Sequential Subcutaneous Thymopentin, Interferon Alpha-2A and Interleukin-2 in Metastatic Renal Cell Cancer

To determine the activity of sequential administration of thymopentin (TP-5), interferon alpha-2a (IFN) and interleukin-2 (IL-2) in metastatic renal cell cancer (RCC), 17 patients with RCC were treated with TP-5 50 mg/d on days 1 to 14, IFN 3 MIU/d on days 14, 15, 21, 22 and IL-2 18 MIU/d on days 16 to 20, and 23 to 27. Treatment was given subcutaneously and cycles were repeated every 6 weeks. All patients were assessed for toxicity and response. No objective responses were observed. Two patients had a short-lived disease stabilization. Median survival was 9 months. Toxicity was generally moderate. The most important side-effects were related to IL-2 administration. In view of the lack of antitumor activity, the combination of TP-5 + IFN + IL-2 in the doses and schedule used in this trial cannot be recommended. The investigation of chemotherapeutic and immunological agents that can effectively synergize with IFN or IL-2 is essential.

[Multidetector CT urography: diagnostic role in the evaluation of patients with non-traumatic hematuria]

Blood in the urine (hematuria) can originate from any site along the urinary tract and may be the only sign of renal or vesical malignancy. Therefore, literature recommends for the evaluation of any case of macroscopic or microscopic hematuria. Our aim was to define the diagnostic role of multidetector CT urography (MDCTu) in the evaluation of this symptom through the analysis of 181 consecutive patients from January 2003 to March 2006.

Papillary carcinoma of the thyroid: low expression of NCAM (CD56) is associated with downregulation of VEGF-D production by tumour cells

The expression of NCAM was investigated in tissue sections of 61 cases of papillary carcinoma and in 14 lymph node metastases using immunohistochemistry. Tumour cells of 18 primary tumours were not stained, whereas in the remaining 43 cases, NCAM was expressed in less than 5% tumour cells. Similar results were obtained when NCAM expression was evaluated at the RNA level. Reduced expression of NCAM is an early event since 6/15 cases (40%) of micro-carcinoma were NCAM-negative. NCAM-positive tumour cells were more often located at the invasion front of the tumour. It has been reported that NCAM expression may affect lymphangiogenesis. In tissue sections immunostained for podoplanin, it was found that lymphatic vessels were extremely rare inside the body of the tumour, and were mostly associated with foci of chronic inflammation and/or of reparative fibrosis. Lymphangiogenesis is sustained by VEGF-C, VEGF-D, and FGF2. Analysis of micro-dissected samples of the tumour and of the paired normal thyroid tissue revealed that RNA transcripts for VEGF-D were significantly less numerous in the tumour tissue (p = 0.001). The potential role of NCAM in tumour cell biology was investigated by silencing the NCAM gene in the TPC1 thyroid papillary carcinoma cell line. It was found that NCAM down-regulation caused a significant reduction (p < 0.05) in the expression of both VEGF-C and VEGF-D mRNAs. In addition, NCAM-silenced TPC-1 cells were more adhesive to different extracellular matrix components, and were less efficient in cell migration (59% reduction; p < 0.05) and invasiveness (68% reduction). These latter results confirm that modifications of NCAM expression cause profound alterations in the adhesive and migratory properties of tumour cells, but are in apparent discrepancy with the observation that loss of NCAM is usually associated with increased tumour invasiveness in vivo.

[The actual role of bilateral neck exploration in the treatment of primary hyperparathyroidism]

Surgery is the only curative treatment for primary hyperparathyroidism (pHPT). Surgical exploration is recommended for all patients with biochemically documented pHPT and signs or symptoms of the disease. Some patients are asymptomatic, others have subtle symptoms that disappear after parathyroid surgery. Felix Mandl successfully performed the first parathyroidectomy in 1925, using a bilateral neck exploration (BNE) with examination of all four glands and this remained the procedure of choice for pHPT into the 1990s. As over 80% of pHPT cases are due to a single parathyroid adenoma, many authors have questioned the need of BNE and have proposed directed unilateral approaches, termed "mini-invasive parathyroidectomies". The aim of this report is to define which is the actual role of the conventional surgical approach to pHPT.

[Intraoperative quick parathyroid hormone assay in thyroid surgery: preliminary experience on 36 cases]

Through the analysis of our preliminary experience on 36 consecutive cases of thyroid surgery, we assessed the feasibility of the rapid intraoperative assay of the intact parathyroid hormone (iPTH) as predictive risk factor of hypocalcemia versus seric calcium level on the first post-operative day to select the patients eligible to an early discharge. Furthermore, we managed to determine if iPTH level during thyroid surgery could point out the cases in which parathyroid autotransplantation is necessary, as the macroscopic evaluation of the parathyroid gland's viability is inadequate.

[Renal giant angiomyolipoma in tuberous sclerosis complex: case report and literature review]

The aim of this paper is to describe a typical clinical case of tuberous sclerosis complex (Bourneville disease) and discuss controversial issues about the management of this rare condition, with a short revision of the literature. Particularly, we define which is the role of the surgeon in the treatment of this very rare condition, that should be primary approached conservatively.

[The Bochdalek hernia in the adult: case report and review of the literature]

The Bochdalek hernia, the most common diaphragmatic hernia, except the hiatus hernia, is located on the posterolateral side of this muscle. This pathology is generally diagnosed in children; in fact only 105 such cases occurring in adults have been described in the literature. In these cases, surgical intervention is made necessary by the severity of potential complications. The Author's attention was drawn to a woman of 60 years of age, affected by pituitary nanism, who suffered from a left hand Bochdalek hernia. The symptomatology, characterised by abdominal pains and constipation had been presented for about one year. The computerised tomography confirmed the hernia of abdominal viscera in the thorax cavity. The intervention was conduced via the abdomen: the hernia were reduced, the hernial hole were closed with a double strata and the muscular plane reinforced with a synthetic prosthesis (dual mesh). The postoperative process was regular and the patient dismissed on 11th postoperative day.

[Benign cicatricial stenosis of colorectal anastomosis: considerations on 2 cases]

During the surgical treatment of two patients with benign anastomotic colorectal stenosis, the Authors registered the presence of concomitant tenacious adherence of the anastomotic line to the sacral bone. Such event, according to the Authors, could represent one of the causes of failure and greater risk of perforation during the treatment with the different endoscopic therapies that, nevertheless, ought to be considered the gold standard in the therapy of benign structures. The Authors developed their hypothesis physiopathologic on the basis of personal experience and of the search a diagnostic procedure able to highlight the presence of a tenacious adherence with solid structures during the operative evaluation. If further studies focused on this subject will bring to satisfactory results, this would represent a further aid for the evaluation of the best therapeutic approach of the benign post anastomotic stenosis.

[Inflammatory tumors of the cecum in emergencies: surgical considerations and case report]

A cecal mass of uncertain etiology encountered during surgery for presumed appendicitis is a dilemma for the surgeon. The differential diagnosis of an unsuspected ileocecal mass must include neoplasm, diverticular disease, inflammatory bowel disease and severe appendicitis involving the ileocecal region. Right hemicolectomy is the gold standard for the treatment of the unsuspected ileocecal mass. The Authors report a case of inflammatory tumour of caecum secondary to appendicitis in a young adult.

[Principles of surgical technique of the anterior access to the thoraco-lumbar spine]

General surgeons are more and more frequently requested to prepare an operative exposure of the spine, in order to perform anterior maneuvers of removal and stabilization of the vertebral bodies. Since 1989 to date, in collaboration with the neurosurgical équipe of Prof. G. Cantore, Neurological Sciences Department, La Sapienza University of Rome, the Authors have collected 116 cases of vertebral diseases: among them, 48 involved the thoraco-lumbar junction of the spine (D12-L2). In this paper, Authors' aim is to state precisely the surgical technique of the anterior access to the thoraco-lumbar junction: attention has been focused on this tract of the column stating its anatomical complexity and the high invasivity of the procedures requested for its exposure. Therefore, such notes of technique have been elaborated to make safer the neurosurgical demolitive and reconstructive procedures and, most of all, to reduce the surgical trauma whenever it is possible.

[Abdominal approach to the treatment of the vestigial retrorectal tumors: our experience]

Although the vestigial retrorectal cysts are still rare, the number of the observed ones is destined to increase, as methods by imaging become routinely used in the clinical practice. Once diagnosed, the removal of retrorectal lesions should be mandatory. Therefore, by reporting three clinical cases, the Authors propose notes of technique above the abdominal approach used for the surgical treatment of these retrorectal congenital neoformations. In their experience, the anterior route had no postoperative complications, short stay, no neurological consequences and good long-term results.

Total removal of an intramedullary cavernous angioma by transthoracic approach

Intramedullary cavernous angiomas are rare vascular malformations; all published cases have been surgically approached posteriorly by standard laminectomy. We describe the case of a 63-year-old man with an intramedullary cavernous angioma, anteriorly located in the thoracic spinal cord. The angioma was operated on by transthoracic approach and totally removed.

[Orthotopic replacement of the bladder in the female]

Orthotopic substitution of the bladder in females is a procedure which is increasing worldwide. Patients with tumours of the bladder neck or the trigon, or with multifocal tumours, expanded carcinomas in situ or massive pelvic adenopathies are not eligible for the procedure. The main consideration should be the risk of urinary incontinence or hypercontinence. Our experience relates to 8 patients, the neobladder being constructed using the Studer technique. Six months postoperatively daytime continence was 100% and night-time continence 75%.

[Diaphragmatic eventration in the adult: repair with Gore-Tex surgical mesh]

The Authors report the case of a fifty-nine-year-old patient, affected by complete eventration of the left diaphragm and cranial stomach dislocation with axial volvulus, associated with an upward movement of part of the left colon and some jejunal loops. The subclinical condition had been occasionally discovered during a routine chest X-ray at the age of eighteen and the patient remained without symptoms up to five years ago, when he began to show significant digestive and cardiorespiratory symptoms. The patient has been successfully treated via thoracotomy with phrenic alloplastic using Gore-Tex patch and has obtained an immediate remission of the symptoms. Left diaphragmatic eventration of the adult is a rare pathology, either congenital or acquired, with few and definite surgical indications such as severe digestive and cardiorespiratory symptoms. Different surgical techniques including the use of patches are herein illustrated.

[Postoperative sacrocele: prevention and surgical considerations]

In the Authors experience with surgical management of sacral chordomas, an unusual complication represented by posterior herniation of the rectum was observed. Weakness of the posterior pelvic floor is at the basis of this complication, which the Authors defined "sacrocele". Posterior herniation of the rectum highly impairs the patient quality of life and may contraindicate radiation therapy. Therefore, the Authors routinely reconstruct the posterior pelvic floor by using a polyglactin mesh following any sacrectomy. This technique is simple and safe. Authors' experience on a limited series is presently reported.

[Blind-ending branch of bifid ureter: apropos of a case]

The Authors report on a case of blind-ending ureter. A young woman (29 years old) underwent surgery because of recurrent urinary tract infections and left loin pain. The operation consisted in a radical resection of the blind branch together with Coen's operation for the coexistence of vesicoureteral reflux. Authors' goal was to review the international Literature on this rare pathology pointing out their opinion on the existing terminology which is still far from being clear and definite.

[Endoscopic palliative treatment of a neoplastic esophageal fistula: report of a case]

Oesophago-respiratory neoplastic fistulas present serious problems of management, because of the severe status of the patient. Therefore, a palliative treatment, to allow for a gradual respiratory and digestive function recovery with clinical improvements is needed. Surgical palliation has a mortality rate of 40% and a long post-operative hospitalization. Endoscopic palliation, on the other hand, has the same percentage of success of surgical palliation, but has the advantage to be performed in those patients with severe health conditions immediately improving the symptomatology and not excluding a subsequent surgical approach. The Authors present the case of a 70-year-old patient with a neoplastic relapse on the oesophago-gastric anastomosis, associated to an oesophago-respiratory fistula manifesting as severe dysphagia and dyspnoea. An endoscopic palliative treatment of the fistula was performed introducing a metallic coated prosthesis into the oesophagus. Severe clinical conditions regressed immediately and after 3 months they are unchanged. The Authors suggest endoscopic palliation with oesophageal prosthesis as the best therapeutic choice in those cases not amenable to surgery.

Orthotopic ileal neo-bladder: Complications and failures. Our experience

– Between 1989 and June 1996, 126 continent orthotopic ileal neo-bladders were constructed according to Studer after radical cystectomy due to infiltrating bladder tumour. Out of these cases there were 6 peri-operative deaths (4.7%), 11 early complications (8.7%) and 42 late complications (33.3%). Functional failures were also noted in a negligible percentage amounting to 7.2%. We report on the methods used to treat the complications and the failures strictly tied to the operation and on the techniques adopted to avert them.

Ureteral anastomosis in the orthotopic ileal neobladder: comparison of 2 techniques

PURPOSE

The functional results and complications of 2 different ureteroileal anastomoses were evaluated in patients with bladder cancer undergoing radical cystectomy and orthotopic ileal bladder substitution.

MATERIALS AND METHODS

Between 1989 and 1995, 102 patients underwent creation of a low pressure neobladder. In the first 50 cases the ureteroileal anastomosis was created with a split-cuff nipple technique as an additional antireflux mechanism. In the next 52 cases the ureteroileal anastomoses were constructed via the direct end-to-side technique counting on the antireflux protection of the afferent tubular limb.

RESULTS

Stenosis occurred in 7 of the 100 ureters (6 patients) treated with the split-cuff nipple technique and 7 of 104 treated with a direct end-to-side anastomosis. This complication occurred more commonly in the left ureter (11 of 14 patients). Reflux was noted at cystography in 10 cases with the split-cuff nipple method and 12 with end-to-side anastomoses, and was symptomatic in only 3 patients. Four ureteral strictures were treated successfully with primary open repair. Percutaneous dilation and stenting were performed for 8 ureteral strictures: 2 cases were successful, 3 failed and 3 are unresolved.

CONCLUSIONS

We observed no differences between the antireflux split-cuff and end-to-side anastomoses with regard to stricture formation or ureteral reflux. Therefore, we do not believe that there is a need to create antireflux ureteral anastomoses due to the tubular afferent ileal segment and given that the reflux is asymptomatic in most patients. Strictures may be treated with percutaneous balloon dilation and stenting but open repair appeared to be more effective.

Orthotopic ileal bladder substitution in female patients: Our experience

Orthotopic bladder reconstruction in women was introduced to guarantee voluntary micturition via the urethra as already obtained in men. A meticulous urethra-sparing surgical procedure and a low-pressure reservoir allow urinary continence to be preserved. Careful selection of patients can reduce the already low risk of urethral relapse. An orthotopic ileal neobladder was performed in 8 women following radical cystectomy for infiltrating bladder carcinoma. Follow-up ranged from 10 to 47 months. There were no serious clinical complications. At 6 months the complete urinary continence rate was 100% during the day and 75% at night with 4-hour interval voiding. At 12 months neobladder capacity varied from 250 to 400 ml and pressure at maximum capacity from 8 to 25 cm water. Urodynamic parameters were stable over a period of time. Four patients died of distant metastasis and 4 are alive and disease-free. In our opinion an orthotopic ileal neobladder in women gives excellent functional results and is a satisfactory option in selected female patients.

Orthotopic ileal neobladder in female patients after radical cystectomy: 2-year experience

We describe a surgical technique to conserve urinary continence in 7 women who underwent radical cystectomy with construction of an orthotopic ileal neobladder for infiltrating bladder carcinoma. The selection of the patients and the surgical procedure to preserve the anatomical and functional integrity of the female urethra are described. Followup ranged from 7 to 28 months. There were no postoperative deaths or serious clinical complications. The urinary continence rate was 100% during the day and 71% at night with micturition at regular 3-hour intervals. The vesical capacity varied from 250 to 400 cc and pressure at maximum capacity from 10 to 25 cm. water. Urinary flow was satisfactory and the urethral pressure profile showed a normal sphincteric mechanism at rest. Two patients died of metastases at 14 and 8 months postoperatively, and 5 are alive and disease-free. We believe that these results confirm the possibility of obtaining micturition in women via the urethra following radical cystectomy.

Local immunotherapy of superficial bladder cancer by intravesical instillation of recombinant interleukin-2

Local immunotherapy of superficial bladder cancer by endovesical administration of recombinant interleukin-2 (rIL-2) was investigated in a phase I-II study. Twenty-five patients with Ta-T1, N0, M0, G1-G2 transitional cell carcinoma of the bladder received an induction course of rIL-2 (10 daily instillations) with the tumor in place using an interpatient dose escalation scheme from 3 to 18 x 10(6) IU/day. Seven to fourteen days after the end of the induction course, the objective clinical response was evaluated and transurethral resection of the bladder tumor was carried out. Four maintenance courses (10 daily instillations) were started 1 month after surgery and carried out every 4 months at a dose of 6 x 10(6) IU/day in all patients. Follow-up visits were scheduled bimonthly during treatment and then every 6 months. No evidence of laboratory, local or systemic toxicity was observed even at the highest rIL-2 dosages. Induction of a local inflammatory response could be demonstrated at the tumor site after intravesical rIL-2 treatment. The significant reduction in tumor diameters observed in some patients may be interpreted as a sign of the biological activity of this rIL-2 regimen. Further exploratory work is required to evaluate the clinical efficacy of this immunotherapeutic approach.

[Abdominal aortic aneurysm and rectal cancer: what surgical strategy?]

The incidence of abdominal aortic aneurysm and colorectal cancer association is 0.5-1%. This concomitance of two potentially lethal diseases creates a decision making problem regarding priority of treatment. The Authors report a case in which colorectal cancer and abdominal aortic aneurysm were present. This patient first underwent surgery for colorectal cancer, then for aortic aneurysm. Moreover, the Authors review the Literature and discuss their decisional principles about treatment priorities.

[Anomalies of the inferior vena cava: observations on the anterior approach to the vertebral column]

The inferior vena cava is formed through a complex process of embryogenesis from the sixth to the tenth week of gestation. Improper completion of the process of embryogenesis may result in four anatomic anomalies: 1) duplication of the inferior vena cava; 2) left-sided inferior vena cava; 3) retroartic left renal vein and 4) circumaortic left renal vein. The Authors report the cases of two patients in which duplication of the inferior vena cava and retroartic left renal vein were respectively observed. The importance to avoid injuries and subsequent bleeding from these anomalous structures during surgical operations is stressed. Moreover, a correct preoperative diagnosis may reduce these complications.

Neoadjuvant M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin) for infiltrating transitional cell carcinoma of the bladder

BACKGROUND

Based on the excellent results with combination chemotherapy such as M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin) in patients with advanced disease, neoadjuvant chemotherapy has been advocated to improve survival and in some cases to permit bladder conservation.

METHODS

A Phase II study of neoadjuvant M-VAC chemotherapy was performed in patients with T2-T4N0M0 bladder tumors. After clinical staging, three cycles of M-VAC were given. After patients underwent postchemotherapy clinical restaging, pathologic restaging (partial or radical cystectomy) was planned.

RESULTS

Forty-six patients are evaluable. A clinical response was attained in 78%. Six patients (13%) had stable disease, and four (9%) had progression. After chemotherapy, 17 patients underwent radical cystectomy, none of whom were pTO. In this group, 10 of the 17 (59%) are alive at a median follow-up of 37+ months (range, 8-62+ months). Eleven patients had a partial cystectomy; 7 of the 11 (64%) are alive, 6 (55%) with a preserved bladder. Eighteen patients had clinical restaging only, and did not have pathologic staging. Median follow-up for this group is 36+ months (11-65+ months). Twenty-one of the 29 (72%) patients managed with conservative surgery or transurethral resection of the bladder alone are alive with a functional bladder. Median survival for all patients has not yet been reached. Two-year survival is 82%, and 3-year survival is 70%.

CONCLUSIONS

The current study is of interest in terms of bladder conservation. Assessment of the true success of any bladder-preserving treatment will require longer follow-up.

Phase II study of continuous intravenous infusion of recombinant interleukin-2 in patients with advanced renal cell carcinoma

BACKGROUND

The goal of this study was to evaluate the therapeutic efficacy and toxicity of recombinant interleukin-2 (rIL-2) administered by continuous intravenous (CIV) infusion to patients with metastatic renal cell cancer (RCC).

PATIENTS AND METHODS

Thirty patients with RCC were given rIL-2 18 MIU/m2/d CIV. The schedule consisted of two induction cycles and four maintenance cycles with a 3-week rest period between cycles. Each induction cycle consisted of two infusion periods lasting 120 and 108 hours, respectively, separated by a 6-day rest period. Each maintenance cycle consisted of a 120-hour infusion period.

RESULTS

Among 29 assessable patients, the objective response rate was 14% (95% confidence interval, 2% to 26%); one patient achieved a complete response, and 3 partial responses. Ten patients (34%) had stable disease (SD). Median survival was 11 months. Toxicity was generally manageable. Hypotension was universal, but required dose reduction in only 2 patients. Increase in serum creatinine levels was observed in 20 patients, and returned to normal in all but 4 patients after discontinuation of treatment.

CONCLUSION

Results confirm the efficacy of rIL-2 in patients with RCC and the feasibility of the treatment in a normal oncology ward. However, responses are observed in a minority of patients, and treatment-related toxicity, as well as technical problems, may be troublesome to many patients.

Carboplatin and 5-fluorouracil in poor performance status patients with advanced urothelial cancer

BACKGROUND

In view of the difficulties in administering aggressive treatment to elderly patients, frequently with concomitant medical problems, a treatment program with the combination of carboplatin and 5-FU for advanced urothelial tumors was designed. The aim was to maintain an efficacious therapeutic schedule while minimizing toxicity.

PATIENTS AND METHODS

Twenty-three patients with advanced bidimensionally measurable urothelial carcinoma were given carboplatin 100 mg/m2 and 5-fluorouracil 500 mg/m2 days 1-3 which was escalated to carboplatin 125 mg/m2 and 5-fluorouracil 625 mg/m2. 5 patients were > 70 years, the ECOG performance status was 2-3 in 10 patients (43%), and the creatinine was > 2.0 mg/dl in 3 patients (13%). Five patients (22%) had pre-existing cardiac disease, and 1 had hepatopathy. Nine patients (39%) had prior cisplatin.

RESULTS

Ten patients remained at level 1, and 12 others had the dosage escalated to level 2. Twenty-one patients are evaluable for response. Response was observed in 5 of 21 (24%) evaluable patients (95% confidence limits 15%-33%), only at dose level 2. There was 1 CR (5%) and 4 PR (19%). There were no responses in patients who had prior DDP versus 5 of 13 (38%) responses in patients who had not had prior DDP. The median time to response was 2 months. The median duration of response was 8 months. At level 2 myelotoxicity was significant, and led to a return to level 1 in 2 patients. Nine of 12 patients (75%) treated at level 2 had grade 3 leukopenia, and 1 patient had nadir sepsis. 4 patients (33%) had grade 4 thrombocytopenia.

CONCLUSIONS

Moderate activity was shown with this regimen in untreated patients at level 2. This regimen presents a feasible outpatient alternative for patients who are unable to undergo more aggressive chemotherapy.

[Anterior approaches to the spinal column: considerations of the surgical technic]

The anterior approach to the vertebral column is indicated in the tumors or traumas of the vertebral body with prevalent anterior expression. This method allows to control easily all the structures in front of the rachis. Furthermore, the current reconstructive techniques require the exposure of a long tract of the vertebral column. The Authors report their experience with the anterior approach in 22 patients (9 males, 13 females) affected by different pathologies: 10 primary tumors divided as follows: 4 sacral chordomas, 1 L1 chordoma, 2 sacral neurinomas, 1 L5 malignant melanotic schwannoma, 1 D9 osteoblastoma, 1 D6 intraspinal cavernoma, and 1 D3 myeloma; 4 metastatic tumors (2 D10, 1 L4 and 1 L5); 5 fractures of the vertebral body (1 L1, 1 L1-L2, 2 L4 and 1 L5); 2 echinococcal cysts respectively arising from the D11 body, the sacrum and ilium. The Authors overall performed 8 thoracotomies, 6 for dorsal location; in 1 case of L1-L2 fracture a thoracophrenolaparotomy was performed; in 7 cases involving the L3-L5 segment an abdominal anterolateral extraperitoneal approach was followed; finally in 6 cases a transperitoneal laparotomy to approach the sacrum and ilium was performed.

[The osseous location of echinococcal cysts: comments on a clinical case]

Primary bone location of hydatid disease is extremely rare. The clinical case herein reported represents a primitive bone location of echinococcus in the ileal and sacral area. The aspecific symptoms did not allow for a preoperative diagnosis. The latter was possible only after a CT scan performed for other reasons. The patient underwent a CT scan and MIR which showed a diffuse involvement of the ilium and sacrum along with the presence of two cysts (anterior and posterior). Surgery was performed through an anterolateral extraperitoneal and posterior access in the gluteal region. Asportation "en bloc" of the cysts was not possible. Therefore, they were opened, aspirated and washed with hypertonic solution (33% NaCl). Following surgery Albendazole was prescribed to the patient. At 22 days from surgery, a CT scan confirmed the disappearance of the cysts along with the presence of bone lesions.

Recombinant tumor necrosis factor for superficial bladder tumors

Twenty patients with histologically documented superficial bladder cancer (Ta, T1, Tis) were treated with intravesical administration of TNF 400-1800 micrograms. Of 18 patients with a marker lesion, 2 obtained a complete response for 8+ and 18 months. Two had a partial response and were given other intravesical therapies after 5 and 7 months. No or minimal systemic absorption of TNF was observed and documented in 4 of 20 patients by pharmacokinetic studies, and no patients developed antibodies to intravesically administered TNF. TNF was well tolerated in doses up to 1800 micrograms. No systemic or local side effects were observed. Modest activity was attained with intravesical TNF, even in pretreated patients.

[Nerve-sparing cystectomy and ileal bladder substitution]

Nerve-sparing techniques and bladder substitution following radical cystectomy allow today to obviate functional sequelae once registered in this type of surgery. Intraoperative identification of the pelvic plexus, which provides autonomic innervation to the corpora cavernosa, is necessary to preserve sexual function. Ileal orthotopic bladder substitution with preservation of the distal urethral sphincter assures a micturition per urethram and the urinary continence. The Authors report their experience with the Studer and Zingg procedure (ileal orthotopic bladder reservoir) performed in 26 cases. Results, technique, complications, and long-term evaluation are stressed.

[Primary non-Hodgkin's lymphomas of the stomach]

Histological and staging classifications of gastric non-Hodgkin lymphomas are reported. On the basis of their experience and taking into account the above mentioned principles, the authors dwell upon the advantages and limits of endoscopy for the diagnosis of such neoplasms. The primary role of surgery in the management of gastric lymphomas is also confirmed.

[Mechanical staplers in orthotopic ileal neo-bladder using the Studer and Zingg method: our experience]

Detubularized orthotopic low-pressure bladder substitute following radical cystoprostatectomy allows micturition per urethram and urinary continence. We performed the Studer and Zingg procedure with ileal reservoirs in 26 bladder cancer patients, using staplers in 11 cases. A reduced operating time and a low postoperative complication rate were observed in these cases. Furthermore, functional results were comparable to those obtained with manual sutures and lithiasis was never observed.

Techniques of rectal oncologic survey

The possibility of constructing very low anastomoses using stapling devices led many surgeons to reduce the length of the distal clearance to 1-2 cm. This made it possible to perform a low anterior resection instead of an abdominoperineal resection of the rectum in a greater number of cases. Furthermore, the enthusiasm in preserving sphincteric function induced some Authors to perform a local excision for tumors of the distal portion of the rectum. On the other hand, in order to improve patients' survival after curative operations for cancer, either of the rectum or rectosigmoid junction, other surgeons have adopted a more aggressive approach, extending exeresis to the peri-aortocaval and pelvic nodes, and to the possible liver metastases as well. On the basis of our experience (374 cases from 1972 to March 1989) and a critical review of the literature, indications, techniques, and results of curative operations for both rectal and recto-sigmoid junction cancer are examined. The role of extended abdomino-pelvic lymphadenectomy is also discussed. The Authors believe that in the absence of a reliable evaluation of the potential of these tumors, an aggressive approach is required. Local excision is reserved to very selected cases, which should undergo an intensive follow-up in order to detect recurrences at a very early stage.

[Digestive reconstruction using mechanical staplers after total gastrectomy]

From 1980 up to nowadays, after total gastrectomy for gastric cancer, the intestinal continuity was assured by oesophago-jejunostomy and oesophago-duodenoplasty using stapling devices. Two patients died for causes not related to the technique, and other two patients developed a stenosis of the oesophago-jejunostomy, which was easily managed by endoscopic dilatation. In one patient a partial dehiscence of the oesophago-jejuno-anastomosis was treated by total parenteral nutrition. The Authors have systematically adopted mechanical sutures after total gastrectomy. However, possible intraoperative accidents and complications should not be underestimated, although most of them may be due to the operator's inexperience or stapler misuse.

[Aneurysm of the popliteal artery: diagnostic and therapeutic considerations]

The authors settle the roles of the most recent diagnostic methodologies useful to frame the popliteal aneurysm pathology namely digital arteriography, N.M.R., and doppler-flowmetry. They emphasize, in an observed case, the adopted therapeutic criteria, that is basically interventional. The thinness of saphenous veins draws toward the employing of "Goretex".

[Tumor markers in the early diagnosis of thyroid neoplasms]

Radioimmunological techniques were used to assay tumour markers in order to identify neoplasms in patients with thyroid nodules at the earliest possible stage. In the 7 patients with differentiated thyroid tumours, the marker findings were within normal limits. On the basis of these results it is concluded that at the present time these markers are of no value for the early diagnosis of thyroid tumours.

[Mesorectal resection in oncologic surgery]

A surgical technique to "en bloc" resect the mesorectum while performing an anterior resection is here described. The procedure aims at preserving those nerves whose injury is responsible for a series of neurological sequalae, which affect the patient's quality of life. Fifteen dissections were carried out in order to demonstrate the possibility to perform an accurate mesorectal lymphadenectomy while preserving, in most cases, the nervi erigentes and, in some cases, the hypogastric plexus.

Stapled sutures in digestive tract surgery

A six-year experience with mechanical sutures in digestive tract surgery is reported. Forty-nine esophageal resections during azygo-portal disconnection were performed since 1979 up to June 1986. Four patients died in the early postoperative course with no evidence of suture-related complication. One patient developed an anastomotic stricture (2.2%), which was successfully dilated. Fifty-three total gastrectomies with stapled reconstruction were performed between 1980 and June 1986. Two patients died soon after surgery for reasons unrelated to the suturing technique. Two strictures of the esophagojejunal anastomosis (3.9%) occurred two to three months after surgery and underwent successful dilation. One esophagojejunostomy (1.9%) leaked and one (1.9%) underwent uneventful remedial surgery (conversion of an omega-shaped loop to a Roux-en-Y procedure). Ten isoperistaltic jejunal interpositions, six Billroth I partial gastrectomies and 14 Roux-en-Y loops for hepatico- or pseudo-cystojejunostomy were performed since 1983 up to June 1986 in the absence of any operative morbidity or mortality. Twenty-three right colectomies were performed from 1983 to June 1986. The only complication reported was one leakage (4.3%) which spontaneously healed. Ninety-eight patients underwent formal colonic resections (anterior resection of the rectum, left hemicolectomy, subtotal and total colectomy) from 1981 to June 1986. Two patients (2%) died for reasons unrelated to the suturing technique. Three colorectal anastomoses (3%) developed a leak, one of which required surgical revision. One stricture (1%) was recorded in a recurrence-free patient three months after surgery. One patient (1%) complained of minor rectal bleeding. Two patients (2%) developed small anal fissures due to forced passage of the instrument.(ABSTRACT TRUNCATED AT 250 WORDS)