Assessment of postpartum perineal pain after vaginal delivery: prevalence, severity and determinants. A prospective observational study

AIM

Perineal pain is present, after birth, in almost all (95-100%) women who have experienced perineal trauma. It has been shown that women with spontaneous vaginal delivery and minimal or absent perineal trauma will have better recoveries: less pain, more tonic perineal muscles, improved sexual function and lower rates of depression. The purpose of the present study was to prospectively assess the prevalence of perineal pain in a population of women with vaginal birth at term and physiological single newborn.

METHODS

Pain assessment was performed using two subjective scales: the Verbal Numeric Scale (VNS) of 11 points and the Verbal Rating Score (VRS) of 4 points. Data collection period ran from the first postnatal day until 6 months after delivery, with two intermediate measurements at 1 and 7 weeks after birth.

RESULTS

The study enrolled 451 women: 239 primiparous and 212 multiparous, with a response rate of 92% at 6 months. The prevalence of pain was found 88.2% in the first day postpartum, 62.3% one week after birth, 8.0% at seven weeks and 0.7% at six months. With regard to the resumption of sexual activity at 6 months postpartum, a dyspareunia rate of 27% was observed in the Episiotomy group (OR 5.72, P<0.001).

CONCLUSION

The study found that an increase in the extent of trauma is associated with the highest scores in the self-assessment of perceived pain, with long term persistent symptoms. Furthermore, the presence of an episiotomy is a conditioning factor for the sexual function after childbirth (OR 0.43, P<0.001).

A NOTES approach for thoracic surgery: transgastric thoracoscopy via a diaphragmatic incision in a survival porcine model

AIM

Recently the NOTES approach has been extended to mediastinum by a transesophageal access and to the thorax by a transvescical endoscopic approach. The aim of this study was to assess the feasibility and the safety of transgastric endoscopic approach to the thoracic cavity, with lung biopsy, in a survival porcine model.

METHODS

The study was performed on four 20-30 kg female pigs (Sus scrofus domesticus). Following gastric wall incision, the muscular pars of the left diaphragmatic dome was incised along with the parietal pleura and the endoscope advanced into the thoracic cavity. In all animals, a thoracoscopy was performed as well as peripheral lung biopsy. At the end of the operation the endoscope was withdrawn from the thoracic cavity after pleural sac decompression and the diaphragmatic incision closed by endoscopic clips under maximal expansion of lungs. The gastric incision was finally closed by endoscopic clips. Chest-tube placement was not utilized. Animals were sacrificed by day 15 postoperatively.

RESULTS

The gastroscope was easily introduced into the thoracic cavity that allowed to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. No adverse event occurred during the survival period. The postmortem examination 15 days after surgery revealed a good closure of the diaphragmatic incision. At necropsy, the lung biopsies were completely healed. There were no signs of infection in both thoracic and peritoneal cavities. The length of follow-up and number of animals studied might have not been sufficient.

CONCLUSION

This study demonstrates the feasibility of transgastric thoracoscopy in porcine model. Long-term follow-up of much larger series will be necessary for provision of more reliable answers if this approach should be adopted in the future and eventually translated for humans with advantages for patients.

[Analysis of a documental source of the Gynecological-Obstetric Institute of Milan. Year 1907]

The look I have at those origins of the obstetric assistance that are historically accepted, both as documental and narrative sources or monumental and instrumental ones, it is for some way very similar to the curious glance, fascinated and respectful of an archaeologist who begins to look and study some vestiges emerged from deep in the past. He looks to these rests as if he looked at so many evidences of men's lives that have passed through the history and at facts that have characterized the evolution of our society during the last centuries as well. The aim of this work was an historical source of the contemporary assistance. The purpose is the critical analysis and the interpretation of this source itself. The instruments involved in this work are: the description of the source, its intrinsic and extrinsic examination and the interpretation compared to the midwifery considered in the historic context. The followed method is the ''historical method'' suggested by Federico Chabod. As the choose document is in some way a ''no name'', before I enter in this historiographical examination, I believe it is convenient to describe the place where such document was born and has attended to its aims.

Natural orifices transluminal endoscopic surgery (NOTES): an overview of technical challenges and complications of transgastric procedures in anesthetized pigs

AIM

Natural orifice transluminal endoscopic surgery (NOTES) is a new reality that is progressively gaining popularity in the scientific community. The aim of this study was to report the authors' experience with various peroral transgastric procedures performed on the porcine model. The technical difficulties and challenges that arose were also analyzed.

METHODS

Ten anesthetized pigs, divided into an acute (3) and a survival group (7) underwent the following procedures using a double channel endoscope: peritoneoscopy (10), cholecystectomy (6),splenectomy (3), and gastrojejunostomy (3).

RESULTS

All the procedures were completed successfully. There was one complication related to the gastric wall incision. In the survival experiment group all pigs (4) submitted to biliare procedures made an uncomplicated recovery after a follow-up period of 2 weeks. Gastrojejunostomies (3) were instead graved by one technical failure (anastomosis disruption at post-mortem examination) and one case of mortality (premature euthanasia for evidences of sepsis). Complete gastric cleansing was impossible to achieve and overinflation was a common problem. The creation of gastro-enteric anastomoses was technically difficult with the current available devices.

CONCLUSION

Transgastric endoscopic surgery is technically feasible in a porcine model. A new instrumentation is needed and could strongly help to overcome the technical difficulties highlighted. More extensive animal studies are mandatory in order to evaluate the benefits and the limitations of this new technique.

Acute gastrointestinal bleeding following aortic valve replacement in a patient with Heyde's sindrome. Case report

A 58-year old man was admitted to the hospital because of melena. He had a 1-year history of mechanical aortic valve replacement and coronary stent placement because of myocardial infarction and he was taking warfarin and clopidogrel. Esophagogastroduodenoscopy and colonoscopy were negative for bleeding. Capsule endoscopy showed bleeding diffuse angiodysplasia of the small bowel. The patient was treated with octreotide 20 mg, at monthly interval. After 25 months there had been no recurrence of gastrointestinal bleeding. The case suggests that mechanical valve replacement may not prevent gastrointestinal bleeding in Heyde syndrome and that octreotide treatment should be considered in these cases.

Mean and long-term results of the surgical treatment of early gastric cancer

AIM

Interest in the diagnosis and treatment of early gastric cancer (EGC) has been steadily increasing due to the high 5-year survival rate which can reach 85-100% after curative resection. The aim of this retrospective study was to analyze the clinical and histologic characteristics as well as the results of 45 patients undergoing surgical resection for EGC.

METHODS

Between 1998 and 2004, 45 patients, 14 females and 31 males with a mean age of 60.2+/-15 years (range: 31-85) were recruited. Subtotal gastrectomy was performed in 28 (62.2%) patients and total gastrectomy in 17 (37.3%). D1 and D2 resections were performed in 36 and 9 patients, respectively. The carcinoma was limited to the mucosa in 26 (57.8%) patients and extended into the submucosa in 19 (42.2%). Lymph node invasion occurred in 4 (8.8%) patients. Mean follow-up was 36 months (range: 3-63). Survival was calculated using the Kaplan-Meier method. Multivariate analysis of clinic and histologic factors was performed to identify predictive factors for survival.

RESULTS

The 5-year actuarial survival rate was 85% and there was no postoperative mortality. Statistical analysis did not demonstrate any significant statistical relationship between survival and parietal penetration (P = 0.67) or superficial extension (P = 0.38) of the tumor. Survival was clearly influenced (P < 0.001) by lymph node involvement.

CONCLUSIONS

Prognosis of EGC is usually excellent but can be influenced by the presence of lymph node metastases.

Modulation of 5-fluorouracil as adjuvant systemic chemotherapy in colorectal cancer: the IGCS-COL multicentre, randomised, phase III study

The aims of this multicentre, randomised phase III trial were to evaluate: (1) the role of levamisol (LEV); and (2) the role of folinic acid (FA), added to 5-fluorouracil (5FU) in the adjuvant treatment of colorectal cancer. Patients with histologically proven, radically resected stage II or III colon or rectal cancer were eligible. The study had a 2x2 factorial design with four treatment arms: (a) 5FU alone, (b) 5FU+LEV, (c) 5FU+FA, (d) 5FU+LEV+FA, and two planned comparisons, testing the role of LEV and of FA, respectively. From March 1991, to September 1998, 1327 patients were randomised. None of the two comparisons resulted in a significant disease-free (DFS) or overall (OAS) survival advantage. The hazard ratio (HR) of relapse was 0.89 (95% confidence intervals (CI): 0.73-1.09) for patients receiving FA and 0.99 (95% CI 0.80-1.21) for those receiving LEV; corresponding HRs of death were 1.02 (95% CI: 0.80-1.30) and 0.94 (95% CI 0.73-1.20). Nonhaematological toxicity (all grade vomiting, diarrhoea, mucositis, congiuntivitis, skin, fever and fatigue) was significantly worse with FA, while all other toxicities were similar. In the present trial, there was no evidence that the addition of FA or LEV significantly prolongs DFS and OAS of radically resected colorectal cancer patients.

Carotid endarterectomy under local anesthesia in elderly: is it worthwhile?

Carotid endarterectomy (CEA) has a positive effect on stroke free survival in patients with either symptomatic or asymptomatic severe carotid bifurcation stenosis. However, most trials have excluded elder patients. In addition, concerns have arisen regarding the benefits of CEA in the elderly population, especially in women. In this study, we performed an outcome analysis in patients undergoing CEA comparing those eighty and older to their younger counterparts. A total of 262 carotid operations were performed under local anaesthesia between 1998 and 2004; 76 (34%) were carotid reconstructions in 70 patients over 75 yr of age. Twenty patients (26%) presented with asymptomatic critical stenosis. Transient ischemic symptoms were the reason for presentation in 35 patients (46%). Progressive stroke was documented in two patients (3%) and a stroke with persisting neurological deficit was demonstrated in 19 cases (25%). Coronary artery disease was present in 47 patients (38%) and arterial hypertension in 55 (72%). Fifty-nine patients (84%) were classified as ASA group 3. Seventy-one thromboendarterectomies of the carotid bifurcation with direct closure were performed. Five patients had other types of reconstruction. Postoperative complications occurred in three patients. One had a transient neurological deficit and another a lethal stroke; the third patient died from myocardial infarction. The in-hospital mortality was 2.9%, which was not significantly higher than the results of the reconstructions in younger patients (1.5%). Surgery for carotid artery occlusive disease under local anaesthesia can be safely performed in selected patients of more than 75 yr of age.

[Ultrasound-guided endoscopic drainage, without radiological examination, in patients with neoplastic biliary obstruction. Preliminary results]

AIM

Endoscopic stent insertion has become the preferred method for palliation of malignant biliary obstruction. Currently, endoscopic stent placement involves the use of contrast media and radiological equipment to achieve direct opacification of the biliary duct systems, and to determine the location and the extension of biliary obstruction. This report proposes a new combination of ultrasonography and biliary endoscopy, with endoscopic stent placement entirely performed under US-guidance.

METHODS

US-guided stent placement was carried out in 8 patients. A guide-wire and a guiding-catheter were endoscopically introduced and identified, by US, the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10F) were finally inserted over the guide-wire/guiding-catheter by a pusher tube system.

RESULTS

Successful stent insertion was achieved in all patients. There were no complications. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2+/-9.5 vs 4.2+/-2.9 mg/dl at 1 week).

CONCLUSION

Endoscopic stent placement performed under US-guidance, is safe and effective. Further studies in a larger series, including more proximal strictures are suggested.

[Endoscopic palliation of inoperable hilar biliary carcinoma with self-expanding metal stents]

AIM

Prosthetic palliation of patients with malignant hilar stenoses shows particular difficulties, especially in advanced lesions. This is a prospective report of the efficacy of endoscopically inserted single metal stent for complex malignant biliary hilar obstruction.

METHODS

Sixty-one consecutive patients were recruited. Contrast injection was deliberately limited to the distal end of the malignant tumor stenosis. A single metal stent was inserted across the stricture into the duct that was technically easiest for the drainage.

RESULTS

Successful stent insertion was achieved in 59 of 61 (96.7%) patients. In 3 (4.9%) cases stent malfunction occurred. Successful drainage was achieved in 59 (96.7%) patients and complete resolution of jaundice was achieved in 86% of cases. Early complications included 3 (4.9%) cases of cholangitis and 2 (3.2%) cases of stent occlusion. Late occlusion of the stent occurred in 14 patients (22.9%), including 10 (16.3%) cases of cholangitis and 1 case of liver abscess. Median stent patency was 169 days. Median patient survival was 140 days.

CONCLUSION

Metal stent insertion is safe, feasible, and achieves adequate drainage in the great majority of patients with non-resectable hilar cholangiocarcinoma.

Ultrasonography-guided endoscopic stent placement for malignant biliary obstruction: a preliminary report of four cases

We present a new combination of transabdominal ultrasound (US) and biliary endoscopy, with endoscopic stent placement carried out under US guidance. Four patients (two men, two women; average age 66.2 years) underwent US-guided stent placement for palliation of ampullary carcinoma (n = 3) or pancreatic cancer (n = 1). A guide wire and a guiding catheter were endoscopically introduced and identified, by US in the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10 Fr) were finally inserted over the guide wire/guiding catheter by a pusher tube system. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2 +/- 9.5 vs. 4.2 +/- 2.9 mg/dl at 1 week). The present case series shows that endoscopic stent placement performed under US guidance is safe and effective. Further studies of larger series, including more proximal strictures, are warranted.

[Endoscopic palliative treatment of the common bile duct at the hepatic hilum. Results in 583 patients treated in a single center over a 10-year period]

BACKGROUND

The outcomes of endoscopic biliary drainage for malignant stenoses at the hepatic hilum were retrospectively evaluated.

METHODS

From January 1990 to June 2001, 583 patients, 368 males, average age 69+/-18.5 years, were recruited. Endoscopic procedure consisted of insertion of 1 ore multiple stents, plastic or metallic, across the stricture, under mild sedation.

RESULTS

Successful stent insertion was achieved in 518/583 (88.8%) patients and successful drainage in 474 (81.3%) patients. Early complications were observed in 101 (17.3%) patients with related-mortality of 17 (2.9%) patients. Late complications occurred in 39.9% of patients. Survival was of 189 days, on average.

CONCLUSIONS

Endoscopic palliation should be the initial management of choice for malignant biliary stenoses at the hepatic hilum.

[Long-term results of endoscopic treatment of biliary stenosis from laparoscopic cholecystectomy]

BACKGROUND

The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated.

METHODS

Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every three months to avoid cholangitis caused by obstruction.

RESULTS

Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and four patients with incomplete biliary obstruction. Early complications occurred in four patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis.

CONCLUSIONS

Endoscopic treatment should be the initial management of choice for postoperative bile duct stetiosis.

Biliary leaks after laparoscopic cholecystectomy. Results of the endoscopic treatment

BACKGROUND

Significant postoperative bile leaks occur in approximately 0.8 to 1.1% of patients. The goal of endoscopic therapy is to eliminate the transpapillary pressure gradient, thereby permitting preferential transpapillary bile flow rather than extravasation at the site of leak. METHODS. Sixty-four patients were retrospectively evaluated. Endoscopic treatment comprised endoscopic sphincterotomy followed by insertion of a naso-biliary drainage or a stent. Retained stones were extracted by standard procedures.

RESULTS

The cystic duct remnant was the site of bile extravasation in 50 cases, ducts of Luschka were the source in 4 cases, common bile duct in 6 cases and common hepatic duct in 4 cases. Retained bile duct stones were detected in 21 cases and papillary stenosis in 4 cases. Endoscopic therapy involved sphincterotomy in 25 cases with stones extraction in 21 cases followed by nasobiliary drain insertion, and placement of stent in the remainder. Bile leaks resolved in 96.9% of patients, on average 3 days in cases of associated stones or papillary stenosis, and 6.5 days in the remainder. Two cases of mild pancreatitis were evidenced from endoscopic treatment.

CONCLUSIONS

Endoscopic management is the treatment of choice for postcholecystectomy bile leaks.

Self-expanding metal stents for endoscopic treatment of esophageal achalasia unresponsive to conventional treatments. Long-term results in eight patients

BACKGROUND AND STUDY AIMS

The successful use of self-expanding metal stents has been demonstrated in the management of malignant esophagocardial strictures. This report assesses the role stents may play in the treatment of esophageal achalasia in selected patients.

PATIENTS AND METHODS

Between September 1996 and December 1997, eight patients (two men, six women; average age 67.6 years) underwent insertion of a self-expanding metal stent for management of achalasia. Previous myotomy and/or balloon dilation or injection of botulinum toxin had failed in all patients. Four nitinol coil stents and five covered Ultraflex stents, 10 cm long, were inserted, being passed through the gastroesophageal junction under mild sedation.

RESULTS

Stent placement was successful and uncomplicated in all patients. Early complications were seen in five patients: chest pain (1), gastroesophageal reflux (1), proximal migration (1), and distal migration (2). One patient underwent surgery for stent impaction in the colon. During the follow-up period of 35.5 months, on average (range 29 - 44 months), four patients experienced complications: chest pain (2), reflux esophagitis (1) and stent migration (1).

CONCLUSION

General use of self-expanding metal stents for esophageal achalasia cannot be recommended.

[Personal experience with the endoscopic treatment of pancreatic pseudocysts. Long-term results and analysis of prognostic factors]

BACKGROUND

The aim of this study was to assess the safety and utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome of endoscopic drainage were assessed in a prospective analysis.

METHODS

Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients.

RESULTS

Successful drainage was achieved in 27/30 (90%) of patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications; 2 patients had bleeding, 2 had mild pancreatitis, 8 had cyst infection, in relation to the presence of necrosis (5 patients) or stent clogging (3 patients). Nine patients (20.9%) had recurrence of pseudocyst. Endoscopic drainage was a definitive treatment in 37 out of 49 (75.5%) patients (median follow-up: 25.9 months). Presence of necrosis was the only significant prognostic factor for infectious complication.

CONCLUSIONS

Endoscopic drainage provides a successful and safe minimally invasive approach to the management of pancreatic pseudocysts.

Conversion of Lap-Band to gastric bypass for dilated gastric pouch

An 18-year-old female who had undergone a laparoscopic adjustable gastic banding developed several episodes of gastric pouch dilatation (GPD), treated conservatively. The last GPD (31 months after Lap-Band placement) involved the lesser curvature of the stomach and was refractory to medical treatment. Conversion to an open gastric bypass was performed. Gastric bypass is an option in the case of Lap-Band failure.

The EGF-CFC family: novel epidermal growth factor-related proteins in development and cancer

The EGF-CFC gene family encodes a group of structurally related proteins that serve as important competence factors during early embryogenesis in Xenopus, zebrafish, mice and humans. This multigene family consists of Xenopus FRL-1, zebrafish one-eyed-pinhead (oep), mouse cripto (Cr-1) and cryptic, and human cripto (CR-1) and criptin. FRL-1, oep and mouse cripto are essential for the formation of mesoderm and endoderm and for correct establishment of the anterior/posterior axis. In addition, oep and cryptic are important for the establishment of left-right (L/R) asymmetry. In zebrafish, there is strong genetic evidence that oep functions as an obligatory co-factor for the correct signaling of a transforming growth factor-beta (TGFbeta)-related gene, nodal, during gastrulation and during L/R asymmetry development. Expression of Cr-1 and cryptic is extinguished in the embryo after day 8 of gestation except for the developing heart where Cr-1 expression is necessary for myocardial development. In the mouse, cryptic is not expressed in adult tissues whereas Cr-1 is expressed at a low level in several different tissues including the mammary gland. In the mammary gland, expression of Cr-1 in the ductal epithelial cells increases during pregnancy and lactation and immunoreactive and biologically active Cr-1 protein can be detected in human milk. Overexpression of Cr-1 in mouse mammary epithelial cells can facilitate their in vitro transformation and in vivo these Cr-1-transduced cells produce ductal hyperplasias in the mammary gland. Recombinant mouse or human cripto can enhance cell motility and branching morphogenesis in mammary epithelial cells and in some human tumor cells. These effects are accompanied by an epithelial-mesenchymal transition which is associated with a decrease in beta-catenin function and an increase in vimentin expression. Expression of cripto is increased several-fold in human colon, gastric, pancreatic and lung carcinomas and in a variety of different types of mouse and human breast carcinomas. More importantly, this increase can first be detected in premalignant lesions in some of these tissues. Although a specific receptor for the EGF-CFC proteins has not yet been identified, oep depends upon an activin-type RIIB and RIB receptor system that functions through Smad-2. Mouse and human cripto have been shown to activate a ras/raf/MAP kinase signaling pathway in mammary epithelial cells. Activation of phosphatidylinositol 3-kinase and Akt are also important for the ability of CR-1 to stimulate cell migration and to block lactogenic hormone-induced expression of beta-casein and whey acidic protein. In mammary epithelial cells, part of these responses may depend on the ability of CR-1 to transactivate erb B-4 and/or fibroblast growth factor receptor 1 through an src-like tyrosine kinase.

The 60-residue C-terminal region of the single-stranded DNA binding protein of herpes simplex virus type 1 is required for cooperative DNA binding

ICP8 is the major single-stranded DNA (ssDNA) binding protein of the herpes simplex virus type 1 and is required for the onset and maintenance of viral genomic replication. To identify regions responsible for the cooperative binding to ssDNA, several mutants of ICP8 have been characterized. Total reflection X-ray fluorescence experiments on the constructs confirmed the presence of one zinc atom per molecule. Comparative analysis of the mutants by electrophoretic mobility shift assays was done with oligonucleotides for which the number of bases is approximately that occluded by one protein molecule. The analysis indicated that neither removal of the 60-amino-acid C-terminal region nor Cys254Ser and Cys455Ser mutations qualitatively affect the intrinsic DNA binding ability of ICP8. The C-terminal deletion mutants, however, exhibit a total loss of cooperativity on longer ssDNA stretches. This behavior is only slightly modulated by the two-cysteine substitution. Circular dichroism experiments suggest a role for this C-terminal tail in protein stabilization as well as in intermolecular interactions. The results show that the cooperative nature of the ssDNA binding of ICP8 is localized in the 60-residue C-terminal region. Since the anchoring of a C- or N-terminal arm of one protein onto the adjacent one on the DNA strand has been reported for other ssDNA binding proteins, this appears to be the general structural mechanism responsible for the cooperative ssDNA binding by this class of protein.

[An analysis of the psychophysiological components in subjects with temporomandibular disorders. Myographic tension and the management of aggressiveness]

BACKGROUND

The stomatognathic literature doesn't sufficiently stress the role of aggressiveness as a modulator of muscular tensions. Our study focused on the hypothesis that 1) original psychological problems related to the modulation of aggressivity could produce 2) chronic muscular tension of the oral district 3) they can become the basis of the malocclusive phenomenon. The investigation was conducted in the laboratory of Clinical Psychophysiology of the University of Rome "La Sapienza".

METHODS

We have examined the myographic activity of the temporal and masseter muscles of both sides in 20 women with temporomandibular dysfunction and in the control group comparable by age. The myographic tension was examined in three "stimulus situations": a) closed lips without any teeth contact; b) with light teeth contact; c) with compression of the dental arcade. Moreover, we have examined the style of aggressiveness modulation through Rosenzweig's PFS test. Features of the experimental group were. 1) age between 20 and 30 yrs; 2) presence of condylomeniscal uncoordination; 3) deviation of the median line of incisors; 4) lateral deviation in the opening and/or closing mandible.

RESULTS

The experimental group showed a higher score of myographic amplitude for the above-mentioned muscles of both sides in three "stimulus situations". Moreover, it presented at the Rosenzweig's test more elevated scores for the Dominance of Obstacle (O-D); b) less elevated scores for Ego Defence (E-D).

CONCLUSIONS

Results are commented on the basis of an integrated psychophysiological model.

Role of surgery in thymic disorders

Thymomas are relatively slow-growing neoplasms that should be considered malignant tumours. When treated in the early stages, however, they have an excellent prognosis for long-term survival. Surgery, radiation therapy and chemotherapy all play a role in the management of these neoplasms. Surgery is the treatment of choice in thymoma patients and has become an increasingly accepted procedure in the treatment of myasthenia gravis (MG) since 1936, when thymectomy was performed for this disease for the first time. Improvement in myasthenic symptoms is nearly always observed following thymectomy, but the rates of complete remission vary from 7% to 63%. We have studied the potential preoperative factors predicting the evolution of MG.

Treatment of morbid obesity and gastroesophageal reflux with hiatal hernia by Lap-Band

BACKGROUND

Esophageal reflux is common in obese patients. Hiatal hernia is considered a potential contraindication to placement of a Lap-Band.

METHODS

Esophageal investigation in patients who were candidates for a Lap-Band included clinical evaluation of symptoms (scoring system), endoscopic and radiologic evaluation, 24-h pH test, and stationary manometry. Patients with gastroesophageal reflux (GER) with or without hiatal hernia underwent the Lap-Band procedure.

RESULTS

GER was diagnosed in 12/40 morbidly obese patients, 11 of whom received a standard Lap-Band (3 patients were radiologically diagnosed with transient hiatal hernia). One patient with a large hiatal hernia underwent closure of the diaphragmatic esophageal hiatus, and the Lap-Band was positioned similarly to an Angelchik prosthesis. All but 1 patient who was lost at follow-up were symptom-free (range 1-24 months).

CONCLUSION

GER with or without hiatal hernia is not a contraindication for obese patients undergoing a Lap-Band procedure. It accomplishes by a single operation satisfactory treatment of these two disturbing diseases.

Follow-up of Lap-Band complications

BACKGROUND

Proximal gastric pouch dilation (PGPD) and band dislocation (BD) are the most frequent complications of laparoscopic adjustable silicone gastric banding (LASGB).

METHODS

Conservative treatment of PGPD and BD was attempted in all patients by deflation of the band. In the case of failure, laparoscopic exploration was performed.

RESULTS

From January 1996 to July 1998, 8 of 40 patients who underwent LASGB experienced PGPD (n = 7) or BD (n = 1). Debanding was performed in 3 patients with PGPD, while in 4 the pouch dilation was successfully treated with deflation of the band. Two patients (PGPD and BD) were treated with band repositioning. Weight loss was not influenced in patients treated conservatively, compared with patients who did not experience complications.

CONCLUSIONS

PGPD and BD are not always responsible for band failure in LASGB. Conservative treatment can be successful, and repositioning of the band is feasible in selected cases.

Phase I/II study of paclitaxel and vinorelbine in metastatic breast cancer

Paclitaxel and vinorelbine are among the most active new agents in metastatic breast cancer. Both in vitro and in vivo studies have shown that the combined administration of these two microtubule-targeting agents is feasible and worthwhile. Based on the promising preclinical data, patients with metastatic breast cancer no longer amenable to conventional treatment were entered into a phase I/II study in which the vinorelbine dose was fixed at 30 mg/sqm and paclitaxel was started at 90 mg/sqm and then subsequently escalated by 30 mg/sqm per step. Cycles were repeated every 21 days. Hematopoietic growth factor support was provided from the 4th dose level onwards. Grade III neutropenia was observed only in 2 patients treated at the 5th dose level. Thrombocytopenia never reached grade 3. Neurotoxicity was considered dose-limiting, since grade 3 peripheral neuropathy occurred in all three patients treated at the 6th dose level. Other toxicities were mild. Paclitaxel 210 mg/sqm and vinorelbine 30 mg/sqm was the selected combination for phase II. Overall response rate in 34 evaluable patients was 38% (95% confidence interval (C.I.), 22% to 54%). In particular, 3 complete responses (9%) and 10 partial responses (29%) were observed. The observed level of antitumor activity, with an overall response rate of 38% and a median duration of response of 12 months, is of interest, since the study was targeted only to anthracycline-pretreated patients, most of whom had adverse prognostic features. The evaluation of a combination of vinorelbine and paclitaxel as first-line therapy in metastatic breast cancer seems worthwhile and is currently undergoing.

Molecular mechanisms of blood vessel formation

The formation of new blood vessels, angiogenesis, is a tightly regulated process. Extracellular angiogenic inducers stimulate the migration and proliferation of endothelial cells, while negative regulators counteract this effect. Changes in the relative balance of inducers and inhibitors activate the 'angiogenic switch', before stabilizer molecules activate the maturation of nascent blood vessels.

Cripto enhances the tyrosine phosphorylation of Shc and activates mitogen-activated protein kinase (MAPK) in mammary epithelial cells

Cripto-1 (CR-1), a recently discovered protein of the epidermal growth factor (EGF) family, was found to interact with a high affinity, saturable binding site(s) on HC-11 mouse mammary epithelial cells and on several different human breast cancer cell lines. This receptor exhibits specificity for CR-1, since other EGF-related peptides including EGF, transforming growth factor alpha, heparin-binding EGF-like growth factor, amphiregulin, epiregulin, betacellulin, or heregulin beta1 that bind to either the EGF receptor or to other type 1 receptor tyrosine kinases such as erb B-3 or erb B-4 fail to compete for binding. Conversely, CR-1 was found not to directly bind to or to activate the tyrosine kinases associated with the EGFR, erb B-2, erb B-3, or erb B-4 either alone or in various pairwise combinations which have been ectopically expressed in Ba/F3 mouse pro-B lymphocyte cells. However, exogenous CR-1 could induce an increase in the tyrosine phosphorylation of 185- and 120-kDa proteins and a rapid (within 3-5 min) increase in the tyrosine phosphorylation of the SH2-containing adaptor proteins p66, p52, and p46 Shc in mouse mammary HC-11 epithelial cells and in human MDA-MB-453 and SKBr-3 breast cancer cells. CR-1 was also found to promote an increase in the association of the adaptor Grb2-guanine nucleotide exchange factor-mouse son of sevenless (mSOS) signaling complex with tyrosine-phosphorylated Shc in HC-11 cells. Finally, CR-1 was able to increase p42(erk-2) mitogen-activated protein kinase (MAPK) activity in HC-11 cells within 5-10 min of treatment. These data demonstrate that CR-1 can function through a receptor which activates intracellular components in the ras/raf/MEK/MAPK pathway.

[Aneurysms of the splanchnic arteries]

Although visceral aneurysms usually have an asymptomatic course, ruptures associated with high mortality do occur. When an asymptomatic lesion is found, the physician must decide whether it should be treated surgically and which surgical technique should be used. Because this type of aneurysm is relatively rare, the answer to these questions have not been determined previously. The outcome in 16 patients treated by surgical or embolization procedures was evaluated. A group of 16 patients with visceral aneurysms were observed in our institution between 1987 and 1993. Localization of aneurysms was on the splenic artery in 8 cases, renal artery in 4 cases, hepatic artery in 3 patients and superior mesenteric artery in one patient. Hypertension was related to renal aneurysms and angina abdominis to the patient with superior mesenteric artery aneurysm. Of the 16 patients, 8 (6 splenic and 2 hepatic aneurysms) were asymptomatic, 3 (2 splenic and 1 hepatic) were treated as an emergency because they presented with shock. In the splenic group (8 cases), 2 patients underwent embolization procedures with Gianturco's coils, and 6 surgical procedures; in the hepatic group 1 embolization and 1 surgical procedure were performed; and finally in the renal and mesenteric group surgical reconstruction was performed during aortic prosthetic surgery. Because of well documented natural history of progressive enlargement and eventual rupture, the aneurysms of visceral arteries should be corrected surgically when the diagnosis is confirmed by vascular imaging (ultrasounds, CT, RM, angiography). Ruptures are treated with emergency operations, when possible. In high-risk patients, non operative management by selective embolization (in case of splenic and hepatic aneurysms) may be suitable alternative.

Laparoscopic cholecystectomy (LC), intraoperative endoscopic sphincterotomy (ES), and common bile duct stones (CBDS) extraction for management of patients with cholecystocholedocholithiasis

BACKGROUND

A combined method of endoscopic sphincterotomy (ES) with common bile duct stone (CBDS) extraction and laparoscopic cholecystectomy (LC) under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described.

METHODS

From June 1994 to January 1995, 15 consecutive cases considered for elective LC with preoperative diagnosis of CBDS underwent this procedure. Following orotracheal intubation, the patient is turned on the left lateral decubitus for ES and CBDS extraction. Nasobiliary drainage is positioned for per-laparoscopic cholangiogram. Routine LC is finally performed.

RESULTS

These two interventions were successfully accomplished in all patients. Mean duration of the operative time for the combined procedure was 97.7 +/- 30.4 min, range 60-140 min. In four (26.6%) cases an accessory trocar with retracting instrument was used to obviate the bowel distension.

CONCLUSIONS

No complications of ES or LC were observed. Mean hospital stay was 3 days (range 2-5 days). Routine follow-up (mean 3 +/- 2 months, range 1-12 months) did not reveal biliary-related problems in any of the observed patients.

Assignment of the vascular endothelial growth factor gene to human chromosome 6p21.3

BACKGROUND

Vascular endothelial growth factor (VEGF) is an endothelial cell-specific growth factor and a regulator of physiological and pathological angiogenesis. Four different proteins are produced by alternative splicing of a unique transcript generated from a single-copy gene. Knowledge of the chromosomal location of the VEGF gene would help in determining a linkage to any known human congenital syndrome and/or to known chromosomal rearrangements in tumors.

METHODS AND RESULTS

A human chromosome mapping panel was used to assign the VEGF gene to human chromosomes by polymerase chain reaction using VEGF-specific oligonucleotide primers. Amplified DNA fragments were fractionated on a 1% agarose gel. A single band of the expected size was obtained only from the DNA of those hybrid cell lines that contained the human chromosome 6. Three YAC clones containing the VEGF gene were obtained by screening the ICI Diagnostics library. In situ hybridization was then used to locate the VEGF gene in the 6p21.3 region.

CONCLUSIONS

The location of the VEGF gene in the 6p21.3 region is a potential starting point for a linkage study. In addition, the isolation of YAC clones containing the VEGF gene will contribute to the construction of the physical map of this chromosomal region.

A risk model for ovarian carcinoma patients using CA 125: time to normalization renders second-look laparotomy redundant

BACKGROUND

We evaluated the incorporation of CA 125 normalization times into a prognostic model based on pretreatment variables in patients with ovarian carcinoma to determine if they could render second-look laparotomy (SLL) redundant.

METHODS

A total of 54 consecutive patients with ovarian carcinoma who underwent SLL between 1985 and 1990 were included in this analysis. At diagnosis, all of the patients had abnormal CA-125 serum levels, which fell to within the normal range during chemotherapy. Cox's model was used to select pretreatment variables relevant for prognosis. The influence of the time to normalization of CA 125 (< or = vs. > 1 months) and the capability of SLL results to modify prognostic prediction, were also evaluated.

RESULTS

The size of the residual tumor at the beginning of therapy, and Eastern Cooperative Oncology Group (ECOG) performance status (PS) were independently predictive of survival. The time to normalization of CA 125 serum levels (analyzed either as -a continuous or as a two-category variable) also had an independent prognostic role when included in the model. When we examined the inclusion of both CA 125 parameter and SLL into the model together, we found that only CA 125 continued to have an independent prognostic relevance. On the basis of the two pretreatment parameters (PS and tumor size) and of this response parameter (time to normalization of CA 125 values) we selected six subgroups of patients having different outcomes (log rank test of equality over-strata < 0.001). Patients with good prognostic pretreatment variables, and those with intermediate prognosis at the beginning of therapy who showed a quick normalization of CA 125, had an 80% 5-year survival, compared with 16% 5-year survival in the remaining patients. (P < 0.0001).

CONCLUSIONS

Our data suggest that the survival of patients with advanced ovarian carcinoma could be accurately predicted by considering some pretreatment variables and time to CA 125 normalization together, without performing SLL. Our risk model, however, needs to be validated by larger prospective trials, to draw any definitive conclusions about the abandonment of surgically defined response.

Neoadjuvant chemotherapy in locally advanced gastric-cancer - preliminary-results of a phase-ii trial with a modified famtx combination

Twenty-two patients with locally advanced inoperable gastric cancer received neoadjuvant chemotherapy with a modified 5-fluorouracil, doxorubicin, methotrexate (FAMTX) regimen. The patients who achieved at least a stable disease were considered eligible for surgery with curative intent, which was performed in 19 cases. 16 patients (all responsive to neoadjuvant chemotherapy) were rendered disease-free by the combined approach. No treatment-related deaths occurred; grade III leukopenia was observed in only 3 cases. The preliminary results of this study indicate the feasibility of our treatment approach; randomized trials are awaited to properly evaluate the role of neoadjuvant chemotherapy in locally advanced gastric cancer.

Mitoxantrone plus vinorelbine with granulocyte-colony stimulating factor (G-CSF) support in advanced breast cancer patients. A dose and schedule finding study

Mitoxantrone (MTZ) and vinorelbine (VNR) have shown a good efficacy in advanced breast cancer. We conducted a phase I-II trial to determine the MTDs and best schedule of these drugs, in advanced breast cancer patients, when granulocyte-colony stimulating factor (G-CSF) support was given. The starting dose-intensity level was MTZ 3 mg/m2/week + VNR 15 mg/m2/week; dose was escalated at each step by 1 mg/m2/week for MTZ and 5 mg/m2/week for VNR, until dose limiting toxicity (DLT) developed in 33% or more of the patients at the first course. G-CSF 5 micrograms/kg/day d3-13 was administered at each cycle from dose level 2 on. For each dose step we planned 3 different schedules (a = total dose of MTZ on day 1; b = total dose d1 and 8; c = weekly schedule). At the time of this analysis (December 1993) 43 patients with locoregionally advanced or metastatic breast cancer have entered this study, 23 of whom had received prior chemotherapy other than adjuvant. Toxicity has been primarily hematologic. Non hematologic toxicity never caused interruption of dose escalation. Overall 8 patients developed DLT at the first course. Dose escalation was stopped at level 3 in patients receiving schedules a or b, and in those receiving schedule c the dose was escalated until level 5. The MTD was MTZ 6 mg/m2 and VNR 30 mg/m2 weekly. Age, dose level, and PS were found to be correlated with neutrophil and platelet nadirs, but dose level was the only independent variable predictive of myelotoxicity at multiple regression analysis. Forty-one patients were evaluable for response.(ABSTRACT TRUNCATED AT 250 WORDS)

Carboplatin (CBDCA)-hexamethylmelamine (HMM)-oral etoposide (VP-16) first-line treatment of ovarian cancer patients with bulky disease: a phase II study

Hexamethylmelamine (HMM) and oral etoposide (VP-16) have shown to be active against platinum-resistant epithelial ovarian cancer. On this basis a three-drug regimen including carboplatin (CBDCA) plus HMM and oral VP-16 was tested in previously untreated ovarian cancer patients with tumor size > 2 cm. Since October 1991, 29 chemotherapy-naive ovarian cancer patients with tumor larger than 2 cm (20 stage III and 9 stage IV) have been treated for a total of 153 courses. CBDCA was administered i.v. on Day 1. The dose was individualized using the Calvert formula (the target dose was AUC = 5). VP-16 was administered orally at the dose of 50 mg/m2 Days 1-14, HMM at the dose of 150 mg/m2 po Days 14-28. Therapy was repeated every 28 days for a total of 6 courses. In order to avoid severe leukopenia and delays in the treatment administration, G-CSF 5 micrograms/kg/day sc Days 8-14 (or until postnadir recovery of neutrophil count > 10,000/mm3) and Days 22-28 was administered. All patients were evaluable for toxicity. No treatment-related deaths occurred. Myelotoxicity was the main side effect. It was grade 3-4 in a total of 13/29(45%) patients. One patient discontinued treatment after the first course due to HMM-related gastrointestinal toxicity. The actual delivered dose intensity was 89% of the planned dose. At the time of this analysis (April 1994) 26 patients are evaluable for response. Fifteen patients achieved a clinical complete remission and 9 a partial response for a 92% overall response rate. Fourteen patients accepted second-look laparotomy. We observed 11 pathological complete regressions (42%; 95% CI, 21-63). At a median follow-up of 16 months 3 deaths have occurred. Only 2 patients with NED at second-look laparotomy have relapsed. We stopped the accrual since the 95% confidence interval of the pCR-rate observed exceeded 20%. This new first-line regimen seems to be highly effective in patients with poor-prognosis advanced ovarian cancer, although the data are not yet sufficiently mature for a final analysis of time to progression and overall survival.

Laparoscopic cholecystectomy in obese patients compared with nonobese patients

Obese patients treated by laparoscopic cholecystectomy currently appear to be the largest risk subgroup amenable to consistent scientific evaluation. Here we report our experience and compare the results in obese patients with those obtained in nonobese patients undergoing the laparoscopic procedure. Laparoscopic cholecystectomy in obese patients was technically more difficult with significantly longer operating time (p < 0.01), but intraoperative and postoperative technical complications were not significant in the groups analyzed. Obese patients present significant anesthesiological complications (p < or = 0.001). The results of this experience and the literature review indicate that the therapeutic advantages proved in nonobese patients can be extended to the obese population.

Phase I/II study of carboplatin and oral etoposide with granulocyte-colony stimulating factor in advanced nonsmall cell lung cancer

BACKGROUND

A combination of carboplatin (CBDCA) and oral etoposide is better tolerated than, and as effective as, more aggressive chemotherapy regimens in patients with advanced nonsmall cell lung cancer (NSCLC). A Phase I/II study was conducted to determine whether the addition of the granulocyte-colony stimulating factor (G-CSF) allows the administration of higher doses of CBCDA.

METHODS

The starting dose of CBDCA was 300 mg/m2 on day 1 every 28 days, in combination with a fixed dose of oral etoposide 50 mg/m2/day days 1-21, G-CSF (5 micrograms/ kg/day subcutaneously) was administered from day 7 until postnadir neutrophil count of more than 10,000/mm3, and from day 25 through day 28.

RESULTS

From March 1991 to November 1993, 39 previously untreated patients with NSCLC (18 Stage IIIb and 21 Stage IV) entered this trial. Overall eight patients experienced dose-limiting toxicity in the first two courses. Five of them were older than 70 years. Age, CBDCA dose, CBDCA area under the curve (AUC), and performance status were correlated with severe neutropenia and thrombocytopenia, but carboplatin AUC was the only independent variable predictive of severity of both at multiple regression analysis. Thrombocytopenia was the major dose-limiting toxicity in this study. The maximum tolerated CBDCA dose and AUC were 600 mg/m2 and 8 respectively. No treatment-related death occurred. There was 1 (2.5%) complete response and 14 (36%) partial responses (overall response rate of 38.5%). AUC was more predictive of response achievement than carboplatin dose. Higher carboplatin dose and AUC were also associated with longer survival by univariate analysis, but by Cox regression analysis age was the only parameter independently predictive of survival.

CONCLUSION

The administration of G-CSF permits safe escalation of CBDCA dose and AUC up to 600 mg/m2 and 8 respectively, in combination with a fixed dose of oral etoposide. Age older than 70 years represents a major obstacle to dose escalation. The increase of the body exposure to carboplatin seems to be associated with a better outcome. The determination of CBDCA AUC permits a better prediction of myelotoxicity and response rate.

[Solitary gastric plasmacytoma. Case report and review of the literature]

The authors report a case of extramedullary gastric plasmacytoma followed from the clinical onset of the disease until the death of the patient. The literature on this topic was reviewed. The male patient underwent total gastrectomy with left splenopancreatectomy when he was 40 years old; after surgery followed by adjuvant chemotherapy and radiotherapy, the plasmacytoma relapsed; the patient died 4 years after the first operation. Gastric plasmocytoma is a rare pathological entity; different postsurgical therapeutical approaches are derived from the inclusion of this gastric neoplasm in the lymphomas or in the extramedullary plasmacytomas. The authors emphasize a better response of the disease to adjuvant chemotherapy than to radiotherapy after surgery. it suggests the necessity of a separation of gastric plasmacytomas from the other gastric lymphomas.

5-Fluorouracil-interferon-alpha 2b adjuvant treatment of Dukes C colorectal cancer

PURPOSE

To determine whether interferon: alpha 2b can improve results of 5-fluorouracil adjuvant treatment of Dukes C colorectal cancer patients, we compared the outcome of patients receiving a fluorouracil-interferon combination to that of historic controls treated with fluorouracil alone.

METHODS

Fifty-seven Dukes C colorectal cancer patients were given 5-fluorouracil-interferon-alpha 2b adjuvant treatment from October 1986 to September 1990. The results were compared with those obtained in 51 consecutive patients treated at the same institutions with 5-fluorouracil (5-FU) alone (used at the same doses and schedule) between 1983 and 1986. The main prognostic variables were similar in the two groups.

RESULTS

No life-threatening toxicity occurred in either group. The addition of interferon (IFN) slightly impaired tolerance to the treatment; however, the dose of IFN had to be reduced only in five patients and discontinued in one patient. Grade 3 and 4 myelotoxicity was rare and not substantially different in the two groups. Interferon-related side effects (fever, flu-like syndrome, malaise, etc.) were frequent, but, in general, mild or moderate. At the time of this analysis (July 1992), median follow-up was 49 (range, 20-70) months in the group of patients treated with 5-FU+IFN, and 86 (range, 68-103) months in the group receiving 5-FU alone. There were 17 recurrences and 15 cancer-related deaths among patients receiving combined treatment, and 27 deaths in the group treated with 5-FU alone. Both five-year relapse-free survival (65 percent vs. 47 percent; P = 0.043) and cause-specific survival (64 percent vs. 46 percent; P = 0.038) were significantly better in the patients receiving combined treatment. After correction for the influence of prognostic pretreatment variables, 5-FU+IFN again afforded a significant advantage in terms of both relapse-free (P < 0.01) and overall survival (P < 0.001).

CONCLUSION

5-FU-IFN-alpha 2b treatment seems to improve the prognosis in Dukes C colorectal cancer patients.

Preoperative chemoimmunotherapy with Carboplatin, epidoxorubicin, 5-Fluorouracil and alpha-2b interferon in locally advanced inoperable gastric-cancer

Twenty-six patients with locally advanced, inoperable gastric cancer were treated with carboplatin, epidoxorubicin, 5-fluorouracil (FEP) plus alpha 2b interferon. Total gastrectomy was performed in patients achieving clinical complete or partial response. The overall response rate after neoadjuvant chemotherapy was 67%. In 13/15 patients undergoing surgery no residual tumor was evident after resection. After a median follow-up of 14 months, 4/13 disease-free patients have relapsed. The median survival time is 13 months for all patients, and 19 months for disease-free patients; in four patients survival time exceeds twenty-four months. Our multimodality program is effective in locally advanced gastric cancer and warrants further evaluation.

Computerized tomography of the abdomen and pelvis with peritoneal administration of soluble contrast (IPC-CT) in detection of residual disease for patients with ovarian cancer

Forty-five ovarian cancer patients were submitted to abdominopelvic computed tomography after intraperitoneal administration of soluble contrast in large fluid volumes (3 liters of normal saline) (IPC-CT), for a total of 66 exams. In all cases standard abdominopelvic CT scanning had previously missed the presence of disease. Peritoneal access was achieved by a temporary Teflon catheter inserted blindly. No major complications related to peritoneal access or fluid administration occurred. Laparotomy was performed in all cases to evaluate accuracy of this new diagnostic procedure. Overall, 32/66 exams showed no abnormal findings. In 9/32 cases persistence of disease was demonstrated by laparotomy. The remaining 34 exams were suggestive of persistence of tumor. In 19 cases CT scan showed nodular images or peritoneal thickness. Persistence of disease was confirmed by laparotomy in all instances. In 15 cases only an abnormal diffusion of soluble contrast into peritoneum (suprahepatic, anterior, or parietocolic region) was demonstrated. In 11/15 persistence of tumor was found at laparotomy. To summarize, IPC-CT revealed persistence of tumor in 30/39 cases (77% sensitivity). Positive results were predictive of persistence of disease in 30/34 cases (88% specificity). This new procedure was able to detect persistence of disease in most of our patients showing negative standard CT (30/39 vs 0/39; P < 10E-8) and its diagnostic accuracy was even better than standard CT+serum tumor markers (30/39 vs 16/39; P < 0.001). In conclusion, IPC-CT could be very effective in monitoring response to treatment and could markedly reduce the number of ovarian cancer patients requiring second-look laparotomy.

Carboplatin and alpha-2b interferon intraperitoneal combination as first-line treatment of minimal residual ovarian cancer. A pilot study

21 untreated ovarian cancer patients with stage III and minimal tumour size, were given weekly intraperitoneal (i.p.) carboplatin (150 mg/m2) and alpha-2b interferon (IFN) (30 million U/m2) for a total of 12 courses, from June 1989 to February 1993. To date, a total of 248 courses have been administered. Toxicity was seldom severe, although fever (179 courses), fatigue (141 courses) and other IFN-related side-effects were very frequent. No patient refused to continue treatment, but in 5 patients IFN dose had to be reduced, and in 1 it was discontinued. The IFN mean delivered dose intensity was 19.8 million U/m2 week. Grade 3-4 myelotoxicity occurred in 7 patients (39 courses), but no deaths related to treatment occurred. The actual mean dose intensity of carboplatin was 121.5 mg/m2 week. To date, 20 patients have completed treatment and are evaluable for response. Of 11 patients with tumour size < or = 5 mm, 10 (91%) achieved a pathological complete response (pCR) as did 4/9 (44%) of those with tumour > 5 mm at entry, for a 70% (95% confidence interval 50-90) overall pCR rate. At a median follow-up of 21 months (range 4-46), only one death occurred. The probability of being alive at almost 4 years was 91% in the entire group (100% in those with tumour size less than 5 mm). Only 1 of 14 patients who achieved a pCR relapsed. This i.p. combination seems a feasible approach to previously untreated ovarian cancer patients with minimal tumour burden. IFN dosage should be reduced to improve tolerance. In view of the very high pCR rate achieved in the group of patients with smaller tumours, a randomised trial is warranted to compare this approach to standard treatment in these patients.

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.

Thymectomy for myasthenia gravis: predictive factors and long term evolution. A retrospective study on 46 patients

Forty-six patients with myasthenia gravis (MG) underwent transternal thymectomy between 1975 and 1991 and were observed over a long term follow up period (mean 6 years). Surgery was well tolerated and was followed in 32.6% of patients by remission of symptomatology. The severity of symptoms according to the Osserman scale was significantly reduced: slight forms of myasthenia increased soon after thymectomy more frequently than moderate and severe forms. Response to thymectomy at 3 months, according to the Hankins scale, was found to be positive (remission or amelioration of symptoms) in 31/41 patients, and worse in patients with thymoma. Probability of clinical remission and death were both significantly correlated with clinical response at three months after thymectomy. No other preoperatory clinical factor (onset age, sex, initial severity of MG, interval from symptom onset to thymectomy) was found to predict the response to treatment. Preoperatory mediastinic CT had a good reliability (> 85%) in diagnosing thymona, but was rarely able to distinguish between thymic hyperplasia and atrophy.

Intraperitoneal (ip) cisplatin-mitoxantrone-interferon-alpha 2b in ovarian cancer patients with minimal residual disease

Forty-one ovarian cancer patients with less than 2 cm residual disease after systemic cisplatin-based chemotherapy received 4 courses of an ip regimen including cisplatin (75 mg/m2), mitoxantrone (20 mg/m2), and interferon-alpha 2b (30 mil IU/m2). The most important side effects were abdominal pain and fatigue. Overall 15/41 patients (37%) required narcotic analgesia for severe abdominal pain. In 1 case laparotomy was necessary due to bowel obstruction. Grade 3-4 myelotoxicity was observed in 18/41 patients (28 courses). No treatment-related death occurred. Pathological complete response (pCR) was achieved in 23/37 (62%) evaluable patients. Four-year disease-free survival was 50%, and no relapse occurred after 32 months. The estimated 4-year progression-free survival (PFS) and overall survival were 35 and 60%, respectively. Patients who achieved pCR showed significantly better survival than the others (P < 0.000). At multivariate Cox's analysis pCR achievement was the most important predictor of PFS (P < 0.005) and survival (P < 0.02). Age (< or = 60 vs > 60) and CA-125 serum levels at entry (normal vs increased) also showed independent predictive value. On the basis of multivariate analysis results we created a risk model for survival and PFS based on age and CA-125 at entry. We identified three subgroups of patients with significantly different outcomes. With this new ip combination long-term disease-free survival is achieved in a significant part of ovarian cancer patients with small tumor burden. A longer follow-up is needed to see whether it can cure some of these patients, and further comparisons with other ip or systemic regimens are needed to draw definitive conclusions about its role in these patients.

[Integrated therapy in panic attack disorders]

For the past years or so, studies on panic attack disorders (PAD) have accounted for a large proportion of psychiatric research. In spite of the attempts to clarify the etiopathogenesis of PAD, its characteristic psychopathological aspects and the evolutionary stages of its development, its nosographic status is still controversial (despite its inclusion in DSM III-R) and the same is true of the therapeutical approach. Using these observation as their starting point, the authors have divided the present paper into four parts. In the first they attempt to classify PAD in nosographical terms, whereas the second reviews all pharmacological therapies put forward over the past ten years. The third part consists of a short summary of the most widely used psychotherapeutic approaches, and in the last the authors suggest a model of integrated PAD therapy which is still being clinically experimented. The practice of associating pharmacological therapy with a psychotherapeutic approach has certainly been widely used for some time, but the authors underline that the two methods are only fully integrated in the presence of a therapeutic project resulting in a treatment protocol with controls during the course and at the end of treatment. In this context, the psychodiagnostic stage before therapy is particularly important since it provides as precise as possible a picture of the subject's basic personality and psychopathological state. These factors can lead to a wide varation in the choice of drug therapy, and even jeopardise therapeutic success. On the other hand, an exclusively psychotherapeutic approach to PAD does not rule out the onset of recurrent episodes during treatment.(ABSTRACT TRUNCATED AT 250 WORDS)