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Breast cancer is the most common tumor in women and represents the leading cause of cancer death. Radiation therapy plays a key-role in the treatment of all breast cancer stages. Therefore, the adoption of evidence-based treatments is warranted, to ensure equity of access and standardization of care in clinical practice.This national document on the highest evidence-based available data was developed and endorsed by the Italian Association of Radiation and Clinical Oncology (AIRO) Breast Cancer Group.We analyzed literature data regarding breast radiation therapy, using the SIGN (Scottish Intercollegiate Guidelines Network) methodology (www.sign.ac.uk). Updated findings from the literature were examined, including the highest levels of evidence (meta-analyses, randomized trials, and international guidelines) with a significant impact on clinical practice. The document deals with the role of radiation therapy in the treatment of primary breast cancer, local relapse, and metastatic disease, with focus on diagnosis, staging, local and systemic therapies, and follow up. Information is given on indications, techniques, total doses, and fractionations.An extensive literature review from 2013 to 2021 was performed. The work was organized according to a general index of different topics and most chapters included individual questions and, when possible, synoptic and summary tables. Indications for radiation therapy in breast cancer were examined and integrated with other oncological treatments. A total of 50 questions were analyzed and answered.Four large areas of interest were investigated: (1) general strategy (multidisciplinary approach, contraindications, preliminary assessments, staging and management of patients with electronic devices); (2) systemic therapy (primary, adjuvant, in metastatic setting); (3) clinical aspects (invasive, non-invasive and micro-invasive carcinoma; particular situations such as young and elderly patients, breast cancer in males and cancer during pregnancy; follow up with possible acute and late toxicities; loco-regional relapse and metastatic disease); (4) technical aspects (radiation after conservative surgery or mastectomy, indications for boost, lymph node radiotherapy and partial breast irradiation).Appendixes about tumor bed boost and breast and lymph nodes contouring were implemented, including a dedicated web application. The scientific work was reviewed and validated by an expert group of breast cancer key-opinion leaders.Optimal breast cancer management requires a multidisciplinary approach sharing therapeutic strategies with the other involved specialists and the patient, within a coordinated and dedicated clinical path. In recent years, the high-level quality radiation therapy has shown a significant impact on local control and survival of breast cancer patients. Therefore, it is necessary to offer and guarantee accurate treatments according to the best standards of evidence-based medicine.

Aim. Breast IRRADIATA (Italian Repository of RADIotherapy dATA) is a collaborative nationwide project supported by the Italian Society of Radiotherapy and Clinical Oncology (AIRO) and the Italian League Against Cancer (LILT). It focuses on breast cancer (BC) patients treated with radiotherapy (RT) and was developed to create a national registry and define the patterns of care in Italy. A dedicated tool for data collection was created and pilot tested. The results of this feasibility study are reported here. Methods. To validate the applicability of a user-friendly data collection tool, a feasibility study involving 17 Italian Radiation Oncology Centers was conducted from July to October 2021, generating a data repository of 335 BC patients treated between January and March 2020, with a minimum follow-up time of 6 months. A snapshot of the clinical presentation, treatment modalities and radiotherapy toxicity in these patients was obtained. A Data Entry Survey and a Satisfaction Questionnaire were also sent to all participants. Results. All institutions completed the pilot study. Regarding the Data Entry survey, all questions achieved 100% of responses and no participant reported spending more than 10 min time for either the first data entry or for the updating of follow-up. Results from the Satisfaction Questionnaire revealed that the project was described as excellent by 14 centers (82.3%) and good by 3 (17.7%). Conclusion. Current knowledge for the treatment of high-prevalence diseases, such as BC, has evolved toward patient-centered medicine, evidence-based care and real-world evidence (RWE), which means evidence obtained from real-world data (RWD). To this aim, Breast IRRADIATA was developed as a simple tool to probe the current pattern of RT care in Italy. The pilot feasibility of IRRADIATA encourages a larger application of this tool nationwide and opens the way to the assessment of the pattern of care radiotherapy directed to other cancers.

Background COVID-19 is a new human-infecting coronavirus for which the World Health Organization declared a global pandemic. The first Italian cases occurred in February 2020: since then, there has been an exponential increase in new cases, hospitalizations and intensive care assistance demand. This new and sudden scenario led to a forced National Health System reorganization and review of welfare priorities. The aim of this study is to evaluate the effects of this pandemic on ordinary activities in two plastic surgery divisions in Rome, hosted in a COVID-19 and a non-COVID-19 hospital. Methods The data of this comparative retrospective study was collected between 9 March and 9 April 2019 and the same period of 2020 from two plastic surgery units, one in a COVID-19 hospital and second in a non-COVID-19 hospital in Rome, Italy. The 2019–2020 data of the two hospitals was compared regarding the number of surgeries, post-operative dressings and first consultations performed. Results Both units sustained a decrease in workload due to lockdown effects. Statistically significant differences for day surgery procedures (p value = 0.0047) and first consultations (p value Conclusions The long-term effects of healthcare reshuffling in the “COVID-19 era” imply a delay in the diagnosis and treatment of skin cancer and cancellation of many reconstructive procedures. These findings pose a question on the future consequences of a long-term limitation in plastic surgery healthcare. Level of evidence: Level III, risk/prognostic study.

A systematic review with a meta-analysis was performed to determine the prevalence and risk factors for secondary de novo adenocarcinoma in the colon used as a urinary diversion not exposed to the fecal stream. The systematic review of the literature identified 47 patients with secondary adenocarcinoma in a colonic urinary diversion not exposed to the fecal stream. The diagnosis of secondary adenocarcinoma was determined due to the presence major local symptoms and because the cancer in half of the patients was detected at an advanced stage. Diagnosis at an earlier stage was associated with long-term cancer-free survival. The authors concluded that cystoscopy-colonoscopy screening as suggested by the American Gastroenterology Society for the general population should be applied to patients who have colon urinary diversion not exposed to the fecal stream. For patients with active high-grade inflammation, difficulty with self-catheterization, or symptoms, cystoscopy should be performed earlier. Resection of the tumor at an early stage offers better clinical outcomes with longer survival rates.

We present the outcomes and the recurrences of 848 patients with pilonidal disease (PD) treated by biopsy punch excision (BPE) and we weigh our results against progressively obtained operative experience. BPE is a modified 'merged' version of both the Bascom 'pit picking' procedure and the Gips procedure. It employs biopsy punches of different calibre, depending on whether treatment is in the natal cleft (calibre as small as possible) or lateral (larger calibre punches or even small incision). Sometimes this procedure is referred to as the Bascom-Gips procedure.In all, 848 consecutive patients with PD were treated from January 2011 until December 2016 (sex 622 [73.4%] men and 226 [26.6%] women; median age 26.2 years, mean age 24.6 ± 28.99 [range 14-55] years, men 25.1 years, women 24.8 years). Of these 848 patients, 287 were operated in 2011-2012, 301 in 2013-2014 and 260 in 2015-2016. The recurrence rates were recorded 12, 24 and 60 months after surgery both cumulatively and by examining the outcomes of the three biennia individually (years of treatment 2011-2012 or group A, 2013-2014 or group B, 2015-2016 or group C).The mean operating time was 34 ± 24.45 min. Postoperative complications included early (24 h; n = 22 or 2.6%) and delayed (24 h; n = 26 or 3.1%) postoperative bleeding. Postoperative fluid collections (2 weeks) occurred in 83/848 patients (9.8%) and included haematoma (n = 25) and seroma (n = 58). Full recovery was obtained after a mean of 21 ± 12.72 days and work/school/university activities were resumed after a mean of 4 ± 12.02 days. Twelve-, 24- and 60-month follow-ups were possible in 725 (85.5%), 682 (80.4%) and 595 (70.2%) patients out of 848. An overall significant (ꭓBPE is an effective, disease-targeted, minimally invasive and inexpensive way to treat PD. Its results are influenced by the experience of the team involved, especially regarding early recurrences/failure of surgery. At least 5-year follow-ups are needed to ascertain the outcome of surgery for PD.

Introduction: Breast cancer is the most common tumor in women and represents the leading cause of cancer death. Radiation therapy plays a key-role in the treatment of all breast cancer stages. Therefore, the adoption of evidence-based treatments is warranted, to ensure equity of access and standardization of care in clinical practice. Method: This national document on the highest evidence-based available data was developed and endorsed by the Italian Association of Radiation and Clinical Oncology (AIRO) Breast Cancer Group. We analyzed literature data regarding breast radiation therapy, using the SIGN (Scottish Intercollegiate Guidelines Network) methodology ( www.sign.ac.uk ). Updated findings from the literature were examined, including the highest levels of evidence (meta-analyses, randomized trials, and international guidelines) with a significant impact on clinical practice. The document deals with the role of radiation therapy in the treatment of primary breast cancer, local relapse, and metastatic disease, with focus on diagnosis, staging, local and systemic therapies, and follow up. Information is given on indications, techniques, total doses, and fractionations. Results: An extensive literature review from 2013 to 2021 was performed. The work was organized according to a general index of different topics and most chapters included individual questions and, when possible, synoptic and summary tables. Indications for radiation therapy in breast cancer were examined and integrated with other oncological treatments. A total of 50 questions were analyzed and answered. Four large areas of interest were investigated: (1) general strategy (multidisciplinary approach, contraindications, preliminary assessments, staging and management of patients with electronic devices); (2) systemic therapy (primary, adjuvant, in metastatic setting); (3) clinical aspects (invasive, non-invasive and micro-invasive carcinoma; particular situations such as young and elderly patients, breast cancer in males and cancer during pregnancy; follow up with possible acute and late toxicities; loco-regional relapse and metastatic disease); (4) technical aspects (radiation after conservative surgery or mastectomy, indications for boost, lymph node radiotherapy and partial breast irradiation). Appendixes about tumor bed boost and breast and lymph nodes contouring were implemented, including a dedicated web application. The scientific work was reviewed and validated by an expert group of breast cancer key-opinion leaders. Conclusions: Optimal breast cancer management requires a multidisciplinary approach sharing therapeutic strategies with the other involved specialists and the patient, within a coordinated and dedicated clinical path. In recent years, the high-level quality radiation therapy has shown a significant impact on local control and survival of breast cancer patients. Therefore, it is necessary to offer and guarantee accurate treatments according to the best standards of evidence-based medicine.

The PTEN hamartoma tumor syndrome (PHTS) is a heterogeneous set of multisystem disorders caused by germline pathogenic variants in the PTEN tumor suppressor gene. Manifestations include developmental anomalies and proliferative lesions. Evidence of involvement of the GI tract has accrued over time, leading to the incorporation of GI manifestations (multiple hamartomas, glycogenic acanthosis and colorectal cancer) into the diagnostic criteria. Polyps of the upper and lower GI tract are found in most adult patients and in a significant fraction of children. Polyps tend to be of mixed histology, with a predominance of hamartomas and ganglioneuromas. PHTS patients are also at increased risk of colorectal cancer, and surveillance by colonoscopy is advised starting at the age of 35-40 years. A number of additional manifestations, including eosinophilic gastrointestinal disorders, have been observed in few or single cases, and their association with PHTS has yet to be determined.

The COVID-19 pandemic has led to countries enforcing the use of facial masks to prevent contagion. However, acquisition, reuse, and disposal of personal protective equipment (PPE) has generated problems, in regard to the safety of individuals and environmental sustainability. Effective strategies to reprocess and disinfect PPE are needed to improve the efficacy and durability of this equipment and to reduce waste load. Thus, the addition of photocatalytic materials to these materials, combined with light exposure at specific wavelengths, may represent promising solutions. To this aim, we prepared a series of masks by depositing micrometer-sized TiO2 on the external surfaces, the masks were then contaminated with droplets of bacteria suspensions and the coatings were activated by light radiation at different wavelengths. A significant reduction in the microbial load (over 90%, p &lt, 0.01) was observed using both Gram negative (E. coli) and Gram positive (S. aureus) bacteria within 15 min of irradiation, with UV or visible light, including sunlight or artificial sources. Our results support the need for further investigations on self-disinfecting masks and other disposable PPE, which could positively impact (i) the safety of operators/workers, and (ii) environmental sustainability in different occupational or recreational settings.

An altered balance between metalloproteinases (MMPs) and their inhibitor tissue inhibitor of metalloproteinases (TIMPs) may influence the healing process of a minor amputation following a successful vein graft. To speed up this process, negative pressure wound therapy (NPWT) and advanced moist wound dressing have been proposed. We determined the systemic and local release of MMP‐1, ‐2, ‐3, ‐9, TIMP‐1, and TIMP‐2 by enzyme linked immunosorbent assay (ELISA) technique and their influences in the healing process in 26 patients who underwent minor amputation after a successful revascularisation procedure. Twelve patients (group 1) were medicated with NPWT and 14 (group 2) with advanced moist wound dressing. Plasma samples were collected on the morning of surgery and thereafter at 1, 3, and 5 months; exudates were collected 3 days after surgery when amputation was performed and thereafter at 1, 3, and 5 months. Fifteen age‐matched healthy male volunteers served as controls. All wounds healed in 5 ± 0.5 months. Follow‐up plasma and local release of MMP‐1, ‐2, ‐3, and ‐9 were overall significantly lower when compared with the preoperative levels, while those of TIMP‐1 and ‐2 were significantly higher with no differences among the groups. Despite no differences in the healing process being observed among the two types of medications, at 1 month the local release of MMP‐2 and ‐9 was significantly lower (P = .013 and .047, respectively) and that of TIMP‐1 was significantly higher (P = .042) in group 1 as compared to group 2. A correct and aggressive local approach to the wound is able to promote the healing of the lesion stimulating the extracellular matrix turnover with local MMP/TIMP adequate balance and favouring the creation of granulation tissue. However, a successful restoration of an adequate blood flow remains the key point of a durable and rapid wound healing.

The COVID-19 pandemic has led to countries enforcing the use of facial masks to prevent contagion. However, acquisition, reuse, and disposal of personal protective equipment (PPE) has generated problems, in regard to the safety of individuals and environmental sustainability. Effective strategies to reprocess and disinfect PPE are needed to improve the efficacy and durability of this equipment and to reduce waste load. Thus, the addition of photocatalytic materials to these materials, combined with light exposure at specific wavelengths, may represent promising solutions. To this aim, we prepared a series of masks by depositing micrometer-sized TiO2 on the external surfaces; the masks were then contaminated with droplets of bacteria suspensions and the coatings were activated by light radiation at different wavelengths. A significant reduction in the microbial load (over 90%, p < 0.01) was observed using both Gram negative (E. coli) and Gram positive (S. aureus) bacteria within 15 min of irradiation, with UV or visible light, including sunlight or artificial sources. Our results support the need for further investigations on self-disinfecting masks and other disposable PPE, which could positively impact (i) the safety of operators/workers, and (ii) environmental sustainability in different occupational or recreational settings.

Background and Aim: Metachronous, isolated adrenal metastases from breast cancer are extremely rare. The aim of this study was to evaluate the results of adrenalectomy as a treatment of this uncommon condition.Methods: Twelve female patients (median age: 68 years) underwent 13 adrenalectomies for isolated, metachronous metastases of breast cancer. Ten resections were performed thorugh open surgery and two were preformed through a laparoscopic approach. As main study endpoints, postoperative mortality, postoperative morbidity and disease-free survival were considered. Median length of follow-up was 40 months.Results: Postoperative mortality was absent. Postoperative morbidity was 17%: one patient presented a postoperative pneumothorax requiring drainage and one patient required re-hospitalization 8 days after contralateral adrenalectomy for electrolyte imbalance. Two patients died of recurrent metastatic disease, 28 and 33 months respectively after adrenalectomy. One patient remained alive with hepatic metastases at 32 months from resection of adrenal recurrence. All in all, disease-free survival at 48 months was 75%.Conclusions: Adrenalectomy for metachronous, isolated metastases of breast cancer can be performed with no postoperative mortality and minimal postoperative morbidity, enabling good long-term disease-free survival.

Several studies evaluated the presence of SARS-CoV-2 in the environment. Saliva and nasopharyngeal droplets can land on objects and surfaces, creating fomites., Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) environmental contamination occurs through droplets and biological fluids released in the surroundings from patients or asymptomatic carriers. Surfaces and objects contaminated by saliva or nose secretions represent a risk for indirect transmission of coronavirus disease 2019 (COVID-19). We assayed surfaces from hospital and living spaces to identify the presence of viral RNA and the spread of fomites in the environment. Anthropic contamination by droplets and biological fluids was monitored by detecting the microbiota signature using multiplex quantitative real-time PCR (qPCR) on selected species and massive sequencing on 16S amplicons. A total of 92 samples (flocked swabs) were collected from critical areas during the pandemic, including indoor (three hospitals and three public buildings) and outdoor surfaces exposed to anthropic contamination (handles and handrails, playgrounds). Traces of biological fluids were frequently detected in spaces open to the public and on objects that are touched with the hands (>80%). However, viral RNA was not detected in hospital wards or other indoor and outdoor surfaces either in the air system of a COVID hospital but only in the surroundings of an infected patient, in consistent association with droplet traces and fomites. Handled objects accumulated the highest level of multiple contaminations by saliva, nose secretions, and fecal traces, further supporting the priority role of handwashing in prevention. In conclusion, anthropic contamination by droplets and biological fluids is widespread in spaces open to the public and can be traced by qPCR. Monitoring fomites can support evaluation of indirect transmission risks for coronavirus or other flu-like viruses in the environment. IMPORTANCE Several studies have evaluated the presence of SARS-CoV-2 in the environment. Saliva and nasopharyngeal droplets can land on objects and surfaces, creating fomites. A suitable indicator would allow the detection of droplets or biofluids carrying the virus. Therefore, we searched for viral RNA and droplets and fomites on at risk surfaces. We monitored by qPCR or next generation sequencing (NGS) droplets through their microbiota. Although the study was performed during the pandemic, SARS-CoV-2 was not significantly found on surfaces, with the only exception of environmental areas near infectious patients. Conversely, anthropic contamination was frequent, suggesting a role for biofluids as putative markers of indirect transmission and risk assessment. Moreover, all SARS-CoV-2-contaminated surfaces showed droplets’ microbiota. Fomite monitoring by qPCR may have an impact on public health strategies, supporting prevention of indirect transmission similarly to what is done for other communicable diseases (e.g., influenza and influenza-like infections).

Vesicoureteral reflux (VUR) is a common urological complication in renal transplant patients.of this study is to evaluate the performance of contrast-enhanced voiding urosonography (CEvUS) in the diagnosis and classification of reflux into the renal allograft, to evaluate and classify VUR into the allograft using voiding cystourethrography (VCUG) and CEvUS, to compare the two methods, and to propose a new classification of reflux into the allograft based on CEvUS and VCUG assessment, in line with the international reflux grading system. From January 2017 to July 2019, 84 kidney transplant patients were enrolled. All patients underwent VCUG and CEvUS. In 76 cases there was agreement between VCUG and CEvUS (90 %) (Kappa = 0.7). The sensitivity of CEvUS using VCUG as the gold standard was 90 %, and the specificity was 92 %. Of the 7 cases diagnosed by VCUG and not by CEvUS, 6 were grade 1 and 1 was grade 2. Transplant patients with reflux symptoms should undergo CEvUS. If the outcome is negative, VCUG should be performed. The classification that we propose is better suited to describe VUR in transplant patients, because it is simpler and takes into account whether reflux occurs not only during urination but also when the bladder is relaxed.Vesikoureteraler Reflux (VUR) ist eine häufige urologische Komplikation bei Patienten mit Nierentransplantation. ZIEL: dieser Studie ist es, die Leistung der kontrastmittelverstärkten Miktionsurosonografie (CEmUS) bei der Diagnose und Klassifizierung des Reflux in das Nieren-Allotransplantat zu bewerten, den VUR in das Allotransplantat mittels Miktionszystourethrografie (MCU) und CEmUS zu bewerten und zu klassifizieren, die beiden Methoden zu vergleichen und eine neue Klassifikation des Reflux in das Allotransplantat basierend auf der CEmUS- und MCU-Beurteilung in Übereinstimmung mit dem internationalen Reflux-Klassifikationssystem vorzuschlagen. Von Januar 2017 bis Juli 2019 wurden 84 nierentransplantierte Patienten eingeschlossen. Bei allen Patienten wurden MCU und CEmUS durchgeführt. In 76 Fällen bestand Übereinstimmung zwischen MCU und CEmUS (90 %) (Kappa = 0,7). Die Sensitivität von CEmUS bei Verwendung der MCU als Goldstandard betrug 90 %, die Spezifität betrug 92 %. Von den 7 Fällen, die mittels MCU, aber nicht durch CEmUS diagnostiziert wurden, hatten 6 Patienten Grad 1 und 1 Patient hatte Grad 2. Transplantationspatienten mit Refluxsymptomen sollten sich einer CEmUS unterziehen. Wenn das Ergebnis negativ ist, sollte eine MCU durchgeführt werden. Die von uns vorgeschlagene Klassifikation ist besser geeignet, um den VUR bei Transplantationspatienten zu beschreiben, da sie einfacher ist und berücksichtigt, ob der Reflux nicht nur bei der Blasenentleerung, sondern auch bei entspannter Blase auftritt.

SARS-CoV-2 environmental contamination occurs through droplets and biological fluids released in the surroundings from patients or asymptomatic carriers. Surfaces and objects contaminated by saliva or nose secretions represent a risk for indirect transmission of COVID-19. We assayed surfaces from hospital and living spaces to identify the presence of viral RNA and the spread of fomites in the environment. Anthropic contamination by droplets and biological fluids was monitored by detecting the microbiota signature using multiplex RT-PCR on selected species and massive sequencing on 16S-amplicons.A total of 92 samples (flocked swab) were collected from critical areas during the pandemic, including indoor (3 hospitals and 3 public buildings) and outdoor surfaces exposed to anthropic contamination (handles and handrails, playgrounds). Traces of biological fluids were frequently detected in spaces open to the public and on objects that are touched with the hands (>80%). However, viral RNA was not detected in hospital wards or other indoor and outdoor surfaces either in the air system of a COVID-hospital, but only in the surroundings of an infected patient, in consistent association with droplets traces and fomites. Handled objects accumulated the highest level of multiple contaminations by saliva, nose secretions and faecal traces, further supporting the priority role of handwashing in prevention.In conclusion, anthropic contamination by droplets and biological fluids is widespread in spaces open to the public and can be traced by RT-PCR. Monitoring fomites can support evaluation of indirect transmission risks for Coronavirus or other flu-like viruses in the environment.ImportanceSeveral studies searched for SARS-CoV-2 in the environment because saliva and nasopharyngeal droplets can land on objects and surfaces creating fomites. However, the ideal indicator would be the detection of the biofluid. This approach was not yet considered, but follows a traditional principle in hygiene, using indicators rather than pathogens. We searched for viral RNA but also for droplets on surfaces at risk. For the first time, we propose to monitor droplets thorugh their microbiota, by RT-PCR or NGS.Even if performed during the pandemic, SARS-CoV-2 wasn’t largely spread on surfaces, unless in proximity of an infectious patient. However, anthropic contamination was frequently at high level, suggesting a putative marker for indirect transmission and risk assessment. Moreover, all SARS-CoV-2-contaminated surfaces showed the droplets’ microbiota.Fomites detection may have an impact on public health, supporting prevention of indirect transmission also for other communicable diseases such as Flu and Flu-like infections.GRAPHICAL ABSTRACT

Purpose: Radiation therapy (RT), by using ionizing radiation (IR), destroys cancer cells inducing DNA damage. Despite several studies are continuously performed to identify the best curative dose o...

Several surgical sealant devices are commercially available after their rigorous clinical testing with no apparent complications reported so far in the current literature. Cyanoacrylate glue can be used to stabilize the anastomoses and permit a better tensile strength in cardiovascular surgery. We first report the case of a 71-year-old male patient presenting with symptoms of progressive limitation of walking distance, 13 months after a successful femoroinfrapopliteal bypass surgery, because of a calcified tissue extrinsically stenosizing the first segment of the previous bypass graft, caused by the use of cyanoacrylate glue.

Background Patients with asymptomatic Stage IV colorectal cancer represent a significant heterogeneous group. National statistics represent an effective method to follow in real time the clinical outcomes of patients, and they may represent an important tool to analyze and to compare different therapeutic approaches. The aim of our study was to analyze the reviews of national data and single institutions reports, which compared the clinical outcomes of patients with asymptomatic Stage IV colorectal cancer and un-resectable metastases who had resection of the primary tumor with those who did not have resection. We gave special attention to the number of missing established relevant variables, to determine the appropriateness of the results of the published studies. Material We performed a systematic review of papers comparing patients who had and who had not primary tumor resection. Screened reports included the time of publication from June 2012 to June 2018; 2556 papers were identified and 27 were included into the review. The primary outcome was observed survival. We analyzed the number of major missing variables in National Data Bases and Single Institution Reports, to assess the overall validity of the conclusions of the analyzed reports. Results In the majority of the reports and in the meta-analysis of studies with propensity score matching, resection of the primary tumor was correlated to improved survival and to the possibility for a better response to postoperative chemotherapy. Conclusions The high number of missing significant variables, and a clear clinical selection in single center reports make any analysis error-prone. National statistics might represent a valid method to follow in real time the clinical outcomes of these patients, comparing different therapeutic approaches. There is the need for improvement in national data collection, to make descriptive national statistics the ground for future progress in treatment. (PROSPERO) CRD 42018089691.

The request for totally implantable venous access devices (TIVADs) has rapidly grown up through the last decades. TIVADs are implanted by direct vein puncture or by surgical approach with vein cutdown. The authors present a comparative prospective study evaluating external jugular vein (EJV) and cephalic vein cutdown techniques. Two hundred and fifteen patients were consecutively submitted to TIVAD implantation to perform chemotherapy. Patients were divided in two groups, depending on the implantation technique. Group A patients (106) underwent implantation via EJV cutdown and group B (109) patients underwent implantation by cephalic vein cutdown. The following variables were investigated: operating time, need for conversion to other approaches, complications, and intraoperative and postoperative pain. In Group A patients, the success rate of the procedure was 100 per cent, whereas in 11 patients (10.1%) of Group B, a modification of the initial approach was needed. Mean operative time was 23.9 ± 9.2 minutes in Group A and 35.4 ± 11.9 in Group B, and this was statistically significant (P0.05). Complication rates at 30 days were similar. Considering intraoperative pain, a difference was found between the two groups because the mean value of pain in Group A was lower than that in Group B (4.13 ± 0.3 vs 5.22 ± 1.24), even if not significant. External jugular vein cutdown approach is quick and safe and allows a very high success rate with very low risk of complications. For these reasons, this approach could be considered as a first choice in TIVAD placement.

Islami et al . (1) reported the proportion and the type of cancers that are referable to excess of body weight (EBW) in United States. The study revealed 37,670 cancer cases in men and 74,690 cancer cases in women 30 years or older in US from 2011 to 2015 that could be ascribed to high body mass index. Interestingly, Islami et al . (1), found that the amount of population attributable fraction (PAF) for EBW was higher in women than in men, paralleling the close association between high body mass index (BMI) and increased risk for several female-specific cancers, such as breast cancer.

Cystic adrenal neoplasms are uncommon and may be incidentally discovered during radiologic procedure not directly performed for the evaluation of adrenal disease. Cystic pheochromocytomas are uncommon neoplasms that originate from the adrenal medulla, clinically differing from the more frequent solid pheochromocytomas. Here, we report a case of 72 year-old woman affected by asymptomatic pseudocystic pheochromocytoma (70x50mm), incidentally discovered, with a false negative 123I-monoiodobenzylguanidine (123I-MIBG) scintigraphy. Histopathological examination led to diagnosis of pseudocystic pheochromocytoma with typical architecture. The screening for germline mutation of succinate dehydrogenase complex subunits (SDHB, SDHC), Von Hipple-Lindau syndrome (VHL) and multiple endocrine neoplasia type 2 (RET) genes were negative, finding only some polymorphisms for RET and SDHB. We emphasize the relevance of an accurate pre-operative diagnosis, especially in rare diseases, and the requirement of experience and multidisciplinary management in these rare pathologies.

Pheochromocytoma (PHEO), a rare catecholamine-producing tumor, is a disease entity with variable clinical manifestations. The classic triad of symptoms are palpitations, headaches, and diaphoresis, but the signs and symptoms are wide ranging and mainly reflect the hemodynamic and metabolic actions of the catecholamines produced and secreted by the tumor. We describe the rare case of a patient affected by nonfunctioning and asymptomatic PHEO associated with the incidental discovery of renal oncocytoma, and review the literature.

An epidermal inclusion cyst (EIC) of the breast is a rare, benign condition that may potentially be malignant. The present study conducted a systematic review of the literature in order to identify pathological hypotheses, clinical characteristics, and diagnostic and treatment options. A search for relevant studies was conducted through the Scopus, Embase and Medline databases during September 2014. The search term employed was ῾epidermal inclusion cyst breast᾽. Studies were selected if they contained adequate information regarding symptoms at presentation, diagnostic tools, pathology, characteristics, type of procedure performed and follow-up routines. A total of 35 papers describing 91 patients affected by EIC of the breast were identified. Following this, a total of 82 patients, including an additional case supplied from the present study, were selected for further analysis. EIC of the breast typically occurs during the fifth decade of life. A palpable mass of the breast was present in 65 (79%) patients. Ultrasonographic imaging was consistently utilized as a diagnostic tool in all the cases analyzed, whereas fine-needle aspiration cytology was used in 70% of the cases and mammography in 65%. No tumor recurrence was reported at a mean follow-up time of 53 months. The present study demonstrated that elliptical excision is the preferred treatment for EIC of the breast, with pathological analysis required to exclude malignancy.

otally implantable venous access devices (TI-VADs) consist of a central venous catheter(made of silicone rubber or polyurethane) and asubcutaneously-implanted injection port made oftitanium or plastic, providing a simple, safe, andpermanent means of accessing the vascular systemfor intravenous delivery of drugs and fluids.

Fournier's gangrene (FG) is a rare surgical emergency and a life-threatening condition with a rapidly progressive gangrene defined as a necrotizing fasciitis of the perineal or genital areas leading to septic shock and death if untreated. Risk factors are diabetes, immune compromise, obesity, drug use, or genital trauma. Patients are treated by incision and drainage. Aim of the study is to analyze cases of early manifestations of FG and consider aspect of diagnosis based on clinical presentation and the importance of precocious surgical treatment. We had experience of early lesions of FG in 22 cases. We report three cases in which the initial clinical presentation was typical of precocious signs referable to FG. Foley catheter was used in all cases, no diverting colostomy was performed. The patients were treated by artificial i.v. feeding. No extensive demolition of perineal tissues were operated, neither plastic surgery was required. Antibiotic therapy combined to surgical treatment with incision and drainage were performed in all cases. Admission in the intensive care unit was effective when indicated. No mortality was registered in all 22 cases of the series. FG is rare, severe condition requiring a multidisciplinary approach. An early diagnosis and an aggressive surgical treatment, improved by antibiotic therapy, hyperbaric oxygen therapy and proper wound care are the key points of FG management. In selected patients, colostomy or cystostomy must be considered when simple catheterization is not sufficient. Severe cases must be therefore referred to high-volume and specialized centres with specialist professional and intensive care facilities.

Multifocal fibrosclerosis is a very rare fibroproliferative syndrome involving multiple organ systems. In our report we present the case of multifocal sclerosing thyroiditis characterized by multiple fibroelastic foci similar to breast “radial scar”, which can be misdiagnosed as multifocal papillary carcinoma. The diagnosis of multifocal sclerosing thyroiditis, in according with Armed Forces Institute of Pathology (AFIP) textbook on thyroid tumors, was made only after histological and himmunohistochemical examination. We consider the multifocal sclerosing thyroiditis as the first stage of multifocal IgG4-related sclerosing disease for the presence of IgG4 within fibrosclerotic tissue of thyroid. Total body CT-scan and plamatic IgG4 levels must be investigated in order to exclude or confirm the presence of systemic disease.

BACKGROUND: Partial (or sub-total) adrenalectomy, first proposed for the treatment of hereditary, bilateral pheochromocytoma in order to preserve adrenocortical function and avoid lifelong steroid replacement therapy, has been adopted more recently in case of sporadic, monolateral tumors, like functioning adenomas or pheochromocytomas, in order to minimize the risk of potential adrenal failure, especially in young patients. METHODS: Based on a literature review and personal experience, the authors critically review this surgical procedure. RESULTS: The authors discuss surgical approach and indication for partial adrenalectomy, and focus on technical aspects and clinico-pathologic results. CONCLUSIONS: Because of the rarity of adrenal tumors and the consequent lack of consistent series, many issues such as correct surgical indications and technical aspects (management of the main adrenal vein, section margins, hemostasis of the adrenal stump, and surgical and functional results) still need to be debated.

Introduction Gastrointestinal stromal tumors (GISTs) arising in the duodenum represent a rare entity and can be very demanding to manage. The diagnosis can be difficult (as these tumors can be misdiagnosed as pancreatic head tumors), and to treat owing to the complex anatomy of the duodenum and of the pancreatic head. Complete resection may require extensive procedures such as pancreaticodudodenectomy. Methods and results An extensive literature review regarding clinico-pathological features, diagnostic investigations and surgical options in the management of duodenal GISTs has been performed. Conclusions Duodenal GISTs have uncertain malignant potential, and they may be asymptomatic, or present with abdominal pain or bleeding. A preoperative diagnosis can be difficult to obtain. Endoscopic ultrasound and fine needle aspiration cytology (FNAC) may be helpful. Surgical R0 resection remains the only curative approach. However, owing to the complex anatomy of the duodenum, limited resection is not always feasible. In these cases, extensive procedures such as pancreaticoduodenectomy or pancreas-preserving duodenectomy are the treatment of choice.

Primary aldosteronism (PA) represents the main cause of endocrine secondary arterial hypertension in which aldosterone production is inappropriately elevated. Primary hyperparathyroidism (PHPT) is an endocrine disease characterized by hypercalcemia due to overproduction of parathyroid hormone (PTH). Although these two endocrine pathologies are secondary to hypertension in middle aged population, the occurrence of the PHPT in PA patients has rarely reported in the literature. The aim of the study was to describe some PA patients with concurrent PHPT, referred in a tertiary center of arterial hypertension.We performed a retrospective study. In particular, the registry of 306 patients with PA seen in our center since 2004 was examined and revealed 8 patients (2.6%) with concurrent PHPT.There are several possible explanations for the association of these two endocrine disorders, including the combination was a random finding that PA inheres PHPT or vice versa.

Lumbar hernias, which are rare hernias of the posterolateral abdominal wall, can be divided into two groups: primary lumbar hernias, often the expression of a congenital defect, which typically arise in two areas of weakness, the superior triangle and inferior triangle and acquired (or diffuse) lumbar hernias which are usually due to previous lumbar trauma or surgery. Clinical examination may be adjuvated by ultrasound or CT scan, which can reveal the abdominal wall defect with the hernia content (viscera or extraperitoneal tissue). Surgical repair of lumbar hernias, both primary and acquired, has rapidly developed through recent years, similarly to the treatment of more frequent kinds of hernia (groin, epigastric), evolving from direct repair to mini-invasive techniques, even if, since the rarity of these hernias, precise knowledge of this complex anatomic region is required. Nowadays there are two valid alternatives: open tension-free repair (with use of mesh), and mini-invasive repair. Both are safe and effective, even if smaller hernias can be treated by open approach, with loco-regional anesthesia and good cosmetic effect. Larger hernias, or hernias with suspected viscera involvement, should require larger incisions and viscera exploration. For this reason laparoscopic access would be preferable.

We report the case of a 63-year-old woman with occult breast cancer who presented with a hard metastatic nodule in the left axilla. Although histology identified a metastatic carcinoma in the lymph nodes, numerous tests failed to detect the primary tumor. Resected lymph node was positive for both estrogen and progesterone receptors, suggesting the breast as the site of the primary tumor. Left modified radical mastectomy was performed. Pathology revealed an invasive lobular carcinoma (2.5 x 2 mm in size) with extensive lymphatic involvement, which strongly expressed both vascular endothelial growth factor-C (VEGF-C) and VEGF-D.Riportiamo il caso di metastasi ascellare sinistra da carcinoma occulto della mammella in donna di 63 anni. Nonostante la FNAC deponesse per metastasi da carcinoma, nessun accertamento pre operatorio è riuscito a determinarne la provenienza. L’istologia del linfonodo asportato, ha dimostrato la presenza di recettori per gli estrogeni ed il progesterone nel tessuto metastatico. Sottoposta a mastectomia radicale modificata sinistra, l’accurato esame del pezzo operatorio ha rivelato la presenza di carcinoma lobulare infiltrante (2,5 x 2 mm) con ampio coinvolgimento linfatico e con sopra espressione del fattore di crescita endoteliale vascolare (VEGF-C e VEGF-D).

Malignant Fibrous Histiocytoma (MFH) rarely affects the abdomen and only a few cases arising in the mesentery have to date been discovered. In this paper, two cases of MFH of the mesentery are described and a review of the literature is reported.

The request for totally implantable venous access devices (TIVADs) has rapidly grown up through the last decades. TIVADs are implanted by direct vein puncture or by surgical approach with vein cutdown. The authors present a comparative prospective study evaluating external jugular vein (EJV) and cephalic vein cutdown techniques. Two hundred and fifteen patients were consecutively submitted to TIVAD implantation to perform chemotherapy. Patients were divided in two groups, depending on the implantation technique. Group A patients (106) underwent implantation via EJV cutdown and group B (109) patients underwent implantation by cephalic vein cut-down. The following variables were investigated: operating time, need for conversion to other approaches, complications, and intraoperative and postoperative pain. In Group A patients, the success rate of the procedure was 100 per cent, whereas in 11 patients (10.1%) of Group B, a modification of the initial approach was needed. Mean operative time was 23.9 ± 9.2 minutes in Group A and 35.4 ± 11.9 in Group B, and this was statistically significant (P < 0.05). Complication rates at 30 days were similar. Considering intraoperative pain, a difference was found between the two groups because the mean value of pain in Group Awas lower than that in Group B (4.13 ± 0.3 vs 5.22 ± 1.24), even if not significant. External jugular vein cutdown approach is quick and safe and allows a very high success rate with very low risk of complications. For these reasons, this approach could be considered as a first choice in TIVAD placement.