosuppression. In salvage group, 9 out of 21 evaluable patients responded (43%), but duration of responses was short (median range of 5 months) and 2-year overall survival rate was 8% after transplantation. In consolidation group, 19 patients are alive and 15 are without disease progression with a median follow-up of 42 months (17, 161) after diagnosis. Five-year disease-free survival rate is 28% (median range of 35 months) and 5-year overall survival rate is 48% (median range of 41 months). Intensification does not seem to be long term beneficial for initial chemotherapy refractory patients, despite objective responses rate better than classical treatment. On the other hand, results seem better than conventional treatments in case of chemosensitive disease and should be confirmed prospectively in larger cohort of patients. Moreover, other research directions are open like intensification supported by hematopoietic growth-factors and peripheral stem cells, definition of best conditioning regimen, use of taxanes, and intensification in first line chemotherapy after initial surgery.

High-dose sequential chemotherapy with stem cell support for non-metastatic breast cancer

The importance of dose-intensity has been suggested in breast cancer. The aim of this study was to evaluate the feasibility of a high-dose intensity doxorubicin-cyclophosphamide regimen with supporting G-CSF and blood stem cells. Twenty-five patients with non-metastatic breast cancer received four cycles of doxorubicin (75 mg/m2) and cyclophosphamide (3000 mg/m2) at 3 week intervals. Apheresis was performed after the first cycle and if necessary after the second cycle. Stem cells were reinfused after the third and fourth cycles. G-CSF was started on day 3 of each cycle (5 microg/kg/day) and was stopped the day before the last apheresis or when absolute neutrophil count was above 0.5 x 10(9)/l. Median received dose-intensity was respectively 25 mg/m2/week (range 22-26) and 1000 mg/m2/week (range 904-1065) for doxorubicin and cyclophosphamide. Grade IV thrombocytopenia occurred in 8% of cycles. Two patients needed platelets and 12 red cell transfusion. Fifteen patients were readmitted for a median duration of 4 days (range 1-7). We have established a safe, outpatient, high-dose intensity doxorubicin-cyclophosphamide regimen with supporting G-CSF and blood stem cells which can be submitted for comparison with the current standards.

Minimally invasive, video-assisted parathyroid surgery for primary hyperparathyroidism

A new video-assisted surgical procedure for treatment of primary hyperparathyroidism combined with intraoperative quick PTH measurement was developed. This procedure was successfully used in 6 patients with a single parathyroid adenoma preoperatively localized by neck ultrasound examination.

A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies

OBJECTIVE

To evaluate the clinical effectiveness of retroperitoneal drainage following lymphadenectomy in gynecologic surgery.

METHODS

One hundred thirty-seven consecutive patients undergoing systematic lymphadenectomy for gynecologic malignancies were randomized to receive (Group A, 68) or not (Group B, 69) retroperitoneal drainage. The pelvic peritoneum and the paracolic gutters were not sutured after node dissection. Perioperative data and complications were recorded.

RESULTS

Clinical and surgical parameters were comparable in the two groups. Postoperative hospital stay was significantly shorter in Group B (P < 0.001), whereas the complication rate was significantly higher in Group A (P = 0.01). This was mainly due to a significant increase in lymphocyst and lymphocyst-related morbidity. Sonographic monitoring for lymphocyst showed free abdominal fluid in 18% of drained and 36% of not-drained patients (P = 0.03). Symptomatic ascites developed in 2 drained (3%) and 3 not-drained (4%) patients (NS), respectively.

CONCLUSIONS

Prophylactic drainage of the retroperitoneum seems to increase lymphadenectomy-related morbidity and postoperative stay. Therefore, routine drainage following lymphadenectomy seems to be no longer indicated when the retroperitoneum is left open.

Multiplane transesophageal echocardiography to detect effectiveness of selective pulmonary recombinant tissue-type plasminogen activator thrombolysis in pulmonary embolism and patent foramen ovale

A functionally patent foramen ovale can create a relevant right-to-left shunt during massive pulmonary embolism. This associated feature, although maintaining adequate cardiac output, may explain both the paradoxic embolism and the uneffectiveness of peripherally administered drugs. This case demonstrates the potential of transesophageal echocardiography in monitoring the hemodynamic findings of such patients and, consequently, the effectiveness of thrombolytic treatment.