D. F. D'Amico

Parathyroid Carcinoma: Sixteen New Cases and Suggestions for Correct Management

AbstractWe undertook a retrospective study in 16 patients with parathyroid carcinoma, with the aim of conveying experience from management of this rare cause of hyperparathyroidism (HPT). From 1980 to 1996 we operated on 309 patients with HPT, 290 of whom had primary HPT, and parathyroid carcinoma was diagnosed in 16 (5.2%) cases. In none was the malignancy diagnosed preoperatively. The average serum calcium and parathyroid hormone levels were significantly higher (np < 0.05) than in patients with parathyroid adenoma, and the mean tumor size was 2.9 cm (median 2.5 cm, range 1.5–4.5 cm). Twenty-eight operations were performed with resulting normalization of serum calcium levels for more than 6 months in 11 patients. Six patients presented prolonged postoperative hypocalcemia (2–10 months), and five patients had persistent HPT. Ten patients experienced recurrent disease; the median disease-free period was 24 months (range 4–72 months). None of the patients was treated with chemotherapy, one patient underwent radiation therapy (50 Gy in 25 sessions) but required reoperation for local recurrence 4 months later. Three patients are still alive (two with recurrence). Average survival was 40 months (median 31 months, range 11–131 months).

Validation of the BCLC Prognostic System in Surgical Hepatocellular Cancer Patients

BACKGROUND/AIMnPrognosis assessment in surgical patients with hepatocellular carcinoma (HCC) remains controversial. The most widely used HCC prognostic tool is the Barcelona Clinic Liver Cancer (BCLC) classification, but its prognostic ability in surgical patients has not been yet validated. The aim of this study was to investigate the value of known prognostic systems in 400 Italian HCC patients treated with radical surgical therapies.nnnMETHODSnWe analyzed a prospective database collection (400 surgical, 315 nonsurgical patients) observed at a single institution from 2000 and 2007. By using survival times as the only outcome measure (Kaplan-Meier method and Cox regression), the performance of the BCLC classification was compared with that of Okuda, Cancer of the Liver Italian Program, United Network for Organ sharing TNM, and Japan Integrated Staging Score staging systems.nnnRESULTSnTwo hundred twenty-five patients underwent laparotomy resection; 55, laparoscopic procedures (ablation and/or resection); and 120, liver transplantations. In the surgical group, BCLC proved the best HCC prognostic system. Three-year survival rates of patients in BCLC Stages A, B, and C were 81%, 56%, and 44% respectively, (P < .01); whereas all other tested staging systems did not show significant stratification ability. When all 715 HCC patients were considered, surgery proved to be a significant survival predictor in each BCLC stage (A, B, and C).nnnCONCLUSIONSnBCLC staging showed the best interpretation of the survival distribution in a surgical HCC population. The BCLC treatment algorithm should consider the role of surgery also for intermediate-advanced stages of liver disease.

Male hypogonadism in cirrhosis and after liver transplantation.

Liver is deeply involved in the metabolism of proteins, hormones, enzymes, cytokines, as well as in sex hormones catabolism. Gonadal function requires a normal liver function, and it is well known that clinical signs of hypogonadism are common in patients with liver cirrhosis. Few studies have focused on hypothalamic-pituitary-gonadal alterations in male cirrhotic patients or after orthotopic liver transplantation (OLT). The pathogenesis of hypogonadism in cirrhotic patients is complex and not well explained. It involves both a gonadal and a hypothalamic-pituitary dysfunction. After OLT the hypothalarnic-pituitary-gonadal function partially improves, showing that the hepatic dysfunction before OLT is deeply involved in its pathogenesis. After OLT some alterations persist in some patients, both because of pre-existing gonadal alterations (toxic-metabolic damage) and immunosuppressive pharmacological side effects. Further studies will explain the relationship between hypogonadism and OLT outcome, and the role of androgen therapy in hypogonadism after OLT, in the early months and in the long term.

Prospective Validation of a New Priority Allocation Model for Liver Transplant Candidates: An Interim Analysis

BACKGROUNDnThe system that controls the waiting list (WL) and organ allocation for liver transplantation (OLT) seeks to achieve 3 main goals: objectivity, low dropout risks and good post-OLT results. We sought to prospectively validate a priority allocation model that is believed to achieve objectivity without penalizing dropout risk and post-OLT results.nnnMETHODSnWe evaluated a study group of 272 patients enrolled in 2006-2007. WL candidates were divided into 2 categories: cirrhotic patients classified according to Model for End-Stage Liver Disease (MELD) score (MELD list and patients with hepatocellular carcinoma (HCC) organized according to a specific score (non-MELD list). The allocation algorithm for donor-recipient match assigned an optimal graft to the first MELD candidate with a MELD score of >or=20; a suboptimal graft, to the first non-MELD patient. A respective control group of 327 patients transplanted from 2003-2006 was characterized by a unique WL with a free allocation policy. We performed an interim analysis of this prospectively controlled study.nnnRESULTSnAlthough the study group showed a lower percentage of OLT (P < .05) than the control group (37% vs 45%), it selected patients for OLT based on a higher MELD score (P < .05), thus obtaining similar dropout, post-OLT survivals, and intention-to-treat (ITT) survival probabilities as the controls. Among MELD patients, we observed a significantly reduced dropout and better ITT survival profiles than those of the control group (P = .02), whereas the similar results were delivered among non-MELD patients (P > .05). Among patients with a MELD score of >or=20, the prevalences of suboptimal grafts (0% vs 48%) and of early graft losses (0% vs 21%) were lower in the study than in the control group (P < .05).nnnCONCLUSIONSnWe prospectively validated a priority allocation model based on objective criteria that achieved high ITT survival rates.

Perendoscopic Nd:YAG laser therapy of colorectal neoplasms

The range of application of Nd:YAG laser is now wide and of particular interest in the treatment of neoplastic lesions of the large bowel, both benign and malignant, which, besides the debilitating of vegetative lesions, may also provide a good hemostasis of the bleeding ones. Yag laser treatment of malignancies is indicated in patients not suitable for surgery due to the extent of the disease or to the high anesthesiologic/surgical risk. The treatment of choice for benign neoplasms is represented by endoscopic polypectomy, being Yag laser therapy reserved to patients with very large polyps and with a high anesthesiologic risk. Yag laser therapy is also recommended in teleangiectasies with active or previous bleeding, since it allows the complete ablation of such lesions with subsequent outstanding hemostasis. Furthermore this treatment may be advantageously associated to other operative endoscopic procedures, such as diatermotherapy, dilatation and injection therapy. It is also to be outlined that Yag laser therapy is currently used to cure benign diseases and for the palliation of advanced cancer in inoperable patients. Our laser instrument is an Nd:Yag laser MBB Medilas 2 with maximum power of 100 watts at the tip, with non-contact laser fibers. We use flexible optic fiberendoscopes of several sizes, according to the type of lesion to be treated. Moreover we have employed both Savary dilators of progressive caliber from 5 to 15 mm and Rigiflex pneumatic balloons. Adequate bowel preparation by means of isosmotic solution was achieved in patients with non stenotic neoplasm, or evacuative enemas and fluid diet in patients with bowel neoplastic stenoses. The patients were premedicated with benzodiazepines. Stenotic malignant lesions have been treated with endoscopic dilatation before laser treatment. At each session 4,000 - 8,000 joules of energy were administered; all patients received an average of 5 - 6 laser sessions. Followup laser sessions have then been preformed every 2 months. From November 1st, 1992 to February 28th, 1995, 130 patients (78 males and 52 females) with an average age of 65 years (range 39 - 91) underwent Nd:Yag laser therapy of the large bowel for a total of 722 laser sessions. In 91 patients suffering from colorectal cancer with a mean extension of 5 cm 492 Nd:YAG laser sessions were performed with an average of 5.4 sessions per patient (range 1 - 19).