Papillary Thyroid Microcarcinoma: Differences between Lesions in Incidental and Nonincidental Settings-Considerations on These Clinical Entities and Personal Experience

Papillary thyroid microcarcinoma (PTMC) represents 35-40% of all papillary cancers; it is defined as a nodule ≤ 10 mm at the time of histological diagnosis. The clinical significance of PTMC is still controversial, and it may be discovered in two settings: incidental PTMC (iPTMC), in which it is identified postoperatively upon histological examination of thyroid specimens following thyroid surgery for benign disease, and nonincidental PTMC (niPTMC), in which it is diagnosed before surgery. While iPTMC appears to be related to mild behavior and favorable clinical outcomes, niPTMC may exhibit markers of aggressiveness. We retrospectively review our experience, selecting 54 PTMCs: 28 classified as niPTMC (52%) and 26 classified as iPTMC (48%). Patients with niPTMC showed significant differences, such as younger age at diagnosis (p < 0.001); a lower male/female ratio (p < 0.01); a larger mean nodule diameter (p < 0.001); and a higher rate of aggressive pathological findings, such as multifocality, capsular invasion and/or lymphovascular invasion (p = 0.035). Other differences found in the niPTMC subgroup included a higher preoperative serum TSH level, higher hospital morbidity and a greater need for postoperative iodine ablation therapy (p < 0.05), while disease-free long-term survival did not differ between subgroups (p = 0.331) after a mean follow-up (FU) of 87 months, with one nodal recurrence among niPTMCs. The differences between iPTMC and niPTMC were consistent: patients operated on for total thyroidectomy and showing iPTMC can be considered healed after surgery, and follow-up should be designed to properly calibrate hormonal supplementation; conversely, niPTMC may sometimes exhibit aggressive behavior, and so the FU regimen should be closer and aimed at early detection of cancer recurrence.

Management of low colorectal anastomotic leakage using negative pressure therapy with Transanal Minimally Invasive Surgery (TAMIS): description of a case and review of the literature

Anastomotic leakage (AL) represents a major post-operative complication after low anterior resection (LAR) for rectal cancer. It is associated with increased morbidity, mortality, length of hospital stay and risk of permanent stoma. Herein we report the case of a 75-year-old male patient submitted to a minimally invasive LAR who developed an AL on the fifth post-operative day. This complication has been successfully managed by placing a Vacuum-Assisted Therapy device (Endo-SPONGE®) with an unusual Transanal Minimally Invasive Surgery (TAMIS) approach; the size of the abscess cavity was measured and the Endo-SPONGE® was cut according to the size of the fistulous defect. This procedure has been performed at regular intervals, achieving quick reduction of anastomotic defect. After the discharge from our department, the patient was addressed to adjuvant treatment. TAMIS may represent an alternative to the endoscopic approach to position an Endo-SPONGE® whenever a conservative management of an AL is required.

Surgical treatment of elastofibroma dorsi. Personal experience and a review of the literature

AIM

To report our experience in treating elastofibroma, an uncommon lesion, usually arising into subscapular area; it has been included between soft tissue tumors and is characterized by progressive growth and benign behavior METHODS: Patients with an histologically proved elastofibroma, operated at our ward unit over a 3-year period, entered this study. Early results of surgical treatment have been analyzed and compared to those of Literature, focusing on selection criteria, hospital morbidity and relative risk factors RESULTS: Fourteen surgical procedures have been performed on 11 patients; EF presented as bilateral on 3 patients (27.3%) and these patients were treated with sequential 2-stages excision. All patients received complete surgical resection according to marginal excision technique; mean operative time was 75.8 ± 21.4 min. (range 55-135) while mean size of resected EF was 8.57 ± 2.2 cm. (range 5-12). Three patients developed significative postoperative seroma (21.4%), while neither hemorrhages nor recurrences have been observed. Increased B.M.I. was the only factor significantly related to hospital morbidity at univariate analysis (p = 0.0339) CONCLUSIONS: Patients carring elastofibroma larger than 5 cm. and symptomatic should undergo surgical treatment; marginal excision represents the standard technique; we recommend the use of ultrasound energy device for tissue dissection: its current use seems to prevent postoperative bleeding. Development of postoperative seroma seems related to increased patient's B.M.I. and to larger size of EF, rather than to different methods of dissection.

KEY WORDS

Chest wall tumors, Elastofibroma dorsi, Elastin, Marginal resection, Soft-tissue tumors.

Small bowel adenocarcinoma: natural history of recurrence after surgical resection

Small bowel adenocarcinomas (SBA) are a rare entity associated with a poor prognosis and an advanced stage of disease at diagnosis. Surgical resection is considered the gold standard of treatment for stage I-III, while stage IV disease approach is still debated. We present a case of a young woman affected by a duodenojejunal junction SBA treated with surgical resection and FOLFOX adjuvant chemotherapy. The patient later underwent a palliative duodenojejunal bypass for peritoneal carcinomatosis.

Hybrid sequential treatment of a giant serous mesenteric cyst: description of a case and review of the literature

Mesenteric cysts are uncommon benign abdominal tumors that may extend from the root of the mesenteric layers of the gastrointestinal tract into the retroperitoneum or the peritoneal cavity; they are usually asymptomatic and often represent an occasional finding. Definitive diagnosis is confirmed by the surgical intraoperative view and by histopathological examination. Surgical excision of the cyst is the treatment of choice. We present a case of a female patient who presented with back pain and a palpable abdominal mass. Due to large size of the mass and its contiguity with midline, patient underwent an hybrid combined surgical technique, with a first open phase followed by a laparoscopic excision. Complete surgical removal of the cyst was successfully performed without bowel resection, intraoperative spillage of cystic content and without morbidity. Histopathology confirmed diagnosis of simple mesenteric cyst. We strongly recommend a combined approach whenever a large intraperitoneal benign cystic lesion has been diagnosed.

Sustainable Innovation: The Italian Scenario Studied Through Higher-Order Partial Least Squares-Path Modeling

What is the real meaning of sustainable innovation? How is sustainable innovation different from other forms of innovation? How does sustainable innovation contribute to societal development? How can we measure the sustainable innovation of a country-which indicators and which synthesis methods should we use? In this paper we try to answer these previous questions. Starting from the concept of sustainable innovation, as it has been extensively discussed in recent years in a range of disciplines from economics to engineering and sociology, the paper focuses on the basic criteria (such as indicators and statistical models) required to evaluate the sustainable innovation at the regional level, choosing Italy as a case study. From the elementary indicators of innovation, on one hand, and sustainability, on other hand, a composite indicator of sustainable innovation has been computed. The statistical model used to compute this composite indicator has been a Higher-Order Partial Least Squares Path model. The results obtained applying this model to the Italian scenario are discussed, the ranking of the different Italian regions, and the impact of the composite indicator sustainable innovation on economic results of each region are discussed.

Unusual Ulcerated Merkel Cell Carcinoma of the Skin: Report of a Case

Merkel cell carcinoma is an aggressive skin cancer, usually related to a severe prognosis. Treatment consists of wide surgical excision, adjuvant radiotherapy and/or polychemotherapy, but local-regional and distant relapses are common. Detection of histopathological and biological factors may select subgroups of patients suitable for different treatments. Herein we report the case of a patient treated for a wide bleeding and ulcerated Merkel cell carcinoma. Ulceration represents an uncommon feature because the tumor usually spreads from the dermis into subcutaneous fat, so it may be added to poor prognostic indicators. After surgical excision and postoperative radiotherapy, the patient recurred at regional nodes. Axillary lymphadenectomy was followed by courses of polychemotherapy. We obtained a satisfactory survival (31 months) by timing these different therapeutic possibilities.

The determinants of Italian NEETs and the effects of the economic crisis

In recent years, the share of young people not in education, employment, or training (NEETs) has shown a remarkable increase in many European countries, such as Italy. The wide diffusion of NEETs represents an alarming social issue, as being NEET predisposes young people to long-term unemployment and social exclusion. It also has a significant negative impact on the economic growth and welfare equilibrium of countries. The aim of this paper is to analyze the determinants of the NEET condition in Italy through a step by step procedure beginning with the identification of their main characteristics and then proceeding with a focus on specific homogeneous clusters of NEETs. The decomposition of the gaps in the probabilities of being NEET between the various clusters allows verifying how personal characteristics effectively act. Furthermore, the influence of unobserved factors in the professional condition of young people has been analysed in more detail through a bivariate selection probit model on the propensity to look for a job against the condition of being inactive. The results confirm the crucial role of the education system, as well as the importance of the economic and social disparities between gender and the Italian territorial districts.

Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results

BACKGROUND

Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System.

MATERIALS AND METHODS

Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed.

RESULTS

Median operative time was 267.50 min (255-305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23-34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2-5). Median length of stay was 6 d (5-8).

CONCLUSIONS

Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

[Congenital esophageal cyst: a case report]

Congenital oesophageal cysts are extremely rare findings in the context of masses developing in the mediastinum. The embryogenetic and physiopathological aspects of these lesions have yet to be fully clarified. Preoperative diagnostic investigations may be only partly successful in indicating the correct diagnosis. Surgical excision is always indicated, via either the thoracoscopic or thoracotomic routes. We report here on case of a duplication oesophageal cyst which we diagnosed and treated successfully in our department. The clinical and therapeutic aspects of these lesions are discussed and compared with other cases reported in the literature.

Effector Th-1 cells with cytotoxic function in the intestinal lamina propria of patients with Crohn's disease

A large body of evidence points to a pivotal relationship between Th-1 cells and mucosal inflammation in Crohn's disease (CD). The aim of the present study was to assess whether CD is associated with specific functional activity of lamina propria T lymphocytes (LPT), particularly purified CD4, such as cytotoxic activity and specific cytokine-secreted profile. The results showed that CD4 LPT in patients displayed a chronically activated memory-like surface phenotype and, when compared to controls, had a significantly enhanced antibody-redirected cytotoxicity. Interestingly, the ratio of perforin expression in CD4 LPT was higher compared to controls, and a redirected lysis of human RBC mediated by a CD4 subset of intestinal lamina propria was evident, suggesting a cytolytic pore-forming mechanism. Moreover, a unique Th-1 cytokine profile pattern in the CD4 cells from CD was defined. These effector cells produced 12 times more IFN-gamma, two times more TNF-alpha, and three times less IL-4 than controls. In contrast, no increase in IL-2 was detected, while IL-5 was undetectable. Our studies suggest that these preexisting in vivo activated CD4 LPT may play an important role in the inflammatory process in CD, thus directly contributing to the intestinal lesions.

Effector Th-1 cells with cytotoxic function in the intestinal lamina propria of patients with Crohn's disease

A large body of evidence points to a pivotal relationship between Th-1 cells and mucosal inflammation in Crohn's disease (CD). The aim of the present study was to assess whether CD is associated with specific functional activity of lamina propria T lymphocytes (LPT), particularly purified CD4, such as cytotoxic activity and specific cytokine-secreted profile. The results showed that CD4 LPT in patients displayed a chronically activated memory-like surface phenotype and, when compared to controls, had a significantly enhanced antibody-redirected cytotoxicity. Interestingly, the ratio of perforin expression in CD4 LPT was higher compared to controls, and a redirected lysis of human RBC mediated by a CD4 subset of intestinal lamina propria was evident, suggesting a cytolytic pore-forming mechanism. Moreover, a unique Th-1 cytokine profile pattern in the CD4 cells from CD was defined. These effector cells produced 12 times more IFN-gamma, two times more TNF-alpha, and three times less IL-4 than controls. In contrast, no increase in IL-2 was detected, while IL-5 was undetectable. Our studies suggest that these preexisting in vivo activated CD4 LPT may play an important role in the inflammatory process in CD, thus directly contributing to the intestinal lesions.

Imipenem/cilastatin (1.5 g daily) versus meropenem (3.0 g daily) in patients with intra-abdominal infections: results of a prospective, randomized, multicentre trial

An open-label prospective, randomized, parallel multicentre study was undertaken to compare the efficacy and tolerability of 1.5 g/day intravenous imipenem/cilastatin with 3 g/day intravenous meropenem in the treatment of intra-abdominal infections. A total of 287 patients were enrolled: 201 patients, divided between the 2 treatment groups, were evaluable. Clinical outcome, bacteriological outcome, untoward microbiological effects, and clinical and laboratory adverse experiences were evaluated. 98% of patients receiving imipenem/cilastatin therapy were cured, with 96% showing eradication of infection. 95% of those on meropenem were cured, with 98% showing eradication. These differences in clinical and bacteriological outcome between the 2 treatments were not statistically significant. Two patients receiving imipenem/cilastatin and 5 receiving meropenem had untoward microbiological effects. There was a 0.7% frequency (1/139 patients) of possibly or probably drug-related clinical or laboratory adverse experiences with imipenem/cilastatin and a 2.7% frequency (4/148) with meropenem. The mean time to defervescence was significantly less for patients in the imipenem/cilastatin treatment group than for those receiving meropenem. This study shows that 1.5 g/day of imipenem/cilastatin is equivalent to 3.0 g/day meropenem in clinical and bacteriological outcome, as well as in incidence of side effects.

MR cholangiography (MRC) in the evaluation of CBD stones before laparoscopic cholecystectomy

BACKGROUND

The aim of our work was to evaluate the predictive value of MR cholangiography (MRC) in detecting CBD stones before laparoscopic surgical treatment.

METHODS

MRC was performed as a unique preoperative imaging modality in 45 selected patients (16 male; 29 female; age range: 28-72; mean age: 54.4) before laparoscopic cholecystectomy. MRC imaging was obtained with a 3D Turbo Spin-Echo sequence (TR = 3000 ms, TE = 700 ms, Echo Train Length--128) with an acquisition time of 5 min 48 s. Diagnostic confirmation was obtained in all the cases at i.o. cholangiography. When a stone was detected it was removed by transcystic or transcholedochal approach.

RESULTS

Eighteen of the 45 patients (40%) had CBD stones. MRC correctly evaluated 16 out of 18 stones, with a resulting sensitivity of 88.9%, specificity 100%, positive predictive value 100%, negative predictive value 90%, and accuracy 95.6%.

CONCLUSIONS

Despite the good results of MRC, it cannot be proposed as a screening technique to be performed in all patients submitted to laparoscopic cholecystectomy due to high cost and the limited amount of MR equipment. In conclusion, only selected patients should be submitted to MRC before laparoscopic cholecystectomy.

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases.

PATIENTS AND METHODS

One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases.

RESULTS

In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films.

CONCLUSIONS

MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

[The role of surgery in the treatment of appendicular abscesses]

The management of appendiceal abscesses is still discussed and many different approaches are nowadays adopted. The aim of this study was to analyze retrospectively our experience with this disease to value the results of drainage of the abscess and appendectomy in one stage in presence of appendiceal abscesses. We studied 44 patients consecutively observed in our Department of General Surgery all submitted to drainage of the abscess and appendectomy for acute appendicitis with periappendiceal abscess. Preoperative ultrasonography showed an accuracy of 85.7% in detecting the presence of an abscess. Mean size of the abscesses were 5 cm (from a minimum of 3 cm to a maximum of 9 cm). The mean duration of surgical operation was 48 minutes (min 35'-max 95'), with a mean in-hospital stay of 6.2 days. Morbidity rate was 9% and was due in 75% of cases to wound infection and in 25% of cases to wound dehiscence. Neither major morbidity nor mortality were observed. In consideration of the results the authors conclude that even in presence of an appendiceal abscess, appendectomy with abscess drainage is not only a safe operation with a low morbidity rate but the procedure of choice allowing a significative reduction of hospitalization and health cost.

[Fistulectomy with closure by first intention in the treatment of perianal fistulae]

The authors report in a retrospective study their experience in the treatment of anal fistulas suggesting the total exercises of the fistula with primary closure of external and internal anal sphincters and rectal mucosa. In our department of surgery between 1987 and 1993, 36 patients (22 males and 14 females) with anal fistulas (17 intersphincteric, 15 trans-sphincteric and suprasphincteric) were treated with this technique. Postoperative in-hospital stay ranged between 2 and 5 days (mean 3.1) and surgical healing needed 12-15 days. A dehiscence of distal tract was observed in 3 cases (8.2%). in these cases secondary closure of the wound needed 24-28 days. All the patients controlled at follow-up (it lasted at least 1 year) did not show rectal incontinence for gas or stools. The authors conclude that total exeresis with primary closure is a safe procedure indicated in the treatment of anal fistula not associated to inflammatory bowel disease in consideration of earlier healing and minor costs.

[Trends in the incidence of acute appendicitis in Italy during the past 30 years]

The incidence and mortality rate of acute appendicitis for the years 1955 and 1987 were calculated on the basis of data used by ISTAT. In 1955 the incidence was 5.7 per 1000 whereas in 1987 this had fallen to 3.7 per 1000. In both years examined there was a prevalence of females (in 1987 females accounted for 4.3 per 1000 in comparison to 3 per 1000 recorded for for males). In 1987 the lowest incidence was recorded in the over 60 years olds, whereas the highest incidence was in males between 1 and 14 years old (7.57 per 1000) and females between 15 and 24 years old (12.17 per 1000). Mortality diminished from 0.42% in 1955 to 0.05% in 1987. The highest rate of mortality was recorded in those patients over 60 years old (1.5%).

In vivo study of xibornol on phagocyte functions

Polymorphonuclear leukocytes (PML) represent the first step of defense against bacteria and fungi. Since many antimicrobial drugs have been reported to inhibit phagocyte function, we tested the interference of xibornol, a new antimicrobial agent, on phagocyte functions, in order to evaluate its possible use in chronic respiratory diseases. In the patients treated with xibornol (500 mg every 8 h for 7 days) we did not find any modification in phagocytosis frequency (PMF), phagocytosis index (PHI), nitroblue tetrazolium (NBT), reduction frequency (NRF), microbicidal activity and neutrophil mobility of PML, before, during and after the end of therapy.