Prognostic value of specific KRAS mutations in patients with colorectal peritoneal metastases

BACKGROUND

There is little evidence on KRAS mutational profiles in colorectal cancer (CRC) peritoneal metastases (PM). This study aims to determine the prevalence of specific KRAS mutations and their prognostic value in a homogeneous cohort of patients with isolated CRC PM treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

MATERIALS AND METHODS

Data were collected from 13 Italian centers, gathered in a collaborative group of the Italian Society of Surgical Oncology. KRAS mutation subtypes have been correlated with clinical and pathological characteristics and survival [overall survival (OS), local (peritoneal) disease-free survival (LDFS) and disease-free survival (DFS)].

RESULTS

KRAS mutations occurred in 172 patients (47.5%) out of the 362 analyzed. Two different prognostic groups of KRAS mutation subtypes were identified: KRASMUT1 (G12R, G13A, G13C, G13V, Q61H, K117N, A146V), median OS > 120 months and KRASMUT2 (G12A, G12C, G12D, G12S, G12V, G13D, A59E, A59V, A146T), OS: 31.2 months. KRASMUT2 mutations mainly occurred in the P-loop region (P < 0.001) with decreased guanosine triphosphate (GTP) hydrolysis activity (P < 0.001) and were more frequently related to size (P < 0.001) and polarity change (P < 0.001) of the substituted amino acid (AA). When KRASMUT1 and KRASMUT2 were combined with other known prognostic factors (peritoneal cancer index, completeness of cytoreduction score, grading, signet ring cell, N status) in multivariate analysis, KRASMUT1 showed a similar survival rate to KRASWT patients, whereas KRASMUT2 was independently associated with poorer prognosis (hazard ratios: OS 2.1, P < 0.001; DFS 1.9, P < 0.001; LDFS 2.5, P < 0.0001).

CONCLUSIONS

In patients with CRC PM, different KRAS mutation subgroups can be determined according to specific codon substitution, with some mutations (KRASMUT1) that could have a similar prognosis to wild-type patients. These findings should be further investigated in larger series.

Search for Gamma-Ray Spectral Lines from Dark Matter Annihilation up to 100 TeV toward the Galactic Center with MAGIC

Linelike features in TeV γ rays constitute a "smoking gun" for TeV-scale particle dark matter and new physics. Probing the Galactic Center region with ground-based Cherenkov telescopes enables the search for TeV spectral features in immediate association with a dense dark matter reservoir at a sensitivity out of reach for satellite γ-ray detectors, and direct detection and collider experiments. We report on 223 hours of observations of the Galactic Center region with the MAGIC stereoscopic telescope system reaching γ-ray energies up to 100 TeV. We improved the sensitivity to spectral lines at high energies using large-zenith-angle observations and a novel background modeling method within a maximum-likelihood analysis in the energy domain. No linelike spectral feature is found in our analysis. Therefore, we constrain the cross section for dark matter annihilation into two photons to ⟨σv⟩≲5×10^{-28}  cm^{3} s^{-1} at 1 TeV and ⟨σv⟩≲1×10^{-25}  cm^{3} s^{-1} at 100 TeV, achieving the best limits to date for a dark matter mass above 20 TeV and a cuspy dark matter profile at the Galactic Center. Finally, we use the derived limits for both cuspy and cored dark matter profiles to constrain supersymmetric wino models.

Bounds on Lorentz Invariance Violation from MAGIC Observation of GRB 190114C

On January 14, 2019, the Major Atmospheric Gamma Imaging Cherenkov telescopes detected GRB 190114C above 0.2 TeV, recording the most energetic photons ever observed from a gamma-ray burst. We use this unique observation to probe an energy dependence of the speed of light in vacuo for photons as predicted by several quantum gravity models. Based on a set of assumptions on the possible intrinsic spectral and temporal evolution, we obtain competitive lower limits on the quadratic leading order of speed of light modification.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study

INTRODUCTION

Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach.

MATERIALS AND METHODS

This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery.

RESULTS

The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001).

CONCLUSIONS

According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Survival comparison in gastric cancer patients between 7th and 8th edition of the AJCC TNM staging system: The first western single center experience

BACKGROUND

The objective of this study was to compare the 7th and the 8th edition of American Joint Committee on Cancer staging system (AJCC TNM) in terms of better stratification in our gastric cancer resected patients.

METHODS AND MATERIALS

A retrospective analysis of a single western center series was made. Patients who underwent surgery from January 2004 to December 2016 were enrolled in the study. We compared survival rates across patients classified according to the 7th and the 8th AJCC TNM staging system.

RESULTS

Among 295 patients we observed 9.8% stage migration according the 8th edition. Of these 2.1% and 7.9% of patients showed respectively a higher and a lower stage. 5 years Overall Survival (5Y-OS) according to the 8th edition for stage IIIB and IIIC were 32% versus 9% showing a better stratification compared to the 7th edition in which 5Y-OS were respectively 26% versus 22%.

CONCLUSION

Restaging system seems to improve survival rate discrimination in particular comparing stage IIIB and stage IIIC; whereas in stage IIIA this is not so clear. More studies are necessary to confirm these data.

A 5-D Implementation of FGM for the Large Eddy Simulation of a Stratified Swirled Flame with Heat Loss in a Gas Turbine Combustor

Numerical simulations are foreseen to provide a tremendous increase in gas-turbine burners efficiency in the near future. Modern developments in numerical schemes, turbulence models and the consistent increase of computing power allow Large Eddy Simulation (LES) to be applied to real cold flow industrial applications. However, the detailed simulation of the gas-turbine combustion process remains still prohibited because of its enormous computational cost. Several numerical models have been developed in order to reduce the costs of flame simulations for engineering applications. In this paper, the Flamelet-Generated Manifold (FGM) chemistry reduction technique is implemented and progressively extended for the inclusion of all the combustion features that are typically observed in stationary gas-turbine combustion. These consist of stratification effects, heat loss and turbulence. Three control variables are included for the chemistry representation: the reaction evolution is described by the reaction progress variable, the heat loss is described by the enthalpy and the stratification effect is expressed by the mixture fraction. The interaction between chemistry and turbulence is considered through a presumed beta-shaped probability density function (PDF) approach, which is considered for progress variable and mixture fraction, finally attaining a 5-D manifold. The application of FGM in combination with heat loss, fuel stratification and turbulence has never been studied in literature. To this aim, a highly turbulent and swirling flame in a gas turbine combustor is computed by means of the present 5-D FGM implementation coupled to an LES turbulence model, and the results are compared with experimental data. In general, the model gives a rather good agreement with experimental data. It is shown that the inclusion of heat loss strongly enhances the temperature predictions in the whole burner and leads to greatly improved NO predictions. The use of FGM as a combustion model shows that combustion features at gas turbine conditions can be satisfactorily reproduced with a reasonable computational effort. The implemented combustion model retains most of the physical accuracy of a detailed simulation while drastically reducing its computational time, paving the way for new developments of alternative fuel usage in a cleaner and more efficient combustion.

Extended lymphadenectomy in elderly and/or highly co-morbid gastric cancer patients: A retrospective multicenter study

BACKGROUND

Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients.

METHODS

In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy.

RESULTS

Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p < 0.001 and 72.6% vs. 58.1% in D1, p < 0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p = 0.008 and 47.5% vs. 30.6% in D1, p = 0.001, respectively), although it was present only in DSS when highly co-morbid elderly patients were considered.

CONCLUSION

Extended lymphadenectomy confirmed better survival rates in gastric cancer patients. Due to high postoperative complication rate and no significant improvement of the OS, D1 lymphadenectomy should be considered in elderly and/or highly co-morbid gastric cancer patients.

Factors influencing survival after hepatectomy for metastases from gastric cancer

PURPOSE

To investigate clinical factors influencing the prognosis of patients submitted to hepatectomy for metastases from gastric cancer and their clinical role.

METHODS

Retrospective multi-center chart review. We evaluated how survival from surgery was influenced by patient-related, gastric cancer-related, metastasis-related and treatment-related candidate prognostic factors.

RESULTS

One hundred and five patients submitted to hepatectomy for metastases from gastric cancer, in the synchronous and metachronous setting of the disease. In 89 cases a R0 resection was achieved, while in 16 a R+ hepatic resection was performed. Adjuvant chemotherapy was administered to 29 patients. Surgical mortality was 1% and morbidity 13.3%. Median disease-free survival was 10 months, median overall survival was 14.6 months. Overall 1, 3, and 5-year survival rates were 58.2%, 20.3%, and 13.1%, respectively. Survival was influenced independently by the factor T of the gastric primary (p < 0.001), by the curativity of surgical procedure (p = 0.001), by the timing of hepatic involvement (p < 0.001) and by adjuvant chemotherapy (p < 0.001). T4 gastric cancer, R+ resection, synchronous metastases, and abstention from adjuvant chemotherapy were associated with a worse prognosis; T4 gastric cancer and R+ resections displayed a cumulative effect (p < 0.001).

CONCLUSIONS

Our data show that R0 resection must be pursued whenever possible. Furthermore, in the synchronous setting, the coexistence of T4 gastric primaries and R+ resections suggests prudence and probably abstention from hepatectomy. Finally, a multimodal treatment associating surgery and chemotherapy offers the best survival results.

Survival prognostic factors in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy treatment: analysis from a single oncological center

Background

The aim of our study is to analyze survival, treatment-related morbidity, and safety in our experience of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Methods

Sixty-four patients were treated. Survival curves were calculated according to the Kaplan-Meier method. Univariate and multivariate analyses were done, and Cox’s proportional hazard model was used to identify significant factors.

Results

Global 5-year overall survival was 55 %. Overall survival was also evaluated according to neutrophils to lymphocytes ratio and neutrophils to platelets ratio. Overall survival according to pre-operative serum albumin level shows a difference in the two groups (P < 0.05). We observed minor or no adverse events in 53 cases (89.8 %), while 3 patients (5.1 %) showed a grade III–IV complication and 3 post-operative deaths (5.1 %). Post-operative complication also influenced overall survival; patients in whom a minor complication occurred had a 3-year overall survival (OS) of 62 % vs. a 3-year OS of 28 % in patients who underwent a major complication (P < 0.1).

Conclusions

Hyperthermic intraperitoneal chemotherapy (HIPEC) could be a valid and feasible option for selected patients affected by gastrointestinal malignancies’ peritoneal carcinomatosis.

Pre-operative parameters could be evaluated to choose patient who could benefit from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Emergency transanal haemorrhoidal Doppler guided dearterialization for acute and persistent haemorrhoidal bleeding

AIM

The effectiveness of Doppler guided transanal haemorrhoidal dearterialization (THD) for arresting persistent haemorrhoidal bleeding in patients admitted as an emergency was studied.

METHOD

Eleven patients with severe anal bleeding underwent emergency THD as definitive treatment for haemorrhoids. In the majority of patients antiplatelet or anticoagulant therapy was ongoing and severe anaemia was present in six patients.

RESULTS

The mean operative time was 39.7 min. Six to nine feeding arteries were ligated. Intra-operative blood loss was nil. Bleeding was well controlled in all patients. No blood transfusion was required. Mean pain score per verbal numeric scale was 3.6 and 1.4 on day 1 and day 3 respectively. The mean time to resumption of normal activities was 8 days. No major complications were experienced. Six months follow-up demonstrated good control of haemorrhoidal disease.

CONCLUSION

THD is effective in controlling acute haemorrhoidal bleeding with a low incidence of postoperative complications.

Small bowel mesentery solitary fibrous tumor. A rare neoplasia in a young male

Extrapleural Solitary Fibrous Tumors (SFT), in particular small bowel mesentery SFTs, are extremely rare neoplasms. We describe the case of a young male hospitalized for unspecific abdominal symptoms and evidence of a well-circumscribed mass arising from the small bowel mesentery. Histopathological and immunohistochemical analysis on the surgical specimen confirmed the diagnosis of SFT. A Pubmed search revealed only another case of small bowel mesentery SFT, confirming the extremely rarity of this tumor.

Simultaneous surgery for obstructive coronary artery disease and ulcerated gastric cancer

A patient with ulcerated gastric cancer causing mild anaemia and simultaneous three-vessel coronary artery disease (CAD) underwent “off pump” coronary artery bypass grafting (OP-CABG) and total D2 gastrectomy.

Small bowel metastasis from lung cancer: a possible cause of acute abdomen. Case report and literature review

OBJECTIVE

Lung cancer represents the leading cause of tumor death in the world with 50% of patients presenting metastatic disease at the time of diagnosis. Gastrointestinal (GI) lung cancer metastasis were thought to be extremely rare, but a much higher incidence has been noted in several autoptic reports. Clinical relevance of GI metastasis is low, but can increase with the higher number of newly diagnosed patients and with the efficacy of systemic chemotherapy in advanced stages. Prognosis of complicated GI lung cancer metastasis seems to be worse than the natural course of the disease and acute bleeding or perforation of metastatic site can be accelerated by chemotherapy.

CASE REPORT

We describe the clinical case of a patient presenting with acute abdomen due to small bowel perforation from GI lung cancer metastasis. A review of the most recent published literature on GI lung cancer metastasis was performed.

DISCUSSION

GI metastasis from lung cancer may occur within the clinical course of the disease and require surgical treatment followed by a poor outcome. Percentage of lung cancer patients with GI metastasis can reach level of 14%. Large cells carcinomas causing kidney and adrenal metastasis are more likely associated with GI localization of the disease.

CONCLUSIONS

Complications of GI metastases, although rare, must be considered as possible cause of acute abdomen in patients with lung cancer. Identification of clinical indicators of GI metastasis may help in the therapeutic strategy.

[Metastatic gastric cancer successfully treated with surgery and chemotherapy. Case report]

A case of long-term survivor 50-year-old man treated for advanced gastric cancer with two liver metastases is described. Patient underwent a total gastrectomy with D2 lymphadenectomy and atipic liver resection. After surgery, chemotherapy with PELF achieved a complete clinical response; six month from the fourth cycle, Ca19.9 levels slowly increased until 185 U/mL and a retro-peritoneal lymphadenopathy was detected by US. Three different chemotherapeutic combinations (FOLFOX, FOLFIRI, FOLFOX4) was administrated but two new liver recurrences spread out. From November 2007 until now, patient received 8 CDF cycles and he obtained a complete clinical response supported by persistent negativity of TC-PET scans. The radiological investigations performed after last admission in our Department for jaundice, revealed multiple liver lesions with Ca 19.9 levels of 6.766 U/mL. The patient required placement of metallic biliary endoprosthesis. He is still alive 41 month after primary surgery. We consider this case a successful example of survival increasing by integrated surgery-chemotherapy treatment but also an expression of the failure of current available therapy in the definitive cure for gastric cancer. Metastatic gastric cancer should be considered a disease treatable but not curable.

[Preliminary experience in treatment of locally advanced gastric adenocarcinoma with peri-operative chemotherapy]

AIM

Gastric Cancer (GC) is a poor prognosis neoplasm and it is often diagnosed at advanced stage. Neoadjuvant Chemotherapy (NAC) may increase the possibility of complete surgical resection and improve Overall Survival (OS).

PATIENTS AND METHODS

Since November 2006, six patients with gastric adenocarcinoma, diagnosed by endoscopy, endoscopic ultrasonography and total body 18FDG-PET-CT, were enrolled in a program of peri-operative chemotherapy, according to the following inclusion criteria: cT2N+M0 or cT3-4NxM0, age < 75 years, Karnofsky Performance Status > 60%, absence of hepatic, renal and bone marrow failures. The patients undergo three cycles of pre-operative and post-operative chemotherapy based on Epirubicine, Cisplatin, and 5-Fluorouracil (ECF) as MAGIC Trial proposed. Fifteen days after the end of pre-operative chemotherapy the patient undergoes endoscopic ultrasonography and total body 18FDG-PET-CT to evaluate the tumor response to treatment, and then he is addressed to surgery. Thirty days after surgery he starts the post-operative chemotherapy.

RESULTS

All patients completed the pre-operative chemotherapy. Five patients underwent D2 subtotal gastrectomy and only one patient D1 total gastrectomy. No peri- and post-operative mortality and morbidity were observed. One month after surgery all patients started chemotherapy. During post-operative chemotherapy two patients developed subclavian vein thrombosis, one patient developed renal failure.

CONCLUSIONS

Although surgical resection remains the key component in the treatment of GC, it is clear that improved outcome will depend on a multidisciplinary treatment. NAC is associated with appreciable toxicity and it may improve the OS, allowing the downstaging of the primary tumor and increasing its resecability, as shown by MAGIC trial.

[Laparoscopic intraperitoneal hyperthermic perfusion in palliation of malignant ascites. Case report]

Malignant ascites is a pathological condition, due to several abdominal and extra-abdominal neoplasms, representing a difficult challenge in treatment. Different medical and surgical options have been proposed, but none of them have shown efficacy, leading only to partial and temporary relief of symptoms. Laparoscopic intraperitoneal chemotherapy may be a valid therapeutic option in patients in whom medical therapies have failed and peritoneovenous shunting is contraindicated. A 49-years old woman with malignant ascites, secondary to peritoneal localization of right pleural mesothelioma, underwent, after failure of medical therapy, laparoscopic intraperitoneal chemotherapy (with Cisplatin 25 mg/m2/L and Doxorubicin 7 mg/m2/L). An important and lasting reduction of ascites and abdominal symptoms was documented till the exitus, due to pulmonary embolism after 11 months. Laparoscopic intraperitoneal chemotherapy may be a good therapeutic option to palliative malignant ascites in patient not eligible for a radical cytoreductive treatment, but further investigations are needed to standardized dosage and perfusion procedure.

Human hepatocyte transplantation for acute liver failure: state of the art and analysis of cell sources

Liver transplantation is the only treatment available for acute liver failure. However, mortality rates remain high because of the shortage of donor organs. Indeed up to 20% of patients with acute liver failure may survive without transplantation. In the last two decades, research has focused on the development of alternative or supportive measures to deal with acute liver failure; one of the most studied is hepatocyte transplantation, because it is thought that the function of the liver can only be replaced with a biological substrate characterized by functioning liver cells. Hepatocyte transplantation has been successful in many animal models of acute liver failure, although only several clinical attempts have been made in humans with encouraging but not yet convincing results, mainly because of the lack of a reliable source of live liver cells. Allogenic and xenogenic fresh or cryopreserved hepatocytes have been tested. Recent research has focused on fetal hepatocytes and progenitor liver cells of both hepatic and bone marrow origin. The ability to preserve and bank human hepatocytes would allow pooling of cells from multiple donors to increase the numbers for transplantation. The development of a reliable and large-scale available source of live liver cells would probably have a major impact on the introduction of hepatocyte transplantation in clinical practice.

Cryopreserved human hepatocytes from cell bank: in vitro function and clinical application

We Aimed to analyze the in vitro function of isolated and cryopreserved human hepatocytes (CHH) from a cell bank and to define their potential clinical application in a bioartificial liver (BAL) device.

METHODS

Over 24 months, 103 not transplantable livers were utilized for human hepatocytes isolation and cryopreservation. Hepatocytes isolated by collagenase were analyzed for yield, viability, diazepam metabolism, and production of human albumin after isolation and cryopreservation in LN(2).

RESULTS

The causes for refusal for transplantation were macrosteatosis >60%, ischemic damage due to donor hypotension, and nonviral cirrhosis in 60%, 11%, and 8%, respectively. Cell yields averaged 7 million hepatocytes per gram of liver of mean viability of 80% +/- 13%. The viability of CHH after thawing averaged 50%. Thawed hepatocytes showed diazepam metabolism, and human albumin synthesis comparable to fresh cells. CHH were utilized as the biological component of a BAL for temporary support as three applications of two patients affected by fulminant hepatic failure awaiting urgent transplant. Ten to 13 billion viable CHH were loaded into each BAL. Liver function showed bilirubin and ammonia reduction at the end of each treatment. One patient was successfully bridged to emergency OLTx after one BAL; in the second case there was spontaneous recovery of liver function after two BAL.

CONCLUSIONS

Recovery of donor human livers unwanted for transplantation allowed isolation and cryopreservation of viable and functionally active human hepatocytes, which have been banked and successfully used for clinical applications of a BAL device.

One-stage resection without colonic lavage in emergency surgery of the left colon

OBJECTIVE

Intra-operative colonic lavage is a widespread procedure introduced to decompress and clean the colon of its faecal load during emergency surgery of the left colon in order to perform a safe anastomosis. This type of lavage is never performed at our institution. The aim of this study was to evaluate the safety and acceptability of emergency left-sided colectomy without colonic lavage in a consecutive series of patients admitted at our department for perforation and obstruction of the left colon.

PATIENTS AND METHODS

All 44 patients (29 with obstruction and 15 with perforation) on whom a one-stage left-sided colon resection was performed without colonic lavage between January 1998 and June 2004 were evaluated in a retrospective review. During this period all patients with acute disease of the left colon underwent a one stage resection without colonic lavage. The only exclusion criteria for anastomosis were: haemodynamic instability, ASA > 3, unresectable tumour. Death, anastomotic leakage and wound infection were main outcome measures.

RESULT

The leak rate was 4.5% and mortality 2.3% due to one case of postoperative myocardial infarction. A 16% morbidity rate was recorded due to 4 wound infections and 3 minor complications.

CONCLUSION

The procedure is safe. The low morbidity and mortality of one stage resection without colonic lavage can justify future prospective studies enrolling a large number of patients to compare its results with those obtained by one stage resection with colonic lavage.

Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial

BACKGROUND

Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea.

STUDY DESIGN

This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications.

RESULTS

In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p < 0.0001) per day and the average duration was 7.1 +/- 2.9 days (p < 0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups.

CONCLUSIONS

Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

The role of laparoscopy in patients with suspected peritonitis: experience of a single institution

PURPOSE

In this report, we retrospectively evaluate the effect of a laparoscopic approach in the diagnosis and treatment of acute abdominal pain in patients with suspected peritonitis.

PATIENTS AND METHODS

We evaluated the clinical records of patients admitted to our institution between January 1995 and July 2001 with a diagnosis of acute abdomen and suspected peritonitis.

RESULTS

Ninety four of 229 patients underwent diagnostic laparoscopy. In this series, 83 (88.3%) of the cases were successfully treated by emergent laparoscopy for an acute abdomen. Eleven (11.7%) required conversion to an open laparotomy procedure. Overall, the preoperative diagnosis was confirmed by laparoscopy in 67 (71.27%) of the cases. It was not confirmed in 27 (28.73%). Postoperative mortality was 4.25%. Morbidity was 8.5%.

DISCUSSION

Data reported in the literature establish that laparoscopy offers adequate visualization of the entire abdomen and pelvic cavity in the diagnosis of an abdomen acute secondary to peritonitis. In this series, laparoscopy confirmed the diagnosis in 97.8% of the patients, and minimally invasive treatment was achieved in 88.3% of the cases. Female patients with gynecologic disease particularly benefitted from a laparoscopic approach, which permitted the correct evaluation of this condition and may have prevented unnecessary laparotomy. We believe that laparoscopy is an accurate modality for the diagnosis and treatment of patients with an acute abdomen and suspected peritonitis when the diagnosis cannot be clearly made by physical examination and noninvasive methods.

A new method of preemptive analgesia in laparoscopic cholecystectomy

BACKGROUND

Although laparoscopic cholecystectomy (LC) results in less pain then open cholecystectomy, it is not a pain-free procedure. The aim of this study was to test a new method of preemptive analgesia.

METHODS

By simple randomization 60 patients were assigned to two groups (30 in each group). Group A, the placebo group, received 200 ml of 0.9% saline, and group B received 5 mg/kg of a local anesthetic solution (ropivacaine) in 200 ml of 0.9% saline. Local anesthetic or placebo solution were administer before creation of the pneumoperitoneum.

RESULTS

Pain intensity, as rated by visual analog and verbal rating scales, and stress response data were significantly less in the group receiving ropivacaine than in the placebo group. No patients in treatment group received an additional dose of analgesic, whereas two patients in placebo group needed an additional analgesic.

CONCLUSIONS

Our results support the clinical validity of preemptive analgesia, but the timing of intraperitoneal administration of local anesthetic is very important. Only application before creation of the pneumoperitoneum may preempt every neuronal central sensitization.

Radiation-induced angiosarcoma of the breast: case report and self-criticism of therapeutic approach

Angiosarcoma (AS) of the breast is a rare and highly aggressive vascular cancer. It presents as a primitive or radioinduced form. The case of a 46-year-old woman who underwent quadrantectomy of the breast plus axillary lymph node dissection and radiotherapy postoperatively (QUART) for ductal infiltrant carcinoma is reported in the following. Ten years later, the patient underwent mastectomy with immediate reconstruction, for local recurrence that was diagnosed as an AS of the breast at final pathological examination. She did not receive any adjuvant treatment due to local post-operative complications related to breast reconstruction. We criticize our therapeutic approach and we recommend more attention about local recurrence suggesting that tru-cut needle biopsy of local recurrence of the breast after QUART, should be the correct diagnostic approach.

[Role of surgery in the treatment of primary gastric lymphoma and assessment of new therapeutic approaches]

Controversy remains regarding the best treatment for primary gastric lymphoma (PGL). Recent developments in diagnosis and chemotherapy have changed strategies for this disease. Fourteen patients with primary gastric non-Hodgkin's lymphoma underwent surgery. Before surgery 9/14 patients underwent Helicobacter pylori eradication, and 4/14 were treated with chemotherapy. In two patients chemotherapy was not possible because of risk of perforation recurred. Total gastrectomy with N2 lymphadenectomy, splenectomy, biopsy of mesenteric lymph nodes, and hepatic biopsy were done. Then patients underwent post-operative chemotherapy. Involved-field radiation therapy was made in four patients. The overall survival was 64.2 percent. Surgery was the treatment of choice in cases of gastric lymphoma non-responsive to medical therapy and to control complications or when gastroscopy did not supply correct diagnosis.

Subcutaneous right leg metastasis from rectal adenocarcinoma without visceral involvement

The occurrence of cutaneous metastasis from colorectal cancer is rare, with a reported frequency of less than 4 to 5 percent. Typically signifies widespread disease and a poor prognosis. Metastases from adenocarcinoma of the colon-rectum usually occur within two years of resection of the primary tumour, and the average survival of a patient with cutaneous metastasis has been reported as ranging from 3 to 18 months. The case reported here concerns a patient who developed a skin metastasis without evidence of visceral involvement after treatment of rectal carcinoma. It is advisable to implement cutaneous biopsy in patients with a history of carcinoma; this may establish the diagnosis of metastatic disease and change the methods of therapeutic intervention and prognosis.

Crustacean cardioactive peptide is a modulator of oviduct contractions in Locusta migratoria

Crustacean cardioactive peptide (CCAP) stimulates the contractions of locust oviducts. CCAP increased the basal tonus and increased the frequency and amplitude of phasic contractions, as well as the amplitude of neurally-evoked oviduct contractions in a dose-dependent manner. Oviducts from Vth instar larvae and adult locusts aged 10 days or less, were more sensitive to CCAP than oviducts from adult locusts aged 12 days or more. This may be indicative of a differential expression of number or subtypes of CCAP receptors on the oviducts at different ages, and may be related to reproductive functions or to functions of CCAP on the oviducts during ecdysis. The oviducts appear more sensitive to CCAP when compared with previously published reports of CCAP actions on the hindgut. CCAP actions on the amplitude of neurally-evoked contractions of the oviducts are similar to those of proctolin, however, the oviducts are more sensitive to CCAP. No CCAP-like immunoreactive structures were discovered in the nerves innervating the oviducts, or on the oviducts themselves, confirming the previously published suggestion (Dircksen et al., 1991) that CCAP acts as a neurohormone at the oviducts. Cells showing CCAP-like immunoreactivity were discovered in the fat body associated with the oviducts and represent a potential source of CCAP, along with CCAP released from the transverse nerve and perivisceral organs.

Increased blood volume and CD34(+)CD38(-) progenitor cell recovery using a novel umbilical cord blood collection system

A major problem with the use of umbilical cord/placental blood (UCB) is the limited blood volume that can be collected from a single donor. In this study, we evaluated a novel system for the collection of UCB and analyzed the kinetics of output of hematopoietic stem cells in the collected blood. Sequential UCB fractions were collected from 48 placentas by gravity following common procedures. When UCB flow was ended, collection was continued using the device. Nucleated cell (NC) density in each fraction was evaluated and the expression of CD34, CD38 and other hematopoietic markers was assessed by flow cytometry. The total collected volume was 60.9 +/- 26.2 ml (mean +/- SD, range 17-141.5). The device yield (volume collected using the device/total volume) was 26.5 +/- 15.1%. No significant difference was observed in NC count in sequential fractions. A significant increase in CD34(+) cell content in sequential fractions and a 2.07 +/- 1.18-fold increase in the percentage of CD34(+) cells in the last versus first fraction were observed. Furthermore, within the CD34(+) population, the percentage of CD38(-) pluripotent stem cells in the first fraction was 3.24 +/- 1.39, while in the last fraction it raised to 34.43 +/- 22.62. Thus, at the end of a collection performed following current procedures, further blood rich in the most primitive progenitor cells can be recovered. Therefore, the optimization and standardization of collection procedures are required to obtain maximal recovery from each placenta and increase the percentage of UCB units suitable for clinical use.

Malignant lymphoma complicating ulcerative colitis

Carcinoma of the colon as a complication of chronic ulcerative colitis is relatively common, whereas malignant lymphoma is apparently rare. We report two cases of patients with malignant lymphoma complicating ulcerative colitis, a CD 30 + T-cell lymphoma of the intestine and a low grade B-cell non-Hodgkin's lymphoma of MALT type. It is important to be aware of the possibility of malignant lymphoma in ulcerative colitis in order to evaluate correctly any lymphoid infiltrate seen in a biopsy, especially when anti-inflammatory treatment seems to be ineffective or when symptoms change.

Efficiency of doxorubicin handling by isolated hepatocytes is a valuable indicator for restored cell function

Pig liver is a possible source of hepatocytes for extracorporeal bio-artificial liver devices. In order to evaluate recovered hepatocyte function following enzymatic isolation, we developed a cytochemical method that is based on the capacity of hepatocytes to sequester the anthracycline antitumour drug doxorubicin within intracellular acidic compartments. Doxorubicin is a naturally fluorescent molecule. Thus, the process of drug concentration within hepatocytes can be visualized in living conditions by fluorescence microscopy. Porcine hepatocytes harvested from heart-beating donors were grown either as isolated cell suspensions or as tissue monolayers. Immediately after isolation and at fixed culture times, cells were incubated with 0.1 mM doxorubicin in Hanks' balanced salt solution for 10 min at 37 degrees C in 5% CO2-humidified atmosphere and observed by fluorescence microscopy. Parallel electron microscopy was performed to compare fluorescence data with general cell morphology. To monitor lysosomal acidification capacity, the fluorescent pH-sensitive vital dye LysoSensor-Blue was used. Doxorubicin fluorescence showed different patterns of nuclear and cytoplasmic staining, according to the time allowed for cell recovery and the culture method. In particular, cytoplasmic fluorescence changed from a diffuse staining, that could be observed after cell isolation and in hepatocyte suspensions, to a punctate perinuclear and pericanalicular fluorescence detectable in fully recovered hepatocyte monolayers. This study indicates that the 'doxorubicin-fluorescence test' may be considered a simple and rapid procedure for assessing hepatocyte functional condition. It may provide valuable and 'real time' guidelines for judging the correct way these cells are to be collected, preserved and utilized for clinical purposes.

Application of a clinical score for the diagnosis of acute appendicitis in childhood: a retrospective analysis of 197 patients

PURPOSE

The aim of this study was to validate a clinical scoring system for the diagnosis of acute appendicitis in childhood.

METHODS

The authors retrospectively applied a clinical scoring system on 197 consecutive pediatric patients operated on for acute appendicitis. They therefore looked for a correlation between the management suggested by the scoring system and pathologic diagnosis on surgical specimens.

RESULTS

Based on final pathologic specimen, surgery has been performed unnecessarily in 23% of cases. The proposed scoring system could have reduced unnecessary surgery to 2%. Only 8% of patients with acute appendicitis would have been discharged home. Sensitivity and specificity of the scoring system used in this study was 87% and 86%, respectively.

CONCLUSION

The clinical scoring system proposed in this study could be of help in early clinical diagnosis of appendicitis to reduce the rate of unnecessary emergency surgery.