Fulvio Freda

Primary thyroid angiosarcoma: an unusual localization

The finding of thyroid nodules is a very common occurrence in routine clinical practice. Approximately 5% to 7% of the entire population have thyroid nodules. Vascular lesions are one of the most controversial issues in thyroid pathology. These include benign lesions such as hemangiomas and, rarely, malignant tumors such as angiosarcomas or undifferentiated angiosarcomatoid carcinomas. In particular, angiosarcoma of the thyroid gland is a rare, highly aggressive malignant vascular tumor and in Italy the greatest geographical incidence of this lesion is witnessed near the Alps. Here, a case of thyroid angiosarcoma in a 71-year-old man with a history of goiter for about 20 years is described. The unusual localization of this lesion, the difficulties in reaching a definitive diagnosis for this particular histological type of primary tumor and a history of long-standing multinodular goiter in thyroid of an older man from outside the Alpine region prompted us to report this case of thyroid angiosarcoma mainly to discuss surgical, histopathological and immunohistochemical features.

Involvement of the Ubiquitin-Proteasome System in the Formation of Experimental Postsurgical Peritoneal Adhesions

We investigated the Ubiquitin-Proteasome System (UPS), major nonlysosomal intracellular protein degradation system, in the genesis of experimental postsurgical peritoneal adhesions. We assayed the levels of UPS within the adhered tissue along with the development of peritoneal adhesions and used the specific UPS inhibitor bortezomib in order to assess the effect of the UPS blockade on the peritoneal adhesions. We found a number of severe postsurgical peritoneal adhesions at day 5 after surgery increasing until day 10. In the adhered tissue an increased values of ubiquitin and the 20S proteasome subunit, NFkB, IL-6, TNF-α and decreased values of IkB-beta were found. In contrast, bortezomib-treated rats showed a decreased number of peritoneal adhesions, decreased values of ubiquitin and the 20S proteasome, NFkB, IL-6, TNF-α, and increased levels of IkB-beta in the adhered peritoneal tissue. The UPS system, therefore, is primarily involved in the formation of post-surgical peritoneal adhesions in rats.

Prostaglandin E1 versus lumbar sympathectomy in the treatment of peripheral arterial occlusive disease: randomised study of 86 patients.

BACKGROUND AND AIM The aim of this study was to compare the effects of a pharmacological and a surgical vasodilatatory therapy in the treatment of chronic arterial diseases of the lower limbs. METHODS AND RESULTS After giving their informed consent, 40 patients were randomised to receive a slow (approximately 2-hour) infusion of 40 microg of prostaglandin E1 twice daily for 28 days (group A), and 46 were randomised to undergo lumbar sympathectomy, including the second and third ganglion. Twenty-four (60%) of the patients in group A experienced complete remission, seven (17.5%) were partial responders, and nine (22.5%) failed to respond. Of the 46 patients in group B, 29 (63%) experienced complete remission, seven (15.2%) were partial responders, and 10 (21.7%) failed to respond. CONCLUSIONS Broadly similar results were obtained with the two types of treatment, both of which are indicated mainly in Fontaine stages IIB and III (non-advanced), particularly when revascularising therapy is impossible or excessively risky. The two strategies can be advantageously combined with direct revascularisation surgery and may therefore constitute a first-line approach favouring subsequent therapy.

Outcome of surgical treatment of carcinoma of the pancreas.

Aims and background Pancreatic resections for neoplastic diseases have a high risk of severe intra- and postoperative complications and are associated with high mortality rates. They should be performed as a rule in centers specializing in this type of surgery. However, it is becoming increasingly likely that such tumors may have to be treated in surgery units which are not specifically dedicated to pancreatic surgery. The aim of this study was to assess the improvements in clinical results in a non-specialized general surgery setting in the light of the most recent progress in surgical techniques, drug treatments and nutritional support. Methods and study design We analyzed 48 patients with pancreatic cancer treated in our institution over the period from 1980 to 1998: 36 had cancer of the head of the pancreas, 5 of the ampulla, 1 in the second duodenal portion, and 6 of the body-tail. The operations performed consisted of 13 Whipple pancreaticoduodenectomies with cutting and stapling of the distal pancreatic stump at the level of the isthmus, 4 left pancreasectomies, 2 local resections of the ampulla, 21 palliative operations, and 2 exploratory laparotomies. Results and conclusions The patients were submitted to follow-up including clinical examinations, blood-chemistry tests, and instrumental investigations. The mean survival was 18 months in the cases where radical surgery was performed, compared to 11 months after palliative surgery. We conclude that an improved prognosis can obtain after pancreatic resection. This is attributable to a more accurate preoperative staging and to the aid of the various forms of nutritional support and pharmacological prophylaxis currently available.

SOLID-CYSTIC PSEUDOPAPILLARY TUMOR OF PANCREAS: DESCRIPTION OF TWO CASES AND LITERATURE REVIEW

The authors report the cases of two young female patients aged 17 and 27 years who underwent surgery for a rare tumor of the pancreas, Frantzs tumor or solid-cystic pseudopapillary tumor. Solid-cystic pseudopapillary tumor of the pancreas is a rare tumor, accounting for 2.7% of pancreatic exocrine tumors. About 90% of these tumors occur in young women and they can reach very large dimensions. Due to their rareness and behavior, they are often associated with diagnostic and therapeutic problems. In most cases surgical treatment is curative and neither chemotherapy nor radiotherapy should be added. In the few cases where surgery is not possible, radiotherapy can be used because these tumors appear to be radiosensitive.

Prosthetic hernioplasty in elderly people: personal experience

BackgroundInguinal hernia is the most prevalent among the herniasthat interested the abdominal wall with higher incidencein male than female, moreover it is more frequent inelderly than in younger patients. The incidence risesfrom 11 per 10,000 person-years aged 16-24 years to200 per 10,000 person-years aged 65 years and above.According to the literature the safest approach to geria-tric patients is to perform hernioplasty in open surgeryusing local anaesthesia. The elderly patient has special fea-tures, typically related to thegeneral conditions. Localanesthesia and postoperative analgesia are sufficient tosolve the problems of old age. Over the last twenty yearsthe surgical treatment of inguinal hernias has undergonesignificant changes. Today, the use of prothesis is the tech-nique most used.There are not many differences between the techni-ques “tension free sutures less” and “tension free suturesno less”.MaterialsFrom January 2005 to December 2011 at the Depart-ment of Gerontology, Geriatrics and Metabolic Diseasesat the Second University of Naples, we operated 293patients for inguinal hernia, whose 92 elderly patients(older than 65 years) underwent surgical prosthetic her-nioplasty for simple inguinal hernias. Patients withrecurrence, bilateral hernia, large size hernia and allcases that underwent general anaesthesia were excludedfrom the study.ResultsIn the elderly there are multiple concomitant diseasescompared with young, like respiratory or cardiovascularor metabolic diseases, for example.We reported only 1 recurrence (1.08% of cases) withthe “tensionfreenosutureless” technique. As concernspostsurgical pain, no type of analgesic treatment wasrequired for the most of cases treated.Thanks to the prothesis and concomitant use of localanaesthetic you get a decrease of hospitalization timefor the patients.The duration of surgical treatment is about 45 min;the most of patients were discharged either one dayafter or two days after surgery due to severe concomi-tant pathologies such as ischemic cardiopathy, hyperten-sion, renal insufficiency,obesity, hepatic cirrhosis,moderate-severe BPCO or decompensated diabetesmellitus.The “tension free suture less” and “tension free nosuture less” techniques also decreases morbidity con-nected to respiratory (atelectasis, infection) and circula-tory complications (deep vein thrombosis, pulmonaryembolism). If performed correctly, these techniques,which are based on reinforcing the posterior wall of theinguinal canal through the use of a prosthesis, display arecurrence rate of 0.1-0.3%.The surgical prosthetic hernioplasty associated withthe so-called “nerve sparing” technique - that is to iden-tify and preserve the nerves during surgery - reducepostoperative pain and allow the patients to return soonto them normal physical activity.ConclusionsIt is our opinion that the best treatment of inguinal herniain the elderly patients is the surgical prosthetic hernio-plasty associated with local anaesthesia. It is to be consid-ered, moreover, that thanks to the use of“nerve sparing”