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Extended right or left hemicolectomy are the most common surgical treatments for splenic flexure colon cancer. Extended resection (including distal pancreasectomy and/or splenectomy), has been often indicated for the treatment for the splenic flexure cancer, because the lymphatic drainage at this site is poorly defined and assumed as heterogeneous. Between January 2006 and May 2016, 103 patients with splenic flexure colon cancer were enrolled in the study. We evaluated the clinicopathological findings and outcomes of all patients and associated them to the different surgical treatment. Out of 103 selected cases an extended right hemicolectomy was performed in 22 (21.4%) patients, an extended left hemicolectomy in 24 (23.3%) patients, a segmental resection of the splenic flexure in 57 (55.3%) patients; the combined resection of adjacent organs showing tumor adherence was carried out in 11 (10.7%) patients. The tumor infiltrated near organs (T4) in 5 patients. No significant differences in complications were found among the three groups. In all groups no differences were found in the total number of harvested lymphnodes. After a median follow-up of 42 months, 30 recurrences and 19 deaths occurred (12 for tumor progression). There was no difference in overall and progression free survival among the three different surgical treatments. According to our results, the partial resection of splenic flexure was not associated with a worse prognosis and it was leading for a satisfactory oncological outcome. It is our opinion that the extended surgery is seldomly indicated to cure splenic flexure cancer.

// Maria Napolitano 1 , Crescenzo D’Alterio 1 , Eleonora Cardone 2 , Anna Maria Trotta 1 , Biagio Pecori 3 , Daniela Rega 2 , Ugo Pace 2 , Dario Scala 2 , Giosue Scognamiglio 4 , Fabiana Tatangelo 4 , Carmela Cacciapuoti 5 , Roberto Pacelli 6 , Paolo Delrio 2 , Stefania Scala 1 1 Immunology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori “Fondazione Giovanni Pascale” – I.R.C.C.S.-Naples, Italy 2 Colorectal Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori “Fondazione Giovanni Pascale” – I.R.C.C.S.-Naples, Italy 3 Radiotherapy, Istituto Nazionale per lo Studio e la Cura dei Tumori “Fondazione Giovanni Pascale” – I.R.C.C.S.-Naples, Italy 4 Pathology, Istituto Nazionale per lo Studio e la Cura dei Tumori “Fondazione Giovanni Pascale” – I.R.C.C.S.-Naples, Italy 5 Trasfusional Service, Istituto Nazionale per lo Studio e la Cura dei Tumori “Fondazione Giovanni Pascale” – I.R.C.C.S.-Naples, Italy 6 Department of Advanced Biomedical Sciences, Federico II University School of Medicine, and Istituto di Biostrutture e Bioimmagini – C.N.R., Naples, Italy Correspondence to: Stefania Scala, e-mail: scalaste@gmail.it ; s.scala@istitutotumori.na.it Keywords: MDSC, Treg, radiotherapy, rectal cancer Received: November 03, 2014 Accepted: December 31, 2014 Published: January 21, 2015 ABSTRACT Short-course preoperative radiotherapy (SC-RT) followed by total mesorectal excision (TME) is one therapeutic option for locally advanced rectal cancer (LARC) patients. Since radio-induced DNA damage may affect tumor immunogenicity, Myeloid-derived suppressor cells (MDSCs) and T regulatory cells (Tregs) were evaluated in 13 patients undergoing SC-RT and TME for LARC. Peripheral Granulocytic-MDSCs (G-MDSC) [LIN − /HLA-DR − /CD11b + /CD14 − /CD15 + /CD33 + ], Monocytic (M-MDSC) [CD14 + /HLA-DR −/low CD11b + /CD33 + ] and Tregs [CD4 + /CD25 hi+ /FOXP3 + - CTLA-4/PD1] basal value was significantly higher in LARC patients compared to healthy donors (HD). Peripheral MDSC and Tregs were evaluated at time 0 (T0), after 2 and 5 weeks (T2-T5) from radiotherapy; before surgery (T8) and 6–12 months after surgery (T9, T10). G-MDSC decreased at T5 and further at T8 while M-MDSC cells decreased at T5; Tregs reached the lowest value at T5. LARC poor responder patients displayed a major decrease in M-MDSC after SC-RT and an increase of Treg-PD-1. In this pilot study MDSCs and Tregs decrease during the SC-RT treatment could represent a biomarker of response in LARC patients. Further studies are needed to confirm that the deepest M-MDSC reduction and increase in Treg-PD1 cells within 5–8 weeks from the beginning of treatment could discriminate LARC patients poor responding to SC-RT.

The aim of the study is to evaluate the usability aspects of new deployable, expandable, electrode prototypes, in terms of suitability solutions for laparoscopic applications on the liver, endoscopic trans-oral and trans-anal procedures, electroporation segmentation in several steps, mechanical functionality (flexibility, penetrability), visibility of the electrode under instrumental guidance, compatibility of the electrode with laparoscopic/endoscopic accesses, surgical instruments, and procedural room and safety compatibility. The electroporation was performed on an animal model (Sus Scrofa Large White 60 kg) both in laparoscopy and endoscopy, under ultrasound guidance, and in open surgery. Electrodes without divergence, with needles coming out straight, parallel to each other, and electrodes with peripheral needles (four needles), diverging from the electrode shaft axis (electrode with non-zero divergence) have been tested. To cause an evaluable necrosis effect, the number of electrical pulses was increased to induce immediate liver cell death. Histological samples were analyzed by staining with Haematoxylin/Eosin or by immunohistochemical staining to confirm complete necrosis. The prototypes of expandable electrodes, tested in laparoscopy and endoscopy and in open surgery, respectively, are suitable in terms of usability, electroporation segmentation in several steps, mechanical functionality (flexibility, penetrability), visibility under instrumental guidance, compatibility with laparoscopic/endoscopic accesses, surgical instruments and procedural room safety, patient safety (no bleeding and/or perforation), and treatment efficacy (adequate ablated volume). Electroporation treatment using new deployable expandable electrode prototypes is safe and feasible. Moreover, electrode configurations allow for a gradual increase in the ablated area in consecutive steps, as confirmed by histology and immunohistochemistry.

Purpose To assess the safety and efficacy of oxaliplatin (OXA) plus dual inhibition of thymidilate synthase during preoperative pelvic radiotherapy (RT) in patients with poor prognosis for rectal carcinoma. Methods and Materials Sixty-three patients with the following characteristics, a clinical (c) stage T4, cN1-2, or cT3N0 of ≤5 cm from the anal verge and/or with a circumferential resection margin (CRM) of ≤5 mm (by magnetic resonance imaging), received three biweekly courses of chemotherapy with OXA, 100 mg/m 2 ; raltitrexed (RTX), 2.5 mg/m 2 on day 1, and 5-fluorouracil (5-FU), 900 mg/m 2 (31 patients) or 800 mg/m 2 (32 patients); levo-folinic acid (LFA), 250 mg/m 2 on day 2, during pelvic RT (45 Gy). Pathologic response was defined as complete pathological response (ypCR), major (tumor regression grade(TRG) 2 to 3, with ypCRM-ve and ypN-ve) or minor or no response (TRG4 to -5, or ypCRM+ve, or ypN+ve). Adjuvant 5-FU/LFA regimen was given in cases of cT4, ypN+ve, or ypCRM+ve. Results Overall, neutropenia (40%) and diarrhea (13%) were the most common grade ≥3 toxicities, and tolerability was better with a 5-FU dose reduction. No significant difference in pathologic response was seen according 5-FU dosage: overall, a ypCR was obtained in 24 (39%) patients, and a major response in 20 (32%) patients. The 5-year probability of freedom from recurrence was 80% (95% confidence interval, 68%–92%); it was 56% for the minor/no response group, while it was around 90% for both the ypCR and the major response group. Conclusions OXA, RTX, and 5-FU/LFA administered during pelvic RT produced promising early and long-term results in rectal carcinoma patients with poor prognosis. The postoperative treatment strategy applied in our study supports the risk-adapted approach in postoperative management.

The standard treatment of CRC patients with hepatic metastases is systemic chemotherapy; however, 5-year survival is disappointingly poor despite recent advances. On the other hand, in patients who undergo immediate radical surgical resection of hepatic metastases, 5-year survival reaches 30-40%. Unfortunately, only 15-20% of patients with hepatic metastases are initially eligible for a radical surgical approach. The majority of patients undergoing liver resection relapse after surgery. For this reason, new onco-surgery approaches have been investigated in recent years and the addition of biological agents to chemotherapy, such as bevacizumab and cetuximab, and the improvements of surgical techniques have opened a new scenario in the management of colorectal liver metastases. Recently, the EORTC trial has demonstrated that perioperative chemotherapy (Folfox regimen) is feasible and improves progression-free survival in patients with resectable liver metastases. Chemotherapy and surgery can finally collaborate. In the unresectable setting, the association of chemotherapy with bevacizumab and cetuximab is particularly promising in improving resectability rate. In particular, K-RAS is a molecular response predictive factor that could be particularly useful in selecting the best treatment option in patients with unresectable liver disease.

TAMIS allows transanal excision of rectal lesions by the means of a single-incision access port and traditional laparoscopic instruments. This technique represents a promising treatment of rectal neoplasms since it guarantees precise dissection and reproducible approaches. From May 2010 to September 2015, we performed excisions of rectal lesions in 55 patients using a SILS port. The pre-operative diagnosis was 26 tumours, 26 low and high grade displasias and 3 other benign neoplasias. 11 patients had a neoadjuvant treatment. Pneumorectum was established at a pressure of 15–20 mmHg CO2 with continuous insufflation, and ordinary laparoscopic instruments were used to perform full thickness resection of rectal neoplasm with a conventional 5-mm 30° laparoscopic camera. The average operative time was 78 min. Postoperative recovery was uneventful in 53 cases: in one case a Hartmann procedure was necessary at two postoperative days due to an intraoperative intraperitoneal perforation; in another case, a diverting colostomy was required at the five postoperative days due to an intraoperative perforation of the vaginal wall. Unclear resection margins were detected in six patients: thereafter five patients underwent radical surgery; the other patient was unfit for radical surgery, but is actually alive and well. Patients were discharged after a median of 3 days. Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for low rectal tumors. The feasibility of TAMIS also for malignant lesions treated in a neoadjuvant setting could be cautiously evaluated in the future.

Surgical treatment of distal rectal cancer has long been based only on abdominoperineal excision, resulting in a permanent stoma and not always offering a definitive local control. Sphincter saving surgery has emerged in the last 20 years and can be offered also to patients with low lying tumours, provided that the external sphincter is not involved by the disease. An intersphincteric resection (ISR) is based on the resection of the rectum with a distal dissection proceeding into the space between the internal and the external anal sphincter. Originally described as an open procedure, it has also been developed with the laparoscopic approach, and also this technically demanding procedure is inscribed among those offered to the patient by a minimally invasive surgery. Indications have to be strict and patient selection is crucial to obtain both oncological and functional optimal results. The level of distal dissection and the extent of internal sphincter resected are chosen according to the distal margin of the tumour and is based on MRI findings: accurate imaging is therefore mandatory to better define the surgical approach. We here present our actual indications for ISR, results in terms of operative time, median hospital stay for ISR in our experience and review the updated literature.

Purpose Neoadjuvant therapy is able to reduce local recurrence in rectal cancer. Immediate surgery after short course radiotherapy allows only for minimal downstaging. We investigated the effect of delayed surgery after short-course radiotherapy at different time intervals before surgery, in patients affected by rectal cancer. Methods From January 2003 to December 2013 sixty-seven patients with the following characteristics have been selected: clinical (c) stage T3N0 ≤ 12 cm from the anal verge and with circumferential resection margin > 5 mm (by magnetic resonance imaging); cT2, any N, < 5 cm from anal verge; and patients facing tumors with enlarged nodes and/or CRM+ve who resulted unfit for chemo-radiation, were also included. Patients underwent preoperative short-course radiotherapy with different interval to surgery were divided in three groups: A (within 6 weeks), B (between 6 and 8 weeks) and C (after more than 8 weeks). Hystopatolgical response to radiotherapy was measured by Mandard’s modified tumor regression grade (TRG). Results All patients completed the scheduled treatment. Sixty-six patients underwent surgery. Fifty-three of which (80.3%) received a sphincter saving procedure. Downstaging occurred in 41 cases (62.1%). The analysis of subgroups showed an increasing prevalence of TRG 1–2 prolonging the interval to surgery (group A—16.7%, group B—36.8% and 54.3% in group C; p value 0.023). Conclusions Preoperative short-course radiotherapy is able to downstage rectal cancer if surgery is delayed. A higher rate of TRG 1–2 can be obtained if interval to surgery is prolonged to more than 8 weeks.

Colon cancer rarely combines with abscess of the abdominal wall. We here describe a case treated by extensive surgery, biological mesh abdominal wall repair and negative pressure therapy. A 58-year-old woman presented with a locally advanced right colon cancer with abdominal wall abscess and no evidence of distant metastasis. Extended right hemicolectomy was performed with en-bloc excision of the bladder dome, the right annex and full thickness removal of the anterior abdominal wall including the abscess. Abdominal wall repair was perfomed by a biological mesh (PermacolTMBiologic Implant) and to facilitate healing the patient was then treated with Vacuum-Assisted Closure (V.A.C.?) Therapy. Histology showed a mucinous moderately differentiated adenocarcinoma without nodal metastases (n = 57). Surgical margins including the abdominal wall was tumor free. The postoperative clinical course was uneventful. VA.C.? Therapy treatment reported excellent results in terms of active promotion of the granulation tissue, this allowing for a subsequent placement of a skin graft. Patient is alive and disease-free one year after surgery. The present case shows some peculiar characteristics such as the size of the initial lesion, the abdominal wall abscess and the use of innovative devices such as biological mesh and V.A.C.? Therapy. We demonstrate that extensive surgery for locally advanced colon cancer, in high-volume centers, provides favorable results in terms of survival and quality of life.

The purpose of this study was to assess repeated exercise on the B-200 Isostation as part of rehabilitation work tolerance for nonsurgical patients with lumbar spine disorders. For a consecutive 7-month period, treatment subjects were randomly assigned according to birth date for participation in two groups: a standard work tolerance program only or standard work tolerance program plus inclusion of exercise on the B-200 Isostation. Each patient had similar referral diagnosis requiring conservative treatment. Treatment groups were compared with a control population of volunteers who had neither back pain nor known underlying spinal pathology. All study patients had objective measurement of range of motion, isometric strength, and velocity of motion, on the B-200 Isostation before treatment and at follow-up 3 weeks after treatment. The data showed no significant difference of percent improvement when comparing patients in either of the randomized assigned treatment groups. There was a higher percentage of improvement for each treatment group as compared with the control individuals, however. Based on our study using the B-200 Isostation, there is little objective justification for including exercise on the B-200 dynametric Isostation as part of the rehabilitation routine for improvement of functional physical capacity.

In the last years a wide range of new technique offers the possibility to have R0 resection in colorectal cancer. We report our experience about Single Port Laparoscopic Surgery (SPL) for not advanced right colon cancer and about pelvectomy with cilindric Abdominal Perineal Resection (APR) for advanced rectal cancer. SPL offer mainly cosmetic advantages but also quicker recovery. No touch technique with adequate surgical margin and lymphectomy were respected. Operative time of SPL was 85- 115 minutes, the incision was 5 cm long. There were no complications. Length of hospital stay was 4-6 days. With advanced pelvic cancer, pelvic exenteration with en-bloc resection is indicated. Then we propose a case of a 55 years old woman with a pelvic recurrence from a metastatic rectal cancer involving the right obturator fossa, the vaginal stump, the right ureter. Modern surgical technique give us the chance to offer the most appropriate oncologic surgical treatment.

Address: 1Department of General and Specialistic Surgery, Second University of Naples, Italy, 2Colorectal Surgical Oncology, National Institute of Tumors of Naples, Italy, 3Radiotherapy, National Institute of Tumors of Naples, Italy, 4Radiotherapy, Hospital G. Moscati of Avellino, Italy, 5Medical Oncology, National Institute of Tumors of Naples, Italy, 6Pathology, National Institute of Tumors of Naples, Italy, 7Radiology, National Institute of Tumors of Naples, Italy and 8Endoscopy, National Institute of Tumors of Naples, Italy * Corresponding author

Uterine leiomyosarcomas carry a dismail prognosis. Diagnosis is often an unexpected pathology discovery after hysterectomy for fibroma. Prognosis depends on the degree of locoregional extension and thus on early diagnosis. Extended surgery in case of relapse is sometimes the only possible approach for symptoms control and improvement of quality of life. A case of massive involvement of the abdomen by a relapsed uterine leiomyosarcoma treated by extreme surgery is here presented.

Pharmacist-operated Drug Information Centres (DICs) in Italy were surveyed to gather current information concerning the status, availability and scope of their services.40 DICs were identified and a questionnaire was mailed to them. Topics covered in the questionnaire included staffing, resources, activities and services. The results were compared with previous survey results to identify trends.Information from 36 DICs was analysed (response rate = 90%). Almost all regions of the country are represented. Pharmacists, part-time or full-time, are the most frequent employees working in the DICs. 91% of DICs participate in the P/T committee, 74% takes part in the technical scientific committee for clinical experimentation and/or to the Medical Ethics committee and 60% participate in the hospital infection committee. 90% of DICs produce newsletters and/or bulletins and are involved in research projects. Regarding the question-answer service, requests are mainly concerned with clinical comparative efficacy, therapeutic use, adverse effects. The most frequent users are physicians (67%) followed by pharmacists (16%) while other professionals use DICs to lesser extent. The most frequently used information sources, include "Goodman and Gilman's the pharmacological basis of therapeutics", Martindale: the Extra Pharmacopeia and Physician's Desk Reference; journals such as the Medical Letter, Adverse Drug Reactions Bulletin and Drug and Therapeutic Bulletin, Micromedex, Medline and IOWA databases. Data collected through the questionnaire and details about organisation and activity of Italian DICs are available in "Eupharma", the web-site of the Italian Society of Hospital Pharmacy (SIFO) at the URL http://www.sifo.it.The results parallel the European and American trends. In future communication and collaboration at European level could help to identify best practice models that would result in the standardisation of the activities and in the harmonisation of programs in common areas of interest.

The longbow and crossbow are infrequently encountered by the forensic pathologist. As these weapons become more popular for sport and hunting, more fatalities may be anticipated. Three crossbow deaths (two homicides and one suicide) are presented. Included is the first report of a multiple shot death. The design and physics of the crossbow are described. The proper preservation of evidence, as well as wound analysis and interpretation, in such deaths are detailed.

A work tolerance program was used for rehabilitation treatment of 45 patients with spinal dysfunction. Patients entering the treatment group were prospectively evaluated by objective physical capacity assessment (PCA). Treatment patients averaged 4 weeks of three, one half day sessions per week. These patients were compared with a control group of 33 patients who did not participate in the rehabilitation program but were evaluated by PCA. A telephone review of all patients in each group was carried out at 6- and 12-month follow-up. Results demonstrated that 78% of the rehabilitation treatment group were discharged with an improved functional work capacity. Most importantly, at 6-month follow-up, 73.0% of patients in the treatment group were productively working while only 38% of control group patients were actively employed. In addition, 84.4% showed an improvement in spinal range of motion. The subjective pain scale ratings of these treatment patients demonstrated only 44.4% decreased pain, while 51.1% stayed the same, and two patients increased discomfort. Further medical diagnostics or intervention was required in 24.4% of treatment patients. These findings definitely show that a spinal rehabilitation work-tolerance program based on objective measurement will enhance an increased rate of return to productive employment activity. There is poor correlation of subjective pain assessment when compared to objective PCAs. Therefore, recommendations of patients for return-to-productive work should be based pain ratings. When adjusted for nonselection patients, the authors community-based hospital program showed similar results to other programs. The work tolerance and rehabilitation program in Concord, New Hampshire, demonstrated a significant cost-effective approach; being less expensive, less time-consuming, and less psychologically oriented.

The technique for lumbar discography is not well standardized. To better understand lumbar pathology, we have developed a consistent, reproducible, and relatively simple procedure for lumbar discography. We describe our technique and discuss variables that may differ among individual lumbar discography procedures.

It has been suggested that deep partial-thickness burns of the hand which remain unhealed by 14 days should be excised and totally resurfaced. Controlled data supporting this suggestion is not available. Therefore, a prospective randomized study was performed on 222 burns of the hand to evaluate if excision and skin grafting had any advantage over conservative management. Full-thickness burns were eliminated from the series by excision and grafting them as soon as possible after the diagnosis had been made. To eliminate the very superficial burns, randomization did not take place until the wound had remained unhealed for ten days and would not heal for at least another week. In the two groups, the first ten days were managed similarly with topical antibacterials, escharotomies when necessary, and splinting in the "safe" position. Conservatively managed hands were treated with scarlet red gauze dressing as soon as all eschar had been removed. Those cases randomized into the excision and grafting group were operated upon approximately day 14. Physical therapy was the same in both groups except for the immediate period after grafting. Results were recorded by active and passive joint measurements and photographs on predetermined days throughout the study. In this study, spontaneous healing, taking as much as five weeks, gave acceptable results, comparable to excision and grafting performed at two weeks. The use of range of motion exercises, accurate splinting and pressure allowed optimal healing and prevented stiffness and contractures in both groups. There was no significant difference between the two treatment modalities.

In this paper we present a new learning algorithm for radial basis function neural networks (RBFNN's) based on a supervised fuzzy clustering technique. Our methodology follows the conditional fuzzy clustering presented by W. Pedrycz (1998) and permits to obtain a completely automatic clustering, where data agglomeration is based on both input and output pattern values.