Effect of preoperative chemoradiotherapy on outcome of patients with locally advanced esophagogastric junction adenocarcinoma-a pilot study

BACKGROUND

To date, few studies of preoperative chemotherapy or chemoradiotherapy (crt) in gastroesophageal junction (gej) cancer have been statistically powered; indeed, gej tumours have thus far been grouped with esophageal or gastric cancer in phase iii trials, thereby generating conflicting results.

METHODS

We studied 41 patients affected by locally advanced Siewert type i and ii gej adenocarcinoma who were treated with a neoadjuvant crt regimen [folfox4 (leucovorin-5-fluorouracil-oxaliplatin) for 4 cycles, and concurrent computed tomography-based three-dimensional conformal radiotherapy delivered using 5 daily fractions of 1.8 Gy per week for a total dose of 45 Gy], followed by surgery. Completeness of tumour resection (performed approximately 6 weeks after completion of crt), clinical and pathologic response rates, and safety and outcome of the treatment were the main endpoints of the study.

RESULTS

All 41 patients completed preoperative treatment. Combined therapy was well tolerated, with no treatment-related deaths. Dose reduction was necessary in 8 patients (19.5%). After crt, 78% of the patients showed a partial clinical response, 17% were stable, and 5% experienced disease progression. Pathology examination of surgical specimens demonstrated a 10% complete response rate. The median and mean survival times were 26 and 36 months respectively (95% confidence interval: 14 to 37 months and 30 to 41 months respectively). On multivariate analysis, TNM staging and clinical response were demonstrated to be the only independent variables related to long-term survival.

CONCLUSIONS

In our experience, preoperative chemoradiotherapy with folfox4 is feasible in locally advanced gej adenocarcinoma, but shows mild efficacy, as suggested by the low rate of pathologic complete response.

Moderate alcohol consumption predicts long-term mortality in elderly subjects with chronic heart failure

OBJECTIVE

Moderate alcohol consumption is related to a reduction of mortality. However, this phenomenon is not well established in the elderly, especially in the presence of chronic heart failure (CHF). The aim of the study was to verify the effect of moderate alcohol consumption on 12-year mortality in elderly community-dwelling with and without CHF.

SETTINGS

community-dwelling from 5 regions of Italy.

PARTICIPANTS

A cohort of 1332 subjects aged 65 and older.

MEASUREMENT

Mortality after 12-year follow-up in elderly subjects (≥65 years old) with and without CHF was studied. Moderate alcohol consumption was considered ≤250 ml/day (drinkers).

RESULTS

In the absence of CHF (n=947), mortality was 42.2% in drinkers vs. 53.7% in non-drinker elderly subjects (p=0.021). In contrast, in the presence of CHF (n=117), mortality was 86.5% in drinkers vs. 69.7% in non-drinker elderly subjects (p=0.004). Accordingly, Cox regression analysis shows that a moderate alcohol consumption is protective of mortality in the absence (HR=0.79; CI 95% 0.66-0.95; p<0.01) but it is predictive of mortality in the presence of CHF (HR=1.29; CI 95% 1.05-1.97; p<0.05).

CONCLUSIONS

Our data demonstrates that moderate alcohol consumption is associated with an increased long-term mortality risk in the elderly in the presence of CHF.

Complete response to preoperative chemoradiation and survival in esophageal cancer: a pooled analysis of three single-institution phase II trials

This pooled analysis was performed using individual patient data from three phase II trials that included on the whole 113 esophageal cancer treated preoperatively with chemoradiotherapy (CRT), in order to analyze the efficacy and survival outcomes according to the achievement of the pathologic complete response (pCR). Thirty-nine patients were treated with 5-fluorouracil/cisplatin and RT (40 Gy), 33 patients received paclitaxel/cisplatin weekly during weeks 1-6 with and RT (46 Gy), 41 patients were treated with induction bio-chemotherapy with cetuximab and FOLFOX-4 followed by concomitant cetuximab and RT of 50.4 Gy. One hundred and two out of 113 resected patients were included in the survival analysis. The median overall survival (OS) time for the whole population was 21.5 months. The 12, 24, and 36 months OS rates were 85.4, 45.2, and 33%, respectively. The difference in survival probability between patients with pCR and patients with partial response or stable disease after treatment was significant (P= 0.0002, hazard ratios = 0.21, 95% CI 0.18-0.60). On multivariate analysis, the pathologic response and histology were the only covariates independently associated with OS (P= 0.0157 and P= 0.0212, respectively). In our series, complete responder patients had a significant longer survival probability after treatment when compared to patients with partial response or stable disease.

Chemoradiotherapy as adjuvant treatment of gastric cancer

Historically, radiotherapy has been occasionally used in the treatment of gastric cancer. More recently, the results of INT-0116 trial have shown an improvement of disease-free and overall survival by chemoradiation with a significant impact on the management of this tumor. Based on these data, there has been an increasing interest in radiotherapy and its association with chemotherapy for patients with locoregional disease as a part of an adjuvant treatment after surgery in high-risk patients. However, many questions remain to evaluate; first of all the toxicity of this approach and its efficacy after adequate surgery.

Cetuximab, a chimeric human mouse anti-epidermal growth factor receptor monoclonal antibody, in the treatment of human colorectal cancer

The recent successful development of monoclonal antibodies that target key components of biological pathways has expanded the armamentarium of treatment options for patients with colorectal cancer (CRC). In particular, the epidermal growth factor receptor (EGFR), a tyrosine kinase growth factor receptor involved in CRC development and progression, is exploited by the newest monoclonal antibody that is available for use in CRC patients. Cetuximab, the first chimeric monoclonal antibody, which has been generated against the EGFR, is currently registered in USA, Europe and worldwide, in combination with irinotecan in the treatment of metastatic CRC patients who have progressed on irinotecan containing chemotherapy. Cetuximab is well tolerated and does not exacerbate the toxicity of concomitant chemotherapy. Furthermore, a series of phase III clinical trials are currently evaluating the combination of cetuximab with standard chemotherapy regimens in the first-line treatment chemotherapy-naïve patients with metastatic CRC.

Neo-adjuvant and adjuvant chemotherapy of gastric cancer

Gastric cancer is still a major health problem and a leading cause of cancer mortality despite a worldwide decline in incidence. Surgery is the primary curative treatment of locoregional gastric cancer. In Western countries, however, at the time of resection, most patients are expected to have regional lymph node involvement with poor prognostic implications. To improve these results, different trials have been carried out in the adjuvant or neo-adjuvant setting. Many phase III trials of adjuvant therapy have been conducted; however, postoperative treatment modalities have not proven to be superior to postsurgical observation alone. Therefore, at present the routine use of adjuvant therapy should be regarded as an investigational approach. Improved clinical trial designs with standardized surgical techniques and the incorporation of newer active drugs are needed. On the contrary, neo-adjuvant chemotherapy has shown promising results as suggested by the final results of UK Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial.

Adjuvant chemotherapy with epirubicin, leucovorin, 5-fluorouracil and etoposide regimen in resected gastric cancer patients: a randomized phase III trial by the Gruppo Oncologico Italia Meridionale (GOIM 9602 Study)

BACKGROUND

This randomized, multicenter, phase III trial evaluated the efficacy and safety of the combination of epirubicin, leucovorin, 5-fluorouracil and etoposide (ELFE regimen) as adjuvant therapy for radically resected gastric cancer patients.

PATIENTS AND METHODS

From June 1996 to June 2001, 228 stage IB-IIIB gastric cancer patients were enrolled. All patients received a total or subtotal gastrectomy with at least a D1 lymphoadenectomy and were randomly assigned to receive surgery alone or surgery followed by chemotherapy.

RESULTS

A total number of 630 cycles was delivered with a median number of 5. With a median follow-up of 60 months, the 5-year overall survival (OS) was 48% in the treatment arm and 43.5% in the control arm [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.69-1.21; P = 0.610); the 5-year disease-free survival (DFS) was 44% in the treatment arm and 39% in the control arm (HR 0.88; 95% CI 0.78-0.91; P = 0.305). In node-positive patients, the 5-year OS was 41% in the treatment arm and 34% in the control arm (HR 0.84; 95% CI 0.69-1.01; P = 0.068), while the 5-year DFS was 39% in the treatment arm and 31% in the control arm (HR 0.88; 95% CI 0.78-0.91; P = 0.051). The most common grade 3-4 toxic effects according to World Health Organization criteria were hematological and gastrointestinal.

CONCLUSIONS

In radically resected gastric cancer patients, adjuvant chemotherapy with ELFE regimen does not improve OS over surgery alone.

Adjuvant chemotherapy with epirubicin, leucovorin, 5-fluorouracil and etoposide regimen in resected gastric cancer patients: a randomized phase III trial by the Gruppo Oncologico Italia Meridionale (GOIM 9602 Study)

BACKGROUND

This randomized, multicenter, phase III trial evaluated the efficacy and safety of the combination of epirubicin, leucovorin, 5-fluorouracil and etoposide (ELFE regimen) as adjuvant therapy for radically resected gastric cancer patients.

PATIENTS AND METHODS

From June 1996 to June 2001, 228 stage IB-IIIB gastric cancer patients were enrolled. All patients received a total or subtotal gastrectomy with at least a D1 lymphoadenectomy and were randomly assigned to receive surgery alone or surgery followed by chemotherapy.

RESULTS

A total number of 630 cycles was delivered with a median number of 5. With a median follow-up of 60 months, the 5-year overall survival (OS) was 48% in the treatment arm and 43.5% in the control arm [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.69-1.21; P = 0.610); the 5-year disease-free survival (DFS) was 44% in the treatment arm and 39% in the control arm (HR 0.88; 95% CI 0.78-0.91; P = 0.305). In node-positive patients, the 5-year OS was 41% in the treatment arm and 34% in the control arm (HR 0.84; 95% CI 0.69-1.01; P = 0.068), while the 5-year DFS was 39% in the treatment arm and 31% in the control arm (HR 0.88; 95% CI 0.78-0.91; P = 0.051). The most common grade 3-4 toxic effects according to World Health Organization criteria were hematological and gastrointestinal.

CONCLUSIONS

In radically resected gastric cancer patients, adjuvant chemotherapy with ELFE regimen does not improve OS over surgery alone.

Lithiasis and Risk Factors

Nephrolithiasis is a worldwide disease with high clinical and economic costs. The increasing incidence in industrialized countries seems to be related to several risk factors, which are partly inherited and partly acquired. Although risk factors in urolithiasis are still under discussion, their identification would provide a notable gain for the patient in terms of stone episodes, and for the health service in terms of costs. This article presents an easy classification of risk factors based on clinical background.

Weekly docetaxel and capecitabine is not effective in the treatment of advanced gastric cancer: a phase II study

BACKGROUND

Capecitabine and docetaxel have demonstrated preclinical antitumor synergy and activity in advanced gastric cancer. We assessed the clinical activity and the toxicity of weekly docetaxel in combination with capecitabine in untreated patients with advanced gastric cancer.

PATIENTS AND METHODS

A total of 38 patients were treated with docetaxel 36 mg/m2 on days 1, 8, and 15 i.v., plus capecitabine, 625 mg/m2 bid per os on days 5 to 18 repeated every 4 weeks.

RESULTS

All patients were assessable for response to treatment and for toxicity. Major responses were observed in eight patients (21%), with three patients achieving a CR (7.8%) and five showing a PR (13%). The median time to progression was 5.4 months and the overall survival was 7.7 months. The safety profile of this schedule was acceptable with a low rate of myelossuppression, diarrhoea and hand-foot syndrome.

CONCLUSIONS

The combination of docetaxel and capecitabine at the doses and schedule investigated in this study is safe, but does not show significant activity in untreated patients with advanced gastric cancer.

Surgery plus ELFE (epirubicin, leucovorin, 5-fluorouracil and etoposide) vs surgery alone in radically resected gastric cancer (GC): Final results of a randomised phase III trial by the Gruppo Oncologico dell’ Italia Meridionale (GOIM)

4014

Background: In a previous phase II study the ELFE regimen resulted to be active and well tolerated for the treatment of advanced GC (Am J Clin Oncol 22:262;1999). Based on this background the G.O.I.M. conducted a randomised phase III study (trial 9602) to evaluate efficacy and toxicity of ELFE regimen as adjuvant therapy for radically resected GC patients (pts). Methods: All enrolled pts underwent total or subtotal gastrectomy with at least a D1 lymphoadenectomy. After stratification for nodal involvement (N+ vs N-) pts were randomised to follow-up alone (116 pts) or 6 cycles of ELFE regimen ( EPI 60mg/m2 d1, LV100 mg/m2 d 1–5, 5FU 375 mg/m2 d 1–5, VP-16 100 mg/m2 d1–3, every 3 weeks). Results: From June 1997 to June 2001, 228 pts with stage IB-IIIB GC were enrolled. Pts characteristics were: median age 63 yrs (29–70); total gastrectomy 148 pts; N+ 163 pts; PS 0–1 according ECOG scale 210. A total number of 638 cycles were delivered with a median number of 5/pt. During chemotherapy, the most frequent G3–4 side-effects graded according to NCI-CTC included alopecia (32%), neutropenia (26%), diarrhea (26%), nausea/emesis (17%), thrombocytopenia (12%) and stomatitis (11%). With a median follow-up of 60 months, the 5-years overall survival was 48% in the treatment arm and 43.5% in the control arm ( p=0.610); the 5-years disease-free survival was 44% in the treatment arm and 39% in the control arm ( p=0.305). Between patients with positive nodes the 5-years overall survival was 41% in the treatment arm and 34% in the control arm( p=0.068), while the 5-years disease-free survival was 39% in the treatment arm and 31% in the control arm (p=0.052). Multivariate analysis showed TNM stage as the only covariate that was independently associated with overall and disease-free survival. Conclusions: In radically resected GC adjuvantELFE chemotherapy produces an absolute difference in overall survival and disease-free survival at 5 years respectively of 4.5% and 5%, but this advantage was not statistically significant.

No significant financial relationships to disclose.

Feasibility of Primary Inguinal Hernia Repair with a New Mesh

BACKGROUND

The purpose of this study was to evaluate the feasibility of primary inguinal repair with open tension-free and sutureless technique using a new polypropylene "patch and plug system" (Prolene 3D patch), and the quality of the treatment in terms of reduction of postoperative discomfort.

METHODS

Fifty-six consecutive patients, mean age 54.5+/-11.2 years, with primary unilateral uncomplicated inguinal hernia, were treated in a day-surgery setting. Collected data included: pain scores at 24 hours, 72 hours, and 7, 15, and 30 days after operation, analgesic medications, return to work and to heavy house and/or moderate sporting activities, and quality of life as measured by Short Form 36 health survey questionnaire (SF-36) before the operation and at 6 months follow-up.

RESULTS

Postoperative pain was low: the mean visual analog scale (VAS) scores were 2.8 at 24 h, 1.8 at 72 h, and 0.9, 0.3, and 0.04 at 7, 15, and 30 days, respectively. Analgesic drugs were not used by 66.0% (n=37) of the patients. The mean global time to return to work and to heavy activities was 9.9+/-4.6 and 14.6+/-7.0, days, respectively. Patient satisfaction showed a significant improvement in all SF-36 domain scores at 6 months follow-up (P<0.001). There were no major complications, recurrences, or mortality.

CONCLUSIONS

The new mesh seems to satisfy all requirements of a feasible, reliable, and effective device for repairing primary inguinal hernia with high patient comfort.

Frailty predicts long-term mortality in elderly subjects with chronic heart failure

BACKGROUND

The elderly are characterized by a high prevalence of chronic heart failure (CHF) and frailty, which is a complex interaction of physical, psychological and social impairment. This study aimed to examine the predictive role of frailty on long-term mortality in elderly subjects with CHF.

MATERIALS AND METHODS

The study assessed long-term mortality after 12-year follow up in 120 subjects with CHF and 1139 subjects without CHF, selected in 1992, from a random sample of the elderly population in the Campania region of Italy. Frailty was assessed according to a 'Frailty Staging System'.

RESULTS

Subjects with CHF were prevalently female (60%) and older than 75 years (mean 75.9 +/- 6.7); subjects without CHF were prevalently female (56.4%) and younger than 75 years (mean 74.0 +/- 6.3). In subjects with and without CHF stratified into classes of frailty there was a statistically significant increase in age, comorbidity, disability and low social support, and a decrease in MMSE score. Moreover, death progressively increased more with frailty in subjects (70.0% to 94.4%, P < 0.03) than in those without (43.8.% to 88.3%, P < 0.0001) CHF. The Kaplan-Meier analysis shows that at 9 years the probability of survival progressively decreased as frailty increased (45.5% to 0%) in subjects with CHF and from 62.8% to 25.9% in subjects without CHF. The Cox regression analysis indicated that frailty is predictive of mortality in the multivariate model adjusted for several variables including sex and age in subjects with and without CHF. Moreover, the analysis showed that frailty is more predictive of mortality in elderly subjects with CHF when it was analyzed either as continuous (1.48 vs. 1.36) or as a dummy (3 vs. 1 = 1.62 vs. 1.24) variable.

CONCLUSIONS

Thus mortality among elderly subjects with or without CHF increases with frailty. Moreover, frailty is more predictive of long-term mortality in elderly subjects with than in those without CHF. Hence, frailty represents a new independent variable for predicting long-term mortality in elderly subjects with CHF.

A phase II study of biweekly oxaliplatin plus infusional 5-fluorouracil and folinic acid (FOLFOX-4) as first-line treatment of advanced gastric cancer patients

The aim of the study was to assess the toxicity and the clinical activity of biweekly oxaliplatin in combination with infusional 5-fluorouracil (5-FU) and folinic acid (FA) administered every 2 weeks (FOLFOX-4 regimen) in patients with advanced gastric cancer (AGC). A total of 61 previously untreated AGC patients were treated with oxaliplatin 85 mg m⁻² on day 1, FA 200 mg m⁻² as a 2 h infusion followed by bolus 5-FU 400 mg m⁻² and a 22 h infusion of 5-FU 600 mg m⁻², repeated for 2 consecutive days every 2 weeks. All patients were assessable for toxicity and response to treatment. Four (7%) complete responses and 19 partial responses were observed (overall response rate, 38%). Stable disease was observed in 22 (36%) patients, with progressive disease in the other six (10%) patients. Median time to progression (TTP) and median overall survival (OS) were 7.1 and 11.2 months, respectively. National Cancer Institute Common Toxicity Criteria grade 3 and 4 haematologic toxicities were neutropenia, anaemia and thrombocytopenia in 36, 10 and 5% of the patients, respectively. Grade 3 peripheral neuropathy was recorded in three (5%) patients. FOLFOX-4 is an active and well-tolerated chemotherapy. Response rate (RR), TTP and OS were comparable with those of other oxaliplatin-based regimens, suggesting a role for this combination in gastric cancer.

Tandem action of exercise training and food restriction completely preserves ischemic preconditioning in the aging heart

Ischemic preconditioning (IP) has been proposed as an endogenous form of protection against ischemia reperfusion injury. IP, however, does not prevent post-ischemic dysfunction in the aging heart but may be partially corrected by exercise training and food restriction. We investigated the role of exercise training combined with food restriction on restoring IP in the aging heart. Effects of IP against ischemia-reperfusion injury in isolated hearts from adult (A, 6 months old), sedentary 'ad libitum' fed (SL), trained ad libitum fed (TL), sedentary food-restricted (SR), trained- and food-restricted senescent rats (TR) (24 months old) were investigated. Norepinephrine release in coronary effluent was determined by high performance liquid cromatography. IP significantly improved final recovery of percent developed pressure in hearts from A (p<0.01) but not in those from SL (p=NS) vs unconditioned controls. Developed pressure recovery was partial in hearts from TL and SR (64.3 and 67.3%, respectively; p<0.05 vs controls) but it was total in those from TR (82.3%, p=NS vs A; p<0.05 vs hearts from TL and SR). Similarly, IP determined a similar increase of norepinephrine release in A (p<0.001) and in TR (p<0.001, p=NS vs adult). IP was abolished by depletion of myocardial norepinephrine stores by reserpine in all groups. Thus, IP reduces post-ischemic dysfunction in A but not in SL. Moreover, IP was preserved partially in TR and SR and totally in TR. Complete IP maybe due to full restoration of norepinephrine release in response to IP stimulus.

Myxopapillary ependymoma of the ischioanal fossa

Ependymomas outside the confines of the cranium and spinal cord are rare. Direct extension into the soft tissues of the sacrococcygeal area may occur from a primary ependymoma of the spinal cord, cauda equina or filum terminale. Alternatively they may occur as a primary pre-sacral, pelvic and abdominal tumour, or as a primary tumour of the skin and subcutaneous tissue of the sacrococcygeal area without any demonstrable connection with the spinal cord. The Authors report a case of myxopapillary ependymoma of the ischioanal fossa, demonstrated by MRI. To our knowledge, our case is the first lesion reported at this site.

True tail dorsal-lumbar: malformation or ancestral remaining?

The case of a healthy newborn presenting a dorsal-lumbar cutaneous appendage is reported. The appendage was excised by ligature. This appendage was not associated with dysraphism or other malformations. It was analysed histologically and then defined as a so called true tail. Although it was been expressed a lot of hypotheses, the etiology of this finding remains disputed. The embryology of malformation and its non identification between known-syndromes is showed. The difference between true tails and not-true tails is discussed. The conclusion is drawn that for its clinical and histological aspect this malformation may be included in true tails.

[Ectopic thyroid: report of a case]

The development of thyroid tissue can occur in any moment of the migration of the thyroid along the thyroglossal duct from the tongue, resulting in lingual (at tongue base), sublingual (below the tongue), prelaryngeal (in front of the larynx), and substernal (in the mediastinum) ectopy. Thyroglossal duct cyst is the most common type of clinical abnormality related to thyroid ectopy. Surgical removal of such ectopic tissue is justified since some Authors describe thyroid cancer arising from aberrant thyroid tissue. The Authors report a case of thyroid ectopy in a patient who underwent 20 years before a left thyroid resection with isthmectomy; during the operation the surgeon described a hypertrophic pyramidal lobe which was left in situ and the patients did not receive any hormone suppressing therapy.

Interleukin-6 serum level correlates with survival in advanced gastrointestinal cancer patients but is not an independent prognostic indicator

Interleukin-6 (IL-6) is a pleiotropic cytokine that has been shown to regulate immune defense mechanisms and hematopoiesis. In addition, IL-6 may also be involved in malignant transformation and tumor progression. A poor prognosis in patients with multiple myeloma, renal cell carcinoma, ovarian cancer, or prostate cancer has been associated consistently with elevated IL-6 serum levels. The aim of this study was, therefore, to assess IL-6 serum levels in 68 advanced gastrointestinal cancer patients and to correlate them with prognosis. IL-6 serum levels were found to be significantly elevated in cancer patients with respect to controls. Moreover, patients with disseminated cancer displayed significantly higher IL-6 serum levels than patients without apparent metastases. On univariate analysis, both overall survival (OS) and time to disease progression (TTP) were shown to be affected by IL-6 serum levels. However, multivariate analysis failed to demonstrate an independent prognostic significance for IL-6 serum levels while confirming the role of previously established variables, such as performance status, carcinoembryonic antigen (CEA) serum levels, and distant metastases. In conclusion, this study showed that IL-6 serum levels were elevated in advanced gastrointestinal cancer patients and correlated with both OS and TTP. However, they were shown not to be an independent prognostic factor.

Counting alleles reveals a connection between chromosome 18q loss and vascular invasion

The analysis of loss of heterozygosity (LOH) is perhaps the most widely used technique in cancer genetics. In primary tumors, however, the analysis of LOH is fraught with technical problems that have limited its reproducibility and interpretation. In particular, tumors are mixtures of neoplastic and nonneoplastic cells, and the DNA from the nonneoplastic cells can mask LOH. We here describe a new experimental approach, involving two components, to overcome these problems. First, a form of digital PCR was employed to directly count, one by one, the number of each of the two alleles in tumor samples. Second, Bayesian-type likelihood methods were used to measure the strength of the evidence for the allele distribution being different from normal. This approach imparts a rigorous statistical basis to LOH analyses, and should be able to provide more reliable information than heretofore possible in LOH studies of diverse tumor types.

Hemodynamic and pulmonary changes during open, carbon dioxide pneumoperitoneum and abdominal wall-lifting cholecystectomy. A prospective, randomized study

BACKGROUND

Carbon dioxide (CO2) pneumoperitoneum effects are still controversial. The aim of this study was to investigate cardiopulmonary changes in patients subjected to different surgical procedures for cholecystectomy.

METHODS

In this study, 15 patients were assigned randomly to three groups according to the surgical procedure to be used: open cholecystectomy (OC), CO2 pneumoperitoneum cholecystectomy (PP), and laparoscopic gasless cholecystectomy (abdominal wall lifting [AWL]), respectively. A pulmonary artery catheter was used for hemodynamic monitoring in all patients. A subcutaneous multiplanar device (Laparo Tenser) was used for abdominal wall lifting. To avoid misinterpretation of results, conventional anesthesia was performed with all parameters, and the position of the patients held fixed throughout surgery. The following parameters were analyzed: mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), cardiac index (CI), stroke volume index (SVI), central venous pressure (CVP), systemic vascular resistances index (SVRI), mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistances index (PVRI), peak inspiratory pressure (PIP), end-tidal CO2 pressure (ETCO)2, CO2 arterial pressure (PaCO2), and arterial pH.

RESULTS

All the operations were completed successfully. The Laparo Tenser allowed good exposition of the surgical field. A slight impairment of the cardiopulmonary functions, with reduction of SVRI, MAP, and CI and elevation of pulmonary pressures and vascular resistance, followed induction of anesthesia. However, these effects tended to normalize in the OC and AWL groups over time. In contrast, CO2 insufflation produced a complex hemodynamic and pulmonary syndrome resulting in increased right- and left side filling pressures, significant cardiac index reduction, derangement of the respiratory mechanics, and respiratory acidosis. All of these effects normalized after desufflation.

CONCLUSIONS

Cardiopulmonary adverse effects of general anesthesia were significant but transitory and normalized during surgery. Carbon dioxide pneumoperitoneum caused a significant impairment in cardiopulmonary functions. In high-risk patients, gasless laparoscopy may be preferred for reliability and absence of cardiopulmonary alterations.

[Hereditary colonic cancer. Analysis of 3 families at risk]

Hereditary colorectal cancer is a clearly identified entity today; it is transmitted as a dominant autosomal heritage, and represents about 25% of large bowel malignancies. The poor prognosis of this tumor, one of the most frequent in Western Countries, despite the improvements in therapeutic field, is due to a delated diagnosis that affects an advanced stage of disease in which the results of treatment are significantly worse, whereas cumulative 5-year survival rate is 35% vs 95% in early stage tumors. Existence of an inherited cancer, even in the absence, at present, of specific biomarkers, allows to identify a high risk population in which early diagnosis of colorectal cancer is possible, on the basis of anamnestic and clinical features. Only in this way, with the extension of the results to general population, prognosis of colorectal cancer will be improved.

[Biliary ileus: a review of the literature and report of a clinical case treated by minilaparotomy]

OBJECTIVE

To evaluate the diagnostic and therapeutic approach to gallstone ileus.

MATERIAL AND METHODS

A gallstone ileus report, diagnosed by integrated radiological approach, treated by minilaparotomy plus enterolithotomy and followed up for two years.

RESULTS

Traditional radiologic findings, ultrasonography and computed tomography showed both the stone in the bowel lumen and the cholecystoduodenal fistula with air in the biliary tract. The enterolithotomy alone worked out the obstruction and no complication was observed.

DISCUSSION

Integrated radiologic examinations are indicated in defining nature, site and seriousness of gallstone ileus. In most cases surgical treatment is mandatory to work out both the bowel occlusion and bilioenteric illness even though it is often wiser to perform an operation of enterolithotomy alone owing to the general and local conditions of the patient. After this surgical approach, bilioenteric fistula disappears in most cases with no residual lithiasis; in the cases in which fistula and/or lithiasis persist, a decisive surgical operation can be performed in a second step.

Retroperitoneal abscess after retained stones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is associated with a significant risk of gallbladder perforations with bile and stone spillage. The retrieval of dropped stones is sometimes impossible, and intraperitoneally retained stones can be the source of serious complications, such as inflammatory masses or abscesses. The authors describe a patient in whom a large retroperitoneal abscess developed as a result of missed stone fragments during cholecystectomy. Although several cases of intraperitoneal abscess have been reported in the literature, retroperitoneal collection is very uncommon. Crushed and infected stones seem to be the essential prerequisite for abscess formation. Therefore, every attempt should be made to avoid stone spillage and intra-abdominally retained stones. Conversion to open surgery has to be considered in the presence of adverse factors, such as primary acute cholecystitis or cholecystitis induced by previous sphincterotomy, or bilirubinate stones believed to be infected. Abdominal abscess treatment requires removal of missed stones by surgical incision or new laparoscopic procedure because simple percutaneous drainage is usually unsuccessful.

Lateral internal sphincterotomy together with haemorrhoidectomy for treatment of haemorrhoids: a randomised prospective study

OBJECTIVE

To investigate anorectal manometric findings in patients with haemorrhoids and to evaluate the clinical effects and physiological consequences of adding a lateral internal sphincterotomy (LIS) to haemorrhoidectomy.

DESIGN

Randomised prospective study.

SETTING

Teaching hospital, Naples.

PATIENTS

48 consecutive patients with prolapsed piles who had anorectal manometry; 10 healthy volunteers served as controls.

INTERVENTIONS

Resting and squeeze pressures, sphincter length and rectoanal inhibitory reflex were recorded. 6 patients were excluded because anal pressures were not raised, so 42 patients were randomised. 22 patients had haemorrhoidectomy plus LIS; and 20 had haemorrhoidectomy alone.

MAIN OUTCOME MEASURES

Morbidity, continence, and anorectal manometry.

RESULTS

Sphincter anomalies were found in 87.5% (n = 42) of patients. Haemorrhoidectomy alone did not affect anal pressures, which returned to the normal ranges after sphincterotomy. Those who had LIS did better postoperatively than those who had did not. 4 patients who did not have a sphincterotomy developed anal strictures. No patient who had LIS developed incontinence of faeces.

CONCLUSIONS

High anal pressures are common in patients with haemorrhoids suggesting that they may have a pathogenetic role; anorectal manometry is useful in the investigation of anal pressure patterns; and when indicated, lateral sphincterotomy avoids pain, urinary retention, and stenosis, and is safe.

[The usefulness of lateral internal sphincterotomy combined with hemorrhoidectomy in the treatment of hemorrhoids: a randomized prospective study]

The aim of this prospective randomized study was to investigate anorectal manometric findings in hemorrhoid patients and to evaluate the clinical benefits and physiological consequences of additioning a lateral internal sphincterotomy (LIS) to haemorrhoidectomy. Anorectal manometry was preoperatively performed in forty-eight consecutive patients with prolapsed piles; resting and squeeze pressures, sphincter length and rectoanal inhibitory reflex were recorded. Ten healthy volunteers served as controls. Six patients were excluded because no raised and pressures were found. Forty-two patients were randomised: Group 1 (n = 22) patients underwent haemorrhoidectomy plus LIS; Group 2 (n = 20) patients underwent haemorrhoidectomy alone. Postoperative course was carefully evaluated; all patients were questioned about continence and anorectal manometry was repeated twice. Sphincter anomalies were found in 87.5% of patients. Haemorrhoidectomy alone did not affect anal pressures, which returned into the normal ranges after sphincterotomy. Postoperative course was better in LIS group. Anal stricture was seen in four patients without sphincterotomy; no patients with LIS experienced and incontinence. This study shows that high and pressures are very frequent in hemorrhoid patients; they are not due to hypertensive and cushions and might have a pathogenetic role. Anorectal manometry is very useful to identify patients with raised anal pressures; in these cases additioning a lateral internal sphincterotomy to haemorrhoidectomy seems justified; it significantly improves postoperative course and can be safely performed.

Serum interleukin-10 levels as a prognostic factor in advanced non-small cell lung cancer patients

STUDY OBJECTIVE

To investigate the prognostic significance of interleukin (IL)-10 serum levels in advanced non-small cell lung cancer (NSCLC) patients.

DESIGN

IL-10 serum levels were measured before chemotherapy, on completion of therapy, and at follow-up by means of a commercially available enzyme-linked immunoassay. The results were then analyzed in comparison with other prognostic variables, and a model predicting overall survival (OS) and time to treatment failure (TTF) was finally generated.

SETTING

University hospital.

PATIENTS

Sixty consecutive patients with TNM stage III or IV NSCLC undergoing conventional platinum-based regimens.

RESULTS

Elevated levels of serum IL-10 were found in cancer patients with respect to healthy control subjects (17.7 +/- 4.4 vs 9.2 +/- 1.5 pg/mL, respectively; p < 0.05), with patients with metastatic disease showing significantly higher levels than patients with undisseminated cancer (21.0 +/- 4.2 vs 14.3 +/- 1.2 pg/mL, respectively; p < 0.05). Following completion of treatment, patients were classified as responders if they had achieved either one of the following: complete response, partial response, or stable disease; and nonresponders, in case of progressive disease. Retrospective analysis of basal IL-10 serum levels in these two subgroups showed a significant difference between responders and nonresponders (15.2 +/- 2.2 vs 21.4 +/- 4.2 pg/mL, respectively; p < 0.05). Moreover, a further significant increase in IL-10 serum levels was observed in nonresponders at the end of therapy (21.4 +/- 4.2 vs 26.0 +/- 4.3 pg/mL, prechemotherapy and postchemotherapy, respectively; p < 0.05), whereas values in responders were found to have significantly decreased (15.2 +/- 2.2 vs 14.8 +/- 2.2 pg/mL, prechemotherapy and postchemotherapy, respectively; p < 0.05). Using univariate and multivariate analyses, both OS and TTF were shown to be affected by the mean pathologic levels of IL-10. Stepwise regression analysis identified IL-10 serum level and stage as the prognostic factors related to OS, and IL-10 serum level and performance status as the prognostic factors related to TTF.

CONCLUSIONS

In conclusion, this study shows that the measurement of pretreatment IL-10 serum levels is of independent prognostic utility in patients with NSCLC and may be useful for detection of disease progression.

Comparison between the biofragmentable anastomosis ring and stapled anastomoses in the extraperitoneal rectum: a prospective, randomized study

Serious complications can be carried by intestinal anastomoses, particularly in the distal and proximal part of the gastrointestinal tract. The biofragmentable anastomosis ring (BAR) has been shown to be a safe anastomotic technique, but its clinical applicability in the extraperitoneal rectum has not yet been completely established. This study compared BAR anastomoses and stapled anastomoses in the middle rectum. Thirty-six consecutive patients initially suitable for elective colorectal anastomosis in the middle rectum were enrolled into this study. All patients had intraperitoneal rectum carcinoma, and 31 underwent a colorectal anastomosis in the middle extraperitoneal rectum. They were randomly allocated to a stapled technique or BAR anastomosis. Intraoperative findings and technical drawbacks, tumor behavior, and postoperative course were recorded. All patients were followed up, and late stenosis rate was investigated by endoscopy. The procedure was carried out in each of the 15 patients randomized to receiving a BAR anastomosis. No major difficulties were encountered, and the time needed was even less than that required for a stapled anastomosis. One patient in the stapled group had an early bleeding that required a further laparotomy. No significant differences in postoperative complications were noted between the two groups, although one patient with stapled anastomosis experienced a clinical leakage that needed loop colostomy. Biofragmentability was regular; buttons were eliminated in 3 weeks without any bowel disturbance. BAR ring insertion in the deep pelvis did not produce a shorter colonic resection. The late stenosis rate was similar between the groups. This study shows that in extraperitoneal middle rectum BAR anastomosis is as feasible and safe as the stapled method. The latter is more expensive, and manual suture is more difficult. Therefore the BAR is now the method of choice for this anastomosis in the authors' unit.

Serum interleukin-10 levels in patients with advanced gastrointestinal malignancies

BACKGROUND

Interleukin-10 (IL-10) is a cytokine with immunosuppressive properties. In this study, the authors investigated the prognostic significance of IL-10 levels in the sera of 58 patients with advanced gastric or colorectal carcinoma.

METHODS

IL-10 serum levels were measured before chemotherapy, on completion of chemotherapy, and at follow-up by means of a commercially available enzyme-linked immunoadsorbent assay kit. The results then were analyzed in comparison with other prognostic variables and a model predicting overall survival (OS) and time to disease progression (TTP) was generated.

RESULTS

Elevated levels of serum IL-10 were found in carcinoma patients compared with healthy controls (19.6 +/- 6.8 pg/mL vs. 9.2 +/- 1.5 pg/mL; P < 0.0001), with those patients with metastatic disease showing significantly higher levels than patients with undisseminated disease (21.9 +/- 6. 7 pg/mL vs. 15.5 +/- 3.6 pg/mL; P = 0.0003). Retrospective analysis of prechemotherapy IL-10 serum levels showed a significant difference between responders and nonresponders (15.8 +/- 2.5 pg/mL vs. 21.6 +/- 7.6 pg/mL; P < 0.0001). Moreover, a further significant increase in IL-10 serum levels was observed in nonresponders at the end of therapy (21.6 +/- 7.6 pg/mL prechemotherapy vs. 31.3 +/- 11.6 pg/mL postchemotherapy; P < 0.0001) whereas no significant differences were observed in responders. Using univariate analysis, both OS and TTP were shown to be affected by the median pathologic levels of IL-10; multivariate analysis related to OS and TTP identified performance status and IL-10 serum level as the relevant prognostic factors, respectively. Finally, stepwise regression analysis identified IL-10 serum level and metastases as the prognostic factors related to both OS and TTP.

CONCLUSIONS

The results of the current study show that measurement of pretreatment serum levels of IL-10 is of independent prognostic utility in patients with advanced gastrointestinal carcinoma and may be useful for the detection of disease progression.

DNA ploidy as a significant prognostic factor after radical resection for large bowel carcinoma: a prospective study

It is controversial whether cell DNA measurement is a reliable method to predict prognosis in radically resected large bowel carcinomas. A study using strict rules was undertaken on 54 consecutive patients to clarify the usefulness of DNA ploidy by image cytometric analysis as a prognostic indicator. The tumors were 39% diploid and 61% aneuploid. DNA ploidy was not related to more advanced stages and it, with histological grade and Dukes' stage, was an independent covariate and influenced both disease-free and overall survival. Aneuploid tumors showed the worse prognosis in all Dukes' stages. This prospective study shows that DNA ploidy is an important independent prognostic indicator of clinical outcome and recurrence rate, and it should be used to both select high-risk patients and guide postoperative treatments, particularly in early-stage large bowel carcinomas.

[Multidisciplinary treatment of hepatocarcinoma]

Radical treatment of the hepatocellular carcinoma (HCC) is complete surgical removal; it may be done by resection or total hepatectomy. Although multicentric carcinogenesis predicts that liver transplantation is likely adequate to treat both the hepatoma and the underlying cirrhosis, it doesn't seem justified in the advanced stages or in absence of end-stage liver disease and therefore liver resection remains the treatment of choice for radical cure of HCC. However, low resectability and high recurrence rate make surgery alone ineffective. Unresectable HCC may be converted to resectable by multimodality radiation/chemotherapy, and embolization of portal branch feeding tumour, improving the function of the nonembolized liver, can extend the surgical indications for HCC. Adjuvant chemoembolization has already shown to reduce recurrence rate after radical resection and it should be widely applied. In unresectable or not converted HCCs as well as in postoperative recurrence, alternative therapies, particularly as multimodality treatment, can improve survival rate. To date, multidisciplinary treatment of hepatocellular carcinoma, waiting for further studies on newer modalities (prevention and gene therapy, especially), represents the best way to improve long-term results.

Metastatic breast carcinoma presenting as urinoma

A rare case of breast carcinoma metastatising to ureter and presenting as urinoma is described. Reviewing the literature, only few cases of urinoma due to metastasis from breast carcinoma have to date been reported. The diagnostic role of immunohistochemical study in defining the disease is discussed.

Espressione di oncogeni di proliferazione e morte cellulare nel carcinoma superficiale della vescica: Expression of oncogenes in relation to cell proliferation and death in superficial bladder carcinoma

Although superficial bladder cancer may be considered “benign”, it is still today a many-sided neoplasm with a prognosis that cannot be well-defined with known traditional parameters. Proliferation indices Ki67 and AgNOR associated with the expression of some oncogenes (p53, Rb, c-myc, BCL2, c-erbB-2) in relation to traditional parameters could help in the prognosis definition of individual patients. 111 patients with superficial bladder cancer were studied for this purpose, relating the grade, stage, follow-up and morphotype to the proliferation indices. Significant correlations were found with AgNOR, but only for grade with Ki67. The study of the oncoproteins and their different expression showed that those alterations typical of infiltration are already present in the superficial forms, with a significant correlation between oncogenic alterations and grade and stage of disease (p53, Rb) on the one hand, and above all of disease-free interval and progression (c-erbB-2) on the other. Lastly, assessment of the oncoproteins c-myc and BCL2, oncogenes connected with the programmed cell death mechanism (apoptosis), showed important correlations with the neoplastic progression of disease in relation to the p53 expression and proliferative activity.

I markers biologici. Introduzione:Biological markers. Introduction

Molecular biology has made giant strides over the last ten years and provides an immense field of research. The Authors first review the concepts of neoplastic proliferation and transformation of the phenotype, analysing cell constitution and its relations with the intercellular space. The most important moment in molecular research was the identification of the growth factors and consequently the process of transduction of signals from the outside into the cell and the retroinhibiting mechanisms of the same signals. The terms oncogene and antioncogene are defined as well as their most significant expressions.

Transrectal Ultrasonography in the Diagnosis of Prostatic Carcinoma: Our Study on 365 Patients

To evaluate the usefulness of transrectal ultrasound associated with needle biopsy of the prostate, 365 patients, with age ranging between 50 and 80 years, were studied for a total of 412 biopsies; the ultrasound exam was performed when the clinical or the prostate specific antigen findings were pathological. Our experience confirms the high sensitivity and specificity of transrectal ultrasonography in detecting prostate cancer. It is our opinion that all the patients with positive or negative digital rectal examination but altered prostatic specific antigen or clinical exam should undergo transrectal ultrasonography associated with needle biopsy. The elevated operability of the studied patients shows the capability of ultrasound to detect the pathology in the early stages and its value in screening diagnosis should therefore be considered.

Intraperitoneal adjuvant immunochemotherapy in operable gastric cancer with serosal involvement

Since the peritoneal cavity is the most common site of initial recurrence in patients after surgery for gastric cancer, an intraperitoneal (IP) adjuvant treatment was tested in patients with resected gastric cancer with serosal involvement. Between March 1986 and September 1991, 44 consecutive patients with resected T3/T4-N0/N+ gastric cancer were given an IP combination, including cisplatin or carboplatin, etoposide, and alpha interferon-2b. The overall survival of these patients was compared with that observed in 47 historical controls (admitted to the same institutions from 1983 to 1986) with similar prognostic characteristics, who had not received adjuvant treatment after surgery. No major complication relating to the IP route was observed. Mild to moderate abdominal pain occurred in nine patients. Grade 3-4 myelotoxicity occurred in 14 patients. Interferon had to be reduced in five patients and suspended in one because of severe fatigue. Emesis occurred in 23/28 patients given cisplatin and 9/16 given carboplatin. At the time of this analysis (September 1992) median follow-up was 42 months (range 12-78) in the group receiving IP treatment, and 97 months (range 74-128) in the historical controls. There had been 20 deaths among treated patients compared with 36 in the control group. The 5-year estimated survival rate was significantly better in the patients who received IP adjuvant treatment (44% +/- 9 versus 23% +/- 6; P = 0.016). Using the Cox proportional hazard model with a backward procedure to correct for the influence of prognostic pretreatment variables, IP treatment again afforded a significant advantage in terms of survival (P = 0.04). Adjuvant IP immunochemotherapy appears to improve prognosis compared with historical controls in patients having operable gastric cancer with serosal infiltration.

Better survival in women than in men after radical resection of hepatocellular carcinoma

During the period between January 1980 and December 1987, 229 male and 39 female adult patients with primary hepatocellular carcinoma (HCC) were hospitalized in our unit. Radical hepatic resection was carried out in 90 (39.3%) males and 17 (43.6%) females in whom no specific cancer treatment had been attempted preoperatively. The 1-, 3-, and 5-year survival rates in the male and female patients were 78% and 70%, 45% and 52%, and 19% and 52%, respectively. The difference was significant after 47 months. No substantial differences were found between the two groups with respect to age, preoperative clinical condition and laboratory data, method of liver resection, postoperative morbidity and mortality, postoperative adjuvant chemotherapy, and histopathology of HCC and the liver. Only the incidence of alcohol abuse was significantly different, being higher in male than in female patients. However, the survival analysis demonstrated that alcohol abuse had had no influence on recurrence rate and long-term survival in either male or female patients. As a control, survival was analyzed for the patients with similar clinicopathological background but without HCC who had undergone distal splenorenal shunt for esophageal varices. There was no significant difference between the male and female patients. The current clinical results seems to support our hypothesis based upon sex hormone receptor studies that HCC may be androgen-dependent.

Adverse effects of preoperative hepatic artery chemoembolization for resectable hepatocellular carcinoma: a retrospective comparison of 138 liver resections

During the past 8 years we have treated 268 patients with primary hepatocellular carcinoma (HCC); total extirpation of the tumor was carried out in 138. Thirty-one of the patients with resectable HCCs had already been treated with transcatheter arterial embolization (TAE) of the liver before they were referred to us. The clinical values of preoperative TAE were retrospectively evaluated for those 31 patients and for the remaining 107 patients without TAE. There were no substantial differences between the two study groups in the clinical and histopathologic backgrounds. No differences were observed in the extent of liver resection, estimated blood loss during surgery, and operation time. During surgery, however, troublesome intra-abdominal complications relevant to TAE were encountered in 15 patients, and detection of tumors was impossible, even with intraoperative ultrasonography, in five patients in the group with TAE. Such findings were not present in any of the patients without TAE. Postoperative morbidity and mortality rates were similar in the two groups. There was no significant difference in the rate of recurrence of tumor in the liver, but the recurrence time was significantly shorter in the group with TAE. TAE did not improve the long-term survival rates in patients either with or without cirrhosis. Results of our study seem to indicate that preoperative TAE is meaningless in the treatment of resectable HCCs and therefore should be avoided, particularly in patients with advanced cirrhosis of the liver.

Intraoperative ultrasonography in resection of small hepatocellular carcinoma associated with cirrhosis

Preoperative detectability rates of hepatocellular carcinoma smaller than 5 cm in 113 cirrhotic patients were 91 percent by ultrasonography, 93 percent by computed tomography, and 92 percent by selective angiography. The combination of two methods produced detectability rates of 97 to 99 percent. One hundred three patients underwent various types of hepatic resection with the aid of intraoperative ultrasonography. Forty-four tumors (43 percent) were embedded in the liver, and these tumors were not detected by conventional surgical exploration. The detectability rates were 38 percent for hepatocellular carcinomas smaller than 2 cm, 57 percent for 2 to 3.5 cm tumors, and 71 percent for 3.5 to 5 cm tumors. All undetectable hepatocellular carcinomas were identified by intraoperative echography. The overall detection rate by this method was 98 percent, which was substantially higher than the preoperative rate. Intraoperative ultrasonography is a useful and indispensable method for performing atypical minor hepatectomy for the treatment of small hepatocellular carcinomas associated with liver cirrhosis.

Androgen receptor in hepatocellular carcinoma as a prognostic factor after hepatic resection

Androgen receptors (AR) in the cytosol of hepatocellular carcinoma (HCC) were assayed in 45 unselected patients in whom radical hepatic resection was performed. Thirty-one patients had detectable amounts of ARs in tumors, ranging from 2.3 to 82.6 fmol/mg protein with the dissociation constants (Kd) of 4.1 - 30.9 x 10(-10) M. The receptor was not found in the remaining 14 cases. AR negative HCCs were significantly more common among women and nonalcoholic patients. Otherwise, there were no significant difference in the clinicopathologic background between patients with AR positive HCCs and those with AR negative tumors. Three patients died of liver failure in the former group, whereas two died in the latter; one patient died of liver failure and the other died of pneumonia (results were not statistically significant). Excluding those five operative deaths, the recurrence rates were 67.9% in the group of patients with AR positive HCCs and 33.3% in the group of patients with AR negative tumors (0.1 less than p less than 0.05). The 5-year survival rate was significantly better (p less than 0.05) in patients with AR negative HCCs (62.2%) than in those with the positive tumors (17.3%). In light of the current results and previous experimental works by others, it is likely that testosterones enhance the growth and invasiveness of human HCC, which is mediated by AR in the tumor.

[Cephalometric evaluation of lower incisor position]

The Authors examined some cephalometric values usually utilized to evaluate lower incisors inclination or anteroposterior position. Mean values and standard deviations of these parameters in a 194 subjects sample was calculated. Validity of these valued in different typology and skeletric classes was finally verified.