Aurelio Picciocchi

Combined-modality therapy in locally advanced primary rectal cancer.

AbstractPURPOSE: Patients with unresectable, locally advanced rectal cancer are reported to have a dismal prognosis. The aim of this study was to analyze the effect of combined-modality therapy on clinical outcome. nMETHODS: From March 1990 to December 1997, 43 patients (28 males; median age, 62 years; median follow-up, 74 months) with locally advanced (T4 and/or N3) nonmetastatic rectal cancer received external-beam radiation (23.6 plus 23.6 Gy (split course), 8 patients; 45 Gy, 35 patients) plus 5-fluorouracil (96-hour continuous infusion, Days 1–4, at 1,000 mg/m2/day) and mitomycin C (10 mg/m2, intravenous bolus, Day 1). Concomitant chemotherapy was repeated at the beginning of the second course (split-course group) or in the last week of radiotherapy (continuous-course group). After 6 to 8 weeks, patients were evaluated for surgical resection and intraoperative radiation therapy (10 to 15 Gy). Thereafter, adjuvant chemotherapy (5-fluorouracil plus leucovorin, 6–9 courses) was prescribed. nRESULTS: During chemoradiation, 5 patients (11.6 percent) developed Grade 3 to 4 hematologic toxicity. After chemoradiation, 29 patients (67.4 percent) had an objective clinical response (complete response, 2.3 percent; partial response, 65.1 percent). Thirty-eight patients underwent radical surgery (anterior resection, 24 patients; abdominoperineal resection, 14 patients; intraoperative radiation therapy boost on the tumor bed, 19 patients), and 2 patients had partial tumor resection. No perioperative deaths occurred in the patient group. Five-year survival and local control rates were 59.9 and 69.1 percent, respectively. Distant metastasis occurred in 44.2 percent of patients. Statistically significant relationships between intraoperative radiation therapy and local control (P = 0.0104), radical surgery and survival (P = 0.0120), and adjuvant chemotherapy and disease-free survival (P = 0.0112) were observed. nCONCLUSIONS: Our data suggest that combined-modality therapy was relatively well tolerated and resulted in good local control and survival. With regard to the impact of surgical resection on survival, additional studies aimed at improving the local response rate are necessary, whereas the positive impact of intraoperative radiotherapy on local control appears to justify the inclusion of this therapeutic modality in prospective multi-institutional trials.

Analysis of complications of endoscopic sphincterotomy for biliary stones in a consecutive series of 546 patients.

AbstractBackground: Endoscopic sphincterotomy (ES) plays an important role in treatment of biliary stones; however, there remain some controversies concerning complications of ES, which in most cases seem not to be predictable.nnMethods: The aim of this study was a retrospective analysis of complications in 546 consecutive patients (267 males, 279 females, average age 63.7 years) who underwent endoscopic retrograde cholangiography (ERCP) for biliary stones from 1988 to 1995.nnResults: ES was performed in 535 patients (98%), and extraction of stones was successful in 493 (92%). In all, 29 complications (5.4%) were observed, including bleeding 13, cholangitis seven, cholecystitis four, pancreatitis three, retroduodenal perforation two; of these, four (14%) required an operation. Overall mortality was 0.3%.nnConclusion: While a significant decrease of the incidence of complications was observed in the course of the study, due to constantly improving experience, no correlation between risk factors and complications was identified.n

Apoptotic index or a combination of Bax/Bcl‐2 expression correlate with survival after resection of pancreatic adenocarcinoma

In the present study, the prognostic impact of factors involved in the apoptosis pathway were tested on 67 consecutive patients treated with surgical resection. Included in the study were all patients resected for pancreatic adenocarcinoma from 1988 to 2003. Expression analysis for p53, Bax, and Bcl‐2 were performed by immunohistochemical staining. Apoptotic cells were identified by the TUNEL method. These data were correlated with survival. Sixty‐seven tumor specimens were included in the study. A strong positive correlation was recorded between p53 overexpression and Bax expression levels (Pu2009<u20090.001). By univariate analysis, overall survival seemed to be improved with Bcl‐2 and Bax expression (respectively, Pu2009=u20090.0379 and 0.0311). The median survival time in patients with low apoptotic index was better versus those with a high index (Pu2009=u20090.0127). Lymph node involvement was the only clinico‐pathologic parameter that significantly correlated with overall survival (Pu2009=u20090.0202). By a multivariate Cox regression analysis, the only immunohistochemical parameter that influenced overall survival was the apoptotic index (Pu2009=u20090.040). Tumors overexpression of both Bax and Bcl‐2 resulted the strongest independent prognostic factor (Pu2009=u20090.013). This is the first study to report a statistically significant association of apoptosis to overall survival for pancreatic cancer patients treated with surgical resection. The contemporary overexpression of Bax and Bcl‐2 represents the strongest prognostic factor. J. Cell. Biochem.

Selective use of endoscopic retrograde cholangiopancreatography to facilitate laparoscopic cholecystectomy without cholangiography A review of 1139 consecutive cases

Background: The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography. Methods: We performed a retrospective analysis of 1139 consecutive patients (376 men and 763 women with an average age of 51.4 years) who underwent laparoscopic cholecystectomy between 1991 and 1999. In all, 227 patients (20%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of four criteria for risk of stones. Results: ERCP allowed us to make a diagnosis of biliary stones in 53.3% of the selected patients. Extraction of the stones was successful in 97% of the cases. In 14% of cases, ERCP was normal; in 32.7%, some useful diagnostic information was obtained. There were three complications (pancreatitis) following endoscopy (complication rate, 1.3%). Laparoscopic cholecystectomy was successful in 92% of patients. The postoperative morbidity rate was 3.2% (major complications, 0.5%). There were no deaths. During a follow-up period ranging from 3 to 97 months, six patients (0.6%) were found to have residual biliary stones. Conclusion: This study confirms the hypothesis that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography.

ERCP in the era of laparoscopic biliary surgery

AbstractBackground: The combined endoscopic and laparoscopic treatment of biliary stones is now highly debated, especially as regards possible complications compared to one-step laparoscopic treatment.nMethods: This study analyzes 407 cases (116 males, 291 females, average age 49 years, range 2–87) observed in the period from May 1991 to July 1994. All patients were evaluated preoperatively for the presence of biliary stones. Considering clinical presentation, blood analysis, ultrasonography, and medical history, 99 patients (24%) were selected for preoperative endoscopic retrograde cholangiopan-creatography (ERCP). One patient refused preoperative ERCP.nResults: Thirty-nine patients (40%) were found to have biliary stones and were submitted to therapeutic endoscopic sphincterotomy (ES). Endoscopic clearance of the bile ducts was achieved in all patients, with one complication (pancreatitis). In performing laparoscopic cholecystectomy, no technical difficulties could be attributed to ERCP, nor were there any conversions in patients who had had preoperative ERCP. Average postoperative hospital stay was 2.5 days. During a follow-up period of from 2 to 39 months, we diagnosed three patients (0.7%) with symptomatic residual stones. They were submitted to successful ERCP and extraction of the stones.nConclusions: We conclude that ERCP offers an accurate preoperative selection of patients, allows for effective planning of treatment, and simplifies laparoscopic surgery.

Use of a self-expanding stent in the palliation of rectal cancer recurrences : A report of three cases

AbstractBackground: Patients with nonresectable rectal cancer recurrences and elderly high risk patients are currently given a colostomy as a palliative therapy. To improve the quality of life in these patients, we inserted a self-expanding metal stent to relieve the symptoms of obstruction caused by a rectal cancer recurrence.n Methods: Three patients (two male, one female; ages 61, 69, and 59), all suffering from a rectal cancer pelvic recurrence and diffuse metastases, had a stent inserted. Using fluoroscopic and endoscopic control, a metal guidewire was passed through the obstruction. A mild dilatation of the stenosis was carried out before positioning of the expandable metal stent.n Results: The procedure was successful at the first attempt in all the patients, and stool evacuation was immediate. Patients complained of rectal tenesmus during the first 48 h, which was treated with nonsteroid anti-inflammatory drugs. However, there were no serious complications related to the procedure. Regular endoscopic and clinical follow-up were carried out. No patient had any evidence of recurrent obstruction.n Conclusion: In cases of inoperable rectal cancer recurrence, the placement of self-expanding metal stents is technically feasible and safe, and it avoids a permanent colostomy.

Synchronous bilateral breast carcinoma in a 50-year-old man with 45,X/46,XY mosaic karyotype : Report of a case

We report a case of synchronous bilateral breast cancer in a patient with ambiguous external genitalia attributed to a 45,X/46,XY mosaicism. To our knowledge, this represents the first such case ever to be reported. Mammography, ultrasonography, computed tomography, and magnetic resonance imaging all showed bilateral suspicious breast masses with microcalcifications. There were no radiological findings of muscle invasion or axillary lymphadenopathy. The patient was successfully treated by bilateral radical modified mastectomy followed by external irradiation and adjuvant endocrine therapy. Histological examination revealed a bilateral ductal carcinoma in situ, with a cribriform and papillary pattern and microfoci of infiltrating ductal carcinoma. The hormonal profile revealed high levels of follicle-stimulating hormone and luteinizing hormone, and low levels of testosterone. Testicular sonography revealed small hypoechoic testicles with bilateral microlithiasis. This case shows that 45,X/46,XY men may have an increased risk of breast cancer and must be followed up carefully.

Periampullary tumors. Analysis of 319 consecutive cases submitted to preoperative endoscopic biliary drainage.

Background: During the last 2 decades, endoscopic retrograde cholangiopancreatography (ERCP) has been widely used for the diagnosis of periampullary tumors and the preoperative or definitive treatment of jaundice. Methods: We performed a retrospective analysis of 319 consecutive patients (184 men and 135 women with an average age of 66.5 years) who underwent ERCP for periampullary tumors between 1987 and 1999. Results: Endoscopic internal biliary drainage was successful in 293 patients (92%), with some differences due to the origin of the tumor. There were five complications (1.5%), including four bleeds and one retroduodenal perforation. There were no deaths related to the endoscopic drainage. Eighty-four patients underwent pancreaticoduodenectomy. The postoperative morbidity rate was 23%, and the overall mortality rate was 4.8%. Conclusion: ERCP is a valid technique for the detailed preoperative assessment of periampullary tumors. It is also a safe method for internal biliary drainage.

Major liver resection for non-Hodgkin's lymphoma in an HIV-positive patient: Report of a case

A very unusual clinical presentation of non-Hodgkins lymphoma (NHL) of the liver is reported herein. The patient was a 35-year-old male who had been HIV-positive since 1987. Following an episode of acute pain in the right upper abdominal quadrant, ultrasonography (US) and computed tomography (CT) were performed, revealing a nodular tomography (CT) were performed, revealing a nodular lesion, 2.5 cm in diameter, localized in the eight segment of the liver. Despite the fact that the lesion became significantly enlarged over a 6-month period, three repeated percutaneous biopsies proved negative. Finally, his increasing pain and the lack of a definitive diagnosis prompted us to perform a right hepatectomy. The patient had an uneventful postoperative course and is well 1 year after his operation. Establishing a diagnosis of extranodal lymphoma can be difficult, especially in HIV-positive or AIDS patients. Thus, performing a laparotomy is justified to confirm a diagnosis and decide upon the most appropriate treatment. However, in about 10% of these patients, only surgical resection allows for the diagnosis. In accordance with other reports, our experience confirms that, in contrast with AIDS patients, HIV-positive patients have a similar prognosis as non-HIV patients, and are suitable candidates for even major surgical procedures.

Phase I-II trial of concomitant continuous carboplatin (CBDCA) infusion and radiotherapy in advanced nonsmall cell lung cancer with evaluation for surgery: final report

PURPOSEnThe goal of this trial was to determine the maximum tolerable dose when carboplatin (CBDCA) was administered in continuous infusion concurrently with radiotherapy in patients with nonsmall cell lung cancer.nnnMETHODS AND MATERIALSnFrom October 1989 to July 1993, 54 patients were studied (male/female ratio: 44 to 10), median age was 62 years. Two patients had Stage II cancer, 22 had Stage IIIA, 24 had Stage IIIB, and 6 had Stage IV. Carboplatin was given for 96 h, starting at a dose of 30 mg/m2/day: 13 patients received 30 mg/m2/day (group A), 12 patients received 50 mg/m2/day (group B), 12 patients received 70 mg/m2/day (group C), 10 patients received 90 mg/m2/day (group D), and 7 patients 110 mg/m2/day (group E). The radiation dose was 50.40 Gy delivered to the target volume in 5.3 weeks.nnnRESULTSnFifty-three of 54 patients were evaluable for toxicity and 52 out of 54 for response. Toxicity (Miller score): Myelotoxicity: in groups A and B it was almost absent; in groups C and D it was moderate (leukopenia G1-2: 45.4% patients; trombocytopenia G1-2: 22.7%, G3: 9%; anemia G1-2: 9%); only in group E was it severe (leukopenia G1 and G3 16.6% respectively; trombocytopenia G3: 33.3%, G4: 16.6%; anemia G1-2: 50%). Nephrotoxicity was present only in one patient of group E and was Grade 3. Nausea and vomiting were related to CBDCA dose. One patient in Group E died of intractable toxicity 3 days after the end of infusion; then the study was closed. The limiting toxicity dose was shown to be 110 mg/m2/day given for 96 h. Clinical response rate: Twenty-six of 52 patients had major response, 24 had minor response, and only 2 patients had progression of disease.nnnSURGERYnTwenty-one of 52 tumors were judged resectable: 18 patients had complete tumor resection, 1 had exploratory thoracotomy, and 2 patients refused surgery. Pathological response rate: Five patients had pathologic state T0 or Tis.nnnCONCLUSIONSnThese results indicate that the maximum tolerable dose of CBDCA infusion for 96 h is 90 mg/m2/day, and this schedule seems to produce an appreciable response rate. Therefore, we have started a Phase II trial, which will permit us to define the true efficacy of this schedule.