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This study aimed to evaluate the incidence of cystadenoma diagnosis in a series of laparoscopic treatments for nonparasitic liver cysts, as well as its management. From 1996 to 2004, 26 patients with a nonparasitic cyst of the liver were selected for laparoscopic liver surgery. Solitary nonparasitic liver cysts were, whenever feasible, completely enucleated. In four patients, the histopathologic examination showed a cystadenoma. Three patients with 13, 9, and 12-cm cysts, respectively, had undergone complete enucleation of the lesion, with no evidence of recurrence in the follow-up visit. One patient with multicystic liver experienced a recurrence and required an open hepatic resection. When a complete laparoscopic enucleation of the cyst can be ensured, a strict follow-up assessment should be considered as the definitive treatment, with surgical intervention demanded only in the case of recurrence or high suspicion for malignancy.

Aims . Seroma formation following axillary dissection is a common complication of breast surgery. The aims of this study were (1) to analyse the risk factors of seroma formation, and (2) to evaluate the role of ultrasound scissors in performing axillary dissection in patients with primary breast cancer undergoing mastectomy and breast-conserving surgery. Methods . Ninety-two women (median age 55 years, range 33–73 years) requiring surgery for known unilateral primary breast cancer (pT1a=1, pT1b=20, pT1c=43, pT2=25, pT3=3) were prospectively randomised to undergo axillary dissection by either using (Group A, 45 patients) or not using (Group B, 47 patients) ultrasound scissors (US). Thirty-eight (41.3%) patients underwent modified radical mastectomy, while 54 (58.7%) underwent breast-conserving surgery. Results . Twenty-eight (30.4%) patients (Group A=9 out of 45, 20%; Group B=19 out of 47, 42%; P=NS) developed a wound seroma. Multivariate analysis using a logistic regression model showed that surgical procedure (RR=8.9; 95% CI: 3.2–25.3), total amount of drainage (RR=7.8; 95% CI: 2.8–22.0), and size of the tumour (RR=6.0; 95% CI: 2.2–16.5) independently correlated with seroma formation. The logistic regression function (RR=19.4; 95% CI: 6–62) correctly allocated 75 out of 92 (81.5%) patients. Conclusions . Size of the tumour, and total amount of drainage represent the principal factors of seroma formation following axillary dissection in patients undergoing surgery for breast cancer. Although the use of ultrasound cutting devices may reduce the risk of seroma formation, further studies are need to verify the real impact on long-term morbidity of such technique.

The aims of this study were (1) to analyze whether correlations exist between lumbar spine (LS) bone mineral density (BMD) and the main preoperative biochemical parameters in a large population of patients with primary hyperparathyroidism (HPT); and (2) to evaluate the LS-BMD changes after parathyroidectomy (PTx) at long-term follow-up. Sixty-two patients (median age 57 years, range 23–82 years) with confirmed primary HPT underwent LS osteodensitometry by dual-energy X-ray absorptiometry with BMD measurements at the L2–L4 region before surgery and at 1 year and 2 years after successful PTx. Three groups of patients were considered: Group A (men, n = 14, 22.6%), Group B (premenopausal women, n = 12, 19.3%), and Group C (postmenopausal women, n = 36, 58.1%). There were no linear correlations (P = NS) among the main biochemical parameters, the age of the patients, and their baseline LS-BMD values that were significantly (P < 0.01) lower in Group C patients. At 2-year follow-up the LS-BMD improved by 13.0%, 11.5%, and 11.7% in Groups A, B, and C, respectively (P = NS). In order to compare groups with the same linear relationship between age and LS-BMD, a subgroup of postmenopausal patients aged ≤60 years (Group C2) was considered. ANOVA showed that the improvement of the LS-BMD at l- and 2-year follow-up was higher (P = 0.002) in Group B than in Group C2 patients. The result was confirmed by using the Mann-Whitney U-test (P = 0.0078). Improvement of LS-BMD after successful PTx was significantly (P < 0.01) higher in premenopausal women, suggesting a possible role of estrogen hormone in complete bone remodeling.

Aim: Axillary node dissection (ALND) is still required in patients with breast cancer (BC), but unfortunately it can cause some complications, such as increased amount of drainage and seroma formation, which subsequently worsen their quality-of-life (QoL). The aim of this study was to evaluate whether the use of a harmonic dissection device (HDD), which reduces the risk of complications, can improve the short-term postoperative QoL of patients who underwent breast surgery. Methods: Sixty-eight women (median age 60, range 34-67 years) undergoing curative surgery for primary pT1-2 BC were enrolled in the study. The patients were randomly divided into two groups according to whether or not a HDD was used (Group 1, N = 32; Group 2, N = 36, respectively). Health-related QoL was measured with the Medical Outcomes Study Short Form (MOS-SF-36). Parameter G1 mean G1 SD G2 mean G2 SD P Age (years) 59.4 11.4 58.0 9.7 0.58 BMI (kg/m2) 23.7 1.8 24.4 2.5 0.19 Drainage output (mL) 402.6 73.3 456.9 59.1 0.0013 No. of the removed nodes 19.8 2.5 20.5 3.2 0.32 N0/N1 23/9 - 27/9 - 0.76 Seroma/No seroma 5/27 - 11/25 - 0.14 Physical function 61.2 22.7 55.4 21.3 0.28 Role physical 67.2 32.7 61.5 23.1 0.96 Bodily pain 60.8 29.9 59.2 29.2 0.82 General health 47.6 25.5 46.3 23.6 0.83 Vitality 48.6 21.8 47.1 22.3 0.78 Social function 69.7 22.1 57.4 22.2 0.025 Role emotional 66.9 24.5 53.3 23.4 0.022 Mental health 56.3 22.5 55.5 21.6 0.8 Tumor size (mm) 19.2 6.9 20.7 6.3 0.35 Quadrantectomy/mastectomy 23/9 - 25/11 - 0.76 Results: Age, body mass index (BMI), tumor stage, number of the removed nodes, type of surgery did not differ (p = NS) between groups. The total output of drainage was significantly reduced in Group 1, and also the formation of seromas was reduced in number. The results of the MOS-S-36 are shown in the Table. Conclusions: In patients undergoing ALND for BC the use of a HDD reduces some postoperative complications, such as output of drainage and seroma formation. However, these benefits have a limited impact on QoL of patients, since a few parameters of the MOS-SF-36 form improve significantly. Disclosure: All authors have declared no conflicts of interest.

A series of 253 consecutive patients with proved primary hyperparathyroidism due to parathyroid tumours was reviewed. There were 68 (26.9%) men and 185 (73.1%) women, with a median age of 57 years (range 13-82 years). All patients, prior to successful parathyroidectomy, underwent one or more preoperative localization procedures such as: neck ultrasonography (US) in 191 (75.5%), (201)Tl/(99m)Tc-pertechnetate subtraction scintigraphy (TPS) in 144 (56.9%), CT scan in 92 (36.4%), (99m)Tc-sestamibi/(99m)Tc-pertechnetate subtraction scintigraphy (MPS) in 90 (35.6%), selective venous sampling (SVS) with parathyroid hormone (PTH) assay in 30 (11.9%), and magnetic resonance imaging (MRI) in 6 (2.4%) patients. The results were compared with operative and histological findings that showed 235 (92.9%) solitary parathyroid adenomas, 13 (5.1%) carcinomas and 5 (2.0%) double adenomas. Sensitivity and positive predictive value were 82.9% and 93.8% for US, 83.6% and 91.8% for TPS, 81.3% and 98.7% for CT scan, 85.1% and 96.1% for MPS, 65.4% and 80.9% for SVS, and 80.0% and 80.0% for MRI respectively. No different results (P=NS) were found using US, TPS, MPS or CT scan, whereas SVS and MRI sensitivity was lower (P

Calcium is essential for many metabolic process, including nerve function, muscle contraction, and blood clotting. The metabolic pathways that contribute to maintain serum calcium levels are bone remodeling processes, intestinal absorption and secretion, and renal handling, but hypercalcemia occurs when at least 2 of these 3 metabolic pathways are altered. Calcium metabolism mainly depends on the activity of parathyroid hormone (PTH). Its secretion is strictly controlled by the ionized serum calcium levels through a negative feed-back, which is achieved by the activation of calcium-sensing receptors (CaSRs) mainly expressed on the surface of the parathyroid cells. The PTH receptor in bone and kidney is now referred as PTHR1. The balance of PTH, calcitonin, and vitamin D has long been considered the main regulator of calcium metabolism, but the function of other actors, such as fibroblast growth factor-23 (FGF-23), Klotho, and TPRV5 should be considered. Primary hyperparathyroidism and malignancy are the most common causes of hypercalcemia, accounting for more than 90% of cases. Uncontrolled hypercalcemia may cause renal impairment, both temporary (alteration of renal tubular function) and progressive (relapsing nephrolithiasis), leading to a progressive loss of renal function, as well as severe bone diseases, and heart damages. Advances in the understanding of all actors of calcium homeostasis will be crucial, having several practical consequences in the treatment and prevention of hypercalcemia. This would allow to move from a support therapy, sometimes ineffective, to a specific and addressed therapy, especially in patients with chronic hypercalcemic conditions unsuitable for surgery.

Breast cancer remains one of the first leading causes of death in women, and currently endocrine treatment is of major therapeutic value in patients with estrogen-receptor positive tumors. Selective estrogen-receptor modulators (SERMs), such as tamoxifen and raloxifene, aromatase inhibitors, and GnRH agonists are the drugs of choice. Tamoxifen, a partial nonsteroidal estrogen agonist, is a type II competitive inhibitor of estradiol at its receptor, and the prototype of SERMs. Aromatase inhibitors significantly lower serum estradiol concentration in postmenopausal patients, having no detectable effects on adrenocortical steroids formation, while GnRH agonists suppress ovarian function, inducing a menopause-like condition in premenopausal women. Endocrine therapy has generally a relatively low morbidity, leading to a significant reduction of mortality for breast cancer. The aim of chemoprevention is to interfere early with the process of carcinogenesis, reducing the risk of cancer development. As preventive agents, raloxifene and tamoxifene are equivalent, while raloxifene has more potent antiresorptive effects in postmenopausal osteoporosis. Endocrine treatment is usually considered a standard choice for patients with estrogen-receptor positive cancers and non-life-threatening advanced disease, or for older patients unfit for aggressive chemotherapy regimens. Several therapeutic protocols used in patients with breast cancer are associated with bone loss, which may lead to an increased risk of fracture. Bisphosphonates are the drugs of choice to treat such a drug-induced bone disease. The aim of this review is to outline current understanding on endocrine therapy of breast cancer.

Hypercalcemia is a relatively common clinical problem, mainly (>90%) related to primary hyperparathyroidism (HPT) and malignancies. The anatomical and functional imaging techniques available for locating enlarged parathyroid glands include ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine imaging techniques. The most commonly employed are US and parathyroid scintigraphy, while CT, MRI, positron emission tomography (PET)/CT, and selective venous sampling are generally used in patients with persistent or recurrent HPT, or when findings of non-invasive studies are negative or conflicting. The reported accuracy is 57-93%, 54-93%, and up to 95% for US, (99m)Tc-sestamibi scintigraphy, and the two modalities combined, respectively. A multimodality approach (x-ray, whole-body scintigraphy, CT, MRI, and PET) is usually recommended for whole body assessment in cases of cancer-induced hypercalcemia (CIH). Imaging studies should evaluate each organ (i.e. breast, kidney, prostate, parathyroid) potentially involved in the pathogenesis of hypercalcemia in patients with CIH. In cases of skeletal metastases, when findings on plain x-ray or bone scans are uncertain, any unexplained region of abnormal uptake should be examined by MRI and/or ¹⁸F-fluoro-2- deoxyglucose (FDG)-PET/CT, which has proved more accurate than classical bone scintigraphy, especially for dealing with hematologic malignancies. A number of radionuclide tracers, other than ¹⁸F-FDG, are available for use in selected cases to locate specific tumors (i.e. ⁶⁸Ga for neuroendocrine tumors). This is a review of recently published information on the imaging techniques currently available for patients with hypercalcemia.

Summary The complementary role of sestamibi scintimammography (SSM) in patients with breast cancer (BC) is well established. The aim of this study was to establish whether a relationship exists between sestamibi uptake, evaluated as a tumour-to-background ratio (TBR), and the main prognostic factors of BC. SSM with the measurement of TBR was performed preoperatively in 102 women (median age 57 years, range 32–81 years) who underwent curative surgery for primary BC. Final pathology showed 4 (3.9%) with pT1a, 17 (16.7%) with pT1b, 44 (43.1%) with pT1c and 37 (36.3%) with pT2 breast carcinomas. The overall sensitivity of SSM was 80.4%. An ANOVA showed significant ( P 0.01 ) differences between the TBR of patients with G1 vs. G3 tumours, and between the TBR of those with G2 vs. G3 breast carcinomas. Moreover, there was a difference ( P = 0.021 ) between the TBR of patients ( n = 12 , 11.8%) with CEA serum levels >10 ng/ml (2.031±0.420), and those with normal ( n = 90 , 88.2%) CEA values (1.713±0.446), whilst no difference ( P =NS) was found between patients ( n = 27 , 26.5%) with CA 15-3 >30 U/ml (1.893±0.401) and those with normal ( n = 75 , 73.5%) CA 15-3 values (1.699±0.462). There was a mild inverse correlation between TBR and both the oestrogen ( R = 0.25 , P = 0.011 ) and the progesterone receptor ( R = 0.23 , P = 0.02 ) rate. The logistic regression analysis showed that only size and CA 15-3 serum levels represent true independent parameters, but the function was able to predict only 11 out of 21 (52.4%) patients with false-negative SSM. TBR is independent of age and mainly correlates with the size of the tumour. There are no reliable preoperative prognostic factors that are really useful for improving SSM sensitivity in patients with small breast carcinomas.

The aim of this study was to evaluate the usefulness of DNA flow cytometry to determine tumor nuclear DNA index (DI), and nucleolar organizer region protein counts visualized by the argyrophil (AgNOR) technique, in confirming diagnosis and predicting clinical outcome of patients with parathyroid carcinoma (PC). We reviewed paraffin-embedded tissue sections, from 15 patients (median age 63 years, range 30–68 years) with PC who died of the disease, which were randomly compared with tissue sections from 15 age- and sex-matched patients with parathyroid adenoma (PA). The proliferative activity in parathyroid tumours as detected by DI and AgNOR counts was evaluated in all specimens. Both DI (1.37 ± 0.33 vs 1.0 ± 0.1) and AgNOR (3.01 ± 0.31 vs 1.54 ± 0.35) counts were higher (P < 0.001) (Student’s t-test) in patients with PC than in those with PA. Diploid (DI = 1), aneuploid (DI>1) and hypoploid (DIn = 11) and diploid (n = 4) PC were 74.0 ± 58.1 and 34.1 ± 18.4 months (P=0.21) respectively. There was a significant relationship between DI and AgNOR counts (R=0.69, P < 0.01), but no correlation was found between survival and both DI (Rho = 0.17, P = 0.55) and AgNOR counts (Rho = 0.26, P = 0.35). Moreover, there was no correlation (P = NS) between the main preoperative biochemical parameters and survival. In conclusion, DI and AgNOR are useful in confirming the diagnosis of PC, but they are of little value in predicting the clinical outcome of patients with PC.

Aim: The aim of this study was to compare the usefulness of computed tomography (CT)-scan, magnetic resonance imaging (MRI), and fine-needle aspiration (FNA) cytology in patients with incidentally discovered adrenal masses. Patients and methods: Thirty-four consecutive patients (six men and 28 women, median age of 47 years, range 26–80) with non-functioning adrenal masses of 2 cm or more (median 3.5 cm, range 2–9) were studied. All patients underwent CT-scan, MRI, and image-guided FNA cytology using spinal-type narrow-gauge needles prior to further procedures. Nineteen patients underwent adrenalectomy. Results: Final pathology showed 13 benign adrenal lesions, four adrenocortical carcinomas, and two unsuspected adrenal metastases. Fifteen patients who did not have surgery were considered definitively as having benign adrenal lesions since the mass was unchanged on CT-scans performed during follow-up. The sensitivity, specificity, and positive predictive value were 66.7, 85.7, and 50.0%, for CT-scan, 83.3, 92.9, and 71.4% for MRI, and 83.3, 100, and 100% ( p Conclusions: Image-guided FNA cytology is a safe and sensitive procedure that may reveal unsuspected adrenal malignancies, and should be performed in all patients with incidentally discovered adrenal masses of more than 2 cm in size.

Several risk factors for breast cancer (BC) have been investigated in different reports, but none has been really useful in preventing BC development. The aim of this study was to evaluate the risk of BC in self-selected symptomatic women in comparison with the healthy population residing in an urban area of Italy. A group of 404 women (median age 59 years, range 26-89 years) with confirmed BC (cases) were age-matched with 389 healthy women (Group A), and 391 (Group B) symptomatic non-screened patients without BC, who were referred to our Breast unit. The results of univariate analysis showed a significant (P0.01) difference between cases and controls in (1) age at menarche, (2) number of birth and age at first births, (3) lactation and months of lactation, and (4) estrogen replacement therapy (ERT) and duration of ERT. Multivariate analysis using a logistic regression model adjusted for age showed that five independent parameters (no pregnancy, age at first birth30 years, no lactation, use of ERT, ERT40 months) significantly (P0.01) correlated with BC onset. The relative odds ratios (ORs) at 95% confidence interval (95% CI) were 5.25, 2.47, 2.82, 2.80, and 5.56, respectively. The cumulative OR (95% CI) calculated from the observed vs. predicted values was 7.15. No differences (P = NS) were found between groups A and B. In conclusion, in our study population, the prolonged use (40 months) of ETR in menopausal women resulted in an increased risk of BC, and represented the only risk factor that could be removed.

was performed in 12 pts and lobectomy in 8; 60% on the left lung. Postoperative chemotherapy was instituted in 12 pts (FOLFIRI was mainly used). Ten had HM (2 previous, 2 after and 6 synchronous to LM) and six had hepatic metastasectomy (5 previous to LM resection). Mean survival after resection was 29.8±11.4 months. The overall 2-year survival following LM resection was 65% (n = 20) and 62.5% (n = 16) at 3-years. Metachronous and synchronous LM presented equal mean survival (29.5 vs 31.2 months; p = 0.799). Survival in our pts was not affected by HM or previous HM resection. Conclusion: Lung metastases of CRC are more associated with rectal cancer (7.5 11%) than to colon cancer (3.5%) and time to diagnosis is normally longer than to HM. Resection of LM with curative intent is infrequent and some authors have found better results in metachronous than in synchronous metastases, not observed in our results. Longer follow-up and larger studies are needed to asses overall survival at 3 and 5 years after resection but data obtained matches the experience of other authors. Disclosure: All authors have declared no conflicts of interest.