How abundant is a species at the limit of its distribution range? Crested porcupine Hystrix cristata and its northern population

The crested porcupine (Hystrix cristata) is a rodent present in Africa and southern Europe (Italy exclusively). The Italian population is expanding from the centre to the north and south, but little is known about the species' abundance. Reliable population density estimates are important for monitoring trends in wildlife populations and for developing effective conservation and management strategies. In this context, we aimed to first report crested porcupine population density on the northern limit of its current distribution range using a non-invasive approach. Specifically, we randomly placed 38 camera traps in an area of 242 km2 in north Italy (Lombardy region), and we applied camera trap distance sampling. We estimated a porcupine density of 0.49 ind·km-2 (±0.33, standard error). The results presented here are the first crested porcupine density estimate accounting for imperfect detection (i.e. species present but not detected). The abundance estimate reported here is fundamental for a better understanding of the species status in Europe and for implementing conservation and management plans.

Mitomycin-C and Lonidamine as Second-Line Therapy for Colorectal Cancer: A Phase II Study

Aims and background

Recent preclinical data have suggested that lonidamine may potentiate the activity of mitomycin C in human colon cancer cell lines LoVo and HT29.

Study design

A phase II study was carried out in 14 patients with advanced colorectal cancer pretreated with fluorouracil and folinic acid. Treatment consisted of lonidamine, 600 mg po, followed after 2 h by mitomycin, 20 mg/m2 by iv bolus, followed by lonidamine, 150 mg tid for 5 days; the cycle was repeated every 6 weeks.

Results

No objective response was seen. Three patients had stable disease; the median survival for the whole group was 4 months. Although hematologic toxicity was negligible, lonidamine-related side effects were moderate to severe in most patients and mainly represented by myalgia and gastric pain.

Discussion

Despite a sound preclinical rationale, this schedule of lonidamine and mitomycin C was ineffective and toxic in patients with advanced colorectal cancer. More experimental data about lonidamine are needed in order to design more effective regimens based on the combination of this interesting drug with other anticancer agents.

Mitomycin-c, Adriamycin, 5-Fluorouracil and Leucovorin (L-FAM2) in the Treatment of Advanced Gastric Cancer: A Phase II Study

Thirty previously untreated patients with advanced measurable gastric cancer were given a combination chemotherapy consisting of 5-fluorouracil, 400 mg/m2, and leucovorin, 200 mg/m2 iv on days 1 to 3, mitomicyn-C, 10 mg/m2 on day 1 (every other cycle) and adriamycin, 40 mg/m2 on day 2, repeated every 21 days. The overall response rate was 46 % (14/30; 95 % confidence limits: 28 %-64 %) including 4 patients with a complete remission. Eight patients progressed. Median duration of remission (CR+PR) was 10 months, with a median survival of 13, 8 and 4 months for CR + PR, NC and PD, respectively. Main toxicities were leukopenia (WHO grade III-IV in 36 % of the patients) and alopecia. One patient died from myocardial infarction after an adriamycin cumulative dose of 480 mg/m2. No other treatment-related death occurred. L-FAM2 is an effective combination for advanced gastric carcinoma. Further studies based on the association of leucovorin and 5-fluorouracil in combination with other active drugs are warranted.

Primary Carcinoid Tumor of the Ovary: Report of an Unusual Case

Carcinoid tumors are endocrine malignancies that are often associated with a characteristic syndrome, the malignant carcinoid syndrome, which is most common in patients with small bowel tumors and liver metastases. In the rare instances when the syndrome is present without liver metastases the primary tumor is usually localized to the bronchus or ovary and secretes hormones directly into the systemic circulation. About two thirds of patients with carcinoid syndrome have evidence of carcinoid heart disease. We report on a case of a primary ovarian carcinoid tumor with an unusual clinical presentation.

Epidermal growth factor receptor tyrosine kinase inhibitors for elderly patients with advanced non-small cell lung cancer

Lung cancer is the leading cause of cancer-related mortality in both men and women and approximately 219,440 new cases of nonsmall cell lung cancer (NSCLC) were estimated to occur in the USA in 2009, which caused 159,390 NSCLC-related deaths. More than 50% of cases of advanced NSCLC are diagnosed in patients older than age 65, and recent Surveillance Epidemiology and End Results (SEERs) data suggest that the median age at diagnosis is 70 years. Until recently, the disease has been undertreated in this patient population, with a perception among many clinicians that elderly patients do not tolerate chemotherapy or radiotherapy. So, single agent chemotherapy is the recommended approach by the ASCO and International Expert Panels in unselected patients. The introduction of novel targeted therapies, such as Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase Inhibitors (TKIs) which improved survival versus placebo in patients who had previously failed on chemotherapy, gives clinicians new, effective, and better tolerated options to consider when treating NSCLC in elderly patients. This paper describes the advances of EGFR TKIs for elderly patients with advanced NSCLC.

Anti-EGFR therapy in colorectal cancer: how to choose the right patient

The anti-epidermal growth factor receptor monoclonal antibodies cetuximab and panitumumab have established efficacy as single agent and in combination with chemotherapy in advanced colorectal cancer. However, only a small percentage of unselected patients (around 10%) are responsive to these costly agents. Mutations in the KRAS gene are associated with resistance to both cetuximab and panitumumab and account for approximately 30% to 40% of resistant patients. Nevertheless, having an intact KRAS is necessary but not sufficient to derive benefit from EGFR inhibition. Further, positive predictive markers that are currently being evaluated include an increase in EGFR gene copy number and additional data suggest that other EGFR downstream pathways such as the PI3K/PTEN/AKT/mTOR and JAK/STAT pathways are also important when considering mechanisms of EGFR antibody resistance. New data seem to support the role of BRAF mutational status. In addition, high mRNA levels of the EGFR-ligands Epiregulin and Amphiregulin have been associated with increased responsiveness to cetuximab. In this article we will review the available clinical and experimental data potentially useful for a better patients' selection.

The use of bevacizumab and trastuzumab beyond tumor progression: a new avenue in cancer treatment?

The use of the Monoclonal Antibodies (MoAbs) Bevacizumab (B) and Trastuzumab (T) beyond clinical progression in colorectal and breast cancer treatment is among the hottest topics in today's clinical oncology. Both observational and prospective studies, based on a sound preclinical basis, seem to support the notion that, simply replacing the cytotoxic drugs combined with the two MoAbs would provide an additional clinical benefit without stopping the biological agent. The aim of this review is to provide a critical analysis of the available clinical data, while waiting for the confirmatory prospective clinical trials still ongoing. The strength and the weakness of this innovative strategy, as well as the associated expense and toxicity issues will be discussed.

Extended lymphadenectomy in cephalic pancreatoduodenectomy. Personal observations

BACKGROUND/AIMS

Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of resected patients (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion may account for local recurrence. Japanese studies have reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases).

METHODOLOGY

At the General Surgical Clinic of Pavia University 20 patients (14 men, 6 women, mean age 62.4 yr) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to the Ishikawa technique, between 1996-2000. R1 nodes consisted of lymph nodes at the pylorus, superior pancreatic head, common bile duct, anterior pancreaticoduodenal region, inferior pancreatic head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior and inferior pancreatic body, mid colic region, common hepatic duct, celiac axis and para-aortic region.

RESULTS

The wide dissection was quite easy in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) consisted of 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 intestinal obstruction by adhesive bands, and 1 wound infection. Eight patients (40%) died during a mean follow-up period of 6 months (neoplastic recurrence 50%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), 12 patients (60%) had a median postoperative survival rate of 18.4 months (range 1-48 months) without neoplastic recurrence. Tumor diameter was less than 4cm in 83.3% of cases.

CONCLUSIONS

An earlier diagnosis (with tumor diameter <4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases and better control local recurrence.

The emerging role of oxaliplatin in the treatment of gastric cancer

Gastric cancer is often diagnosed in locally advanced or metastatic stages and, therefore, of poor prognosis. Many controversies exist about surgery, neoadjuvant, adjuvant and palliative treatments of gastric cancer. So we need to explore a variety of novel management options including the use of new agents and new combinations. Some of these agents include oral fluoropyrimidine, irinotecan, docetaxel and oxaliplatin. Oxaliplatin is a diaminocyclohexane-platinum compound that is significantly different from cisplatin and carboplatin with respect to its activity and toxicity. Oxaliplatin is an alkylating agent inhibiting DNA replication by forming adducts between two adjacent guanines or guanine and adenine molecules. However, the adducts of oxaliplatin appear to be more effective than cisplatin adducts in regard to the inhibition of DNA synthesis. In contrast to cisplatin, oxaliplatin has demonstrated efficacy alone and in combination with 5-fluorouracil in advanced colorectal cancer. Many studies are ongoing to test the combination in noncolorectal gastrointestinal tumors and other malignancies. This review focuses on the increasing amount of data concerning the clinical activity of oxaliplatin-based regimens in advanced gastric cancer.

[Radical surgical treatment of gastric cancer. Personal experience]

After surgical therapy the survival outcome of gastric cancer is still poor. Early diagnosis and radical surgery are the two most important means to improve the prognosis. Radical surgery must include all lymph nodes embryologically related to stomach. The aim of this study was to verify whether an aggressive surgical strategy can increase postoperative survival rate. In the period 1990-1994 eighty two patients with gastric cancer were operated on. The M:F ratio was 1.6:1 and the mean age was 65.3 years (range 23-89). Palliative operations (6 gastroenterostomy) were performed in 7.3% of cases. In the other patients, 36 total gastrectomies (43.9%), 8 total gastrectomies extended to spleen, pancreas and colon (9.7%), 32 distal subtotal gastrectomies (39.1%) were performed. Gastric exeresis was always associated with lymph node dissection extended to level I and II (R2). In some cases level III and IV lymphadenectomy (R3) was performed according to Maruyama-Mishima technique. There were no intraoperative deaths. The operative mortality was 13.6% for total gastrectomies and 3.1% for subtotal gastrectomies. Postoperative complications occurred in 15.9% of total gastrectomies (3 anastomotic fistula, 2 wound infection, 1 subphrenic abscess, 1 melena) and in 3.1% of subtotal gastrectomies (1 sepsis). Stage III and IV cancers represented 74.4% of all cases (stage IIIA 19.6%, IIIB 21.9%, IV 32.9%). Metastatic lymph node involvement (N2+) affected 53.1% of T3 and 88.2% of T4 cancers. The mean survival rate of patients subjected to gastroenterostomy was 6 months. The 2-year survival for total gastrectomies was 42%, for subtotal gastrectomies 28.1%. In our experience, wide removal of lymph nodes and total or extended gastrectomies were performed without any increase of mortality and morbidity. In advanced stages, a wider exeresis increased survival and prevented local recurrence.

[Extended lymphadenectomy for carcinoma of pancreatic head. Personal experience]

Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of patients resected (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion might account for local recurrence. Japanese studies reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases). During the period 1996-2000 at our Institution 20 patients (14 M, 6 F, mean age 62.4 years) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to Ishikawa technique. R1 nodes consisted of lymph nodes at the pylorus, superior head, common bile duct, anterior pancreaticoduodenal region, inferior head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior body, inferior body, mid colic region, common hepatic duct, coeliac truncus and para-aortic region. This wide dissection was quite easy also in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) were 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 mechanical intestinal obstruction, 1 wound infection. Eight patients (40%) died in 6 months in average (neoplastic recurrence 40%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), twelve patients (60%) have a mean postoperative survival rate of 18.5 (range 1-48) months without neoplastic recurrence. Tumour diameter was less than 4 cm in 83.3% of cases. An earlier diagnosis (with tumour diameter < 4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with a R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases with a better control local recurrence.

[Surgical resection of hepatic hilar tumors]

Hepatic hilar cancer has an extremely poor prognosis and resection for cure is a realistic possibility in only 15-20% of patients. Tumours confined strictly to the biliary confluence can often be excised locally without resorting to hepatic resection (Bismuth's type I, II). Tumours extending beyond the second order bifurcation (Bismuth's type III) require hepatic resection. In the period 1996-1998 ten patients with hilar cancer (adenocarcinoma) underwent curative resection at our Institution. There were 9 men and 1 women with a mean age of 61.7 years (range 49-76 yrs). One neoplastic lesion was Bismuth's type I, five type II, four type III. The mean preoperative bilirubin level was 20 mg% and the mean duration of jaundice was 4 weeks. Four patients had skeletonization resection of the tumour and extrahepatic bile ducts, clearing all lymphocellular and other tissue from the hepatic pedicle and coeliac axis. Bilioenteric continuity was reestablished by a Roux-en-Y jejunal loop with separate biliary duct anastomoses. Six patients required also hepatic resection to adequately remove the tumour (1 right hepatectomy, 2 right lobectomy, 2 left hepatectomy, 1 segmentectomy III). Three patients had liver metastases. One patient had involvement of the left arterial and portal branch. The postoperative staging was 2 stage II, 1 stage III, 7 stage IV. In 5 patients hepatic lymph nodes (N1) were involved. In no patient the tumour was found at the margin of resection. The median estimated blood loss for hepatic resection was 1,000 ml and for skeletonization 500 ml. Intraoperative mortality was 0%. Operative mortality was 20%. Three patients had a complicated postoperative course (1 cerebral TIA, 1 multiorgan failure, 1 ictus cerebri). All patients died. The mean postoperative survival was 7.4 months. Four patients (N1+) died of local tumour recurrence at 8, 11, 6, and 8 months. In our experience resective procedures can achieve a longer survival and a better quality of life. The operative mortality may be kept to a minimum by adequate selection of patients and technical expertise.

[Neoplastic obstruction of the vena cava inferior in general surgery]

Patients with primary or secondary tumoral occlusion of the inferior vena cava are difficult to be managed with safety and success. Nevertheless, their survival may be prolonged by an aggressive surgical approach according to the technical advances of liver transplantation. In fact, it is possible to perform a tumoral exeresis including the inferior vena cava by a total vascular exclusion of the liver (HVE) and a pump-driven veno-venous bypass (ECC). The Authors report the management of 8 patients with inferior caval tumoral involvement (8 M, 1 F, mean age 63.7 yrs). Vascular occlusion was caused by caval leiomyosarcoma (n 1), renal cell carcinoma (n 3), hepatocellular carcinoma (n 1), liver metastases (2 colorectal, 1 renal). Five patients (62.5%) underwent surgical treatment (2 laparotomy, 2 wide nephrectomy with partial caval wall resection in HVE, 1 ex vivo liver resection with caval venoplasty in HVE and ECC). Operative mortality was 40%. Three patients underwent medical treatment (radio-chemotherapy, chemoembolization). Total survival rate was 75% at 3 months, 50% at 6 months, and 25% at 24 months. Two patients (25%) are still alive at 3 months from the diagnosis and at 36 months from the operation.

[The surgery of lung metastases of melanoma]

Melanoma is considered one of the most lethal cancers and surgical therapy of its pulmonary metastases is rarely indicated. The only hope for a successful surgical treatment of secondaries from melanoma is a radical resection. Considering the very frequent multiorgan involvement of melanoma metastases, surgery is usually possible in less than 5% of cases. Nevertheless, in selected cases without lymph nodal involvement a 5-year survival rate of 31% has been reported. In any way, it must be remembered that about 10% of lung tumours thought to be metastases are primary cancers. In this occurrence surgery could be a rescuing solution. So, a pulmonary resection is always imperative when some diagnostic doubt exists.

[Surgical therapy of metabolic liver diseases (glycogenosis, hypercholesterolemia)]

Up-to-date, most patients with serious chronic hepatic disease are best treated by liver transplantation. It has been confirmed the striking benefit of liver transplantation also for patients with glycogen storage disease or homozygous familial hypercholesterolemia who were refractory to medical treatment. Nevertheless, the advantage of achieving palliation without transplantation, thereby avoiding the need for chronic immunosuppression, is obvious. With reference to the mentioned above diseases, end-to-side portacaval shunt was used. A favourable effect was noted on body growth and a number of metabolic abnormalities. Hepatic failure did not occur, although in a few patients blood ammonia concentrations and serum alkaline phosphatase levels increased relative to preoperative values. To avoid an incomplete palliation provided by portacaval shunt, appropriate case selection is a problem. The Authors report their personal experience with portacaval shunt for the treatment of glycogenosis and familial hypercholesterolemia.

Paclitaxel, ifosfamide, and carboplatin for the treatment of stages IIIB and IV non-small cell lung cancer: preliminary results

We have treated 26 consecutive chemotherapy-naive patients with stage IIIB/IV non-small cell lung cancer with an innovative regimen based on a 1-hour infusion of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) 125 to 250 mg/m2, ifosfamide 3 g/m2 (with mesna), and carboplatin dosed to an area under the concentration-time curve of 5, every 21 days for a total of six cycles in responding or stabilized patients. Among 22 fully evaluable patients, 14 (64%) achieved a partial remission, six had disease stabilization, and two had disease progression. Hematologic toxicity was remarkably mild; only one patient had grade 3 neutropenia (on day 21). Arthralgias/myalgias (grade 3 in nine patients, grade 4 in one patient) and neurologic toxicity (a cumulative sensory neuropathy of grade 3 or 4 in five patients) were the most common side effects and seem to be dose related. To date, few patients are fully evaluable and survival data are clearly immature. Nevertheless, this regimen seems highly active and quite well tolerated, and deserves further evaluation.

[Primary and secondary pulmonary tumors associated with head and neck carcinoma]

The authors analyze personal and literature results in surgery of primary and secondary lung cancer associated with head and neck malignancies. Eighteen patients with primary lung cancer associated with head and neck cancer were compared with six patients affected by pulmonary metastases from head and neck cancer. In the first group the 3-year postoperative survival rate was 60.5%, in the second group 33%. Differential diagnosis between primary and metastatic lung tumours may be easy when multiple pulmonary nodes are present. When only one pulmonary node is present, diagnosis is more difficult. Thoracotomy is necessary to perform the correct diagnosis and the best postoperative medical treatment.

[Surgical treatment of pulmonary metastasis from breast carcinoma. Personal contribution and considerations on the experience in the literature]

Considering a series of twelve patients operated on at the General Surgical Clinic of the University of Pavia, the authors discuss the results of surgical therapy of pulmonary metastases from breast cancer. According to literature data their results are not so good with a 5-year survival rate of 11%. Nevertheless, selected series of patients have been reported with a 5-year survival rate of 43% after pulmonary resection. So, by a careful selection of the indications the possibility of a surgical treatment would not be eliminated. After breast cancer exeresis it is certain that surgery is the best treatment for a solitary pulmonary nodule when there is some doubt about the diagnosis of primary or secondary lung cancer.

[Surgical approach to posthepatitic cirrhotic patient today]

A posthepatitic cirrhotic patient may undergo elective or urgent abdominal operation for an extra-hepatic or hepatic disease. According to the high postoperative morbidity (61%), surgery is indicated only for symptomatic or complicated cholelithiasis. A surgical procedure for refractory ascites has been devised to create a permanent peritoneo-venous shunt by a one way pressure-sensitive valve (Leveen). The procedure is simple and brings a long lasting relief with recovery in strength and nutrition and improved kidney function. Sclerotherapy is widely used to treat acute variceal bleeding while repeated sclerotherapy is used in the long-term management to eradicate varices. When indicated, liver transplantation is the best treatment to prevent variceal bleeding recurrence. Also portosystemic shunts effectively prevent recurrent variceal bleeding. They are, however, major operations with an important morbidity and mortality, particularly in poor risk patients. The most advocated shunts today are the Warren distal splenorenal shunt and the Sarfeh portacaval shunt using a small diameter prosthetic H-graft. The transjugular intrahepatic portosystemic stent-shunt (TIPSS) is a new treatment for portal hypertension and its complications. From a haemodynamic point of view it allows balanced hepatic perfusion. Postoperative mortality is rare; further bleeding and encephalopathy are reasonably acceptable. The most relevant complications concern dislocation of the prosthesis, stenosis and thrombosis of the shunt, which can be corrected by non-invasive dilatation. Encephalopathy is the main complication of surgical portosystemic shunts. It is usually controlled by protein diet restriction, and administration of lactulose or oral antibiotics. In severe forms the patients may be treated by an oesophageal transection with oesophagogastric devascularization, and by a postoperative suppression of the portosystemic shunt using external maneuvers. Posthepatitic liver cirrhosis is frequently complicated by the onset of an hepatocellular carcinoma. Early detection (aFP, DCP, Echography) and curative resection are the best ways to improve long term prognosis. Segmentectomy achieves a good balance between liver function preservation and radical exeresis for tumours less than 5 cm in diameter. Liver transplantation may be considered for the treatment of long-staging cirrhotic patients in whom hepatocarcinoma development has been recognized at an early presymptomatic stage. Hepatic arterial chemoembolization (gelfoam, lipiodol, mitomycin C or doxorubicin) may improve the survival of patients with unresectable malignant disease of the liver. A marked reduction in liver size may occur in the weeks following an effective chemoembolization with objective (CT scan) and subjective improvement (amelioration of specific symptoms). Liver chemoembolization is absolutely contraindicated in the presence of jaundice disordered liver function (Child C) or complete portal venous obstruction. In the last years, the number of patients treated by liver transplantation has greatly increased. Surgical technique, postoperative management, and immunosuppressive therapy account for the dramatic improvement of the results. However, indications for selection of patients and the timing for liver transplantation are still not well defined.

Bench surgery and liver autotransplantation. Personal experience and technical considerations

Advances in hepatic transplantation have opened the possibility of bench surgery for liver disease. Thus, nonconventional methods such as the ex vivo approach (bench procedure) or the in vivo ex situ preserved liver surgery have been performed in selected cases. These methods have been confined to situations and tumour stages otherwise deemed untreatable, or to situations where resection may not be sufficiently radical. To date, primary liver tumours (hepatocellular, cholangiocellular) and colo-rectal metastases are considered to be suitable conditions. The technique used is that of liver grafting. Hypothermic liver perfusion (U.W., 4 degrees C) and pump-driven veno-venous bypass from portal vein and inferior vena cava to the superior vena cava are performed. The principal aim of bench surgery is to avoid the unnecessary removal of a large amount of normal parenchyma. Resection lines follow the segmental structure of the liver. Sometimes, an atypical hepatectomy with a parenchymal exeresis "à la demande" is required. Authors' experience with four patients undergoing ex vivo operation of the liver (three patients) or surgery on an ex situ hypothermic perfused liver (one patient) is reported. The patients had liver metastases from colonic carcinoma (1 M, 2 F) and from renal carcinoma (1 M). Major hepatic resections were performed. One patient (M) died from neoplastic intestinal recurrence after 16 months. Two patients (F) died after 24 and 9 days for sepsis and pulmonary embolism. One patient (M) died intraoperatively from a massive retroperitoneal bleeding. Being able to remove otherwise unresectable hepatic neoplasms is a worthy objective. In the presence of diffuse chemoresistant colo-rectal hepatic metastases, liver bench surgery is a promising therapeutic hope. At the basis of a good hepatic function there are a correct organ preservation, a perfect bench surgical technique with respect for vascularization and biliary drainage of the hepatic remnant, and an accurate hemostasis of the resection surface.

A comparison of the antiemetic efficacy and safety of intramuscular and intravenous formulations of granisetron in patients receiving moderately emetogenic chemotherapy

A total of 120 patients were treated with granisetron either intramuscular (i.m.) or intravenous (i.v.) in a crossover design, over two successive cycles of moderately emetogenic chemotherapy. Of the 117 patients evaluable for efficacy, 74.4% receiving i.m. and 76.9% receiving i.v. treatment experienced a complete response (no vomiting, no more than mild nausea, no need for rescue medication and no study withdrawal in the 24 h following the onset of chemotherapy). Only a small proportion of the patients experienced any vomiting, either during the first 24 h or in the follow-up period of 4-10 days. There were no statistically significant differences in any of the efficacy parameters between the two routes administration of granisetron. Both formulations of granisetron were also equally well tolerated. The main treatment-related adverse effects were headache and constipation (experienced by 13-15% of patients); local reactions to i.m. injection of granisetron were experienced by 2.6% of patients.

[Surgical treatment of pulmonary metastases in colorectal carcinoma]

After surgical exeresis of pulmonary metastases from colorectal carcinoma the 5-year survival rate is 30% vs 5% in non treated patients. Postoperative survival is longer for patients with a primary rectal cancer. Single pulmonary metastatic lesions, negative ilar and mediastinal lymph nodes, and Dukes' stages A and B are favourable prognostic criteria. The authors review literature's data and report and analyze their clinical observations.

5-fluorouracil by protracted subcutaneous infusion. A pilot study

A feasibility study of 5-fluorouracil (5-FU) delivered by long-term subcutaneous infusion (SCI) was carried out in 10 patients with advanced malignancies refractory to conventional treatment. 5-FU: 200 mg/m2/day was administered by an external infusor (Baxter 5 or 7 Multiday) connected with a 21-gauge needle placed in the thoracic wall. Treatment was continued until progression of disease or toxicity. WHO grade II to III mucositis was experienced by two and one patients, respectively. Grade II diarrhea developed in one patient. Local toxicity was substantial but painless and manageable; skin ulceration was experienced by two patients. A total of 88 weeks of therapy was delivered with a median of 8.8 weeks for each patient (range 2 to 16). Two patients (breast and colorectal cancer) achieved a partial remission; two additional cases showed a > 50% decrease in tumor marker levels. In conclusion, the administration of 5-FU by SCI deserves further evaluation, especially in clinical circumstances in which venous access is limited by thrombosis or technical concerns.

[Surgical treatment of pulmonary metastases of sarcoma]

Lungs are the most common target of metastases from osteogenic and soft tissue sarcomas. Metastases can be successfully treated by surgery. Only a few patients with non treated pulmonary metastases from sarcomas are alive after 5 years. In fact, without surgery the 1-year mortality is 50%. The number of metastases, the site in one or both lungs, the disease-free period and the tumoral doubling time have important prognostic significance. The authors report two interesting cases successfully treated with surgical therapy.

[Surgical treatment of pulmonary metastases of primary neoplasms of the urogenital tract]

The authors review the literature data concerning the surgical therapy of pulmonary metastases from genital and urinary tumours. In both cases a combined chemo-surgical treatment is able to increase longterm survival. Some personal cases successfully treated are reported. The case is reported also of a young girl operated on for pulmonary metastases from a Wilms tumour. Successively, a heart transplantation was performed. She is alive and well.

[An update of Bassini's operation for the treatment of inguinal hernia]

Although the Bassini hernioplasty has been criticized, particularly by North American surgeons because of a high incidence of recurrence, among the techniques used for inguinal hernia repair, the Bassini method, in authors' opinion, is still the best if correctly performed. In fact, the transversalis fascia division is fundamental to obtain a better mobilization of the triple layer (transversalis fascia, transversus abdominis, internal oblique) which can approach the inguinal ligament without tension. Hernia repair is achieved by suturing this layer to the pubic tubercle and inguinal ligament with separated stitches.

[What future for clinical xenograft of the liver?]

In the cyclosporine era liver orthotopic allotransplantation has shown to be very effective in the treatment of many end-stage liver diseases. Currently, the major limitation in clinical transplantation is the shortage of donor organs unlikely solvable by alternative policies or approaches such as living donors and artificial organs. Animals have been considered as an alternative source of organs offering the following advantages: availability of a predictable and ready supply of donor organs, opportunity to practice transplantation as an elective procedure, possibility to match the size of the graft recipient. However, immunologic barriers are thought to make xenotransplantation impractical between widely divergent (discordant) species. Hyperacute xenograft rejection, in fact, consists of an immediate, diffuse intravascular coagulopathy followed by an aggressive cellular reaction. Recipient preformed natural antibodies and complement are involved in the humoral phase of hyperacute rejection. The violence of this reaction depends on the titer of natural antibodies and on the divergency of the species involved. Species more closely related (concordant) exhibit a less aggressive reaction characterized by an acute cellular rejection. Hepatic allografts and xenografts, though, are unusually resistant to humoral injury and undergo a combination of both humoral and cellular rejection. Preliminary studies have demonstrated a prolonged reduction in natural antibodies accomplished by plasmapheresis and cyclophosphamide combined treatment. Furthermore, new therapeutic agents such as FK 506, rapamycin and deoxyspergualin may find widespread application in clinical transplantation. FK 506 has shown to possess a remarkable efficacy in reversing refractory hepatic allograft rejection as well as ability to inhibit humorally mediated immunity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pyogenic liver abscess: a caseload contribution]

Pyogenic hepatic abscesses have been recognized since the time of Hippocrates, but an understanding of their etiology, bacteriology, diagnosis and treatment is an event of the twentieth century. Fortunately mortality rate has declined due to improvements in diagnosis, intensive care, medical and surgical management. In particular, the use of CT and ultrasound scanning has reduced the incidence of unrecognized and therefore untreated liver abscesses. Considering nine patients operated on for liver abscess, the Authors affirm that laparotomic surgical drainage is still the most effective therapy in the majority of cases.

["Aorto-mesenteric compression" syndrome. Report of a case and review of the literature]

The Authors report a case of Wilkie's syndrome recently observed. This unusual observation is suitable for some clinical and therapeutic considerations. X-ray examination and abdominal CT played a decisive role for the diagnosis. Among the large number of operations till now proposed for the management of this syndrome, the Authors preferred the latero-terminal duodeno-jejunum anastomosis. Such intervention, in fact, is easy and quick and allows to preserve a physiological intestinal function.

[Hepatic carcinoma in cirrhosis. Segmental liver resections]

Liver cirrhosis is frequently complicated by the onset of an hepatocellular carcinoma. An accurate monitoring of the cirrhotic patient often assures an early diagnosis, so that an hepatic resection is still possible. Hepatectomy has been accepted as the only chance of cure, but selection of the appropriate extent of surgery has to be made taking into account both the risk of postoperative hepatic failure and oncologic needs. Intraoperative sonography and intermittent hepatic vascular clamping lead to a safer liver resection, while the postoperative course is improved by monitoring the hepatic function and preventing sepsis. In the period November 1973-March 1991, 34 hepatic segmentectomies (unisegmentectomy 47%, bisegmentectomy 38.3%) were performed in our Service in cirrhotic patients with hepatocellular carcinoma. The clinical stage was defined using a modified Child-Bismuth's grading (A 67.6%, B 32.4%). In the majority of cases (53%), tumors were less than 5 cm in diameter. Perioperative blood loss was less than 1,500 ml and fresh frozen plasma was preferred for volume substitution. The operative (one month) mortality rate was 20.5%. Postoperative complications occurred in 45% of cases. The mean survival rate was 14 months. The above results suggest early detection and curative resection as the best way to improve long term prognosis. Segmentectomy achieves a good balance between liver function preservation and radical exeresis. Postoperative intensive care is needed to prevent complications which might lead to hepatic failure.

L-folinic acid and 5-fluorouracil in the treatment of advanced breast cancer: a phase II study

BACKGROUND

The combination of 5-fluorouracil (5-FU) and folinic acid (FA) is an active combination for the treatment of advanced breast cancer (ABC). Theoretically, the biologically active isomer of FA, 1-FA, should be more effective than racemic FA in modulating 5-FU activity.

PATIENTS AND METHODS

Thirty-three patients (pts) with ABC, all previously treated with an anthracycline-based combination for advanced disease were treated with 1-FA: 100 mg/m2 i.v. and 5-FU: 370 mg/m2 i.v. for 5 consecutive days every 4 weeks.

RESULTS

Three complete remission (CR) and 11 partial remission (PR) were obtained for an overall response rate of 42% (95% CI = 25-59). Median duration of response was 10 months, median survival was 15 months for responders, 11 months for NC and 3 for PD. Eleven pts experienced a WHO grade III-IV oral mucositis (33%), 6 pts had grade III and one grade IV diarrhea, two pts had grade IV neutropenia resulting in one toxic death.

CONCLUSIONS

In this heavily pretreated population of pts with ABC, this regimen showed an interesting activity with substantial toxicity. Both the response rate and the pattern of side-effects seem similar to those experienced with the racemic mixture of d,1-FA. Modulated 5-FU warrants an increasing consideration in the treatment of breast cancer.

MICE: a new active combination for non-small cell lung cancer

We have treated 38 patients with stage III/IV non-small cell lung cancer with the following regimen: mitomycin-C = 6 mg/m2, ifosfamide = 3 g/m2, cisplatin = 75 mg/m2, vindesine = 3 mg/m2 (MICE), intravenously (i.v.) on day 1, every 3 weeks. Among 26 patients with stage IV disease, 15 obtained a partial remission (PR) (response rate = 57%, 95% confidence interval = 38-76), with a median time to disease progression and a median survival of 4.9 and 7.1 months, respectively. 6 out 7 patients with stage IIIA disease were documented as PR and 5 of them underwent radical surgery with two pathologically confirmed complete remissions. Overall toxicity was substantial but manageable: 3 patients had grade III/IV leucopenia (although 5 patients had neutropenic fever) whereas 13 patients experienced grade II/II anaemia. In conclusion we believe that MICE regimen is an interesting combination and warrants further evaluations both for palliation and in a neoadjuvant setting.