A combined protocol with piroxicam, chemotherapy, and whole pelvic irradiation with simultaneous boost volumetric modulated arc radiotherapy for muscle-invasive canine urinary transitional cell carcinoma: First clinical experience

The aims of this pilot study were to evaluate the feasibility and efficacy of high-dose hypofractionated volumetric modulated arc radiotherapy (VMAT) applied to whole pelvic region radiotherapy (WPRT) with multilevel simultaneous integrated boost (MLSIB) combined with piroxicam and chemotherapy for the treatment of canine transitional cell carcinoma (TCC) of the lower urinary tract with muscle invasion TCC. Twelve dogs were enrolled, according to stage, in two groups: group 1, TCC confined to the urinary tract; group 2, TCC with metastasis. The planning target volume dose was tailored from 36 to 42 Gy in 6 fractions. All dogs were prescribed piroxicam and radiosensitizing carboplatin, and six received chemotherapy after radiotherapy. Serial follow-ups with computed tomography and magnetic resonance imaging were performed. Disease control and toxicity effects were evaluated according to the Response Evaluation Criteria in Solid Tumors and Veterinary Radiation Therapy Oncology Group criteria. The treatment was well tolerated, and no high-grade side effects were reported. The median overall survival times for groups 1 and 2 were 1,230 and 150 days, respectively. A considerable percentage of patients in group1 (50%) were still alive at the time of writing this paper, and a longer follow-up could enable a more accurate survival analysis. This preliminary analysis shows that VMAT applied to the WPRT with MLSIB is an effective and safe option for dogs with lower urinary TCC, although the presence of metastases worsens the prognosis.

High dose hypofractionated frameless volumetric modulated arc radiotherapy is a feasible method for treating canine trigeminal nerve sheath tumors

The aim of this prospective pilot study was to evaluate the feasibility and effectiveness of curative intent high dose hypofractionated frameless volumetric modulated arc radiotherapy for treatment of canine trigeminal peripheral nerve sheath tumors. Client-owned dogs with a presumptive imaging-based diagnosis of trigeminal peripheral nerve sheath tumor were recruited for the study during the period of February 2010 to December 2013. Seven dogs were enrolled and treated with high dose hypofractionated volumetric modulated arc radiotherapy delivered by a 6 MV linear accelerator equipped with a micro-multileaf beam collimator. The plans were computed using a Monte Carlo algorithm with a prescription dose of 37 Gy delivered in five fractions on alternate days. Overall survival was estimated using a Kaplan-Meier curve analysis. Magnetic resonance imaging (MRI) follow-up examinations revealed complete response in one dog, partial response in four dogs, and stable disease in two dogs. Median overall survival was 952 days with a 95% confidence interval of 543-1361 days. Volumetric modulated arc radiotherapy was demonstrated to be feasible and effective for trigeminal peripheral nerve sheath tumor treatment in this sample of dogs. The technique required few sedations and spared organs at risk. Even though larger studies are required, these preliminary results supported the use of high dose hypofractionated volumetric modulated arc radiotherapy as an alternative to other treatment modalities.

Stereotactic Volume Modulated Arc Radiotherapy in Canine Meningiomas: Imaging-Based and Clinical Neurological Posttreatment Evaluation

A prospective study to assess high-dose hypofractionated volume modulated arc radiotherapy feasibility and efficacy in canine meningiomas was conducted. Thirty-nine patients with encephalic and spinal meningiomas assumed from MRI findings were recruited and received high-dose hypofractionated volumetric modulated arc radiotherapy by a linear accelerator equipped with an external beam modulator micro-multileaf collimator and an XVI cone beam computed tomography system. The prescribed mean dose was 33 Gy in five fractions. The treatment feasibility was tested through planned and delivered dose agreement checks. Regular clinical examinations were performed during and after irradiation time, with regard to mentation, deambulation, cranial nerve dysfunction, and seizures. Serial MRI exams were done 60 days after irradiation and after 4, 6, 12, 18, and 24 mo. Volumetric disease reduction criteria implemented with clinical neurological systematic evaluation were adopted to assess the course and to categorize patients' responses. Complete and partial responses were observed on the whole in 65.5% of alive patients 24 mo after irradiation. Two-yr overall and disease-specific survival rates were 74.3% and 97.4%, respectively, and the putative radiotoxic effects were found to be few and slight.

Volumetric Modulated Arc (Radio) Therapy in Pets Treatment: The "La Cittadina Fondazione" Experience

Volumetric Modulated Arc Therapy (VMAT) is a modern technique, widely used in human radiotherapy, which allows a high dose to be delivered to tumor volumes and low doses to the surrounding organs at risk (OAR). Veterinary clinics takes advantage of this feature due to the small target volumes and distances between the target and the OAR. Sparing the OAR permits dose escalation, and hypofractionation regimens reduce the number of treatment sessions with a simpler manageability in the veterinary field. Multimodal volumes definition is mandatory for the small volumes involved and a positioning device precisely reproducible with a setup confirmation is needed before each session for avoiding missing the target. Additionally, the elaborate treatment plan must pursue hard constraints and objectives, and its feasibility must be evaluated with a per patient quality control. The aim of this work is to report results with regard to brain meningiomas and gliomas, trigeminal nerve tumors, brachial plexus tumors, adrenal tumors with vascular invasion and rabbit thymomas, in comparison with literature to determine if VMAT is a safe and viable alternative to surgery or chemotherapy alone, or as an adjuvant therapy in pets.

Frameless stereotactic volumetric modulated arc radiotherapy of brachial plexus tumours in dogs: 10 cases

OBJECTIVE

Treatment of canine peripheral nerve sheath tumours (PNSTs) is challenging and prognosis after surgical resection is considered poor. The aim of this study was to evaluate the feasibility and effectiveness of stereotactic radiotherapy (RT) of these tumours.

METHODS

10 dogs with clinical symptoms and MRI findings consistent with PNSTs of the brachial plexus, branches and nerve roots were treated with linear accelerator-based volumetric-modulated arc radiotherapy (VMAT) with a dose of 35 Gy/5 fractions. Clinical and MRI follow-up examinations were planned and radiotoxicity and survival times were investigated.

RESULTS

Tumours involved the plexus and proximal nerves in three dogs, the plexus, proximal nerves and nerve roots in five dogs and the nerve roots and proximal nerves in two dogs. Partial response and partial or complete reductions of neurological deficits were observed in all the treated dogs. Local recurrence was observed in 9/10 of treated dogs. No symptom directly referable to radiotoxicity was observed. Mean overall survival of 371 ± 30 days [95% confidence interval (CI) of (315-427)] and mean progression-free survival of 240 ± 30 days (95% CI of 188-291) from this work are comparable with surgical literature data regarding the plexus and proximal nerve localization, but are superior in comparison with nerve root localization.

CONCLUSION

VMAT can be a safe and viable alternative to surgery in cases of canine brachial plexus PNSTs involving the proximal nerves and nerve roots. Advances in knowledge: To our knowledge, this is the first prospective observational clinical study regarding VMAT stereotactic RT treatment for canine brachial plexus PNSTs and suggests that VMAT may achieve at least similar clinical outcome than surgery in a safer way.

Quality assurance of RapidArc in clinical practice using portal dosimetry

OBJECTIVE

Quality assurance data from five centres were analysed to assess the reliability of RapidArc radiotherapy delivery in terms of machine and dosimetric performance.

METHODS

A large group of patients was treated with RapidArc radiotherapy and treatment data recorded. Machine quality assurance was performed according to Ling et al (Int J Radiat Oncol Biol Phys 2008;72:575-81). In addition, treatment to a typical clinical case was delivered biweekly as a constancy check. Pre-treatment dosimetric validation of plan delivery was performed for each patient. All measurements and computations were performed at the depth of the maximum dose in water according to the GLAaS method using electronic portal imaging device measurements. Evaluation was carried out according to a gamma agreement index (GAI, the percentage of field area passing the test); the threshold dose difference was 3% and the threshold distance to agreement was 3 mm.

RESULTS

A total of 275 patients (395 arcs) were included in the study. Mean delivery parameters were 31.0±20.0° (collimator angle), 4.7±0.5° s(-1) (gantry speed), 343±134 MU min(-1) (dose rate) and 1.6±1.4 min (beam-on time) for prescription doses ranging from 1.8 to 16.7 Gy/fraction. Mean deviations from the baseline dose rate and gantry speed ranged from -0.61% to 1.75%. Mean deviations from the baseline for leaf speed variation ranged from -0.73% to 0.41%. The mean GAI of repeated clinical fields was 99.2±0.2%. GAI varied from 84.7% to 100%; the mean across all patients was 97.1±2.4%.

CONCLUSION

RapidArc can provide a reliable and accurate delivery of radiotherapy for a variety of clinical conditions.

Volumetric modulation arc radiotherapy compared with static gantry intensity-modulated radiotherapy for malignant pleural mesothelioma tumor: a feasibility study

PURPOSE

A planning study was performed to evaluate RapidArc (RA), a volumetric modulated arc technique, on malignant pleural mesothelioma. The benchmark was conventional fixed-field intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

The computed tomography data sets of 6 patients were included. The plans for IMRT with nine fixed beams were compared against double-modulated arcs with a single isocenter. All plans were optimized for 15-MV photon beams. The dose prescription was 54 Gy to the planning target volume. The planning objectives for the planning target volume were a minimal dose of >95% and maximal dose of <107%. For the organs at risk, the parameters were as follows: contralateral lung, percentage of volume receiving 5 Gy (V(5 Gy)) <60%, V(20 Gy) < 10%, mean <10.0 Gy; liver, V(30 Gy) <33%, mean <31 Gy; heart, V(45 Gy) <30%, V(50 Gy) <20%, dose received by 1% of the volume (D(1%)) <60 Gy; contralateral kidney, V(15 Gy) <20%; spine, D(1%) <45 Gy; esophagus, V(55 Gy) <30%; and spleen, V(40 Gy) <50%. The monitor units (MUs) and delivery time were scored to measure the treatment efficiency. The pretreatment portal dosimetry scored delivery to the calculation agreement with the Gamma Agreement Index.

RESULTS

RA and IMRT provided equivalent coverage and homogeneity. Both techniques fulfilled objectives on organs at risk with a tendency of RA to improve sparing. The conformity index was 1.9 +/- 0.1 for RA and IMRT. The number of MU/2 Gy was 734 +/- 82 for RA and 2,195 +/- 317 for IMRT. The planning vs. delivery agreement revealed a Gamma Agreement Index for IMRT of 96.0% +/- 2.6% and for RA of 95.7% +/- 1.5%. The treatment time was 3.7 +/- 0.3 min for RA and 13.4 +/- 0.1 min for IMRT.

CONCLUSION

RA demonstrated compared with conventional IMRT, similar target coverage and better dose sparing to the organs at risks. The number of MUs and the time required to deliver a 2-Gy fraction were much lower for RA, allowing the possibility to incorporate this technique in the treatment options for mesothelioma patients.

Critical appraisal of volumetric modulated arc therapy in stereotactic body radiation therapy for metastases to abdominal lymph nodes

PURPOSE

A planning study was performed comparing volumetric modulated arcs, RapidArc (RA), fixed beam IMRT (IM), and conformal radiotherapy (CRT) with multiple static fields or short conformal arcs in a series of patients treated with hypofractionated stereotactic body radiation therapy (SBRT) for solitary or oligo-metastases from different tumors to abdominal lymph nodes.

METHODS AND MATERIALS

Fourteen patients were included in the study. Dose prescription was set to 45 Gy (mean dose to clinical target volume [CTV]) in six fractions of 7.5 Gy. Objectives for CTV and planning target volume (PTV) were as follows: Dose(min) >95%, Dose(max) <107%. For organs at risk the following objectives were used: Maximum dose to spine <18 Gy; V(15Gy) <35% for both kidneys, V(36Gy) <1% for duodenum, V(36Gy) <3% for stomach and small bowel, V(15Gy) <(total liver volume--700 cm(3)) for liver. Dose-volume histograms were evaluated to assess plan quality.

RESULTS

Planning objectives on CTV and PTV were achieved by all techniques. Use of RA improved PTV coverage (V(95%) = 90.2% +/- 5.2% for RA compared with 82.5% +/- 9.6% and 84.5% +/- 8.2% for CRT and IM, respectively). Most planning objectives for organs at risk were met by all techniques except for the duodenum, small bowel, and stomach, in which the CRT plans exceeded the dose/volume constraints in some patients. The MU/fraction values were as follows: 2186 +/- 211 for RA, 2583 +/- 699 for IM, and 1554 +/- 153 for CRT. Effective treatment time resulted as follows: 3.7 +/- 0.4 min for RA, 10.6 +/- 1.2 min for IM, and 6.3 +/- 0.5 min for CRT.

CONCLUSIONS

Delivery of SBRT by RA showed improvements in conformal avoidance with respect to standard conformal irradiation. Delivery parameters confirmed logistical advantages of RA, particularly compared with IM.

Hypofractionated stereotactic radiotherapy and radiosurgery for the treatment of patients with radioresistant brain metastases

AIM

To evaluate the efficacy of different radiotherapy treatment modalities in radioresistant brain metastasis.

PATIENTS AND METHODS

A retrospective analysis was conducted on 78 patients with brain metastases from melanoma, sarcoma, or renal cell carcinoma primary tumours who underwent radiosurgery (20 Gy) and/or hypofractionated stereotactic radiotherapy (6x4 Gy or 7x4 Gy) with or without whole-brain radiotherapy at our Center.

RESULTS

The actuarial median survival times for melanoma, renal cell carcinoma and sarcoma were 23, 22 and 7 months respectively, with a significant correlation to recursive partitioning analysis class.

DISCUSSION

Our results show that these treatments were effective both in symptom palliation and in improving survival, suggesting that although outcomes generally remained poor in this study population, it is possible and important to control intracranial brain metastases.

[Spontaneous pneumoperitoneum: a case secondary to thoracic trauma]

Spontaneous pneumoperitoneum is the radiographic manifestation of free air in the peritoneal cavity without visceral perforations and peritoneal signs, and it occurs in about 10% of the cases of pneumoperitoneum. The etiology can be postoperative, thoracic, abdominal, gynecologic, idiopathic; it generally introduces a benign evolution and does not require surgical treatment but just a conservative approach. The authors describe here a case of spontaneous pneumoperitoneum secondary to thoracic trauma. This case is interesting for the occurrence of pneumoperitoneum without clinical peritoneal signs such as fever and leucocytosis, after closed thoracic trauma in absence of pneumothoracic and pneumomediastinum. Correct clinical approach has allowed a conservative treatment avoiding an useless laparotomy.

Effectiveness of stereotactic body radiotherapy in the treatment of inoperable early-stage lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death worldwide. Stereotactic body irradiation offers a non-invasive treatment modality for patients with early stage NSCLC who are not amenable to surgery or other invasive approaches because of their poor medical condition.

PATIENTS AND METHODS

Forty-three inoperable patients with NSCLC were treated with SBRT at our institution. A mean total dose of 30.5 Gy in 1-4 fractions was applied. The median follow-up duration was 14 months (range 6-36 months).

RESULTS

The actuarial survival at two years was 53%: two patients died from cancer progression whereas a further 8 patients died from comorbidities. Acute toxicity was practically absent, with 7 (16.3%) patients suffering from grade 1 symptoms and two from (4.6%) grade II effects. At the time of this report, only 1 patient had grade II and 6 patients (13.9%) grade I chronic symptoms.

CONCLUSION

Our results compare favourably with recently published studies and confirm that stereotactic radiotherapy has the potential to produce high local control rates with a low risk of lung toxicity in patients not amenable to curative resection. The low grade of side-effects is encouraging for shortening the treatment using a greater dose per fraction.

[HAV infection in patients with chronic hepatitis C]

AIM

In most cases, hepatitis A virus (HAV) infection causes a self-limiting benign acute hepatitis which confers permanent acquired immunity. However, in patients with pre-existing chronic hepatitis, HAV superinfection can cause acute hepatitis with severe progression leading to a fulminant form or linked to the risk of a rapid deterioration of hepatic function. For such a reason, some Authors recommend anti-HAV vaccination for subjects with HCV-correlated chronic hepatitis before the initiation of peg-Interferon and Ribavirin treatment. Subsequently, the real prevalence of IgG anti-HAV antibodies in patients with HC HCV-related and in healthy subjects from Eastern Sicily has been verified.

PATIENTS AND METHODS

In 254 subjects affected by HC HCV-related it has been carried out the research of antibodies IgG and IgM anti HAV. The control group was formed by 685 non hepatopathic subjects, subdivided in range of ages.

RESULTS

97.64% out of the patients affected by HC HCV related exhibit antibodies IgG anti HAV, while only 2.36% of them was negative. The prevalence of infection in the control group has been stratified in relation to different ranges of age of the people taken into consideration.

CONCLUSIONS

The results obtained in this study performed in our geographical area, let us to suggest that it is not necessary the anti HAV vaccination during the phase of pre-treatment for HC HCV-related.

Obesity and related diseases: an epidemiologic study in eastern Sicily

AIM

The aim of this study was to investigate the prevalence of obesity in a non selected cohort of adult subjects living in eastern Sicily.

METHODS

Out of 2 296 examined subjects, 834 (36.3%) were affected by obesity. Of these, only 160 (19.1%) were affected by obesity alone while 674 (80.9%) showed other associated pathologies.

RESULTS

The prevalence of arterial hypertension, diabetes mellitus, hepatic steatosis, hyperdyslipidemia and renal failure was significantly higher (P = 0.000) than in a control group of non-obese subjects comparable for sex and age.

CONCLUSIONS

In a large part of obese patients, the presence of insulin resistance was observed suggesting that this alteration can play a pivotal role in the development of some important metabolic and cardiovascular complications related to obesity.

The combined endoscopic therapy (band ligation and sclerosis) in the eradication of the esophageal varices in the cirrhotic patient: our experience

AIM

In course of liver cirrhosis, esophageal varices develop with an incidence of 8-15% a year, and they constitute a sign of seriousness of portal hypertension. The risk of bleeding is estimated around 10-15% a year. The varices hemorrhage causes a high rate of mortality (around 30-35% for every hemorrhagic event). It follows that it is necessary to plan prophylactic strategies for all the cirrhotic patients, who are at risk of bleeding, or have already bled. Medical treatment with beta-blockers is indicated in the prophylaxis of the first bleeding, while endoscopic treatment represents now the most effective methodology either in acute bleeding, or in the prophylaxis of hemorrhage relapses. The available endoscopic methodologies are the sclerosis or band ligation of esophageal varices. However, unanimous consent about the greater effectiveness of a methodology compared to the other one doesn't exist. As far as the varices eradication is concerned, the authors have done a research to verify if the combined techniques, proposed in various studies appeared in literature, can have some advantages, in comparison with the single methodologies.

METHODS

Thirty-seven patients have been treated: 27 only with sclerosis and 10 with combined methodology (band-ligation followed by sclerosis of the small residual varices).

RESULTS

The group treated with the combined therapy have shown a reduction in relapses and in the main side effects and a better patients' compliance.

CONCLUSIONS

The combination of the two methodologies can have some advantages as for security, easiness of execution, reduction in complications, in varices relapse and, therefore, in the hemorrhagic relapses.

Role of Helicobacter pylori in patients with portal hypertensive gastropathy by liver cirrhosis hepatitis C virus-related

AIM

Portal hypertensive gastropathy (PHG) defines a pathological endoscopic picture characterized by the presence of alterations of the gastric mucosa found in patients with hepatopathy associated to an initial or evident portal hypertension. Gastropathy appears with two forms of different seriousness: the mild form, characterized by diffused congestion, petechiae of gastric mucosa (scarlatina type rash) and by the presence of typical hyperemic and edematous polygonal areas, delimited by a thin snake skin reticulation. In the severe form, together with such aspects, mucosal erosion, red spots, or a diffused hemorrhagic gastropathy are added. The pre-eminent pathogenetic element of such lesions seems to be the pathological increase of the portal pressure. The role of the Helicobacter pylori (H. pylori) in the development of these alterations, in terms of prevalence of infection in hepatopathic subjects, is still controversial. The authors have performed a research to verify if the H. pylori infection is correlated to the presence and/or to the gravity of PHG.

METHODS

One-hundred and nine patients, all suffering from hepatitis C virus (HCV)-correlated liver cirrhosis, with clinical and/or instrumental signs of portal hypertension have been analysed.

RESULTS

The histological prevalence of the infection from H. pylori in our statistical analysis was of 23.8% (26/109 patients).

CONCLUSIONS

The H. pylori infection appears to be not significant for the determination and the preservation of PHG.

[Thyroid maltoma: report of a case without coexistent Hashimoto's thyroiditis]

Maltomas of the thyroid are rare neoplasms that originate from parafollicular B lymphocytes and are often associated with autoimmune thyroiditis (Hashimoto's disease). The authors describe a case of a primary thyroid lymphoma in which no evidence for a previous thyroiditis could be found during clinical evaluation (clinical progression of the tumor, diagnostic studies, preoperative cytology, histology of the surgical specimen). Noteworthy was the development of a severe form of pure red cell aplasia (PRCA) about 6 months after the operation without detectable autoantibodies or signs of previous viral infection. The aplasia resolved completely with corticosteroid therapy.

Abrikossoff's tumour: report of a rare case in anal perianal region

The authors report a rare case of a 47-year old man suffered from Crohn's disease and depression with multiple prominent lesions in the anal and perianal region. The biopsy of these lesions showed the presence of Abrikossoff's tumour. This tumour is very rare in the anal region and usually the lesions are small (0.5-3 cm) and solitary. The authors report this case because they considered it an interesting case for the localization and the appearance of the lesions.

[Gastrointestinal stromal tumors: clinical considerations]

Gastrointestinal stromal tumors (61ST) are an heterogeneous group of non epithelial tumors of the gastrointestinal tract. They are peculiar to extreme cellular variability and uncertain malignancy. Gist are rare tumors that arise from primitive mesenchymal cells located in all gastrointestinal tract. Till now they are object of discussion about their origin, diagnostic standards, prognostic factors, histopathological classification. They are more frequently in over 40 years old people without difference in two sex, but they can appear in the child too and in the young man suffering from HIV. The authors relate two cases of recent observation, and discuss on the biological behaviour of these rare tumors.

[Pilonidal sinus: an retrospective analysis of 205 cases]

Sinus pilonidalis or the sacrococcigea cyst, normally is considered a "small surgical pathology" and actually it is controversial disease regarding its pathogenesis and treatment. Today the congenital hypothesis of this pathology is not considered. The etiopathogenesis exclude vestigia embryonic origin and consider it an inflammatory disease. Traumatism of the sacral region, hirsutism, hormonal secretion stimulating, and furrow sacral furrow cutaneous, explain the prevalence of this pathology in the male sex and in the puberale age. It usually appears after the pubertà and extension one various frequency of presentation in males sex (1.3%) regarding females (0.11%). The symptomatology can be rare or introduce itself in violent and intense way with on abscess of the region, or with only or multiple fistulas orifices from which exit materialclarly purulent. Normally cystic cavity is one, situated in the subcutaneous tissue with annexed inflammatory phenomena. This cavity to times communicates with the skyn fistulating. The treatment of election is surgical and must weighted and be regulated in relation to the entity of the lesion and its inflammatory picture. Sometimes the medical therapy with anti-inflammatory and antibiotic is not control the symptomatology and it need the surgical treatment.

[Propofol and remifentanil in day surgery]

BACKGROUND

AIM OF THE STUDY

to compare AG versus MAC using propofol & remifentanil in a day surgery setting evaluating intra and postoperative clinical conditions and emergence times.

METHODS

Propofol and remifentanil, either for general anesthesia (AG) then conscious sedation (MAC), have been administered to 218 patients undergoing mainly plastic or proctologic surgery as day hospital. AG was induced with propofol 1.5-2 mg/kg followed by a continuous infusion of 10 mg/kg/h and remifentanil infused at 10 micrograms/kg/h; MAC was started with propofol 3 mg/kg/h and remifentanil 4-5 micrograms/kg/h; during the maintenance phase of both AG and MAC, infusion rates of both drugs were adjusted according to clinical needs. Diazepam (0.05-0.06 mg/kg) and/or midazolam (2-3 mg) were given as premedication or coinduction as necessary. All patients received field infiltration with local anesthetics (lidocaine or mepivacaine); patients under GA were artificially ventilated with O2/air through IOT or LMA. Surgical and anesthesiological data were collected on specially designed records, with special attention to time intervals between anesthesia (FA) and surgery (FC) end and eyes opening (EO), orientation (OR), return of spontaneous breathing (SR), extubation (EST), sitting (SED), walking (CAMM), dressing (VEST) and discharge (DIM); data were analyzed with parametric and non parametric analysis of variance.

RESULTS

All emergence intervals were longer under AG than under MAC: the earlier in the range of 4-5 vs 0.5-1 min; for the late intervals; FA-SED 24 +/- 18 vs 15 +/- 8, FA-PIED 65 +/- 48 vs 34 +/- 17, FA-VEST 69 +/- 58 vs 33 +/- 17, FA-CAMM 68 +/- 42 vs 39 +/- 19. Discharge times (83 +/- 67 vs 73 +/- 60) were similar between the two groups. Drugs consumption under AG were roughly double than under MAC; total dose infused of propofol (mg/kg/min) 0.118 +/- 0.044 vs 0.06 +/- 0.036; total dose of remifentanil (microgram/kg/min): 0.106 +/- 0.049 vs 0.066 +/- 0.027. AG resulted in a higher % incidence of intraoperative hypotension and bradycardia: hypotension 61.7 vs 25.7 and bradycardia 30.3 vs 12.4. SaO2 decreased more commonly during MAC than AG (20.9% vs 10.1); intraoperative itching was referred in 20% of MAC patients. Conversions rate from MAC to AG was 2.8%. Psychomotor agitation was more frequent following AG (14%) than MAC (2%); nausea (1%), vomiting, shivering (12%), headache (2%), ortostatic hypotension (2%) were similar between the two groups. Diazepam and/or midazolam caused a significant prolongation of recovery intervals, for both AG and MAC with a mean delay of the order of 100-200%.

CONCLUSIONS

Propofol- remifentanil gave excellent conditions for a wide variety of day surgery procedures, offering good anesthesia with quick emergence; the addition of bdz, even at low doses, prolongs significantly discharge times.

[Variations in interleukin-2 and interleukin-6 due to surgical trauma in cancer patients]

Inflammatory response after surgical trauma, which is necessary for infection control and tissue repairing, can actually produce some cytokines suppressive of the antitumoral immunity response. In this study the authors evaluate pre- and post-operative IL-2 (antitumor response activator) and IL-6 (lymphocytic response inhibitor and tumor growth factor) levels in 26 cancer patients undergoing resective surgery. Analysis of the results showed a significative IL-6 increase and a tendency to IL-2 decrease in the post-operative period. It is thus confirmed, even on the basis of the cytokines, the meaningful immunosuppressive effect of the surgical trauma on neoplastic growth control.

[Type 4 renal tubular acidosis caused by spironolactone. A case report]

The authors describe a case of type 4 renal tubular acidosis, observed in a subject with liver cirrhosis, the pathogenetic cause of which was probably the assumption of spironolactone. It is thought that, even if such an eventuality is not very frequent, it must be considered in clinical practice, in view of the negative consequences that the reduction in urinary ammonium excretion and hyponatriemia, together with this particular form of acidosis, may have on the neurological state of the patients.

[Our preliminary observations of plasma endothelin behavior in type II diabetes mellitus]

INTRODUCTION

Several studies have lately been made to explain the pathophysiologic role of endothelin, a vasoconstrictive peptide, in some clinical syndromes. Within a larger plan of the probable role of this molecule in development of diabetic vasculopathy, we have preliminarily investigated the plasma endothelin-1 level in type II diabetic patients.

MATERIAL AND METHODS

24 type II diabetic patients and 10 healthy control subjects comparable for sex and age were examined. Plasmatic ET-1 was determined by radioimmunoassay (Amersham, UK).

RESULTS

The mean +/- SD was respectively 11.4 +/- 2.9 pg/ml in diabetic patients and 8.2 +/- 3.9 pg/ml in the control group. Statistical analysis showed a significant difference between two groups.

CONCLUSIONS

These results suggest an involvement of endothelin in the vascular complications of diabetes. Nevertheless, to better explain the question, we think further and larger studies are required.

[Urinary enzymes in liver cirrhosis: useful early markers of renal damage?]

Some urinary enzymes (NAG, AAP, lysozyme) considered to be sufficiently sensitive and reliable markers of renal damage were controlled in 20 patients with cirrhosis of the liver and in 20 healthy control subjects. The results, stated as mean +/- SD, showed a statistically very significant increase (p < 0.01) of NAG and lysozyme in cirrhotics. Furthermore, this increase could be at least in part related with the seriousness of clinical condition. On the basis of these results, we think the urinary dosage of NAG and lysozyme is, in the subjects with liver cirrhosis, a bloodless method to show an early renal damage.

Effect of perioperative transfusions on survival in osteosarcoma treated by multimodal therapy

We report on a retrospective study of 155 patients amputated for nonmetastatic osteosarcoma of the long bones. Among the various prognostic variables considered, a significant correlation was found only between survival and transfusions. In this report, the authors consider some hypotheses reported by others for tumors of a different nature and site and conclude that perioperative transfusion may induce depression in the immune response, which is the cause of a shorter survival in the patients reviewed.