Carlo Maria Bianchi

Radioguided surgery for gastrinoma: a case report.

Aims and Background Gastrinomas are the most common neuroendocrine tumors of the duodenopancreatic region. Surgical resection is the primary type of radical treatment. Methods and Study Design At the Institute of General, Gastrointestinal and Breast Surgery we treated a patient with a duodenal gastrinoma that was diagnosed and localized by means of selective celiacmesenteric angiography and labeled octreotide scintigraphy. Surgery was performed using a radioguided technique; in this way we easily detected the small tumor and discovered another tracer-uptaking lesion that turned out to be a metastatic lymph node. Results Surgical resection is the ideal treatment for sporadic gastrinoma: it improves quality of life, prolongs survival, and reduces the incidence of metastases, with a modest percentage of complications and practically zero mortality. Meanwhile, medical treatment is being revaluated, particulary in the case of metastatic disease or polyendocrine MEN1 syndrome. A fundamental aspect in the management of gastrinomas is tumor localization. Endoscopic ultrasonography and labeled octreotide scintigraphy (Octreoscan) proved to be more effective than the usual imaging modalities. Intraoperative ultrasonography, gastroscopy for duodenal transillumination and repeated measurement of blood gastrin levels should be performed intraoperatively in the surgical treatment of gastrinomas. Conclusions The clinical application of radioguided surgery for tracer-uptaking endocrine tumors is still controversial. In our case the decision to use this method was influenced by the fear that the patients obesity and the effects of previous surgery could hamper the identification of the small tumor.

Real-time elastography in the diagnosis of prostate cancer: personal experience

INTRODUCTION Prostate cancer is the most common cancer in men. In the future, a significant further increase in the incidence of prostate cancer is expected. The indication to perform a prostate biopsy is digital rectal examination suspicious for prostate cancer, total prostate specific antigen (PSA) value, free PSA/total PSA ratio, PSA density and PSA velocity, and an evidence of hypoechoic area at transrectal ultrasound scan. Unfortunately the specificity and sensibility are still poor. The aim of this retrospective study is to evaluate the specificity and sensibility of real time elastography versus ultrasound transrectal B-mode scan. METHODS We retrospectively evaluated 108 pts. having undergone TRUS-guided transrectal prostate biopsy (10 samples). The indication for biopsy is: digital rectal examination, total prostate specific antigen (PSA) value, PSA ratio, PSA density and PSA velocity suspicious for prostate cancer, and/or an evidence of hypoechoic area at transrectal ultrasound scan, and/or hard area at real-time elastography. The mean age of patients is 66.8 years, mean PSA 6.5 ng/mL, and mean ratio 16.5%. We compared the histopathological findings of needle prostate biopsies with the results of transrectal ultrasound and transrectal real-time elastography. RESULTS 32/108 (29.6%) pts. were positive for prostate cancer (mean Gleason score 7.08), mean PSA 14 ng/mL and mean ratio 9.5%. Transrectal ultrasound scan shows a sensibility of 69% and specificity of 68%. Transrectal ultrasound scan shows a VPP of 51.4%. Transrectal ultrasound scan shows a VPN of 80.9%. Real-time elastography shows a sensibility of 56% and specificity of 85.7%. Real-time elastography shows a VPP of 60.1%. Real-time elastography shows a VPN of 83%. CONCLUSIONS Elastography has a significantly higher specificity for the detection of prostate cancer than the conventionally used examinations including DRE and TRUS. It is a useful real-time diagnostic method because it is not invasive, and simultaneous evaluation is possible while performing TRUS.

Regenerative Medicine and Diabetes: Targeting the Extracellular Matrix Beyond the Stem Cell Approach and Encapsulation Technology

According to the Juvenile Diabetes Research Foundation (JDRF), almost 1. 25 million people in the United States (US) have type 1 diabetes, which makes them dependent on insulin injections. Nationwide, type 2 diabetes rates have nearly doubled in the past 20 years resulting in more than 29 million American adults with diabetes and another 86 million in a pre-diabetic state. The International Diabetes Ferderation (IDF) has estimated that there will be almost 650 million adult diabetic patients worldwide at the end of the next 20 years (excluding patients over the age of 80). At this time, pancreas transplantation is the only available cure for selected patients, but it is offered only to a small percentage of them due to organ shortage and the risks linked to immunosuppressive regimes. Currently, exogenous insulin therapy is still considered to be the gold standard when managing diabetes, though stem cell biology is recognized as one of the most promising strategies for restoring endocrine pancreatic function. However, many issues remain to be solved, and there are currently no recognized treatments for diabetes based on stem cells. In addition to stem cell resesarch, several β-cell substitutive therapies have been explored in the recent era, including the use of acellular extracellular matrix scaffolding as a template for cellular seeding, thus providing an empty template to be repopulated with β-cells. Although this bioengineering approach still has to overcome important hurdles in regards to clinical application (including the origin of insulin producing cells as well as immune-related limitations), it could theoretically provide an inexhaustible source of bio-engineered pancreases.

Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review

Introduction Brunners gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunners glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion. Case presentation A 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunners glands correspondent to a Brunners gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure. Conclusion BGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.

The Meaning(s) of Chaos. A Semiosis of Stefan Wolpe’s Battlepiece

During his American exile in the period of World War II, Stefan Wolpe composed an epic piano work called Battlepiece. Though the piece includes exceptionally chaotic passages, it is counterbalanced by order and rigorous organization. The present article investigates these features both in their strictly material connotation and in their extra-musical meaning(s). Battlepiece is presented as a musical «metaphor» that relates to the broad imagery of modern warfare and to Wolpe’s ethical concerns (how this work embodies and resists the message of destruction and the suffering of emigration); it also makes references to the realm of visual art. In Battlepiece we glimpse the different aestheticexistential meanings that the composer and the communities around him have attributed to the dialectical tension between chaos and integration during the period between the two world wars, which was characterized by the rise of totalitarian regimes. The overall meaning of Battlepiece, both intra-musical and extra-musical, has to do with the modern sublime. This article discusses Wolpe’s own statements, passages from the published score, the Peer Musikverlag (1995) critical edition, and preparatory material from the Wolpe Collection in the Paul Sacher Foundation in Basel.

Il «Cornet» di Rainer Maria Rilke fra Martin e Viktor Ullmann. Un testo letterario e due poetiche dei dodici suoni

Almost in the same years, during the Second World War, both Frank Martin and Viktor Ullmann worked on a musical setting of Die Weise von Liebe und Tod des Cornets Christoph Rilke (‘The Lay of Love and Death of the Cornet Christoph Rilke’), a short poem by Rainer Maria Rilke. Martin wrote a Lied for Alto and Orchestra, Ullmann a melodrama for Recitation and Piano. The following article compares these two works showing some differences and analogies which rouse in turn some remarks about the characteristics of Rilke’s poem. Martin’s and Ullmann’s stylistic trends, revealing themselves in each Cornet , are illustrated in refer to some of the main musical tendencies of the 20th century.

L’Andante della Sonata n° 5 op. 45 di Viktor Ullmann. Una testimonianza da Theresienstadt

Viktor Ullmann was one of the most prominent composers in Theresienstadt (Terezin), a well-known Ghetto created by the Nazis near Prague during the II World War. As a composer and performer, Ullmann incessantly supported the cultural activities of the camp. This article analyzes some compositional features and extra-musical values of the Andante of Ullmann’s Piano Sonata n° 5 op. 45 – written in 1943. By quoting Karl Kraus’s poem Vor dem Schlaf [Before sleep] the composer could express a sort of ‘hinted resistance’, against Nazis, that also involved certain pitch structures as well as his peculiar enharmonic notation. The various meanings of the musical text and of the poetical one are discussed in their reciprocal relationship, by making references to Ullmann’s Hebrew origins and his interest in Rudolf Steiner’s Anthroposophy. The Andante of the Sonata is compared with other works composed by Ullmann in Theresienstadt, such as the chamber opera Der Kaiser von Atlantis [The Emperor of Atlantis].

A case of bilateral breast cancer and Graves' disease.

We report a case of bilateral breast cancer associated with Graves’ disease characterized by a large goiter and complicated by a severe ophthalmopathy. The hyperthyroidism was treated initially with methimazole and then with thyroidectomy, the ophthalmopathy with intravenous steroids combined with orbital radiotherapy. The breast tumors underwent surgical resection followed by chemotherapy. We describe this case because of the well-known association between breast cancer and thyroid disease, particularly of the autoimmune type, the causes of this being still unclear. Recent literature on this topic is reviewed, discussing the possible role of the Na+-I− symporter and anti-TPO antibodies.