Endoscopic Treatment of Postradiation Strictures

Background

Esophageal stricture is a rare complication of radiotherapy: reports on its incidence and management are therefore anecdotal.

Methods

From January 1978 to September 1992, 44 patients presenting with an esophageal stricture related to a previous radiation treatment were endo-scopically dilated at the Endoscopy Division of the Istituto Nazionale Tumori of Milan.

Results

Esophageal recanalization was obtained in 95 % of the patients treated, and in 79 % of these normal eating habits were restored. No strict correlation was observed between radiation dose and severity of the stricture, or time elapsed between first treatment and endoscopic dilation.

Conclusions

In our experience, endoscopic dilation was a safe effective procedure and represented an effective palliative tool in dysphagic patients with esophageal strictures due to previous local radiotherapy.

Laparoscopy in Staging and Restaging of 95 Patients with Ovarian Carcinoma

The merits of laparoscopy with inspection of diaphragmatic leaves were studied in 95 patients with ovarian carcinoma. Laparoscopy was positive in 19 out of 27 new cases, 11 out of 47 patients previously treated and in apparent complete remission, and 12 out of 21 patients previously treated and with disease. Thirty-one out of 95 patients were shown to have diaphragmatic metastases alone and/or associated with other localizations of disease. In 5 out of 27 new cases the stage was modified after laparoscopy. The histologic-endoscopic correlation was correct in 28/36 positive cases (78 %) and in 31/32 negative cases (97 %). In conclusion, all patients with ovarian carcinoma should be subjected to laparoscopy as staging and restaging before undergoing laparotomy.

Immunohistochemical Reactivity of a Monoclonal Antibody Prepared against Human Ovarian Carcinoma on Normal and Pathological Female Genital Tissues

The reactivity profile of the monoclonal antibody (MAb) MOv18, raised against a poorly differentiated ovarian carcinoma specimen, was studied on normal tissues and tumors from the female reproductive system and on the kidney, which like the oviducts, vagina and uterus, also derives from the intermediate mesoderm. The obtained results indicate that MOv18 recognizes an epitope present on the normal epithelium of the oviducts, on 14-week old fetal kidney and, focally, on proximal and distal tubules of normal adult kidney. A strong reactivity was found on ovarian carcinomas, on invasive squamous carcinomas of the cervix and on endometrial carcinomas and hyperplasias. The antigen recognized by MOv18 (CaMOv18) therefore seems to be an epithelial cell marker associated with intermediate mesoderm differentiation, which can be derepressed during the neoplastic transformation of the ovary and the uterus.

Risk of Colorectal Cancer following Colonoscopic Polypectomy

Aims and Background

To follow a cohort of patients who had undergone polypectomies in order to assess the overall risk of subsequent colorectal cancer in relation with various adenomas characteristics.

Methods

A total of 1,063 patients with adenomatous polyps of the large intestine were treated between 1979 and 1996 at the National Cancer Institute of Milan, during a screening program for colorectal carcinoma. Data on patients who had undergone colonoscopies were collected prospectively. The relation between colorectal cancer and adenomas characteristics was assessed by computing the hazard ratio (HR) values and corresponding confidence intervals (95% CI), according to Cox.

Results

Of the 1,063 patients who met the eligibility requirements, 672 had single adenomas (63.2%) and 391 had multiple adenomas (36.8%). Histological examination revealed 743 cases of tubular adenoma, 196 cases of tubulo-villous adenoma, and 96 cases of villous adenoma. High-grade dysplasia was found in 3.1% of the cases. During the 8,906 persons/year of follow-up, adenocarcinomas of the large bowel developed in 11 patients. Several adenomas’ characteristics at index polypectomy were significant predictors of colorectal cancer occurrence. In univariate analysis the risk of colon cancer was significantly related with multiple adenomas (HR 4.2, 95% CI 1.1-6.5), high-grade dysplasia adenomas (HR 10.0, 95% CI 2.6-38.1) and with adenomas larger than 2 cm (HR 5.0, 95% CI 1.2-20.4). A multivariate stepwise procedure confirmed that the presence of multiple adenomas and presence of high-grade dysplasia are the most important predictors of carcinomas. Hazard ratios for colorectal cancer occurrence, from multivariate Cox's model, were 5.1 (95% CI 1.2-19.9) for multiple compared to single adenomas, and 13.0 (95% CI 3.6-50.7) for adenomas with high-grade dysplasia compared to those with low-grade dysplasia.

Conclusions

High-grade dysplasia, number and size of adenomas were confirmed as the major cancer predictors. Based on this conclusion, a subgroup of patients, who may benefit from intensive surveillance colonoscopy, can be identifiable.

MOv18 Monoclonal Antibody in Diagnostic Applications: Capability to Recognize the Histotype of the Original Tumor

Cells from 52 ascitic fluids and 28 abdominopelvic cavity washings, obtained from 46 ovarian cancer patients, 17 patients bearing malignancies of non ovarian sites and 17 patients with non-malignant ovarian diseases, were tested using 2 methods: traditional cytology and monoclonal antibody immunofluorescence. The immunologic test using the MOv18 MAb, raised against ovarian carcinoma, revealed immunoreactive cells in 83 % of the 36 cytologically positive fluids and in one of the 8 negative fluids from ovarian carcinoma patients and in 18% of the 17 fluids from patients with non-malignant ovarian disease. Forty six cytologically positive ascitic fluids from malignant patients were analyzed in order to evaluate the ability of this MAb to identify the histotype of metastatic cells. Ninety-three percent (26/28) of the effusions from non-mucinous ovarian carcinomas contained MOv18-positive cells, whereas no reactive cells were found in cytologically malignant fluids from patients with ovarian tumors of other oncotypes or with carcinomas of non-ovarian origin. The MOv18 reagent, used as an adjuvant in cytological analysis, can help in the identification of the histotype of metastatic cells of unknown origin.

Evaluation of Quality of Life in Patients with Malignant Dysphagia

Background

In the last 10 years of clinical research there has been increasing interest in the evaluation of quality of life. Several generic and specific instruments have been developed for this purpose. EORTC QLQ C-30 is a cancer-specific questionnaire translated into various languages and validated in several European countries including Italy, where the impact of malignant disease on different areas of quality of life is poorly documented.

Methods

The EORTC QLQ C-30 was administered to 109 patients referred to the endoscopy division of the Istituto Nazionale Tumori, Milan, for endoscopic palliative treatment of malignant dysphagia to test its characteristics in terms of acceptability and clinical validity.

Results

In this group of patients the impact of advanced esophageal cancer was highly evident for Emotional and Physical Functioning, Fatigue and Global QoL scales. Dysphagia is a serious problem for many patients; there is a correlation between grade of dysphagia and four QoL dimensions.

Conclusions

QoL assessment is an important tool to evaluate the adequate management of patients with esophageal cancer. The EORTC QLQ-C30 questionnaire proved to be valid and reliable also in this population.

Laparoscopy Combined with Peritoneal Cytology in Staging and Restaging Ovarian Carcinoma

The merits of laparoscopy, with inspection of the diaphragmatic leaves, and of peritoneal cytology (free fluid or washing) in staging and restaging were studied in 153 patients with ovarian carcinoma. Of 153 patients examined, 83 were new cases, 34 were restaging in patients without clinical and/or radiological signs of disease, and 36 in patients with evident disease. The conversion rate for diaphragmatic metastases alone was 6%. Information about the spread of disease (diaphragmatic metastases) was obtained in 33 new cases (39.7%). In pretreated patients, laparoscopy was positive in 4 of 34 NED restaging and in 24 of 36 ED restaging. The conversion rate for peritoneal cytology was 6.6%, but information about the cellular intraperitoneal spread of the disease was obtained in 31 new cases (37.8%). In pretreated patients, peritoneal cytology was positive in 4 of 34 NED restaging and in 13 of 36 ED restaging.

Accuracy of the Double Contrast Enema in Evaluation of the Abdominal Diffusion of Ovarian Carcinoma

The results of 103 double contrast enemas in 72 patients with ovarian carcinoma (stage III and IV) were compared with laparoscopic and/or laparotomic findings at comparable times. The evaluation of the validity of radiology in detecting the presence of abdominal disease showed an 84% overall accuracy, 75% specificity and 86% sensitivity. The accuracy in detecting signs of adhesion and parietal infiltration of the large bowel was 76.3%, due to the limited size of most of the lesions. Forty-seven of the 72 patients underwent a double contrast enema and laparoscopy during presurgical staging: accuracy in detecting lesions was the same for both examinations (80.4%). When double contrast enema and laparoscopy were used together in the evaluation of abdominal extension of the disease, the diagnostic accuracy rose to 93.6%.

7th SOSORT consensus paper: conservative treatment of idiopathic & Scheuermann's kyphosis

: Thoracic hyperkyphosis is a frequent problem and can impact greatly on patient's quality of life during adolescence. This condition can be idiopathic or secondary to Scheuermann disease, a disease disturbing vertebral growth. To date, there is no sound scientific data available on the management of this condition. Some studies discuss the effects of bracing, however no guidelines, protocols or indication's of treatment for this condition were found. The aim of this paper was to develop and verify the consensus on managing thoracic hyperkyphosis patients treated with braces and/or physiotherapy.

METHODS

The Delphi process was utilised in four steps gradually modified according to the results of a set of recommendations: we involved the SOSORT Board twice, then all SOSORT members twice, with a Pre-Meeting Questionnaire (PMQ), and during a Consensus Session at the SOSORT Lyon Meeting with a Meeting Questionnaire (MQ).

RESULTS

There was an unanimous agreement on the general efficacy of bracing and physiotherapy for this condition. Most experts suggested the use of 4-5 point bracing systems, however there was some controversy with regards to physiotherapeutic aims and modalities.

CONCLUSION

The SOSORT panel of experts suggest the use of rigid braces and physiotherapy to correct thoracic hyperkyphosis during adolescence. The evaluation of specific braces and physiotherapy techniques has been recommended.

Radioactive and conventional pollutants accumulated by edible mushrooms (Boletus sp.) are useful indicators of species origin

Concentrations of artificial radionuclides and trace elements in Boletus samples collected in different areas of the world were detected, respectively, by gamma spectrometry and neutron activation analysis. The particular commercial value of Boletus edulis, B. aestivalis, and B. pinophilus from the Taro Valley (Parma, Italy) has often stimulated local factories to trade edible Boletus imported from several areas of the world as the real Taro Valley mushroom. Starting from this evidence, the calculation of the Chernobyl radioactive contamination in the mushrooms coupled with the presence of particular stable elements and their concentration factors has been demonstrated to be a potential useful tool for identifying the real origin of the samples. In fact, major differences in the radiocesium activity levels and trace element presence were observed even in mushrooms collected in nearby valleys. The radiometric data are supported by the statistical analysis. In particular, both the principal component analysis and the concentration distribution along a regression line support the idea of two different clusters: one referred to the "king boletus" of the Taro Valley and another one to the other conspecific samples from different ecosystems.

Determinants of Helicobacter pylori seroprevalence among Italian blood donors

BACKGROUND/AIM

Helicobacter pylori is a worldwide infection. It is estimated that approximately 50% of the general population is affected, but this percentage varies considerably between countries. To investigate the prevalence of H. pylori infection, a cross-sectional epidemiological study, based on the serological determination of the IgG antibodies against H. pylori, was carried out in healthy Italian blood donors by using a commercially available kit.

METHODS

From March 1995 to March 1997, a total of 2598 consecutive volunteer blood donors were tested for the presence of antibodies against H. pylori. All patients answered a detailed questionnaire which collected sociodemographic characteristics, and smoking, alcohol drinking and dietary habits. Test-positive subjects with gastrointestinal symptoms underwent endoscopy, with biopsies taken for histological diagnosis.

RESULTS

The global prevalence of H. pylori infection in our study was 1161/2598 (45%). It was directly correlated with age (67% in subjects aged > or = 50 years). The prevalence of H. pylori infection was higher in men (46.4%) than women (38.4%), and more frequent in patients with a low educational level, in the lower quintile of height and in the upper quintile of body mass index (BMI). No significant association with smoking and alcohol drinking was found. Inverse associations were found with elevated consumption of milk (chi-square for trend 5.49, P < 0.05), but not other examined food groups. Multivariate analysis selected sex, age, BMI and educational level as the variables independently related to H. pylori infection.

CONCLUSION

This study confirms relatively high prevalence of H. pylori seropositivity among Italian healthy adults and points to sex, age, BMI and sociocultural class as persisting determinant features of H. pylori infection.

Reducing colorectal cancer mortality by repeated faecal occult blood test: a nested case-control study

Randomised trials have shown the efficacy of faecal occult blood testing (FOBT) in reducing colorectal cancer mortality, but observational studies are needed to monitor such efficacy in population programmes. We conducted a nested case-control study on a cohort of 21,879 subjects who participated in a colorectal screening programme from 1978 to 1995, undergoing at least one FOBT test. 95 fatal cases of colorectal cancer were eligible for the study. For each fatal case, 5 non-fatal matched controls were randomly selected from the cohort. FOBT screening history was less common among cases than controls. The odds ratio of colorectal cancer mortality among 'attenders' (defined as those who underwent a second FOBT within 2 years of study entry) with respect to 'non-attenders' was 0.64 (95% confidence interval 0.36-1.15). We also computed odds ratios defining exposure as one or more tests in the detectable preclinical period, hypothesising various lengths for the latter, which, however, yielded an efficacy estimate biased towards the null. A strong inverse relationship was observed between mortality and the number of tests, but this phenomenon is interpretable as 'healthy screenee bias'. The results suggest that the potential efficacy in preventing colorectal cancer mortality through annual FOBT screening may be of the order of one third.

Survival of patients with hereditary colorectal cancer: comparison of HNPCC and colorectal cancer in FAP patients with sporadic colorectal cancer

Conflicting data exist on the prognosis of hereditary colorectal cancer. HNPCC patients, in particular, are often reported to have a better survival. We examined 2,340 colorectal-cancer patients treated in our Institution: 144 HNPCC patients (Amsterdam Criteria), 161 FAP patients and 2,035 patients with sporadic cancer. Data on hereditary-cancer patients treated between 1980 and 1995 was collected in a registry. The 2,035 sporadic colorectal-cancer patients (controls) included all new cases treated in the Department of Gastrointestinal-Tract Surgery during the same period. Observed survival was estimated using the Kaplan-Meier method. Cumulative survival probability was estimated at 5 years within each group and stratified by various clinical and pathological variables. The age distribution at diagnosis of sporadic patients was significantly higher than that of FAP and HNPCC patients (median 60 years vs. 43 and 49 years; p < 0.0001). In the HNPCC group, 40% had a right cancer location, vs. 14% in the FAP group and 13% in the sporadic-cancer group. In the sporadic group, 51% were early-stage cancers (Dukes A or B) vs. 48.4% and 52.1% in the FAP and HNPCC groups respectively. In the HNPCC, FAP and sporadic-cancer groups, the 5-year cumulative survival rate was 56.9%, 54.4% and 50.6% respectively. Survival analysis by the Cox proportional-hazards method revealed no substantial survival advantage for HNPCC and FAP patients compared with the sporadic group, after adjustment for age, gender, stage and tumor location. The hazard ratio for HNPCC was 1.01 (95% CI 0.72-1.39) and 1.27 (95% CI 0.95-1.7) for FAP patients compared with the sporadic-colorectal-cancer group.

Survival of patients with hereditary colorectal cancer: comparison of HNPCC and colorectal cancer in FAP patients with sporadic colorectal cancer

Conflicting data exist on the prognosis of hereditary colorectal cancer. HNPCC patients, in particular, are often reported to have a better survival. We examined 2,340 colorectal-cancer patients treated in our Institution: 144 HNPCC patients (Amsterdam Criteria), 161 FAP patients and 2,035 patients with sporadic cancer. Data on hereditary-cancer patients treated between 1980 and 1995 was collected in a registry. The 2,035 sporadic colorectal-cancer patients (controls) included all new cases treated in the Department of Gastrointestinal-Tract Surgery during the same period. Observed survival was estimated using the Kaplan-Meier method. Cumulative survival probability was estimated at 5 years within each group and stratified by various clinical and pathological variables. The age distribution at diagnosis of sporadic patients was significantly higher than that of FAP and HNPCC patients (median 60 years vs. 43 and 49 years; p < 0.0001). In the HNPCC group, 40% had a right cancer location, vs. 14% in the FAP group and 13% in the sporadic-cancer group. In the sporadic group, 51% were early-stage cancers (Dukes A or B) vs. 48.4% and 52.1% in the FAP and HNPCC groups respectively. In the HNPCC, FAP and sporadic-cancer groups, the 5-year cumulative survival rate was 56.9%, 54.4% and 50.6% respectively. Survival analysis by the Cox proportional-hazards method revealed no substantial survival advantage for HNPCC and FAP patients compared with the sporadic group, after adjustment for age, gender, stage and tumor location. The hazard ratio for HNPCC was 1.01 (95% CI 0.72-1.39) and 1.27 (95% CI 0.95-1.7) for FAP patients compared with the sporadic-colorectal-cancer group.

Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space

BACKGROUND

The management of postoperative leaks into the mediastinum or pleural cavities after esophageal surgery yields unsatisfactory results. A recently described method, drainage of the mediastinum or pleural cavity through suture line defects, has been used in our department with eight patients.

METHODS

A suction tube was advanced over an endoscopically placed guide wire into the abscess from inside the esophagus, and gentle aspiration was used to remove saliva and secretions. Intravenous antibiotics and total parenteral nutrition were also given.

RESULTS

The sepsis was rapidly controlled, and the abscess cavity progressively collapsed in all cases. Seven patients recovered and were discharged 34 to 61 days after operation; one died of concomitant complications.

CONCLUSIONS

This method seems promising for the management of intrathoracic esophageal leaks.

Prevention and treatment of complications after endoscopic prostheses placement in tumors of the upper gastrointestinal tract

Endoscopic intubation is a popular palliative method to resolve immediately malignant dysphagia. However, the complication rate is still high. Between 1978 and 1993, at the Division of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori in Milan, 305 patients suffering from malignant dysphagia, were endoscopically treated by insertion of an endoprosthesis. We report the analysis of data regarding our complication rate, compared with the literature, and our experience in preventing managing complications related to this endoscopic procedure.

Treatment of malignant polyps

From 1975 to 1993, at the Division of Diagnostics and Endoscopic Surgery of the Istituto Nazionale Tumori in Milan, 191 malignant adenomas of colon-rectum have been endoscopically removed. On the basis of histopathologic criteria, endoscopic treatment has been judged adequate in 102 cases (53%), not adequate in 44 (23%), doubtfully adequate in 45 (24%). In 84 patients (44%) endoscopic polypectomy has been followed by surgical resection of the involved intestinal tract, 107 patients (56%) have been treated only by endoscopy. Results have been evaluated on the basis of surgical specimen, clinical follow-up and survival, showing that criteria we have adopted for the adequacy of the endoscopic treatment have a high negative predictive value (96%) and a low positive predictive value (32%). Actuarial survival of patients treated only endoscopically is 97% at 5 years and 95% at 10 years.

Endoscopic stent placement for cancer of the lower esophagus and gastric cardia

We reviewed our results of using stents for palliation of cancer of the lower third of the esophagus and gastric cardia. During a 14-year period, 76 patients with either lower third esophageal cancer (n = 43) or cancer of the gastric cardia (n = 33) received stents for palliation of malignant dysphagia. Successful endoscopic placement was initially achieved in all patients, with 71 patients available for follow-up. Of these, 40 (56%) were subsequently able to eat solid or semi-solid food, 25 (35%) could swallow only liquids, and 6 (8%) were unimproved. The combined early and late complication rate totalled 22%. Early complications included perforation (n = 3) and stent migration (n = 4); late complications consisted of dislodgment (n = 6), obstruction by tumor (n = 2), and severe esophagitis (n = 1). There were no procedure-related deaths, but survival at 1 year was estimated to be only 1.5%, with a median survival of 2.5 months after stent insertion. The endoscopic placement of prosthetic stents for cancer of the distal esophagus and gastric cardia entails a higher complication rate, less successful palliation, and shorter survival time compared to similar treatment for more proximal esophageal cancer.

Endoscopic treatment of polyps in the resected stomach

Between 1974 and 1992, at the Department of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori, in Milan, 27 patients with resected stomach and suffering from epithelial polyps of the gastric stump (10 lesions) and/or anastomosis (25 lesions), were endoscopically treated using electroresection (13 cases), electrocoagulation (2 cases), combined methods (electroresection plus Nd:YAG photocoagulation) (1 case) and biopsy forceps (19 cases). Complications occurred in 4 cases and consisted of hemorrhage. Seven patients developed 15 recurrences. Endoscopic treatment of polyps in patients with resected stomach is a safe and effective treatment, considering the low rate of complication.

Endoscopic treatment of gastric carcinoids

Carcinoids are the most common endocrine tumours, and arise from a multipotential primitive stem cell; the gastric location represents 2% of all carcinoids. From 1979 to 1992 at the Endoscopy Division of Istituto Nazionale Tumori, Milan, 2 patients suffering from single gastric carcinoid were endoscopically treated by electro-resection. No complication occurred during the treatment; 2 year- and 5-year-follow-up was performed in these patients, and no recurrence are observed. Surgical treatment represents the therapy of choice for gastric carcinoids, but endoscopic resection can represent an alternative in selected cases (lesions less than 1 cm or carcinoids with multicentric growth). Endoscopy can be used also in patients at high surgical risk.

Endoscopic treatment of upper gastrointestinal tract malignancies

Palliative endoscopic treatment of the upper gastro-intestinal (UGI) tract includes: dilation, Nd:YAG laser photocoagulation and intubation, used alone or in combination. These procedures are usually performed on an outpatient basis and are associated with a low rate of morbidity and mortality. From 1978 to 1992, 836 patients were treated at the Endoscopy Division of the Istituto Nazionale Tumori, Milan, for inoperable primary or recurrent malignancies of the UGI-tract. Recanalization was obtained in 96% of patients treated; functional results have been computed according to the site and to the endoscopic method. Overall median survival was 6.2 months. The complication rate was 8%. Relief of dysphagia is the goal of palliative treatment in patients with inoperable neoplasms of the UGI-tract.

Endoscopic treatment of malignant dysphagia

Palliative endoscopic treatment of dysphagia in patients with inoperable oesophageal cancer includes: dilation, Nd:YAG laser photocoagulation and intubation, used alone or in combination. Such procedures are usually performed on an outpatient basis and are associated with a low rate of morbidity and mortality. From 1978 to 1988, 476 patients (401 males, 75 females) were treated at the Endoscopy division of the National Cancer Institute of Milan for inoperable primary or recurrent malignancies of the oesophagus or cardia or for extra-oesophageal neoplasms causing dysphagia. Dilation was used in 172 cases, Nd:YAG laser photocoagulation in 90, prosthesis insertion in 72, dilation and laser in 97, and prosthesis and laser in 45. Functional improvement was reported in 75% of patients after dilation, in 89% after laser treatment, in 80% after intubation, in 80% after dilation and photocoagulation, and in 89% after laser and intubation. The median duration of dysphagia-free interval was 4 weeks in dilated patients, 6-8 weeks in photocoagulated patients and 20 weeks intubate patients. Overall median survival was 6.2 months. The complication rate was: 1.4% in dilation treatment, 1.4% in laser photocoagulation, and 8.8% in prosthesis intubation. Mortality related to endoscopic treatment was 2.1% (10/476 patients). Relief of dysphagia is one of the most important goals of palliative treatment in patients with inoperable oesophageal neoplasms. Moreover, endoscopic palliation improves the quality of life in the patients, with a low complication rate.

Two-step endoscopic resection of gastric leiomyomas

Our two-step technique for endoscopic treatment of gastric leiomyomas is illustrated. From January 1979 to June 1991, nine symptomatic patients with sessile leiomyomas of the stomach were treated at the Endoscopy Division of Istituto Nazionale Tumori, Milan. The diagnosis was achieved by means of endoscopic observation of the lesion and, when possible, by ultrasound endoscopy. This new technique consists of first removing superficial portion of the tumor by electrosurgical snare. Second, a cleavage plane is found within the proper muscle layer; the tumor is enucleated as much as possible by tightening the snare around it and creating a pseudo-stalk. No major complication occurred nor were any recurrences observed at 21.8 months in the 7/9 patients treated by endoscopy alone. Endoscopic therapy was performed on an outpatient basis and only large lesions required short hospitalization.

Esophageal intubation for malignant fistulas

Between April 1978 and December 1989 at the Endoscopy Division of the National Cancer Institute of Milan, 140 patients were intubated for esophageal neoplasms; 19 of these subjects underwent endoscopic intubation for malignant fistulas complicated by pneumonia and/or mediastinitis. The prostheses were tolerated well and enabled the restoration of oral nutrition. The mean survival was 4.7 months (range, 0.5-17 months). No major complications occurred. Tube dislodgement was observed in 2 cases (10.5%). Two patients died of causes that were not related to the procedure.

Laparoscopic repair of full-thickness stomach injury

A case of laparoscopic repair of gastric perforation caused by a trocar is reported. Suturing was carried out by the apposition of clips. The potential advantages of this approach are that the treatment is performed at the time of the complication, the duration of the operation is reduced, and the discharge of the patient from hospital is accelerated.

[The endoscopic treatment of gastric adenomas]

Endoscopic polypectomy is the treatment of choice in symptomatic polyps of the stomach. From 1974 to 1989, at the Endoscopy Division of National Cancer Institute of Milan, 37 patients underwent endoscopic polypectomy, to remove 55 gastric adenomas. Areas of malignancy were revealed in 3 patients. Two of them, not operable for advanced age and poor general conditions, are controlled endoscopically. Endoscopic polypectomy can be performed on an outpatient basis or with a short period of hospitalization. It represents the only form of therapy in not operable patients. Furthermore this method allows to prevent the malignant transformation of the adenomas, which, as reported in the literature, ranges between 3.4% to 66.5%. Our experience confirms the validity of this technique which is safe and effective.

[Endoscopic polypectomy of the stomach]

Until 1970 endoscopy of the digestive tract was the only diagnostic method available. After this date, the introduction of endoscopic polypectomy enabled patients affected by these lesions to be treated, and at the same time considerably reduced their length of stay in hospital. The paper reports the results of 346 gastric polypectomies performed in 187 patients from 1974 to the present.

[Endoscopic treatment of colorectal polyps in children]

In paediatric patients colorectal polyps are less frequent than in adults. In infancy, more than 70% of colorectal polyps are non-neoplastic (juvenile or amartomatous). Intestinal and pharmacological preparation are different in children with respect to adults. In infants and young children, endoscopic polypectomy is performed under general anaesthesia. From the technical viewpoint, there are no substantial differences between adult and paediatric patients. Moreover, the fact that juvenile polyps are not neoplastic in nature, generally influences the modalities of follow up. In the Division of Endoscopy of the I.N.T., from 1974 to 1987, 33 colorectal polyps were removed in 20 patients (13 M, 7 F). The age range was 2 to 14 years. Only one complication was observed: a post-polypectomy bleed, which was treated endoscopically. Histologically, there were 18 juvenile polyps, 6 hyperplastic polyps, 1 tubular adenoma; 8 polyps (6 in the same patient) were not retrieved.

First-line chemotherapy with intraperitoneal cisplatin and intravenous cyclophosphamide in ovarian carcinoma. A preliminary report

Between August 1982 and October 1986, the feasibility and activity of five cycles of intraperitoneal (i.p.) cisplatin (CDDP) (90 mg/m2 in 6 h dwelling) and i.v. cyclophosphamide (600 mg/m2) were studied in 24 previously untreated patients with ovarian carcinoma having small or no residual disease after cytoreductive surgery. Six patients (25%) had local complications requiring catheter removal before the end of therapy. Fifteen of the 21 patients (71%) evaluable for activity achieved or maintained a pathologic complete remission. The median disease-free survival was 29+ months (range 18-58+ months). Three patients with tumor progression (two patients previously without evidence of disease, and one patient with minimal residual disease), and three partial responders were documented by laparotomy at the end of therapy. Two patients who achieved pathologic complete response relapsed at 20 and 36 months. All treatment failures (eight cases, 38%) occurred in the peritoneal cavity. Since patients were selected for having the most favorable tumor characteristics to benefit from i.p. treatment, our findings may cast some doubt on the actual contribution of i.p. CDDP at a dose of 90 mg/m2 in the treatment of patients with ovarian carcinoma and small residual disease in the peritoneal cavity.

Sensitivity of Hemoccult test for large bowel cancer in high-risk subjects

From 1979 to 1982, 1233 symptom-free subjects at high risk for colon cancer because of family history and/or personal history of bowel neoplasia (cancer or adenomatous polyp) were examined with a guaiac test (Hemoccult II) for occult blood in stools. The test was positive (H+) in 98 subjects (7.9%). Endoscopy was subsequently performed on 86% of the H+ and on 64% of the H- subjects. Of 20 in invasive cancers found, 15 had been H+ [75.0%; 95% confidence interval (CI), 54.3-91.0%]. Of 96 patients with adenoma(s), 23 were H+ (24%; 95% CI, 16.0-33.0%). However, the sensitivity for adenomas was higher in patients with multiple adenomas or with a single adenoma measuring 2 cm or more in its largest diameter (37.5%; 95% CI, 21.8-54.7%). Of 699 subjects free of neoplastic lesions at endoscopy, 47 had been H+, ie, false positive (6.7%; 95% CI, 5.0-8.7%). Adjusting for differential compliance of H+ and H- subjects to endoscopy, a corrected estimate for sensitivity would be 69% for cancer and 19% for adenomas; the corrected estimate for the false-positive rate would be 5%.

[Laparoscopy in oncological pediatrics]

Laparoscopy permits direct inspection of the peritoneal cavity. Its role is very important in oncology both in the adult and in the pediatric patient. From 1973 to 1985, 147 laparoscopies were performed on 137 patients, aged 2-16; indications were: definition of the nature of neoplastic disease in 8 cases, staging of known neoplasia in 132, restaging in 7. On Hodgkin's disease, splenic involvement in 8/113 cases was revealed by laparoscopy with biopsy. Histological examination was positive in 4 out of 22 cases of ovarian tumors. Morbidity was 1.2%. Although a laparotomy performed after laparoscopy has shown some false negatives, in most cases the clinical and instrumental follow-up has proved reliability of laparoscopic examination.

Radiologic diagnosis of invasive carcinoma on adenomatous polyps of the colon

The radiographic appearance at double contrast enema of 33 cases of invasive cancer on adenomatous polyps (AP) of the colon is reviewed. The radiologic diagnosis of malignancy was prospectively made in 54.5% of the cases. In 45.5% of the cases, malignancy was not suspected at the time of examination. The endoscopic appearance of these lesions was identical to that seen on the barium study. There are no radiologic criteria able to entirely rule out the possibility of a carcinomatous transformation of an AP. However, the radiologic features of malignancy (indentation of the intestinal wall and/or irregular outline of the surface of the polyp) have to be considered quite reliable.

Lymphomatous involvement of intrahepatic and extrahepatic biliary ducts. PTC and ERCP findings

The intra- and extrahepatic biliary ducts were examined by endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography in 10 patients with malignant lymphoma and suggested hepatic involvement. Different radiologic appearances of the biliary tract are described, related to lymphomatous involvement of the liver or extrahepatic tissues, and compared with laparoscopic findings and final diagnosis. The results demonstrate the accuracy of cholangiography by PTC and ERCP and its usefulness in patients in whom non-invasive techniques fail to provide a reliable diagnosis.

Endoscopic diagnosis of gastric lymphomas

From January 1970 to June 1979, 180 gastroscopies were performed in patients affected by lymphoma (168 in patients with non-Hodgkin lymphoma and 12 in patients with Hodgkin's disease). A gastric localization was evidenced in 48 patients with non-Hodgkin lymphoma (15 primaries and 33 secondaries), and no lesions were found in patients with Hodgkin's disease. The gastroscopies were accompanied by histological samples in all the cases and by cytological samples in most of them. The examination allowed a histological classification in 96% of the cases. The endoscopic aspect most frequently observed (48%) was vegetation, which was often associated with multiple ulcerations. The most frequent site (67%) was the vertical portion of the stomach. Gastroscopy was also utilized in the follow-up of 22 of the 48 patients affected by gastric lymphoma: in two of these, gastric localizations missed at other examinations were found.