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Purpose: Metformin is associated with reduced breast cancer risk in observational studies in patients with diabetes, but clinical evidence for antitumor activity is unclear. The change in Ki-67 between pretreatment biopsy and post-treatment surgical specimen has prognostic value and may predict antitumor activity in breast cancer., Patients and Methods: After tumor biopsy, we randomly allocated 200 nondiabetic women with operable breast cancer to either metformin 850 mg/twice per day (n = 100) or placebo (n = 100). The primary outcome measure was the difference between arms in Ki-67 after 4 weeks adjusted for baseline values., Results: Overall, the metformin effect on Ki-67 change relative to placebo was not statistically significant, with a mean proportional increase of 4.0% (95% CI, -5.6% to 14.4%) 4 weeks apart. However, there was a different drug effect depending on insulin resistance (homeostasis model assessment [HOMA] index > 2.8, fasting glucose [mmol/L] × insulin [mU/L]/22.5; P(interaction) = .045), with a nonsignificant mean proportional decrease in Ki-67 of 10.5% (95% CI, -26.1% to 8.4%) in women with HOMA more than 2.8 and a nonsignificant increase of 11.1% (95% CI, -0.6% to 24.2%) with HOMA less than or equal to 2.8. A different effect of metformin according to HOMA index was noted also in luminal B tumors (P(interaction) = .05). Similar trends to drug effect modifications were observed according to body mass index (P = .143), waist/hip girth-ratio (P = .058), moderate alcohol consumption (P = .005), and C-reactive protein (P = .080)., Conclusion: Metformin before surgery did not significantly affect Ki-67 overall, but showed significantly different effects according to insulin resistance, particularly in luminal B tumors. Our findings warrant further studies of metformin in breast cancer with careful consideration to the metabolic characteristics of the study population.

Mandibular motor function is well known to be impaired in the presence of temporomandibular disorders. However, while a vast literature is available concerning accuracy of motor control in limbs, quantitative and objective assessment of mandibular motor control has been seldom performed, also because of the lack of adequate investigative tools. Aim of this work is to present a technique for reliable evaluation of the motor performance of the mandible based on a kinesiography-monitored reach-and-hold task. Nineteen healthy subjects were engaged in a task in which they had to drive a cursor on a screen by corresponding movements of the mandible in the frontal plane and reach 30 random targets sequentially displayed on the screen. The whole task was repeated three times per session in two different days. The individual performance was assessed by different indices evaluating precision and steadiness of target matching. The performance progressively improved in the three trials of the first session, further improved and stabilised in the second session, with an average positioning error of 0·59 ± 038 mm and was slightly correlated with the horizontal dimension of the mandible border movement (r = 0·55). Intraclass correlation coefficient ranged between 0·76 and 0·94 for the different indices indicating good repeatability. The kinesiographic technique allowed for objective and reliable assessment of the voluntary control of the mandible position. Its potential applications include support to the characterisation of temporomandibular disorders and to motor training and progress monitoring in rehabilitation treatments., (© 2011 Blackwell Publishing Ltd.)

Objective: We analyzed 382 patients with pure lobular carcinoma treated up to 2002 with sufficient follow-up to draw prognostic conclusions, all treated by conservative surgery. Our aim was to evaluate the influence of margin status on outcomes with a view assessing the appropriateness of conservative surgery in this breast cancer subtype., Methods: We assessed locoregional relapse, distant metastasis, contralateral breast cancer, breast cancer-related event free survival, disease-free survival and overall survival according to margin status categorized as at least 10 mm versus less than 10 mm (usually considered negative)., Results: The proportions of patients with less than 10 mm margins varied significantly with age (P = 0.02), menopausal status (P = 0.006), and tumor size (P = 0.02) but no other characteristic was significantly related to margin status. As regards unfavorable events during follow-up, none differed significantly between at least 10 mm and less than 10 mm margin groups. In particular, there were 11 (3.7%) local relapses in the same quadrant in at least 10 mm margin group compared to 4 (4.6%) in the less than 10 mm margin group, and 7 (2.4%) ipsilateral breast cancers in the 10 mm or more margin group but none in the less than 10 mm group. These findings indicate that minimal residual disease as evidenced by margins less than 10 mm is eradicated by radiotherapy (backed up in selected cases by reexcision, which in this series was always conservative). The rate of contralateral breast cancer was low at 2.9% indicating that prophylactic contralateral mastectomy is not justified., Conclusions: We conclude that the surgical approach and criteria for adjuvant hormonal and systemic treatment in lobular carcinoma should be the same as for ductal carcinoma, provided that adequate preoperative investigations exclude extensive multifocal and contralateral disease.

Breast cancer is the most common cancer in women. Primary treatment is surgery, with mastectomy as the main treatment for most of the twentieth century. However, over that time, the extent of the procedure varied, and less extensive mastectomies are employed today compared to those used in the past, as excessively mutilating procedures did not improve survival. Today, many women receive breast-conserving surgery, usually with radiotherapy to the residual breast, instead of mastectomy, as it has been shown to be as effective as mastectomy in early disease. The relatively new skin-sparing mastectomy, often with immediate breast reconstruction, improves aesthetic outcomes and is oncologically safe. Nipple-sparing mastectomy is newer and used increasingly, with better acceptance by patients, and again appears to be oncologically safe. Breast reconstruction is an important adjunct to mastectomy, as it has a positive psychological impact on the patient, contributing to improved quality of life.

Background: We reviewed our experience with the transluminal placement of the Djumbodis system in the aortic arch and isthmus in patients with type A acute aortic dissection to assess its impact on true and false aortic lumen evolution., Methods: Between January 2005 and September 2009, 50 patients underwent surgery for type A acute aortic dissection. Twenty-eight patients (group A) were operated on by implanting the Djumbodis prosthesis, and 22 patients (group B) without the prosthesis. Contrast-enhanced computed tomography and magnetic resonance imaging controls were performed on survivors at or soon after discharge and at follow-up., Results: Preoperative and operative data and complication rates were not significantly different between the two groups. Three in-hospital deaths occurred within 30 days, 1 in each group due to aortic rupture. At 1- and 4-year follow-up, actuarial survival was 82% ± 7% versus 90% ± 6% and 73% ± 9% versus 84% ± 9%, in group A and B, respectively (p = 0.35). Three reoperations were performed, 2 in group A and 1 in group B (p = 0.66). At follow-up, there was no significant difference between groups regarding the ratio between true lumen and aortic diameters and false lumen patency rates at the aortic arch, isthmus, and descending aorta level., Conclusions: Placement of the Djumbodis prosthesis does not confer any additional surgical benefit and does not seem to contribute to reducing the incidence of postoperative false lumen patency in patients operated on for type A acute aortic dissection in comparison with conventional surgery., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Few data exist on the potential role of circulating tumor cells (CTCs) in patients with operable breast cancer. If the presence of CTCs in early breast cancer could predict an increased risk for relapse, it might be an early marker for treatment efficacy and could help in deciding treatment continuation., Methods: Thirty milliliters of peripheral blood was taken from 56 breast cancer patients before surgery and again 5 days after surgery, and the presence of CTCs was evaluated. In case of positivity of one of the perioperative samples, another sample was taken after 30 days. The presence of CTCs was assessed with the CellSearch System (Veridex, Warren, NJ)., Results: One to three CTCs were found in 16 (29%) of 56 patients before surgery, in 14 (30%) of 47 patients at day 5, and in 8 (30%) of 27 at day 30. No association with pathological characteristics was found, apart a borderline significant association between presence of CTCs at baseline and vascular invasion (P = 0.07). When we looked at concordance between CTCs at baseline and after day 5 (47 patients), we found 40% discordant samples (10 negative at baseline and positive at day 5, and 9 vice versa)., Conclusions: This study provides evidence of the presence of CTCs in approximately 30% of patients with localized breast cancer both before and after surgery, with change from positive to negative and vice versa in 40% of cases. No association with the pathological variables was found, except for vascular invasion and presence of preoperative CTCs. Long-term follow-up will be required to understand the significance of these data.

Background: Tamoxifen's cost-benefit ratio for breast ductal intraepithelial neoplasia (DIN) is unclear. Since low-dose tamoxifen showed a favorable modulation of breast cancer biomarkers in phase II trials, a monoinstitutional cohort of women with DIN treated with low-dose tamoxifen or no systemic treatment was analyzed., Patients and Methods: A total of 309 patients with DIN received low-dose tamoxifen as part of institutional guidelines and were compared with 371 patients with DIN who received no systemic treatment after surgery., Results: Women with estrogen receptor (ER)/progesterone receptor (PgR) >50% DIN who were not treated had a higher incidence of breast events than women on tamoxifen [hazard ratio (HR) 1.76; 95% confidence interval (CI) 1.00-3.12] or women with ER/PgR <50% DIN (HR 1.72; 95% CI 1.14-2.58). Among untreated patients with ER >50% DIN, recurrence was higher in PgR > or =50% DIN than in PgR <50% DIN, whereas it was similar among low PgR (<50%) DIN against which tamoxifen had no effect. No difference in endometrial cancer incidence was noted., Conclusions: High ER and especially high PgR expression is a significant adverse prognostic indicator of DIN, and low-dose tamoxifen appears to be an active treatment. Women with low-expression ER or PgR DIN do not seem to benefit from tamoxifen. A definitive clinical trial is warranted.

Introduction: In recent decades, a steady improvement in imaging diagnostics has been observed together with a rising adherence to regular clinical breast examinations. As a result, the detection of small clinically occult (nonpalpable) lesions has progressively increased. At present in our institution some 20% of the cases are treated when nonpalpable. The aim of the present study is to analyze the characteristics and prognosis of such tumors treated in a single institution., Methods: The analysis focused on 1,258 women who presented at the European Institute of Oncology with a primary clinically occult carcinoma between 2000 and 2006. All patients underwent radioguided occult lesion localization (ROLL), axillary dissection when appropriate, whole breast radiotherapy, or partial breast intraoperative irradiation and received tailored adjuvant systemic treatment., Results: Median age was 56 years. Imaging showed a breast nodule in half of the cases and a breast nodule accompanied by microcalcifications in 9%. Microcalcifications alone were present in 17.1% of the cases, whereas suspicious opacity, distortion, or thickening represented the remaining 24.6%. Most tumors were characterized by low proliferative rates (68.9%), positive estrogen receptors (92.3%), and non-overexpressed Her2/neu (91.3%). After a median follow-up of 60 months, we observed 19 local events (1.5%), 12 regional events (1%), and 20 distant metastases (1.6%). Five-year overall survival was 98.6%., Conclusions: Clinically occult (nonpalpable) carcinomas show very favorable prognostic features and high survival rates, showing the important role of modern imaging techniques.

Many outcome variables in oral research are characterized by positive values and heavy skewness in the right tail. Examples are provided by many distributions of dental variables such as DMF (decayed, missing, filled teeth) scores, oral health impact profile score, gingival index scores, and microbiologic counts. Moreover, heterogeneity in data arises when more than one tooth is studied for each patient, due to the clusterization.Over the past decade, linear mixed models (LMEs) have become a common statistical tool to account for within-subject correlation in data with repeated measures. When a normal error is reasonably assumed, estimates of LMEs are supported by many statistical packages. Such is not the case for skewed data, where generalized linear mixed models (GLMMs) are required. However, the current software available supports only special cases of GLMMs or relies on crude Laplace-type approximation of integrals. In this study, a Bayesian approach is taken to estimate GLMMs for clustered skewed dental data. A Gamma GLMM and a log-normal model are employed to allow for heterogeneity across clusters, deriving from the patient-operator-tooth susceptibility typical of this clinical context. A comparison to the frequentist framework is also provided. In our case, Gamma GLMM fits data better than the log-normal distribution, while providing more precise estimates compared with the likelihood approach. A key advantage of the Bayesian framework is its ability to readily provide a flexible approach for implementation while simultaneously providing a formal procedure for solving inference problems., (Copyright (c) 2009 John Wiley & Sons, Ltd.)

Objective: : This study was carried out with the aim of presenting our experience with minimally invasive mitral surgery and compare the endoaortic clamp with the external aortic clamp (EAC) techniques., Methods: : Between December 2002 and May 2009, 139 patients (75 men, aged 63 ± 11 years) underwent video-assisted mitral valve surgery through right thoracotomy. Twelve (9%) patients were operated without clamping the aorta, 32 (23%) patients (group A) were operated on by using the endoaortic clamp, and 95 (68%) patients were operated on by using the EAC (group B). There was no significant difference between groups A and B regarding preoperative variables., Results: : Intraoperative procedure-associated problems were experienced in three group A patients (9.3%, two aortic dissections with conversion to sternotomy; one conversion due to bad exposure) and in two group B patients (2%, one conversion to sternotomy for bleeding and one for ascending aorta hematoma). At a mean follow-up of 32 months, 121 patients (97%) were in New York Heart Association class I-II, with satisfactory echocardiographic results. There was one in-hospital and six late deaths (three noncardiac, two cardiac, and one valve related). Five-year actuarial survival was 88% ± 8%. There were three reoperations, one early (<30 days) after complex mitral valve repair, with a 5-year freedom from reoperation of 97% ± 2%. Postoperative levels of myocardial cytonecrosis enzymes as well as the extracorporeal circulation time were significantly lower in group B patients (P < 0.05)., Conclusions: : Intraoperative procedure-associated complications with endoclamping combined with an apparently better myocardial protection forced us to change our practice to the more simple and economic EAC technique.

Idiopathic granulomatous mastitis clinically and histologically mimics an inflammatory carcinoma. A correct approach including ultrasound, clinical and histological analysis can safely identify a patient with this pathology, orienting to adequate therapy with anti-inflammatory and antibiotic drugs and leaving the surgical approach only for case unresponsive to medical therapy.

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by calcification and ossification of ligaments and entheses; it mainly affects the vertebral column. We report the case of a patient with pharyngeal dysphagia and episodic aspiration secondary to DISH involvement of the cervical spine, which had caused alteration in the epiglottic tilt mechanism during deglutition.

Introduction: Diagnosis of breast ductal intraepithelial neoplasia (DIN) has increased over the last decades, but proper postsurgical treatment remains controversial. We analyzed risk factors and treatment outcome in a large series of women treated at one institution., Methods: Women undergoing surgery for DIN at the European Institute of Oncology between 1996 and 2005, with follow-up until December 2006, were included., Results: We evaluated the postsurgical treatment outcome of 974 and 293 patients who underwent breast-conserving surgery (BCS) or mastectomy, respectively. The 5-year cumulative incidence of breast cancer (BC) events was 11.8%, with a significant trend according to age (from 43% in women <36 years to 8% in women >65 years). Among the 727 BCS patients with DIN2-DIN3 histology, 414 (57%) received radiotherapy (RT), and they were both younger and with worse prognostic factors than the 313 patients who did not receive it. In these groups, the adjusted hazard ratio (HR) for RT versus non-RT was 0.40 (95% confidence interval [CI], 0.26-0.63). Among the 691 BCS patients with estrogen receptor (ER)(+) disease, 329 (48%) received low-dose tamoxifen (either 5 mg/day or 20 mg once a week) and they were younger than the 362 who did not receive it. In these groups, the adjusted HR for tamoxifen versus no tamoxifen was 0.68 (95% CI, 0.43-1.07), and the HR was 0.55 (95% CI, 0.32-0.97) after excluding human epidermal growth factor receptor (HER)2/neu-overexpressing DIN., Conclusions: BC events were more frequent in young patients. RT was associated with a lower incidence of BC events. Low-dose tamoxifen was associated with a lower incidence of BC events in patients with ER(+) disease when HER-2 was not overexpressed. Further prospective studies should confirm our observations.

Biliary tract involvement in patients with hepatocellular carcinoma usually occurs in advanced stages and is due to tumour compression or infiltration. In a few cases, however, a tumour thrombus may grow into the biliary ducts (bile duct thrombosis). Identification of this condition is important because surgical treatment may be beneficial in selected cases. A 69-year-old man came from another hospital after repeated sessions of radiofrequency thermoablation and alcoholisation of 3 nodules of hepatocellular carcinoma. At admission to our unit, the nodule in S5-S8 was still viable and a neoplastic thrombus had invaded the right and common bile ducts. S5-S8 sub-segmentectomy, S6 wedge resection and removal of the tumour thrombus were performed. Seventeen months later the tumour thrombus recurred in the hepatic ducts without evidence of intrahepatic recurrence and was again removed. Eight months later a large metastatic lymph node appeared at the hepatic hilum, without evidence of liver recurrence or distant metastases, and the patient underwent lymphadenectomy. Eighteen months after the last procedure the patient is alive without recurrence. The appearance of bile duct thrombosis in the natural history of hepatocellular carcinoma does not necessarily entail an unfavourable prognosis. An early diagnosis is crucial to select the appropriate treatment. Biliary decompression with removal of tumour debris and blood clots and curative resection of the hepatocellular carcinoma can result in effective palliation and occasional long-term survival. Also in the presence of intrabiliary, hepatic or limited extrahepatic recurrence, surgical exeresis is the best therapeutic choice in selected cases.

Purpose: To evaluate the success rate of immediately loaded conventional implants placed in the premaxilla in association with 2 zygomatic implants., Materials and Methods: All patients included had worn complete maxillary dentures for at least 2 years. They were required to have no severe systemic pathologies and could not be on any drugs. They could not have any oral infection, uncontrolled periodontal disease, sinusitis, parafunctional signs, alteration of the occlusal plane, or smoking habits. They had to be good candidates for the insertion of 4 or 5 traditional implants in the premaxilla and 2 zygomatic implants without guided bone regeneration. Primary stability had to be achieved. Impressions for prosthetic rehabilitation were made during first-stage surgery. Temporary fixed cross-arch prostheses were inserted 12 to 24 hours after surgery. Permanent cross-arch screw-retained prostheses were placed after 6 months., Results: Seven patients met all the inclusion criteria and were enrolled in the study (Caucasian, 4 males and 3 females, mean age 56.8 years). In total, 14 zygomatic and 34 conventional implants were placed. The survival rate for zygomatic and conventional implants and fixed prostheses was 100% after 24 months of functional loading., Conclusion: The preliminary results are encouraging, but the long-term clinical prognosis remains to be determined.

Conservative surgery represents the standard care for patients with early breast cancer. The aim of this review was to discuss the extension of conservative surgery in controversial fields such as after primary chemotherapy for large tumours or the possibility to repeat conservative surgery for a local reappearance. The project of a conservative approach to breast cancers continues with sentinel node biopsy which is worldwide performed more and more frequently. In our institute sentinel node biopsy is the standard procedure in the axillary staging of breast cancer even in those clinical scenarios which were previously considered either controversial or a contraindication such as in multicentric breast cancer, during pregnancy, in intra-ductal neoplasias, after primary chemotherapy, and male breast cancer. This conservative approach is completed by the possibility to deliver a partial breast irradiation and to provide patients with more personalized adjuvant treatments tailored on the biological features of the tumour.

Study Design: A systematic review of scientific literature., Objective: The study aimed to determine whether bone morphogenetic proteins (BMPs) are more effective in treating bone defects than traditional techniques, such as grafting autologous bone., Summary of Background Data: BMPs were used in several human randomized controlled trials (RCTs). There are both logical arguments and an empirical basis for using RCTs to evaluate the effects of health care interventions and restrict systematic reviews to such a kind of study design., Methods: An electronic search was made in the databases of MEDLINE, EMBASE (through MeSH and Emtree), and the Cochrane Central Register of Controlled Trials, extended to May 31, 2006, with no linguistic restrictions. RCTs that compare bone regeneration achieved through BMPs versus that obtained by traditional methods entered the study., Results: The 17 publications that met the criteria, divided into subgroups by type of bone, were tabulated by salient characteristics and evaluated through the items proposed by van Tulder et al. However, as the studies differed widely (in terms of site, sample size, dosage of active principle, carrier, clinical and radiologic data recording), it was possible to carry out a metaanalysis of clinical and radiologic outcome only for the subgroup that evaluated the vertebrae, where it was observed that BMPs offer a slightly but statistically significant greater efficacy than do traditional techniques., Conclusions: The use of BMPs at the vertebrae can eliminate the need for surgery to harvest autologous bone. The only large study carried out on the other sites suggests that BMPs should be used at a concentration of 1.5 mg/mL to treat fractures of the tibia. However, further RCTs of good methodological quality are advisable so as to clarify the effectiveness of BMPs in clinical practice.

Glass-ceramic macroporous scaffolds for tissue engineering have been developed using a polyurethane sponge template and bioactive glass powders. The starting glass (CEL2) belongs to the system SiO(2)-P(2)O(5)-CaO-MgO-Na(2)O-K(2)O and has been synthesised by a conventional melting-quenching route. A slurry of CEL2 powder, polyvinyl alcohol and water has been prepared in order to coat, by impregnation, the polymeric template. An optimised thermal treatment was then use to remove the sponge and to sinter the glass powders, leading to a glass-ceramic replica of the template. Morphological observations, image analyses, mechanical tests and in vitro tests showed that the obtained devices are good candidates as scaffolds for bone-tissue engineering, in terms of pore-size distribution, pore interconnection, surface roughness, and both bioactivity and biocompatibility. In particular, a human osteoblast cell line (MG-63) seeded onto the scaffold after a standardised preconditioning route in simulated body fluid showed a high degree of cell proliferation and a good ability to produce calcium nodules. The obtained results were enhanced by the addition of bone morphogenetic proteins after cell seeding.

Background: We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment., Study Design: We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n=55), treatment of breast cancer (n=41), or both (n=27) at four large centers., Results: Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other's cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients., Conclusions: The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.

Aim: The precision of fixed prosthodontic restorations is fundamental for clinical success: well-fitting crowns reduce the risk of recurrent caries and periodontal disease. The aim of this study is to evaluate the internal fit of fixed prosthodontics at the shoulder preparation level by examining horizontal sections., Methods: Twenty-four extracted teeth were resin-embedded and prepared on the platform of an iso-parallelometer with a 90 degrees shoulder with a rounded internal angle. Auro Galva Crown (AGC) copings were cemented in place. The preparations were observed by 3 different assessors at 8 points, first externally and then internally at 2 levels by grinding the specimen perpendicular to the long axis at 0.5 mm and at 0.2 mm from the margin of the preparation. A correction factor was calculated to derive real values from measured values. The results were analyzed using a linear regression with robust standard errors, accounting for within-subject correlation introduced by multiple measurements. Shrout-Fleiss Intraclass Correlation Coefficient (ICC) for Inter-Rater Reliability were calculated at each stage., Results: Internal measurements at 0.5 and 0.2 mm from the margin provided data similar to the external margin data. Average inter-assessor differences were in the range of 2 mm. ICC ranged from 0.93 for the 0.5 mm level to 0.97 for the external level., Conclusions: External measurements effectively predict the internal precision at the shoulder level. Horizontal perimarginal sections allow the fit to be studied through the evaluation of a great number of points. Traditional vertical sections for the evaluation of internal fit enable only a few points to be observed. This internal observation method may be suitable for testing new materials.

Context: Pancreatic fistulas are one of the most common and important complications after pancreatic resection and their consequences are a life-threatening event. Thus, they must be treated in the best way and resolved as soon as possible to avoid their morbidity., Methods: Three cases of pancreatic fistula following pancreatic resection were reported. They were treated with percutaneous embolization using a sclerosing substance, prolamine, injected into the Wirsung duct via drainage catheter., Results: No complications of the technique were revealed and closure of the pancreatic fistula was obtained shortly thereafter., Conclusions: The technique is safe and simple and can be repeated several times. It allows good results without complications. Finally, it avoids additional surgery allowing a shorter recovery time and a lower risk of morbidity.

Purpose: The aim of the study was to evaluate the survival rate of resin-bonded fixed partial dentures delivered between 1993 and 2003 in the Department of Prosthodontics of the University of Turin and in several private practices., Materials and Methods: The analysis took into consideration the following variables: preparations, metallic alloys, metal preparation and conditioning of the inner surfaces, isolation during cementation, type of cement, kind of prostheses, number of abutments, and number of missing teeth included in the prostheses., Results: The estimated survival probability for the first debonding or failure was 85% after 5 years and 71% after 10 years., Conclusions: The use of dental dam during cementation reduced the risk of debonding. No differences in survival rate were found for the other parameters.

Purpose: To evaluate the dimensional contour variations of acrylic resin denture bases before and after storage in water., Materials and Methods: The fit of 40 bases was evaluated by measuring the thickness of a layer made with silicone placed between the bases and the casts. The measurements were repeated on a new set of silicone layers after having stored the bases in water for 42 days., Results: Significant differences were found both for the maxillary and the mandibular bases., Conclusion: Water sorption had an important effect on the contour of the prosthetic bases.

Hypothesis: Although postoperative fractionated radiotherapy (PFR) remains the standard method for conservative treatment of breast carcinomas, widespread experience in the use of full-dose intraoperative radiotherapy with electrons (ELIOT) merits its application in novel clinical situations, although long-term results of ongoing clinical trials have not been fully reported., Design: Retrospective case series., Setting: Division of breast surgery in a comprehensive cancer center., Patients: From June 1999 to September 2003 ELIOT was used as the sole radiotherapy in 355 patients with unifocal invasive carcinoma who were candidates for breast-conserving surgery and most of whom were participating in an ongoing institutional trial. In a group of patients in whom PFR was not considered safe or feasible (because of previous mantle field irradiation for Hodgkin disease, cosmetic breast augmentation, severe cardiopathy, large hypertrophic scarring from skin burns, vitiligo, and geographic or social obstacles), ELIOT was performed outside of the ongoing trial., Results: No particular adverse effects, unusual acute reactions, late sequelae, and local or systemic events were noted in these patients after a mean follow-up of 27.3 months., Conclusions: In appropriated selected patients, when it is critical to perform PFR after breast-conserving therapy, a single dose of ELIOT may be considered to avoid mastectomy, reduce potential treatment toxicity, improve quality of life, and resolve logistic problems. The long-term results of ongoing clinical trials will further delineate patients in whom ELIOT may replace PFR.

Background & Aims: Increased morbidity and mortality from liver disease have been reported in chronic hepatitis B surface antigen (HBsAg) carriers, but data on survival are equivocal. To assess the impact of hepatitis B virus (HBV) infection on survival and liver-related complications, we re-evaluated, after a mean follow-up of 30 years, a cohort of 296 blood donors excluded from donation 30 years ago when HBsAg screening became mandatory., Methods: Clinical and ultrasound examination and biochemical and virologic tests were performed. The cause of death was recorded and survival was compared with a control population of 157 HBV-negative blood donors selected at baseline., Results: Thirty-two (10.8%) cases and 14 controls (8.9%) ( P = 0.625) had died; 3 of 32 (9.3%) and 1 of 14 (7.1%) deaths were liver-related. Hepatocellular carcinoma (HCC) caused death in 2 of 296 and 1 of 157 subjects (0.6% in each group). Alcohol-induced cirrhosis occured in the remaining subject. By Cox regression analysis, survival was independently predicted by older age, abnormal gamma-glutamyl transpeptidase (GGT) levels, and presence of medical comorbidities at baseline. Unequivocal liver disease was found in 4 carriers only. No disease decompensation occurred during follow-up. Fifty-nine (32.2%) carriers cleared HBsAg (yearly incidence, 1.0%). Full-length serum HBV DNA was present in 32.2% of persistently HBsAg-positive individuals (average titer always <10 5 copies/mL)., Conclusions: Over a 30-year period, chronic HBV carrier blood donors from Northern Italy did not develop clinically significant liver disease, hepatocellular cancer, or other liver-related morbidity or mortality at a higher rate than uninfected controls. The presence of medical comorbidities, older age at diagnosis, and abnormal GGT levels were independent predictors of death among chronic HBV carriers.

Objectives: In the rush to implement laparoscopic surgery for gastro-oesophageal reflux disease (GORD), the necessity to treat a short oesophagus with dedicated techniques was not always adequately considered. The aim of this study was to define the frequency, patterns and surgical treatment of the intrathoracic migration of the g-o junction and short oesophagus in GORD., Methods: Between 1980 and 2003 our group indicated surgery only for severe and complicated GORD and for drawbacks of medical therapy. Preoperatively patients underwent clinical-instrumental work up. The various degrees of the intrathoracic migration of the g-o junction were classified according to the barium swallow. A total of 319 patients operated upon were grouped according to the periods 1980-1991 and 1992-2003 with 149 and 170 patients, respectively. In the first period only 'open' procedures were performed; the Collis gastroplasty in addition to the antireflux procedure was performed when reduction of the g-o junction in the abdomen required excessive tension. In the second period mini-invasive techniques were progressively introduced. During laparoscopy, the relationship between the g-o junction and the hiatus, and the need to elongate the oesophagus, was assessed by intraoperative oesophagoscopy., Results: The Collis gastroplasty was performed in 29% in the first period and in 23% in the second period. Radiology was a strong predictor of the necessity to elongate the oesophagus. In the second period, global long-term results improved with respect to the first period; P = 0.047 (first period satisfactory 82%, poor 18%, median FU 84, 12-252 months; second period satisfactory 93%, poor 7%, median FU 34, 6-126 months). In the second period, Collis-Nissen and Collis-Belsey procedures had satisfactory results in 80% and poor in 20%., Conclusions: In surgery for severe GORD, the Collis procedure is required in 23% of operations; radiology helps to plan surgery; intraoperative endoscopy avoids unnecessary oesophageal lengthening.

Background/aims: Bile duct strictures may be malignant or benign. In the absence of previous biliary surgery a precise preoperative diagnosis is often difficult, in particular when a tumor mass is absent in the preoperative radiologic findings., Methodology: A review of 179 patients observed between 1982 and 2001 by the same surgical team with a preoperative diagnosis of malignant stricture of the biliary tree. A surgical procedure was performed in 153 of these cases., Results: The presence of a malignant stricture was confirmed by final pathologic examination in 32 of 38 cases (96%) in which a curative resection was performed. A final diagnosis of inflammatory stricture secondary to choledocholithiasis was made in 3 of the remaining 6 cases (4%), along with one case each of sclerosing cholangitis, granular cell tumor and Mirizzi's syndrome, respectively., Conclusions: Precise preoperative evaluation of biliary structures can be very difficult when a tumor mass is absent. Despite the use of invasive procedures and new techniques such as magnetic resonance cholangiopancreatography, a false-positive rate of 4% may be expected. However, whenever a malignancy is not definitely excluded, biliary strictures should be treated as a cholangiocarcinoma.

The prevalence and clinical presentation of reducible and irreducible hiatus hernia were investigated within a gastro-esophageal reflux disease patient population. Reflux symptoms and esophagitis data were collected on 791 patients. The barium swallow was used to assess the esophagogastric junction. Clinical and endoscopic findings were tested to predict radiographic findings. The esophagogastric junction was normal in 17% of patients, 53% had a sliding hiatus hernia with a reducible esophagogastric junction; in 23% it was irreducible although axial, and 8% had massive incarcerated hiatus hernia. The presence of reducible sliding hiatus hernia did not influence clinical presentation. Axial irreducibility presented with long-standing severe symptoms and esophagitis in 80% of cases. Clinical and endoscopic findings predicted axial irreducibility in 52% of cases. In conclusion, sliding hiatus hernia with an reducible esophagogastric junction does not influence the severity of gastroesophageal reflux disease. An irreducible esophagogastric junction is associated with long-standing severe gastroesophageal reflux disease. Clinical and endoscopic findings may only be indicative of axial esophagogastric junction irreducibility; thus barium swallow should be part of the work-up.

Introduction: The aim of the present study was to evaluate the haemodynamic effects of passive leg elevation on the right ventricular function in two groups of patients, one with a normal right ventricular ejection fraction (RVEF) and one with a reduced RVEF., Methods: Twenty coronary patients undergoing elective coronary artery bypass grafting surgery were studied by a RVEF pulmonary artery catheter. The haemodynamic data reported were collected before the induction of anaesthesia (time point 1), just before (time point 2) and 1 min (time point 3) after the legs were simultaneously raised at 60 degrees, and 1 min after the legs were lowered (time point 4). The patients were divided into two groups: group A, with preinduction RVEF > 45%; and group B, with preinduction RVEF < 40%., Results: In group A (n = 10), at time point 3 compared with time point 2, the heart rate significantly decreased (from 75 +/- 10 to 66 +/- 7 beats/min). The right ventricular end diastolic volume index (from 105 +/- 17 to 133 +/- 29 ml/m2), the right ventricular end systolic volume index (from 61 +/- 13 to 77 +/- 24 ml/m2), the systolic systemic arterial/right ventricular pressure gradient (from 93 +/- 24 to 113 +/- 22 mmHg) and the diastolic systemic arterial/right ventricular pressure gradient (from 58 +/- 11 to 66 +/- 12 mmHg) significantly increased. Also in group A, the cardiac index did not significantly increase (from 3.28 +/- 0.6 to 3.62 +/- 0.6 l/min/m2), the RVEF was unchanged, and the right ventricular end diastolic volume/pressure ratio (RVED V/P) did not significantly decrease (from 48 +/- 26 to 37 +/- 13 ml/mmHg). In group B (n = 6) at the same time, the heart rate (from 72 +/- 15 to 66 +/- 12 beats/min), the right ventricular end diastolic volume index (from 171 +/- 50 to 142 +/- 32 ml/m2) and the RVED V/P (from 71 +/- 24 to 39 +/- 7 ml/mmHg) significantly decreased. The cardiac index and the diastolic systemic arterial/right ventricular pressure gradient were unchanged in group B, while the RVEF and the systolic systemic arterial/right ventricular pressure gradient did not significantly increase, and the right ventricular end-systolic volume index did not significantly decrease. All results are expressed as mean +/- standard deviation., Conclusions: We conclude that passive leg elevation caused a worse condition in the right ventricle of group B because, with stable values of cardiac index, of systolic systemic arterial/right ventricular pressure gradient and of diastolic systemic arterial/right ventricular pressure gradient (which supply oxygen), the RVED V/P (to which oxygen consumption is inversely related) markedly decreased. This is as opposed to group A, where the cardiac index, the systolic systemic arterial/right ventricular pressure gradient and the diastolic systemic arterial/right ventricular pressure gradient increased, and the RVED V/P slightly decreased. Passive leg elevation must therefore be performed cautiously in coronary patients with a reduced RVEF.

We examined the value of multislice computed tomography (CT) with three-dimensional (3D) reconstruction of the images as a pre-treatment examination in order to plan endoluminal stenting in 14 patients with large tumours involving the oesophagus and/or the tracheobronchial tree. The measurement of the stenosis obtained during 3D reconstruction of the CT images corresponded to that obtained by endoscopy and to the prosthesis chosen in all cases, with the exception of one patient undergoing double stenting due to inadequate gaseous distension of the oesophageal lumen. 3D CT may add information with respect to axial imaging, and be helpful to better plan and perform stenting of the oesophagus and airways without burdening the preoperative work-up.

Purpose: The aim of our paper is to define, on the basis of a long experience, the anatomical and radiological classification of the progressive phases of the axial intrathoracic migration of the esophago-gastric junction (EGJ), through a standardised radiological method that allows precise identification of the anatomical structures involved., Materials and Methods: From 1981 to 2001, 1388 patients with gastro-esophageal reflux disease (GERD) were examined by traditional contrast techniques that consisted in taking single contrast radiograms of the patients in different positions after administering a small high-density bolus of barium: with the patient standing up in frontal position, at rest, during forced inspiration, and during straining; standing up in a right front 30 degrees oblique position; and in prone position, in a right posterior 30 degrees oblique projection. On the basis of previous radiological and manometric studies aimed at verifying the diagnostic reliability of the radiological examination [8], the distance of the esophago-gastric junction from the esophageal hiatus was indirectly evaluated in an anterior-posterior projection, according to the criteria introduced by Monges [3]. The sling fibers, which form a radiologically detectable cut at the apex of the angle of His, are the lowest portion of the EGJ., Results: On the basis of the radiological findings, and in agreement with the radiological classifications reported in the literature, we evidenced five groups, with pathologically characteristic signs: - 1(st) group (63%) patients who in orthostatic position have an EGJ regularly placed within the abdomen (16%), and patients with the EGJ regularly placed within the abdomen, but with a small sliding intermittent hiatus hernia (47%); - 2(nd) group (13%) cardial tuberosity malposition; - 3(rd) group (7%) concentric hiatus hernia; - 4(th) group (8%) acquired short esophagus; - 5(th) group (9%) massive incarcerated gastric hiatus hernia., Conclusions: Traditional radiography, performed with an adequate technique and with the necessary expedients, allows for the correct interpretation of the anatomical disoder called GERD, and is therefore the first diagnostic approach in defining correct patient management.

In an attempt to reduce mortality from oesophageal adenocarcinoma, it has been recommended to enroll patients with Barrett's oesophagus in endoscopic surveillance programs in order to detect malignant degeneration at an early and possibly curable stage. The aim of this study was to assess the impact of endoscopic biopsy surveillance on the outcome of Barrett's adenocarcinoma. From November 1992 to December 2000, 328 patients with histologically proven oesophageal adenocarcinoma were referred to our department. One hundred of these patients had Barrett's adenocarcinoma. In 12 (12%) patients, cancer was discovered during endoscopic surveillance for Barrett's metaplasia. The prevalence of gastro-oesophatgeal reflux disease in the Barrett's group was 38.8% versus 8.1% (P < 0.01) of non-Barrett's patients. In the surveyed group, there were 9 (75%) early stage tumours (Tis-1N0), versus 10 (11.4%, P < 0.01) in the non-surveyed patients. Three out of five surveyed patients operated on for high grade dysplasia proved to have invasive carcinoma in the oesophagectomy specimen. All surveyed patients were alive after a median follow-up period of 50 months; the median survival in the non-surveyed group was 24 +/- 3 months (P < 0.01). Endoscopic surveillance of Barrett's oesophagus allows early detection of malignant degeneration and better long-term survival than in non-surveyed patients.

The aim of study was to report our experience with an original technique of oesophagectomy without thoracotomy. The operation consists of two complementary approaches. Laparoscopic access enables the surgeon to mobilize the stomach and dissect the distal oesophagus. Cervical access allows dissection of the upper thoracic oesophagus under vision using a special videomediastinoscope. Six patients with oesophageal carcinoma or high-grade dysplasia in Barrett's oesophagus were selected for this operation over the period from October 2000 to December 2001. The operation was completed by minimally invasive access in 4 of the 6 patients. The mean duration of the operation was 240 minutes, and the postoperative hospital stay 9.5 days. One patient required endoscopic pneumatic dilatation of the pylorus 2 weeks after surgery. This technique enhances the safety of conventional oesophagectomy without thoracotomy by avoiding the "blind" dissection of the upper mediastinum. The advantages of laparoscopy include superior staging of the disease, gastric mobilization, and lymphadenectomy of the lower mediastinum. The ideal candidates for this operation are patients with high-grade dysplasia or T1-N0 adenocarcinoma arising from Barrett's oesophagus.

Background: Sentinel node (SN) biopsy has become accepted as a reliable method of predicting the state of the axilla in breast cancer. The key issue, however, is the accuracy of the pathological evaluation of the biopsied node, which should be done intraoperatively whenever possible., Methods: In our initial experience on 192 patients using a conventional intraoperative frozen section method, the false-negative rate was 6.3%, and the negative predictive value was 93.7%. We devised a new and exhaustive intraoperative method, requiring about 40 minutes, in which pairs of sections are taken every 50 microm for the first 15 sections and every 100 microm thereafter, sampling the entire node. Sentinel node metastases were found in 143 of the 376 T1N0 cases examined (38%)., Results: Metastases were always identified on hematoxylin and eosin sections, although in 4% of cases, cytokeratin immunostaining on adjacent sections was useful for confirming malignancy. In 233 patients the SNs were disease-free; of these patients, 222 had metastasis-free axillary nodes, and 11 (4.7%) had another metastatic node., Conclusion: Extensive intraoperative examination of frozen sentinel nodes correctly predicts an uninvolved axilla in 95.3% of cases (negative predictive value). This method is, therefore, suitable for identifying patients in whom axillary dissection can be avoided.

The closest speaking space (CSS) has been considered stable over time, and therefore useful to determine the vertical dimension of occlusion (VDO) in edentulous patients. Clemençon affirms that, in complete denture wearers, CSS is not constant but depends on the thickness of the resin palatal vault, and that is the air volume needed to pronounce words to remain constant. The aim of this study was to evaluate Clemençon hypothesis in a group of edentulous patients rehabilitated with traditional maxillary denture and mandibular implant anchored overdenture. The CSS was determined by means of a kinematics method using the Elite System(R) at 30, 60, 90, 180, 360 days from delivery. The CSS was assessed twice at each stage: with the unmodified denture and a second time after thickening the resin palatal vault by 2 mm with a calibrated wax layer. The CSS after thickening the resin palatal vault was wider. The wider CSS observed can be because of oro-sensory feedback excited by contact between tongue and palatal vault. As hypothesized by Clemençon thickening the resin palatal vault could be a useful procedure to increase the VDO, in cases in which it is too low from the aesthetic stand point.

Background: Coronary artery disease has been reported to be accelerated in patients with chronic renal failure on maintenance dialysis. Coronary artery bypass grafting (CABG) in patients on long-term dialysis is still a debated issue., Methods: We retrospectively reviewed 19 patients (12 men, 7 women, mean age 64 +/- 11.2 years) with end-stage renal disease who underwent CABG between 1990 and 2000. Operative procedures were CABG alone in 15 (78.9%) patients and CABG associated with valve procedures in 4 (21.1%) patients., Results: The early (30-day) mortality rate was 10.5% (2 of 19 patients). Non-fatal complications occurred in 6 patients (31.5%). Four delayed deaths occurred; the actuarial survivals at 1, 2, 5 and 10 years were 0.86 +/- 0.14, 0.78 +/- 0.10, 0.68 +/- 0.13 and 0.54 +/- 0.15 respectively. Among 13 survivors the mean Canadian Cardiovascular Society class was 1.3 +/- 0.3 (p < 0.001 vs preoperatively). ANOVA procedures showed age (p = 0.01), Canadian Cardiovascular Society class > or = III (p < 0.001), urgent/emergency operation (p < 0.001), left ventricular ejection fraction < 0.50 (p < 0.001), a prior myocardial infarction (p = 0.01), a preoperative mean creatinine level > or = 5 mg/dl (p = 0.02) and a duration of dialysis > or = 60 months (p = 0.03) to be strongly related to early and delayed mortality., Conclusions: CABG in patients with dialysis-dependent chronic renal failure is associated with acceptable results. Accurate patient selection, early referral to surgery, and adequate perioperative management are advisable.

Various types of parameters, including cephalometric ones, have been used in the construction of complete denture. This study aimed to evaluate the utility of cephalometric parameters for this purpose. The position of the anterior teeth in a group of 42 edentulous patients, successfully rehabilitated with complete denture according to clinical parameters, was evaluated by cephalometrics following the Ricketts' design. Data obtained were then compared statistically with those reported by Ricketts for dentate subjects, the position of the maxillary incisors was slightly anterior.

Various types of parameters, including cephalometric ones, have been used in the construction of complete denture. This study aimed to evaluate the utility of cephalometric parameters for this purpose. The position of the posterior teeth in a group of 42 edentulous patients, successfully rehabilitated with complete denture according to clinical parameters, was evaluated by cephalometrics. The following were determined: vertical dimension of occlusion (VDO); orientation of the occlusal plane; and subdivision of the denture space. The cephalometric parameters do not correspond to the clinical positioning of the posterior teeth in successful rehabilitation with complete denture.

Background: Dental implant therapy has entered routine clinical practice. However, the failure rate of implants at 5 years, due to biological factors, is still around 7%. The pathogenesis of implant loss involves a complex network of cells and inflammatory mediators. This study evaluated platelet-activating factor (PAF), a potent phospholipid mediator of inflammation, in soft tissue surrounding failed dental implants versus healthy implants., Methods: PAF was estimated on extracted lipids by bioassay on washed rabbit platelets; inflammatory cell populations were assessed semiquantitatively after staining, and microvessel density was evaluated after immunohistochemical staining., Results: Biologically active PAF was detected in the lipid extracts of samples excised from gingival tissue of patients with failed implants, but not in samples from patients with osseointegrated implants or from healthy edentulous subjects. The amount of PAF detected in failed implants was significantly higher than in healthy implants, suggesting a local production of this mediator., Conclusions: The presence of PAF was associated with histopathological findings of local inflammation and increased blood vessel density.

A 48-year-old woman who underwent emergency cardiac surgery for removal of a thrombus partially occluding the mitral valve, developed pulmonary hypertension right ventricular failure and systemic hypotension, in the immediate postoperative period, a clinical condition not well controlled by high doses of epinephrine and dobutamine. The addition of a continuous infusion of norepinephrine in incremental dosages, caused the rise in cardiac index accompanied before by the reduction in the pulmonary pressure and the stability in the systemic pressure, than by the further reduction in the pulmonary pressure and the increase in the systemic pressure. The conclusion is drawn that norepinephrine is useful in the treatment of right ventricular failure which follows a condition of acute pulmonary hypertension, because the improvement of cardiac performance established without adverse effects on the pulmonary pressures whose values on the contrary progressively declined.

Purpose: The aim of this study was to compare the marginal adaptation of metal-ceramic crowns made with 3 different metal substructures., Materials and Methods: Seventy-five gypsum dies were fabricated from a master steel die. They were randomly divided into 3 groups of 25 dies each. A metal coping was prepared on each die using a different technique for each group: composite alloy, electroforming, and cast high-noble alloy. Ceramic was baked on all of the samples following the same protocol and simulating the shape and size of a maxillary central incisor. All specimens were evaluated under a stereomicroscope at 200x magnification. The marginal gap was measured at 8 different points on each specimen before and after ceramic application and also on the master steel die. A total of 3,600 measurements was evaluated. The results were statistically elaborated by means of a t test and one-way analysis of variance (ANOVA)., Results: The ANOVA revealed a significant difference in mean marginal gap before and after ceramic application within each group. Electroforming (mean 32 microns) and high-noble alloy (mean 31 microns) showed better marginal fit after ceramic application and on the master steel die compared to composite alloy (mean 68 microns; P < 0.0001)., Conclusion: Marginal gaps are influenced by the application of ceramic and by the alloy used for the substructure, and the values obtained were within the limits of clinical acceptability (70 microns).