Inherited cancer syndromes in 220 Italian ovarian cancer patients

BACKGROUND

A subsets of ovarian carcinomas (OCs) are related to inherited conditions including Hereditary Breast and Ovarian Cancers (HBOC) and Lynch Syndrome (LS). The identification of inherited conditions using genetic testing might be a strategic model for cancer prevention that include benefits for the ovarian cancer patients and for their family members.

METHODS

We describe a retrospective Italian experience for the identification of inherited conditions in 232 patients affected by OCs using both somatic and germline analyses.

RESULTS

Immunohistochemical and microsatellite analyses performed on OCs identified 20 out of 101 MMR defective cancers and 15 of these were from patients carriers of the MMR germline pathogenetic variants. BRCA1 and BRCA2 testing offered to 198 OC patients revealed 67 (34%) pathogenetic variant carriers of BRCA1/2 genes. Interestingly LS patients revealed a mean age of OC onset of 45.4 years, which was significantly lower than the mean age of OCs onset of HBOC patients.

CONCLUSIONS

Somatic and germline analyses offered to OC patients has proved to be an efficient strategy for the identification of inherited conditions involving OC also in absence of suggestive family histories. The identification of LS and HBOC syndromes through OC patients is an effective tool for OC prevention.

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC)

BACKGROUND

Breast angiosarcoma is a malignant mesenchymal neoplasm, which accounts for approximately 2% of all soft tissue sarcomas. Secondary breast angiosarcoma (SBA) may be related to chronic lymphedema after a mastectomy with lymph node dissection (Stewart Treves syndrome) and previous radiotherapy for complications from breast radiation treatment. It is a very rare condition; therefore, diagnosis and management are still a challenge.

METHODS

The ANISC collected SBA data by means of a survey sent to all Italian breast centres in the ANISC. The clinicopathological characteristics and the management of this disease were analysed.

RESULTS

Twenty-four centres participated in this survey in which 112 cases of SBA were analysed. The median age of the women with SBA was 68.9 years and it appeared approximately 90 months after the first irradiation for breast cancer. In 92% of cases, a mastectomy was performed without axillary dissection for those patients having a high grade of SBA (74.2%). The prognosis was worse in the high-grade cases (overall survival-OS: 36 months) as compared with the low-grade cases (OS: 48 months). After a follow-up of 5 years, 50.5% of the patients were still alive. Disease-free survival (DFS) was 35 months, and there were no differences between the groups of patients with either high- or low-grade histology.

CONCLUSIONS

Secondary breast angiosarcoma is a very aggressive disease associated with a short survival outcome. The surgical approach still remains an important step in the course of treatment; furthermore, an accurate histological examination is helpful in establishing the prognosis of the patient. A mastectomy is mandatory. A longer OS was observed in patients with low-grade angiosarcoma as compared to high-grade angiosarcoma (C.I. 40-57 vs. 31-41 months).

Breast cancer and thyroid diseases: analysis of 867 consecutive cases

INTRODUCTION

The aim of this study was to evaluate the association of breast cancer with thyroid diseases. Many authors have already studied the possible relationship between these two diseases, but the results are nowadays conflicting.

MATERIALS AND METHODS

Our study examining 867 patients with breast cancer (862 women and 5 men, average age = 61 years old) of whom 141 also had thyroid disease evaluated the recurrence of thyroid diseases and their association with different types of breast cancer. Statistical analyses were performed using SPSS software for Windows; we used nonparametric tests (Chi-square and Mann-Whitney), and the level of significance was set at p < 0.05.

RESULTS

We found a significant association between breast cancer diagnosed after menopause and thyroid disease (p < 0.003). Moreover, we analyzed the role of thyroid autoimmunity identifying an association between chronic autoimmune thyroiditis and breast cancer diagnosed before menopause (p < 0.05). Regarding receptor profile of breast carcinoma, we have found an increased expression of estrogen receptors in patients with autoimmune thyroiditis compared to patients with any other thyroid diseases (p < 0.03). Contrariwise, we do not have found any difference between the group with every thyroid disease and the group without thyroid disease (p < 1.00). We did not find other statistically significant associations with breast cancer's parameters like family history, tumor size, lymph node metastasis, distant metastasis, cancer clinical and pathological stage, differentiation grade and expression of Ki67, p53 and Her2 in the two main groups with or without thyroid disease. Likewise, we did not found other statistically significant association between hypothyroidism or hyperthyroidism and breast cancer.

Laparoscopic cholecystectomy as day-surgery procedure: current indications and patients' selection

AIM OF THE STUDY

To review the current indications, to establish predictive factors of success and the safety of LC as a day-surgery procedure.

METHODS

Randomized clinical trials were searched on PubMed between January 2000 and June 2008 using "laparoscopic cholecystectomy", "day-surgery" as keywords.

RESULTS

A total of 20 trials was identified and analyzed. The indications for LC in day-surgery unit were symptomatic and chronic cholelitiasis without evidence of common bile duct stones; acute cholecystitis and pancreatitis cases were excluded. The trials considered as inclusion criteria: ASA score, BMI, social aspect and the preoperative workout included: abdominal US, liver function tests and routine preoperative tests, while the results considered the reasons for hospital stays and for readmission and measured patient satisfaction; some trials included analyze of costs of LC as day-surgery procedure the role of the surgeon's experience.

DISCUSSION

The present study confirms that day-surgery LC is safe and feasibility in selected patients; serious complications are rare and most frequently prolonged hospital stay and the readmission are connected with minor and more easily controlled complications or social reasons. Outpatient surgery requires careful planning and preparation in order to reach acceptable patients' satisfaction: preoperative workout is extremely imports allowing to reduce errors selection. Considering surgical training, it has been demonstrated that in the centres in which the trainees are involved in day-surgery LC there not significant difference in terms of number of complications, patient outcomes, prolonged stay and readmission. The adequate control of pain, nausea or vomiting is essential component in day-case LC service and it is possible at home after LC.

CONCLUSION

Day-case laparoscopic cholecystectomy is feasible with an acceptable discharge rate and level of patient satisfaction. The success depends on appropriate patient selection and on well-trained staff and skilful operative technique together with safe anaesthesia.

Video-assisted thyroidectomy performed in a one-day surgery setting

BACKGROUND AND AIM

Evidence base data have demonstrated that video-assisted thyroidectomy (VAT) has good results regarding safety, morbidity, patient cure rate, pain and cosmesis. Aim of this study was to evaluate the performance of VAT in an ambulatory setting (i.e. one-day surgery, <24-h stay).

MATERIALS AND METHODS

Between September 2007 and July 2008, 43 patients underwent VAT in a one-day surgery division. Patient selection criteria for VAT were: thyroid nodules <30 mm, gland volume <20 ml, no history of thyroiditis or neck surgery or irradiation, "low risk" papillary carcinoma and absence of enlarged lymph nodes. One-day surgery patient selection criteria were medical and social logistic (Materazzi G, et al. Eur Surg Res 2007;39:182-8). Intraoperative neuromonitoring (IONM) was used for RLN identification. Intact parathyroid hormone (iPTH) levels were determined early postoperatively at +6-h. Postoperative complications, conversion rate were analyzed.

RESULTS

No cases required conversion to open surgery or ordinary recovery (i.e. >24h). Incidence of temporary hypoparathyroidism was 11.6% (5/43) with no case of symptomatic hypocalcemia. Incidence of temporary RLN injury was 2.3% (1 patient) with no case of permanent or bilateral RLN injury. All patients were satisfied with the type of recovery.

CONCLUSIONS

This preliminary report is an example of the safe incorporation between new technologies (IONM, early iPTH measurement) with improvement of the quality and safety of VAT performed in a one-day surgery setting.

The role of EUS and MRI in rectal cancer staging

Rectal cancer continues to be one of the most common tumors worldwide. Its prognosis mainly depends on early diagnosis and precise stage evaluation in order to choose the most effective treatment. In recent years, new and promising technologies have been proposed and are now available in daily practice. Each rectal cancer patient should be considered individually, choosing the diagnostic pretreatment exams that are appropriate for that single clinical case mainly related to the tumor and the available instruments. Clinicians must be informed about the efficacy of these technologies and be aware of any cause of mistake in tumor staging in order to reduce the risk of both improper use and inaccurate staging.

Genetic alteration in hereditary colorectal cancer

Colorectal cancer is a major cause of morbidity and mortality. Both genetic and environmental factors contribute to cancer aetiology. About 15-20% of all colorectal cancers are familial. Approximately 6% of colorectal cancers can be attributed to recognizable heritable germline mutations. The discovery of genes responsible for inherited forms of colorectal cancer have the potential to improve cancer risk assessment and counselling. Genetic testing for hereditary forms of colorectal cancer can confirm or reject diagnoses at the molecular level, determine surveillance intervals for at-risk persons, decrease the cost of surveillance by risk stratification, aid in surgical and chemoprevention decision-making, and help patients in family and career planning. This paper reviews the genetics behind genes and molecular study of the hereditary colorectal cancer. This may help the medical professionals especially internists, gastroenterologists, and oncologists to update their knowledge in this field.

The mesenteric and antimesenteric site of the tumor as possible prognostic factor in colorectal cancer: 5-year survival analysis

INTRODUCTION

Colorectal cancer is still one of the many factors of death both in males and in females. To date, the most important prognostic factors are mainly related to the pathological stage of the disease.

AIM OF THE STUDY

The purpose of this study was to analyze the possible role of tumor circumferential localization on the colonic wall (mesenteric (M) or antimesenteric (AM)) as a possible prognostic factor. In this study, we compare the localization of the tumor with patient's survival. The hypothesis of this study is that M tumors, closer to blood and lymphatic vessels, should be more aggressive in terms of hematogenous and lymphatic spread compared to the AM tumors.

PATIENTS AND METHODS

All patients undergoing curative resection for colorectal cancer were enrolled in this study; there was no statistical difference for age, sex and co-morbidity. The histopathological examination was carried out in the standard manner. Next, we have taken care to survival of neoplastic patients by examining of our 5-year follow-up archive: we divided patients in different groups concerning the different tumor stage and we compare these results with the different localizations of tumor at the operation.

RESULTS

In 45% of cases, we were able to distinguish the different localizations M (160 patients) or AM (47 patients) and this difference is statistically significant (P<0.0001, Pearson Chi-Square-test (PCS-t)). The number of metastatic nodes is statistically higher in the M group compared to the AM group one (P=0.003949). Medium time of follow-up was 36.54 months; AM and M patients have a rather similar survival, only at the end the two curves seem to change but not in a significant manner. Only if we consider the difference between the two groups comparing T3 tumor can we observe a statistically significant difference (P<0.005).

CONCLUSIONS

In conclusion, the localization of M or AM colorectal cancer is feasible in 45% of cases. M tumors have significantly more lymph nodes metastases but a better 5-year survival than AM tumors. A possible explanation for such results might be the different pattern of diffusion of cancer cells.

The application of sentinel lymph node mapping in colon cancer

Lymph node status is the most important prognostic factor for colorectal carcinoma. Complete lymph node dissection has historically been an integral part of the surgical treatment of these diseases. Sentinel lymph node mapping is a newer technology that allows selective removal of the first node draining a tumor. Sentinel node mapping is well accepted for the management of breast carcinoma and cutaneous melanoma, and has resulted in reduced morbidity without adversely affecting survival. Sentinel node mapping is currently being investigated for treatment of colorectal cancers. Recent studies show promise for incorporating the sentinel node mapping technique for treatment of several gastrointestinal malignancies.

The impact of perioperative blood transfusion on clinical outcomes in colorectal surgery

Colorectal cancer is the second-leading cause of cancer-related death in the US. The prognosis of advanced colorectal cancer remains poor in spite of the advances obtained in recent years with new therapeutic agents, new approaches in surgical procedures and new diagnostic methods. Currently, colorectal cancer is the second most common cancer in Europe both in terms of incidence and mortality. Approximately 90% of all cancer deaths arise from the metastatic dissemination of primary tumors. It is a matter of vital importance whether perioperative blood transfusion promotes tumor recurrence and morbidity. This paper reviews the relevant medical literature published in English language on the theoretical background, methodological problems, results, as well as the possible clinical impact of blood transfusions in colorectal surgery with well-controlled trials. Searches were last update August 2007.

Primary colorectal lymphomas: review of the literature

Primary colorectal lymphoma is an infrequent disease of unknown origin and with a growing incidence. Primary colorectal lymphoma accounts for only about 0.2% of large intestinal malignancies. The aim of this study is to review, identify and underline risk factors, presentation, treatment and prognosis of primary colorectal lymphoma, using the three most important studies made in the last years: the Chung-Wei Fan study from the division of colon and rectal surgery, in Taipei [Fan CW, Changchien CR, Wang JY. Primary colorectal lymphoma. Disease of the Colon and Rectum 2000;43:1277-82]; the Wong and Eu [Primary colorectal lymphomas. Colorectal Diseases 2006;8:586-91] study from the Department of colorectal surgery in Singapore and the study of Doolabh et al. [Primary colon lymphoma. Journal of Surgical Oncology 2000;74:257-62] University of Texas Southwestern Medical School, Dallas, Texas.

Laparoscopic colorectal resections with transvaginal specimen extraction for severe endometriosis

INTRODUCTION

Bowel resection is now considered the "gold standard" treatment for severe endometriosis infiltrating the bowel. Laparoscopic colorectal resection can be considered a safe option in order to reduce surgical trauma and complications as well as to improve cosmetics. Transvaginal approach, used for several years to remove large specimens, can be an interesting approach also in case of colorectal resections.

AIM OF THE STUDY

To present our experience on laparoscopic colorectal resection and transvaginal specimen extraction as treatment of severe endometriosis.

RESULTS

Eleven patients (mean age 45+/-12 years) have been operated by a combined team of gynecologist and colorectal surgeons. There were no intra- or post-operative complications. In all cases, the transvaginal route was used to remove the specimen and prepare the bowel for anastomosis. Patients were allowed to free light diet on post-operative day 3+/-1 and discharged on day 5+/-2. The mean follow-up was 4+/-2 months and all patients are well with normal bowel function and symptoms free.

CONCLUSIONS

Our preliminary experience demonstrates such approach is safe and feasible with excellent results in term of post-operative course.

[Current indications for thyroidectomy]

Thyroid surgery, one of the most common interventions in endocrine surgery, is practiced by many specialists who perform this procedure exclusively. It accounts for the bulk of work even in reference centers that treat rare endocrine tumors (e.g. adrenal and gastrointestinal tract cancer). Better results are obtained by experienced and skilled operators. Surgeons who correctly perform thyroid surgery can achieve excellent outcomes even in other areas of endocrine surgery. So it is surprising that not more is being done to teach the procedure, which has always been considered something of an art, perhaps because surgical treatment of rare endocrine tumors is more stimulating to teach than routine surgical procedures. Nonetheless, teaching correct surgical technique is essential for reducing and avoiding postoperative complications caused by inadequate experience and knowledge. Numerous studies have reported that the incidence of complications is high and that the rate is growing: 5% involve permanent injury to the recurrent laryngeal nerve after intervention for a benign tumor, despite repeated reports that the incidence could be reduced to near zero or at least to 1%. Alarmingly high is the 20% incidence of persistent hypoparathyroidism after total thyroidectomy. Here, too, accurate technique could reduce this rate to 1%. An important point is that permanent laryngeal nerve injury and persistent hypoparathyroidism are both sources of considerable discomfort for patients. One of the chief objectives of modern endocrine surgery is, therefore, to reduce the complications rate to acceptable levels by establishing adequate, uniform teaching protocols and universal guidelines that would help improve the practice of surgery.

Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience

BACKGROUND AND AIM

Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects.

MATERIALS AND METHODS

Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present.

RESULTS

All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800ml/day (range 400-1600ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20-2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis.

CONCLUSIONS

After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.

Radiofrequency ablation of primary and metastatic lung tumors: preliminary experience with a single center device

BACKGROUND

This study aimed to assess the feasibility and short-term results for percutaneous radiofrequency ablation in the treatment of primary and secondary lung tumors.

METHODS

Between May 2003 and July 2004, 15 patients (mean age, 64.9 years; range, 51-80 years) with 18 pulmonary lesions (9 primitive non-small cell lung cancers and 9 metastases) underwent the ablation procedure. All the patients had absolute contraindications to the surgery. The procedure was performed under computed tomography (CT) guidance with anesthesiologic assistance using a coaxial Le Veen needle electrode. The results were evaluated by postprocedural CT scan, and then by clinical and laboratory examination and CT scan 1, 3, 6, 9, and 12 months after the treatment.

RESULTS

A complete ablation was obtained for 16 of 18 lesions (88.9%), and a partial ablation was achieved for the remaining 2 lesions (central tumors). In terms of complications, there were five cases of pneumothorax (2 resolved spontaneously and 3 were drained through a coaxial needle), four middle pleural reactions, and one hemothorax that required draining surgically. Follow-up evaluation was performed for 16 of 18 lesions. Stability was observed in one of two central tumors that received partial ablation. The remaining 15 tumors that received a complete ablation were followed up for a mean of 5 months (range, 1-12 months). All 15 lesions appeared to be hypodense at the CT examination. Dimension reduction with progressive fibrotic scar formation was observed in seven of seven lesions during a follow-up period of 6 months or more. A recurrence at the site of the treatment for two of three lesions was observed during a 12-month follow-up period. One of these received a second radiofrequency ablation. Five patients experienced systemic disease progression. In four of these five patients, this progression was not associated with recurrence at the site of the treatment.

CONCLUSION

Radiofrequency ablation seems to be possible for "nonsurgical" patients with primary and secondary lung tumors. Good results in terms of local tumor control were observed during short-term follow-up evaluation.

Lung cancer in Teesside (UK) and Varese (Italy): a comparison of management and survival

BACKGROUND

The survival of lung cancer patients in the UK is lower than in other similar European countries. The reasons for this are unclear.

METHODS

Two areas were selected with a similar incidence of lung cancer: Teesside in Northern England and Varese in Northern Italy. Data were collected prospectively on all new cases of lung cancer diagnosed in the year 2000. Comparisons were made of basic demographic characteristics, management, and survival.

RESULTS

There were 268 cases of lung cancer in Teesside and 243 in Varese. Patients in Teesside were older (p<0.05), were more likely to have smoked (p<0.001), had a higher occupational risk (p<0.001), higher co-morbidity (p<0.05), and poorer performance status (p<0.001). Fewer patients in Teesside presented as an incidental finding (p<0.001) and the histological confirmation rate was lower than in Varese (p<0.01). In Teesside there were more large cell carcinomas (p<0.001), more small cell carcinomas (p<0.05), and fewer early stage non-small cell lung cancers (p<0.05). The resection rate was lower in Teesside (7% v 24%; p<0.01) and more patients received no specific anti-cancer treatment (50% v 25%; p<0.001). Overall 3 year survival was lower in Teesside (7% v 14%; p<0.001). Surgical resection was the strongest multivariate survival predictor in Varese (HR = 0.46) and Teesside (HR = 0.31). Co-morbidity in Teesside resulted in a significantly lower resection rate (p<0.001).

CONCLUSIONS

Patients with lung cancer in Teesside presented at a later stage, with more aggressive types of tumour, and had higher co-morbidity than patients in Varese. As a result, the resection rate was significantly lower and survival was worse.

[Postoperative pneumonia caused by Candida in 500 lung surgery patients]

BACKGROUND

Postoperative infections continue to be one of the most frequent complications in hospitalized patients. The incidence of fungal infection has been steadily rising. While Candida albicans remains the most common yeast species isolated in hospitalized patients, other Candida species have been increasingly isolated.

METHODS

From 1996 to 2001, a prospective study of 500 consecutive lung surgery patients treated by the same surgical team was conducted to monitor the number of postoperative infections and to evaluate the epidemiology of bacterial and fungal infections.

RESULTS

At least one postoperative infection developed in 18% of patients. Of the 51 patients who developed postoperative pneumonia, 24 underwent microbiological examination of sputum. In 19 of them, the culture yielded isolates of one or more Candida species. Slightly under half of patients (47%) with cultures positive for mycetes received treatment with fluconazole until the clinical infection resolved. The drug was well tolerated by all treated patients.

CONCLUSIONS

The incidence of fungal infection has increased also at our center. In 19 of 24 patients with postoperative pneumonia, sputum cultures yielded Candida species isolates. Many factors may be contributing to the rise in fungal infections after surgery. As pneumonia caused by Candida led to a significantly longer length of hospital stay in our case series, we draw attention to the importance of early diagnosis of postoperative mycotic lung disease in order to institute timely and targeted therapy.

Risk factors in surgery

Improved surgical and anesthetic techniques and postoperative care have not significantly changed wound infection rates over the last 30 years. Many risk factors, related both to the host and to the surgical practice, have been identified in different studies. Control of nosocomial infections has become more challenging recently, due to a widespread bacterial resistance to antibiotics and to more frequent surgical indications in elderly patients at increased risk. A change in the microbiology of postoperative infections has also been noticed, characterized by a greater incidence of infections caused by methicillin-resistant Staphylococcus aureus, by polymicrobic flora and by fungi. This paper reviews the most important risk factors encountered in general surgery, that we observed during a 6-year prospective study of wound infection carried out in our Department of Surgery at the University of Insubria in Varese. Furthermore, the epidemiologic data on wound infections recorded in 4,002 patients undergoing general surgical procedures (mostly gastrointestinal operations), are presented and discussed.

Extracorporeal shockwave lithotripsy in patients treated with antithrombotic agents

PATIENTS AND METHODS

Between January 1996 and December 1999, 749 patients underwent electromagnetic SWL. Among them, 23 patients, 19 with renal and 4 with ureteral stones, were receiving antithrombotic drugs (aspirin, ticlopidine, dipyridamole). According to the cardiologist and hematologist, we divided these patients into two groups: Group 1 had a low thromboembolic risk (previous myocardial infarction), and Group 2 had a high thromboembolic risk (aortocoronary bypass, atrial fibrillation, cerebrovascular disease, peripheral occlusive arterial disease). Group 1 patients discontinued their antiplatelet therapy 8 days prior to SWL to permit a sufficient number of functioning platelets to remain. Group 2 patients suspended antiplatelet therapy, and unfractioned heparin 5000 IU tid (8 a.m., 4 p.m., and 12 p.m.) was administered for the 8 days prior to SWL. On the ninth day of withdrawal, SWL was performed in all patients. Close follow-up was performed during the postoperative period (hemoglobin, hematocrit, kidney ultrasonography, plain abdominal film). The antithrombotic therapy was restored in all patients within 10 to 14 days of withdrawal.

RESULTS

Hematomas and thromboembolic events were not observed. At 3 months' follow-up, 14 patients (61%) were stone free, 3 (13%) had <4-mm fragments, and 6 (26%) had >4-mm residual fragments.

CONCLUSION

Our schedules for the suspension or substitution of antithrombotic therapy, although tested in a small number of patients, allowed us to perform SWL without hemorrhagic or thromboembolic complications.

Stage I nonsmall cell lung carcinoma: analysis of survival and implications for screening

BACKGROUND

Skepticism about the radical curability of lung carcinoma, even when diagnosed in Stage I, has been long fostered by the epidemiologists' dogma against lung cancer screening, and by official recommendations not to screen for lung carcinoma. Follow-up of patients with asymptomatic screen-detected Stage I nonsmall cell lung carcinoma (NSCLC), however, shows that patients who underwent radical resection have long term survival rates, whereas patients nonsurgically treated or undergoing suboptimal operations have much poorer prognosis. The latter clinical outcome data strongly suggest the importance of detecting lung carcinoma when it is in Stage I and cast serious doubts on the recommendation not to screen for lung carcinoma.

DATA

The scrutiny of the biology, epidemiology, and clinical features of Stage I NSCLC clarifies important aspects of the ongoing controversy concerning the value of screening for early diagnosis (Stage I) of lung carcinoma. The biologic characteristics of Stage I NSCLC (histologic types, doubling time, metastases) indicate its malignant potential. The asymptomatic screen-diagnosed Stage I carcinomas have longer doubling time than the more advanced cancers; nevertheless, they are not overdiagnosed tumors because they cause fatal outcome if they are not resected. Chest X-ray screening identifies approximately 50% of cancers in Stage I. Screening by helical low dose computed tomography scan detects greater than 80% of lung carcinomas in Stage I. The resectability, the surgical techniques (lobectomy vs. limited resections), and the influence of the extent of surgical resection of Stage I NSCLC on prognosis are reviewed. These data show that radical surgical treatment offers 5-year survival rate to 60-80% of patients with Stage I NSCLC.

SYNTHESIS

Asymptomatic Stage I lung carcinomas, detected by screening or by incidental findings, are truly malignant, because they metastasize and cause fatal outcome if they are not radically resected. The possibility to cure lung carcinomas relies on radical resection (lobectomy or, less frequently, pneumonectomy) of early diagnosed (Stage I) disease, which is usually asymptomatic. The limited parenchymal resections (segment or wedge resections) do not fulfill the requirements of radicality because they are accompanied by higher incidence of local recurrences and shorter survival rates.

CONCLUSIONS

The documented improvement of long term survival of NSCLC, which can be achieved by early diagnosis and radical resection, strongly indicates that the current dogma against lung cancer screening is untrue. Every effort should be made to detect the disease when it is in Stage I and radically operable, by implementing screening in at risk smokers and former smokers, with the most effective screening method that is locally available.

Lung cancer screening in cigarette smokers in the province of Varese, Italy

BACKGROUND

For heavy cigarette smokers and recent former smokers who have accumulated a high risk of lung carcinoma, a primary objective is the early detection of that disease; this goal can be achieved by annual screening with one of the radiologic imaging methods available. While awaiting for the implementation of computed tomography or of other, more sensitive methods, it is quite reasonable to screen those who are at risk with annual chest X-ray (CXR), an examination that is readily available at low cost. Indeed, with the annual CXR screening of heavy smokers, it is possible to detect about 50% of lung carcinomas in TNM Stage I. The 5-year survival rate of patients with asymptomatic, screen-detected Stage I disease after radical surgery is significantly greater than the survival rate of patients with symptomatic disease.

METHODS

At the Center for Thoracic Surgery of the University of Insubria Medical School in Varese we developed a project, called "PRE.DI.CA" (an acronym for "early diagnosis of cancer"), of annual CXR screening for the early diagnosis of asymptomatic lung carcinoma in the high risk population of heavy cigarette smokers and recent former smokers in the province of Varese, Italy. From June 1997 to August 1999, 2444 heavy smokers were enrolled in the PRE.DI.CA project.

RESULTS

About 75% of participants complied with the annual screening protocol. Overall, 23 patients (all males) with asymptomatic lung carcinoma were detected by CXR screening; moreover, 1 patient developed symptoms of lung carcinoma 6 months after his initially negative CXR and was diagnosed with interval carcinoma (Stage IIIA). In the initial (prevalence) screening, the authors detected 16 patients with lung carcinoma in 2444 screened participants (0.65%). In the subsequent incidence screening, the authors detected 7 patients with lung carcinoma in 1361 screened participants (0.51%); it is noteworthy that 5 of 7 patients (71%) with lung carcinoma that was detected by incidence CXR screening had Stage I disease.

CONCLUSIONS

In the province of Varese, Italy, it is possible to make an early diagnosis of lung carcinoma with CXR annual screening in asymptomatic, high risk smokers. Incidence screening in 1361 participants detected 7 patients with asymptomatic lung carcinoma; 5 of 7 patients (71%) with such screen-detected lung carcinoma had Stage I disease.

Screening for lung cancer

The large clinical studies of lung cancer screening carried out more than 20 years ago were interpreted as evidence against screening. Those studies have been recently reassessed in the light of methodologic flaws in the randomization of subjects at risk for lung cancer. There is no evidence to support the former conclusion that screening is ineffective and the consequent official recommendation not to screen for lung cancer. The hypothesis of overdiagnosis of lung cancers diagnosed by screening is false. Clinical evidence supports the concept that the current dogma against screening for lung cancer is untrue. Indeed, the 5-year survival rate of patients with NSCLC detected in stage I and radically resected ranges from 60% to 80%. This rate is in sharp contrast to the 10% survival rate of stage I NSCLC not resected. About 90% of lung cancer cases are detected among smokers and former smokers; these well-known at-risk subjects should be offered a screening test with the goal of detecting the disease when it is in stage I. It is expected that the techniques for early detection of lung cancer will be refined and become more sensitive in the near future, so that it will be possible to detect an increasingly large proportion of lung cancers when they are truly in stage I (i.e., nonmetastatic) and curable by radical surgical resection. Low-dose helical CT scan is currently believed to represent a very useful technique for screening for lung cancer, with a higher sensitivity than chest radiograph screening. Chest radiography for lung cancer screening, however, is cheaper and ubiquitously available, and it should still be recommended if CT scan is locally unavailable. As underscored in a recent commentary in The Lancet, the existing public health policy discouraging the screening for lung cancer is in urgent need of reconsideration.

A prospective study of recurrence rate and risk factors for recurrence after a first renal stone

PURPOSE

We investigate further the recurrence rate and risk factors for recurrence in 300 consecutive patients who presented to our stone clinic after a first stone episode 7 to 17 years ago.

MATERIALS AND METHODS

The medical records of the patients who presented consecutively with a first stone episode from 1980 to 1990 were studied and supplemented by a followup mail questionnaire and telephone interviews. At first visit serum samples were taken from all patients and 24-hour urine samples were collected for metabolic testing.

RESULTS

A total of 195 patients were followed successfully, of whom 52 (27%) experienced symptomatic stone recurrence after a mean plus or minus standard deviation of 7.5+/-5.9 years. However, ultrasound examination of 36 symptom-free patients showed recurrent stones in 28%. Comparison of patients with or without recurrence confirmed that recurrence was not influenced by sex, family history of stones and urinary risk factors. However, age at onset of the disease was lower for patients who had 2 or more stones during followup than those who had only 1 stone or no recurrence.

CONCLUSIONS

Stones can recur as long as 10 years after the first episode, although the rate is lower than previously reported. The metabolic evaluation after a first stone episode needs to be reappraised in terms of its cost-effectiveness, since recurrences do not seem to be predictable from standard laboratory tests.

[Extracorporeal SWL in the treatment of reno-ureteral calculosis in day hospital]

Eighteen years after the first clinical shock wave lithotripsy (SWL), no doubt remains as to its therapeutic efficacy in ureterorenal lithiasis. The advent of lithotriptors with a large shock wave energy range and integration of both ultrasound and radiologic imaging equipment at the shock wave source has meant that outpatients treatment of urolithiasis is now feasible in a good proportion of cases. In our lithotripsy center, from January 1995 to August 1996, 208 out of 310 patients who underwent SWL treatment for renal and ureteral stones, were outpatients. Pretreatment manoeuvres were performed in 10.6% of the patients. No major complications occurred during the treatment. Only three patients (1.4%) were admitted to hospital because of fever, colics or perirenal haematoma in the first two days after SWL therapy. The stone free rate was 67 and 84% respectively one and three months after treatment. In our experience, the possibility of performing SWL treatments without anesthesia and even analgosedation, the absence of complications and the high success rate, make outpatient treatment of urolithiasis safe and suitable in a large number of patients.

[Urethral and prostatic urologic endoscopic surgery in day hospital]

We evaluated urethral and prostatic urological endoscopical surgery in Day Hospital, following rules proposed by Veneto Region in 1996. We made surgical treatments for urethral strictures, BPH obstruction, and sclerosis of the bladder neck in 44 patients (age: 67-84). Laser therapy and classical surgical techniques were used. Our results were good: complete resolution of obstruction, lack of bleeding, early catheter removal, and acceptable costs.

Hyperoxaluria in patients with idiopathic calcium nephrolithiasis

We studied 476 patients with idiopathic renal calcium stone disease (286 M, 190 F) while they ate their customary diets. Each subject collected a 24-hour urine sample and completed a dietary diary for a 3-day period. Daily urinary oxalate excretion (M 0.24 +/- 0.15 mg/dl, F 0.23 +/- 0.15 mg/dl) and nutrient intake values were calculated and multiple regression analyses were performed. Daily urinary oxalate excretion was significantly (p < 0.001) related to urinary volume (R = 0.24), vitamin C intake (R = 0.33) and body mass index (R = 0.37) and inversely related to calcium intake (R = -0.35). We conclude that urinary oxalate reflects endogenous oxalate production, presumably related to body size, but also intestinal absorption of oxalate, related to dietary intake and to the effect of dietary calcium intake which reduces intestinal oxalate absorption.

A study of dietary calcium and other nutrients in idiopathic renal calcium stone formers with low bone mineral content

PURPOSE

Patients with calcium renal stone are reported to have lower bone mineral density. The state of bone density in patients with renal stones have different explanations but the role of nutritional factors seems to be crucial. A group of 48 consecutive male calcium renal stone formers was studied to investigate the relationship between bone density and dietary intake.

MATERIALS AND METHODS

Patients completed a dietary diary for a 3-day period during normal diet. Nutrients and calories were calculated by food composition tables using a computerized procedure. Bone densitometry was assessed at the lumbar spine and femoral neck, and expressed as Z score. A blood sample was collected and was analyzed for serum biochemistry including alkaline phosphatase, parathyroid hormone and 1,25 vitamin D. A 24-hour urine sample was analyzed for calcium, phosphate, oxalate, citrate and other electrolytes.

RESULTS

Dietary calcium intake was significantly lower (p < 0.01) in patients with low than in those with normal bone mineral density. There was no difference in serum parathyroid hormone levels, phosphate and alkaline phosphatase between the 2 groups. The results suggest that some renal stone formers seem to be unable to decrease renal excretion of calcium on a low calcium diet leading to a negative calcium balance.

CONCLUSIONS

A primary abnormality of bone metabolism could be a reasonable explanation of reduced bone density observed in renal stone formers on a low calcium diet since serum parathyroid hormone levels are in the normal range. From a therapeutic point of view these data confirm that restriction of dairy products in renal stone formers should be avoided.

Ureteral calculosis: ESWL in situ and after preliminary manoeuvres

Extracorporeal shock wave lithotripsy is nowadays first choice treatment of ureteral stones. Shock wave generator technology has greatly advanced since the first electrohydraulic lithotriptor was introduced. Third generation lithotriptors combine all these advantages and integrate them into a multi-functional X-ray system. From January 1996 to June 1996, 63 patients (43 male and 20 female) suffering from ureteral calculosis were treated. Stone localisation was in 35 cases (55%) the lumbar ureter, in 3 (5%) the iliac ureter and in 25 (40%) the pelvic ureter. A Storz Modulith SLX lithotriptor with an electromagnetic cylindrical source was used. Easy positioning of the patient and dry coupling make treatment procedures simple. Furthermore, general anesthesia is not required and analgesic sedation (Fentanest and Diazepam) is often unnecessary, especially in ureteral stones.

Extracorporeal shock wave lithotripsy in the treatment of ureteral lithiasis: methodological controversies and therapeutic efficacy

The treatment of ureteral stones has undergone a radical change in the last 15 years. First, the increased use of endoscopic procedures and then the introduction of extracorporeal lithotripsy relegated traditional surgery to a marginal role for this type of disorder. The best available treatment modality for ureteral lithiasis, particularly distal ureteral stones, is still a matter of great controversy among urologist. With the introduction in clinical use of second- and third generation lithotripters, which are even less invasive and require no anesthesia, interest has increased in treating patients by extracorporeal lithotripsy, reducing endoscopic monoeuvres to a minimum. The absolute contraindications to extracorporeal lithotripsy for ureteral stones are the same as those for renal stones: intractable hemostatic alterations, pregnancy, physical structure that limits positioning and altered patency of the urinary tract. From June 1990 to December 1994, 270 patients with ureteral stones were treated by extracorporeal lithotripsy at our center. The Dornier MPL 9000 lithotripter was used in 68 cases (25%) and the modified HM3 Dornier in 202 (75%). Pretreatment manoeuvres were performed in 130 patients (48%). Endoscopic manoeuvres were not performed in 140 patients treated in situ. 18 patients (13%) treated initially in situ subsequently underwent post-treatment manoeuvres which were required only in 3 patients who had undergone pretreatment. All patients were examined as outpatients 3 months after the treatment. A total of 241 patients (89%) were stone free, 121 who had undergone pretreatment manoeuvres and 119 who had been treated in situ. 29 patients (11%) were not stone free: 23 patients subsequently underwent endoscopic lithotripsy, 2 surgery and 4 stone removal by Dormia probe. The possibility of performing treatment without anesthesia, the absence of complications and the high proportion of successes make extracorporeal lithotripsy, particularly the in situ procedure, the treatment of choice for ureteral stones. Ureterorenoscopy has been proposed by some authors as the first treatment for mid and pelvic ureteral stones which are difficult to localize with the lithotripter. However, although this method is very efficacious and less expensive, the percentage of complications is greater and patient compliance is less.

Clinical observations on 2086 patients with upper urinary tract stone

The present series comprises 2086 consecutive patients who were studied in a stone clinic during a period of 15 years. Each patient was subjected to a comprehensive protocol including a fully biochemical investigation. Calcium stones were by far the commonest accounting for 61% of cases; infection, uric acid/calcium oxalate and cystine stones accounted respectively for 24%, 8%, 5% and 2%. Nephrolithiasis was more prevalent in males with the male to female ratio 1:0.76, on the other hand infection stones were more frequent in females with the male to female ratio 1:1.6. The peak age incidence of renal calcium stones occurred in the third to fifth decades, although about 3.4% reported onset of disease in the first and second decades of life. The onset of cystine stones was always in the first and second decades, while uric acid stones affected older patients. Renal stones were recurrent in about 50% of cases. In a retrospective analysis it was found the interval to first recurrence to be less than 5 years in about half patients. The cystine and uric acid groups had the highest rate of recurrence. In patients with calcium stones a definite metabolic or mechanical cause for their stones was found respectively in 8.2% and 10.1%. Particularly primary hyperparathyroidism was revealed in 2.8%. A metabolic defect could be found in 54% of the patients with idiopathic calcium stones. In these patients with idiopathic calcium stones the prevalence rate of hypercalciuria was 33%. In patients with uric acid stones and with mixed uric acid/calcium oxalate stones a definite metabolic cause for their stones was found respectively in 9.5% and 4.1% whereas an underlying disease of the urinary tract was diagnosed respectively in 8.5% and 6.2%. In patients with struvite stones the incidence of persistent infection was 46% (Proteus 18%). In this group the presence of an underlying disease of the urinary tract was diagnosed in 18.8% whereas a definite metabolic disease was demonstrated in 8.5%, a urinary risk factor for metabolic stone disease in 42% and a previous episode of metabolic stone disease in 33%.

[Preoperative prediction of the presence of lymph node metastasis of prostatic carcinoma: reliability and clinical significance]

A total of 28 patients with clinically localized prostate cancer have undergone laparoscopic pelvic staging lymphadenectomy. In 21% of the patients pelvic lymph node metastases were diagnosed. If the Gleason score on needle biopsy was less than 6, the likelihood of lymph node metastases was 15%, whereas 50% of patients with a Gleason score of 6 or more had lymph node spreading; Whatever cutoff was used, the preoperative PSA value unreliable to predict the regional nodal status.

Experimental and clinical urinary diversion

In order to achieve an appropriate technical experience and explore clinical feasibility of laparoscopic urinary diversion, the authors planned a laboratory experiment. In ten male pigs weighing about 25 kilograms cystoprostatectomy was performed. Ureterocutaneostomy or ureterosigmoidostomy were carried out next. For ureterocutaneostomy a channel was bluntly dissected through the abdominal wall. The ureter was grasped by a clamp passed through the stroma, drawn outside and anstomosed to the skin. Operative time was about 30 minutes. For ureterosigmoidostomy a longitudinal incision of approximately 1 cm was made through the wall of the sigmoid colon in order to reach the mucosa. A very small opening in the angle of the incision was made. A suture was placed in the ureteral tip and secured to the colon wall. Finally, the ureter was covered in its bed with antireflux technique. Operative time was about 180 minutes. Laparoscopic ureterocutaneostomy was also successfully applied in a compromised patient to resolve a particular clinical situation.

Extracorporeal shock-wave lithotripsy with MPL9000 for the treatment of urinary stones in pediatric patients

Extracorporeal shock-wave lithotripsy (ESWL) is now applied as the treatment of choice in most cases of urinary stones. Its acceptance in pediatry, however has been only gradual despite numerous positive studies. We report on fourteen young patients (mean age: 9.7 years) who were all treated by ESWL with the MPL9000 lithotriptor for renal stones. Each patient received an average of 1440 shocks with generator energy set at 14.4 Kv. Six of these patients required either analgosedation or anesthesia. No observable complications of treatment occurred. At one-month follow up, the kidneys of twelve patients were found to be stone-free, while two still presented fragments that could pass spontaneously. At three-month follow-up, thirteen patients were stone-free and a single patient retained some fragments. From this data we infer that ESWL with the MPL9000 lithotriptor may be used safety and efficiently to treat urolithiasis in younger patients.

Urological laparoscopy: our preliminary results

From the beginning of urological applications of laparoscopy, this technique has found many clinical indications. In our center, after an experimental training in animals, we performed 48 operations using laparoscopy: 18 pelvic lymphadenectomies (15 for prostate cancer, 2 for bladder tumor and 1 for penis carcinoma), 11 ligatures of the spermatic vein (3 bilateral), 4 orchidopexies, 10 excisions of renal cysts, 4 nephrectomies and 1 adrenalectomy. For cryptorchidism, laparoscopy is a less invasive alternative to surgical exploration; in case of prostate cancer, laparoscopic pelvic node dissection has a lower incidence of complications and requires few days of hospitalisation. The excision of renal cysts by laparoscopy, in case of large symptomatic pathology, is an efficacious operation with low morbidity. In case of nephrectomy for small wrinkled kidneys or severe hydronephrosis, long execution time makes cost/benefit ratio somewhat debatable; adrenalectomy, instead, is easier than nephrectomy and offers many advantages in comparison with traditional surgical approach. All indications will be better evaluated at a later date, with the indispensable learning period and the continuous progress of technical equipment.

[Laparoscopic cystectomy: an experimental model of urinary diversion]

During our experimental trial we achieved laparoscopic cistectomies with urinary diversion to prove our manual capability with the reconstructive surgery. We executed, on male pigs, 10 cistectomies with urinary diversion using laparoscopic technique. We performed 5 ureterocutaneostomies on 5 pigs and, in the other ones, 5 ureterosigmoidostomies. During UCS the pigs laid in lateral position, and during USS in supine position. The average time of the operation is going to reduce in consideration of the overcoming of the initial techno-instrumental difficulties and is 60 minutes for cistectomy, 30 minutes for ureterocutaneostomy and 120 minutes for ureterosigmoidostomy.

[Laparoscopic nephrectomy]

Laparoscopic nephrectomy is a new procedure in which the entire kidney is removed introducing it in an Endopouch and, after morcellation pulled out through a 12 mm port. After an initial experimental experience, in our Institute we have performed one laparoscopic nephrectomy for left pyelonephritic kidney and ureteral reflux. The operation required the positioning of 5 trocars and 4 hours for its execution. The discharge of the patient was possible four days after.

[Renal cysts resection]

Six patients with inferior and middle polar renal cysts of 8-15 centimeters of diameter, underwent the resection of the cyst by laparoscopic technique. The operation required an average time of execution of two hours and the positioning of four trochars to consent an adequate access. The absence of important complications during and after the operation has allowed a quick dismission of the patients. The laparoscopic treatment of renal cysts represent a valid choice to traditional surgery and percutaneous needle aspiration.