Effective management of extensive tissue loss after abdominoperineal resection for Buschke-Loewenstein tumor

The giant condyloma acuminatum or Buschke-Loewenstein tumor is a rare, sexually transmitted disease. It is an epithelial tumor characterized by its high potential of malignancy towards developing into a highly invasive squamous cell carcinoma. The present case concerns a drug addicted 40-year-old man who smuggled drugs using his rectum. He had a partially ulcerated mass in the perianal area of about 20 x 10 cm. He reported a progressive growth of this neoplasm during the last 3 years associated with perianal pain, obstructed defecation, bad sitting posture, no fever and weight loss. Our first approach was a left laparoscopic loop colostomy for a fecal diversion and antalgic purpose, and biopsy of the perineal mass. Then, he underwent a complete excision of the perianal neoplasm. The pathologist's positive diagnosis of a well differentiated squamous cell carcinoma, evidently necessitated the radicalization of the surgical procedure of abdominal perineal resection. In consideration of the surgical wound depth and size, a VAC Therapy with Negative Pressure Wound Therapy was applied. The BLT incidence rate has been steadily increasing over the last decade especially among male patients. An aggressive surgical approach is usually to get the best oncologic outcome but the difficult management of the perianal wound is challenging. In our experience VAC therapy has been shown to be an effective tool in promoting the healing of the perineal wound after abdominoperineal resection.

Total laparoscopic splenectomy for giant epidermoid cyst: a case report

INTRODUCTION

Splenic cysts are benign tumors, accidentally detected using US or CT scan. They are classified into true cyst (primary, 25%) and pseudocyst (secondary, 75%). Conventional treatment of splenic cyst, especially giant, symptomatic and complicated has been open or laparoscopic total splenectomy. Recently, partial splenectomy is recommended as well to preserve its hematopoietic function and homeostasis of blood, but it is not considered safe for complications as intra and post operative bleeding.

CASE REPORT

A 46 years old man, martial arts practitioner, underwent US abdomen scan because of left upper quadrant pain, with evidence of a splenic mass. He underwent also CT and MRI, which revealed "oval giant splenic mass of 12 cm diameter located in superior splenic pole that can be firstly referred to cyst". Considered patient's frequency to thoraco-abdominal traumas, we decided to perform a total laparoscopic splenectomy. Surgical treatment was performed with a three trocar technique and lasted 150 minutes. Post-operative follow-up was regular and abdominal drain was removed in 4th POD (Post Operative Day). Patient was discharged in 5th POD. Pathological examination revealed epidermoid cyst.

CONCLUSIONS

Total splenectomy needs to be performed in cases of giant cyst and in our limited experience it is a safe approach.

[Peritoneal adhesions: pathophysiology]

Peritoneal adhesions will form as a consequence of all types of trauma of the peritoneal serosa, be they mechanical, thermal, chemical, infective, or ischemic. Any stimulation induces deposition on the serosa of a fibrin-rich exudate that results in a weaker or stronger adhesion of the viscera to other viscera or to the wall parietal peritoneum. These adhesions are mostly temporary and are eliminated by the action of the fibrinolytic agents present in the peritoneum. In optimal conditions, repair of the injured peritoneum occurs thanks to early mesothelial proliferation over the entire damaged surface, with little production of permanent fibrous adhesions. Some traumatic events are more prone than others to inhibit fibrinolysis through the production of cytokines, that trigger the production of plasminogen inhibitors, thus determining a greater number of more tenacious adhesions. Some stimuli producing postoperative adhesions are iatrogenic in nature and can be individuated and corrected to reduce the production of such adhesions and avoid the onset of adhesion syndromes.

[Traumatic shock--physiopathologic aspects]

Traumatic shock is a complex phenomenon that represents the culminating element of a series of events. It is, in fact, the outcome of an imbalance-decompensation of the organism's defence mechanisms, in which the oxygen supply to the mitochondria is hampered by a macro and/or microcirculation failure. Basically, it is a form of hypovolemic shock in which further factors have a role, including the activation of inflammation mediators. It should also be stressed that part of the cellular damage is caused by tissue reperfusion. Good hemodynamic compensation is maintained with loss of up to 30% of the circulation mass but, beyond this amount, a fall of the cardiac index, peripheral pO2, and an increase of blood lactates will ensue. Hypoxia causes capillary injury and increased permeability, resulting in the formation of edema and finally in loss of the self-regulating power of the microcirculation. Moreover, it strongly stimulates pro-inflammatory activation of the macrophages and the release of vasoactive substances, such as prostaglandins and thromboxanes. The inflammatory response is triggered by cascade systems (such as the complement, coagulation, kinins, fibrinolysis), cell elements (endothelium, leukocytes, macrophages, monocytes, mast cells) and the release of mediators (cytokines, proteolytic enzymes, histamine, etc.) and others interacting factors. In severe trauma, the inflammatory process extends beyond the local limits, maintaining and aggravating the state of shock and causing a Systemic Inflammatory Response Syndrome (SIRS), with involvement and injury of healthy organs and tissues even at a distance from the site of trauma, raising a risk of onset of ARDS (Acute Respiratory Distress Syndrome), sepsis, MODS (Multiple Organ Dysfunction Syndrome). Tissue reperfusion (reoxygenation) also induces the production of toxic metabolites, such as hydroxylated anions, superoxide, hydrogen peroxide: peroxidation of the phospholipid cell membranes alters the barrier functions, permitting entry of substances such as calcium, which interfere with the intracellular enzymatic systems.

Acute gastric anisakiasis: an Italian experience

Anisakidosis is a parasitic disease of the human gastrointestinal tract caused by ingestion of larvae of marine nematodes such as Anisakis spp. or, rarely, Pseudoterranova spp., present in raw or undercooked fish. We report the first series of gastric Anisakis infection (anisakiasis) from a single centre in Italy. In our department, we observed 3 cases, all in women who were urgently hospitalized following intense epigastric pain and vomiting, developed after the ingestion of raw fish. The patients underwent urgent gastroscopy within a few hours. In each, a worm was extracted from the gastric mucosa by means of biopsy forceps. This was followed by prompt clinical improvement. The worm was identified by its macroscopic and microscopic characteristics as an Anisakis spp. larva (L3). In 2 cases, laboratory tests revealed marked leukocytosis and eosinophilia in the peripheral blood 3-4 days after ingestion of the raw fish. The diagnosis of anisakiasis can be made by endoscopy, radiology and abdominal ultrasound, but is often made only at surgery. In the gastric form of the disease, urgent gastroscopy has both a diagnostic and a therapeutic role, because the worm can be removed by means of biopsy forceps.

Temozolomide (TMZ) 3 weeks on/1 week off in the treatment of progressive low grade gliomas: A phase II GICNO study

1514

Background: Encouraging results have been obtained inlow grade glioma (LGG) patients (pts) following TMZ therapy at the standard schedule of 200 mg/m2 for five-days every 28 days. A continuous dose TMZ schedule leads to DNA repair enzyme AGAT level depletion in tumor cells. By removing TMZ-produced methyl adducts, AGAT contributes to the development of resistance to alkylating agents. Methods: Pts with a diagnosis of LGG received TMZ 75 mg/m2/d for 21 days every 28 days at clinical or radiological progression. MiniMax Simon’s design with P0=0.2, P1=0.4, α=0.1, β=0.1 was used and a sample size of 36 pts was planned. The primary end-point was to assess the response rate (RR=CR+PR), and the secondary end-point to investigate the correlations between 1p/19q deletions by FISH and MGMT promoter methylation by methylation specific PCR (MSP). Results: 22 oligodendroglioma (O), 4 oligoastrocytoma (OA) and 10 astrocytoma pts (A) were enrolled (median age of pts 47 years, range 24–69 years; median KPS 90, range 50–100). Eleven pts were pre-treated with radiotherapy; 5 (13.5%) had enhancing lesion at MRI scan. RR was 30.5% (11 PR), all RR being obtained in pts with non-enhancing lesions; 20 pts (55.5%) had disease stabilization; 8/11 responders were assessable for 1p/19 q deletions and, of these, 6 pts (75%) had combined 1p/19q deletion. Median PFS was 17.4 months (interquartile ranges, 9.3–25). PFS at 1 year was 73% (SE 8%). Preliminary data on molecular assessment are: 29 pts were assessable for 1p and 19q deletions, both being present in 19 pts (65.5%). 1p/19 q loss was significantly greater in pts with O/OA than A (p=0.01). Of 11 assessable pts, 7 (63.6%) presented MGMT promoter gene methylation and all 7 pts presented 1p and 19q deletions (p=0.03). Grade 3 lymphopenia was observed in 4 pts (11.1%) and 1 patient had G2 reversible renal toxicity. Conclusion: TMZ for 21 days every 28 is an active and well tolerated regimen in pts with LGG. The analysis to verify any correlation between molecular markers and clinical outcome is ongoing.

[Table: see text]

[Gastro-intestinal stromal tumours (GISTs): prognostic and therapeutic features]

The prognostic factors may be different evaluated. The biological behaviour is only hypothetical, according to the duration of symptomatology, the site and size of the tumour, the presence of hemorrhagic or necrotic areas, the cytological modifications and, above all, the number of mytosis: 5 mytosis x 50 HPF are considered significant for malignancy. In last thirty years we have reported 40 GISTs, mostly gastric. All of them have been operated on with simple enucleation or organ resection. In the benign GISTs (26 pts) we have reported early mortality only in 5 cases; in the borderline forms (6 pts), in 4 rapidly evolving cases, the tumour had > 5 cm in size and the mytosis were > 5 x 50 HPF. Also in the malignant GISTs we have noted a good correlation between survival and clinical and histopathological findings. As well in this experience the biological behaviour of GISTs is difficult in interpretation. Anyway the dimensions, the genetic modifications and the number of mytosis are considered good indicators for malignancy. We have always indicated a surgical treatment, enlarged according to the invasion of adjacent organs.

Area under the curve of methotrexate and creatinine clearance are outcome-determining factors in primary CNS lymphomas

Although high-dose methotrexate (HD-MTX) is the most effective drug against primary CNS lymphomas (PCNSL), outcome-determining variables related to its administration schedule have not been defined. The impact on toxicity and outcome of the area under the curve (AUC(MTX)), dose intensity (DI(MTX)) and infusion rate (IR(MTX)) of MTX and plasmatic creatinine clearance (CL(crea)) was investigated in a retrospective series of 45 PCNSL patients treated with three different HD-MTX-based combinations. Anticonvulsants were administered in 31 pts (69%). Age >60 years, anticonvulsant therapy, slow IR(MTX) (</=800 mgm(-2)h(-1)), and reduced DI(MTX) (</=1000 mgm(-2)wk(-1)) were significantly correlated with low AUC(MTX) values. Seven patients (16%) experienced severe toxicity, which was independently associated with slow CL(crea). A total of 18 (40%) patients achieved complete remission after chemotherapy, which was independently associated with slow CL(crea). In all, 22 patients were alive at a median follow-up of 31 months, with a 3-year OS of 40+/-9%; slow CL(crea) and AUC(MTX) >1100 micromol hl(-1) were independently associated with a better survival. Slow CL(crea) and high AUC(MTX) are favourable outcome-determining factors in PCNSL, while slow CL(crea) is significantly related to higher toxicity. AUC(MTX) significantly correlates with age, anticonvulsant therapy, IR(MTX), and DI(MTX). These findings, which seem to support the choice of an MTX dose >/=3 gm(-2) in a 4-6-h infusion, every 3-4 weeks, deserve to be assessed prospectively in future trials. MTX dose adjustments in patients with fast CL(crea) should be investigated.

[Risk factors of surgical wound infection]

Surgical Site Infection (SSI) continues to be a major source of morbidity following operative procedures. The aging of the population means that not only will the number of operations likely increase, but the National Nosocomial Infections Surveillance (NNIS) Risk Index, which standardizes the risk of SSI for an aging population, will be greater. The NNIS report for 1986-1996 described an SSI rate of 2.6% for all operations at the reporting hospitals. It seems likely that overall SSI rates are likely to be greater than reported. All surgical wounds are contaminated by bacteria, but only a minority actually demonstrate clinical infection. The SSI are the biological summation of several factors: the inoculum of bacteria introduced into the wound during the procedure, the unique virulence of contaminants, the microenvironment of each wound, and the integrity of the patients host defense mechanisms. Risk factors were studied in single and multivariate analyses. Although an SSI rate of zero may not be achievable, continued progress in understanding the biology of infection at the surgical site and consistent applications of proven methods of prevention will allow us to further reduce the frequency, cost, and morbidity associated with SSI.

Factors affecting prognosis in patients with short bowel syndrome

Aim of the study is to analyse physiopathological implications of massive intestinal resection and factors affecting prognosis in patients with short bowel syndrome. Twenty massive intestinal resections were performed. The causes of bowel resection were: intestinal infarction (11 cases), Crohn's disease (5 cases), small bowel volvulus (4 cases). All intestinal resections were more than 50-60% of the intestinal length. In eighteen patients intestinal anastomosis was performed immediately. In all the patients postoperative therapy with parenteral nutrition (PN) was performed. The operative morbidity and thirty-day mortality were respectively 30% (6 cases) and 35% (7 cases). The diarrhea was the dominant symptom. The average weight was 20% lower compared to the initial weight. The length of residual small bowel and type of anastomosis strongly affect survival of patients underwent massive intestinal resections. Parenteral nutrition (PN) has great importance in postoperative treatment. A useful treatment, in severe short bowel syndrome, can be small bowel transplantation.

Sentinel lymph node biopsy for sparing axillary dissection in selected patients with breast cancer

Axillary lymph nodal status in breast cancer remains one of the more important prognostic factors. In early breast cancer axillary lymph node metastasis are found only in 10-18%. It can be deduced that in all these patients a complete axillary dissection is an overtreatment. The concept of sentinel lymph node (SN) was applied to breast cancer. Of course if SN examination gives negative findings, the patient will avoid axillary lymphadenectomy. 134 patients with localized breast cancer were evaluated for enrollment into the study. In 40 (29.8%) patients lymphoscintigraphy was performed together with an injection of vital dye to identify the SN, in 94 (70.1%) only vital dye was utilized. The mapping procedure was successful in 129 cases (96.2%). In our study there was concordance between SNs and axillary nodes in 120 out off 124 cases (96.7%). The false-negative rate was 4.8% (4/83). The overall sensitivity of the SN biopsy was 91.1% (41/45), with a negative predictive value of 95.1% (79/83). Five patients had SN negative and they decided do not undergo axillary lymphadenectomy. This study demonstrates that accurate SN identification was obtained combining lymphoscintigraphy and blue dye. Moreover, each method requires a suitable learning curve. After an accurate training, complete axillary lymphadenectomy can be avoided in selected patients.

A multicenter study of treatment of primary CNS lymphoma

OBJECTIVE

To characterize the therapeutic variables correlated to outcome in 370 patients with primary CNS lymphoma.

METHODS

Planned treatment was radiotherapy (RT) in 98 patients, chemotherapy (CHT) in 32, RT followed by CHT in 36, and CHT followed by RT in 197 patients. High-dose methotrexate (HD-MTX; 1 to 8 g/m2) was used in 169 patients and intrathecal CHT in 109.

RESULTS

One hundred sixteen patients are alive (median follow-up 24 months), with a 2-year overall survival of 37%. Patients treated with CHT followed by RT had improved survival with respect to patients treated with RT alone. Patients receiving HD-MTX-based primary CHT survived longer than those treated with other drugs. HD-MTX associated with other cytostatics, in particular HD-cytarabine, produced better results than HD-MTX alone. No correlation between MTX dose and survival was found. In patients receiving HD-MTX, consolidation RT or intrathecal CHT did not improve survival. Age, performance status, lactate dehydrogenase serum level, CSF protein level, site of disease, and use of HD-MTX were all predictors of survival.

CONCLUSIONS

Combination CHT-RT is superior to RT alone. Patients treated with primary CHT containing HD-MTX exhibited improved survival. In these patients, the addition of HD-cytarabine was associated with a better survival, whereas intrathecal CHT was not correlated to outcome. RT may be unnecessary in patients achieving complete remission after receiving HD-MTX-based primary CHT.

Initial experience with sentinel lymph node mapping and biopsy in breast cancer. Preliminary results on 80 consecutive patients

Sentinel node biopsy, in breast cancer, is a promising surgical technique for predicting histological findings in the remaining axillary lymph nodes, especially in patients with clinically node-negative breast cancer. 80 patients with breast cancer were evaluated for enrollment in this study. For mapping procedure 32 patients underwent lymphoscintigraphy in combination with an injection of vital blue dye, while 48 utilized only vital dye. In all patients, after sentinel node (SLN) biopsy, a complete axillary dissection was performed. The mapping procedure was possible in 79 cases (98.7%). The SLNs were positive in 27 (34.1%), in 52 patients SLNs were negative and in 50 of these all axillary nodes were negative. There was concordance in 77/79 cases (97.4%). The false negative rate was 3.8% (2/52). The overall sensitivity of the SNL biopsy was 93.1% (27/29), with a negative predictive value of 96.1% (50/52). This study demonstrates that accurate SLN identification was obtained combining lymphoscintigraphy and blue dye. Moreover, each method requires a suitable learning curve. Further studies are needed to define an accurate patient selection and the most speedy and precise method for intraoperative histological examination of SLNs.

[Ano-rectal traumatic lesions. Etiology and treatment]

From January 1976 to December 2000, in the Surgical and Specialistic Sciences Department, Ist Chair of Surgical Physiopathology, University of Bari, we observed 13 cases of ano-rectal trauma. Except in wartime, these traumas are unusual. The aetiology is variable. In our experience we found 3 lesions due to firearms (24%), 2 patients with polytrauma after car accidents (15%), 3 iatrogenic lesions (24%), 1 lesion due to compressed air (7%), and 4 lesions due to objects used for autoeroticism (30%). Timely diagnosis and treatment were essential for a good outcome. The surgical choice was based on the patient's condition, the aetiology of the lesion and its anatomical site. We constructed 7 temporary colostomies and performed 2 Hartmann's operations. In 4 patients we extracted objects from the rectum. Four patients died.

[Diaphragmatic trauma: retrospective analysis of 25 patients]

Traumatic diaphragmatic injuries are increasing and they must be considered in every thoraco-abdominal trauma. The Authors carried out a retrospective analysis of 25 cases, whose diagnosis was often difficult due to the predominant clinical effects of associated injuries. All patients underwent surgical operation with laparotomy to achieve reduction of herniated viscera and repair of the diaphragmatic lesion.

[Acute colonic pseudoobstruction: physiopathology and treatment]

The acute colonic pseudo-obstruction is a rare condition. Pathophysiological knowledges, nowadays, are still discussed. Several associated pathological conditions (cardiological, neurological, metabolic) would mainly cause, with different mechanisms, a sympathetic-parasympathetic imbalance. In Authors' experience with 19 patients the sudden onset and the rapid evolution to a serious condition set the difference with a mechanical obstruction. The radiological control was essential to the therapeutic options. The endoscopic decompression was successful in 2 cases; the tube cecostomy was effective in 13; the right emycolectomy was necessary in 1 case with multiple diastasic cecal perforations. Mortality rate: 3 patients (15.70%).

Prognostic factors in breast cancer: the predictive value of the Nottingham Prognostic Index in patients with a long-term follow-up that were treated in a single institution

The Nottingham Prognostic Index (NPI) is an index, derived from a retrospective multivariate study, that is able to predict survival in patients with breast cancer. The index is based on tumour size, lymph node stage and histological grade and allows the stratification of patients into three different prognostic groups. The aim of this study was to verify, according to our experience with a long-term follow-up, the effect of some prognostic variables on survival and to establish the independent influence of each of them by means of a survival regression analysis. Then we applied the NPI to the same group of patients in order to assess the predictive power and reproducibility of the index. 402 patients treated from January 1979 to December 1987 were evaluated. In multivariate analysis (Cox proportional hazard model), only size, lymph node involvement and histological grade remained independent prognostic factors. The survival curves obtained after applying the NPI are similar to those for the factors with independent prognostic significance derived from our multivariate analysis. Our improved survival rates may be attributed to the administration of adjuvant therapies to a larger number of patients. The NPI allow us to accurately predict prognosis and we advocate its more common use.

[Hartmann's operation in acute perforated diverticulitis]

Acute perforated diverticulitis of the colon is still a serious clinical event that requires an emergency treatment which is based upon clinical staging and pathological characteristics. Surgical treatment, performed in Hinchey's stages III and IV, is correlated with the presence of infection in the peritoneal cavity: it is always necessary to remove the septic focus, but there are different reconstruction strategies. The resection of the diseased colonic segment can be performed with primary anastomosis or Hartmann's operation with reconstruction in a later time. In our experience, based on 97 patients (33 of which, Hinchey's III and IV, underwent emergency surgical treatment) we preferred Hartmann's operation which carries a low risk of mortality in seriously ill patients.

Improved acceptability of laparoscopic surgery and increasing rate of cholecystectomy implications for surgeon and patients

BACKGROUND/AIMS

The aim of our study was to evaluate the impact of introduction of laparoscopic cholecystectomy (LC) and reasons for the increase in cholecystectomy rate, by a retrospective review of all admissions for gallbladder disease before and after the introduction of laparoscopic surgery in our department.

METHODOLOGY

Chi-squared test was used for statistical analysis of the comparisons.

RESULTS

Comparing the 2 periods, cholecystectomy rate increased by 35% (p<0.01) and patients aged 25-44 years were more likely to undergo LC (p<0.001); a 35% decrease in unjustified refusal (p<0.02) was also observed. The number of both longstanding disease patients and asymptomatic ones operated upon was not different (p=1; p=0.06), while a 46% increase (p=0.02) in cholecystectomy rate was shown in patients with low-grade symptoms or at 1st colic episode.

CONCLUSIONS

An increase in the patient pool due to improved acceptability was responsible for the increase in cholecystectomy rate after introduction of laparoscopic surgery, rather than lowered surgical threshold, as previously suggested by other authors. Judiciousness is required to prevent the increased acceptability of LC from leading to its uncontrolled and unrestricted use, as alteration of the surgical threshold may occur without surgeon awareness, particularly when dealing with low grade symptomatic patients.

[Use of filgrastim, granulocyte colony stimulating factor (G-CSF), in radiotherapy to reduce drop-outs because of radiogenic leukopenia]

Radiotherapy patients are at risk of developing leukopenia, which risk depends on the irradiated volume, the rate of irradiated bone marrow and the radiation dose. Radiogenic leukopenia may cause radiotherapy drop-out, with consequent effects, on local tumor control and clinical outcome. The introduction of granulocyte growth factors, such as filgrastim, has permitted to accelerate normal neutrophil count recovery in irradiation-related neutropenia both in vitro and animal models; clinical experience in humans is still lacking, relative to both indications and scheduling. In the Oncologic Radiotherapy Department of Treviso Hospital, 31 patients irradiated for Hodgkin disease, rectal cancer and other malignancies, who presented leukopenia requiring treatment discontinuation, were given filgrastim to assess its actual effect in avoiding further drop-outs and to compare two administration schedules (2 or 3 vials, 30 MIU, weekly). Filgrastim treatment was continued throughout the radiotherapy cycles, for 1 to 5 weeks. Eighteen patients had received previous chemotherapy and 11 were undergoing concurrent 5-fluorouracil chemotherapy-irradiation. A mean 203% increase in leukocyte count was observed (136% in the patients treated with 2 vials/week and 274% in those receiving 3 vials/week); this increase was more apparent in women that in men (256% versus 91%) and slightly higher in patients 50 years old and with target volumes < 5000 ml. Filgrastin treatment was well tolerated by all patients, with no discontinuations due to adverse effects; 9 patients (29%) reported skeletal pain, which was marked in 2 of them only. Eighty percent of patients completed all the radiotherapy cycles with no discontinuation, while 6 patients dropped out because leukopenia persisted. Biweekly filgrastim administration was effective to prevent unscheduled radiotherapy discontinuation in 75% of patients and triweekly administration was effective in 86% of patients. In our experience, filgrastim administration was well tolerated and effective in decreasing the irradiation drop-outs caused by treatment-related leukopenia. Since this drug is rather expensive, we decided to use routinely the lower dosage of biweekly administration (with one vial given on Friday and Saturday, to permit neutrophil recovery during the day off) and to reserve the higher dosage (3 vials a week) to the patients with large body areas, big target volumes and persistent leukopenia during previous chemotherapy.

[Hypersplenism in surgery]

We studied 86 patients suffering from hypersplenism, associated with portal hypertension (39 patients), hematologic disease (45 patients) and with Gaucher's disease (2 patients). Inclusion criteria were the presence of thrombocytopenia < 100.000 x mm3 and leucopenia < 4.000 x mm3. No meaningful differences about the improvement of hypersplenism in portal hypertension were observed between the patients submitted to shunt and splenectomy and those submitted to shunt only. On the contrary, splenectomy caused a quick normalization of the leukothrombocytopenia in the patients suffering from hematologic disease, which, moreover, allowed to perform radio- and chemotherapy in those suffering from malignancies. We reported absence of mortality and a low and aspecific morbidity.

[Rare causes of serious digestive hemorrhages]

The rare causes of massive hemorrhage in the gastrointestinal tract are not completely classifiable. They are characterized by high variability, as shown in several isolated reports. In our experience of 17 cases, clinical and endoscopic features were sometimes typical of a rare pathology, others were referable to common pathologies and exactly diagnosed only by angiography or surgery. Our experience points out the difficulties in the surgical prescription and timing, when the endoscopic diagnosis was lacking or unsure, or when a massive haemorrhagic recurrence forced diagnostic laparatomy. The role of endoscopy and the advantages of intraoperative enteroscopy have been compellingly demonstrated. Diagnostic and therapeutic angiography has been the main method in vascular hemorrhage.

[Can the prophylactic treatment of mycotic mucositis improve the time of performing radiotherapy in head and neck tumors?]

Radiotherapy-related mucositis is the most frequent complication in the patients submitted to irradiation for head and neck cancers. Many such patients may develop mycotic infections which may lead to treatment discontinuation, with possible consequences on the local control of these cancers. In this study, we investigated the efficacy of fluconazole in preventing mycotic mucositis in 80 patients undergoing radiation therapy for head and neck cancers. The patients were randomized to two groups: 41 patients in group A received the supporting treatment we usually administer, plus fluconazole (50 mg/day) starting from the 6th irradiation session throughout the treatment; 39 patients in group B received the same baseline treatment, but were given the drug only when mycotic infections appeared. The clinical characteristics, treated sites, treatment doses and volumes were similar in the two groups of patients. Fluconazole was well tolerated and no early or late toxicity was observed. We had 1 mycotic mucositis and 14 non-scheduled treatment discontinuations in group A, vs. 19 and 30, respectively, in group B. Radiation therapy lasted 52.3 days (mean) in group A and 55.6 days (mean) in group B; the differences were statistically significant. In our experience, fluconazole, used prophylactically from the 6th radiotherapy session on, reduced the number of mycotic infections and improved radiotherapy schedule in our head and neck cancer patients.