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Esophageal cancer (EC) is an aggressive malignancy with increasing incidence worldwide. Surgery is still the most effective treatment, however, both the high rate of local and distant recurrences and surgery-related complications led us to investigate new preoperative strategies. In this review, we discuss the role of neoadjuvant therapy for locally advanced EC with a focus on preoperative chemoradiation (trimodality treatment). Furthermore, the last fifteen years of published literature and our experience have been also reviewed. In the preoperative setting, few trials have reported a significant benefit with fluoropyrimidine and platinum compound-based neoadjuvant chemotherapy, compared to surgery alone. A large number of phase III trials and meta-analyses have demonstrated improved outcomes with preoperative chemoradiation vs. neoadjuvant chemotherapy or surgery alone. Therefore, trimodality therapy can be considered the most effective option in the management of locally advanced EC. Addition of drugs targeting VEGF or HER2 to standard chemotherapy appears to be feasible but needs to be explored more accurately. FDG-PET may predict both response to neoadjuvant treatments and prognosis

Background: Adjuvant chemoradiotherapy does not represent the standard of care in patients with resected highrisk gastric cancer; however, results from phase 2 and randomizedtrials suggestimprovementin overall survival.We assessedthefeasibilityandtoxiceffectsofchemoradiotherapy as adjuvant treatment in locally advanced gastric cancer. Design: Pilot study. Setting: University hospital. Patients: Twenty-nine patients with T4Nor any TN23 gastric cancer previously treated with potentially curative surgery were enrolled. All of the patients received combined adjuvant chemotherapy with FOLFOX-4 (ie, a combination of folinic acid [leucovorin], fluorouracil, and oxaliplatin [Eloxatin]) for 8 cycles and concomitant radiotherapy (45 Gy in 25 daily fractions over 5 weeks). Radiotherapy was begun after the first 2 cycles of FOLFOX-4, which was reduced by 25% during the period of concomitant radiotherapy. Main Outcome Measures: Treatment toxic effects according to the National Cancer Institute–Common Toxicity Criteria classification, overall and disease-free survival rates, and identification of prognostic indicators. Results: All of the patients completed treatment. Severe hematologic and gastrointestinal toxic effects occurred in 10% and 33%, respectively. No acute hepatic or renal toxic effects were observed; 1 patient experienced severe neurotoxicity. Disease-free and overall survival rates at 1, 2, and 3 years were 79%, 35%, and 35% and 85%, 62.6%, and 50.1%, respectively, and were shown to be substantially better than those observed in untreated patients. Long-term outcome was related to TNM stage, basal serum tumor marker level, and, particularly, lymph node ratio. Conclusion: A multimodal approach with FOLFOX-4 and radiotherapy is feasible and effective for the treatment of patients with resected high-risk gastric cancer.

To date, few studies of preoperative chemotherapy or chemoradiotherapy (crt) in gastroesophageal junction (gej) cancer have been statistically powered, indeed, gej tumours have thus far been grouped with esophageal or gastric cancer in phase iii trials, thereby generating conflicting results. We studied 41 patients affected by locally advanced Siewert type i and ii gej adenocarcinoma who were treated with a neoadjuvant crt regimen [folfox4 (leucovorin&ndash, 5-fluorouracil&ndash, oxaliplatin) for 4 cycles, and concurrent computed tomography&ndash, based three-dimensional conformal radiotherapy delivered using 5 daily fractions of 1.8 Gy per week for a total dose of 45 Gy], followed by surgery. Completeness of tumour resection (performed approximately 6 weeks after completion of crt), clinical and pathologic response rates, and safety and outcome of the treatment were the main endpoints of the study. All 41 patients completed preoperative treatment. Combined therapy was well tolerated, with no treatment-related deaths. Dose reduction was necessary in 8 patients (19.5%). After crt, 78% of the patients showed a partial clinical response, 17% were stable, and 5% experienced disease progression. Pathology examination of surgical specimens demonstrated a 10% complete response rate. The median and mean survival times were 26 and 36 months respectively (95% confidence interval: 14 to 37 months and 30 to 41 months respectively). On multivariate analysis, TNM staging and clinical response were demonstrated to be the only independent variables related to long-term survival. In our experience, preoperative chemoradiotherapy with folfox4 is feasible in locally advanced gej adenocarcinoma, but shows mild efficacy, as suggested by the low rate of pathologic complete response.

Laparoscopic cholecystectomy is associated with a significant risk of gallbladder perforations with bile and stone spillage. The retrieval of dropped stones is sometimes impossible, and intraperitoneally retained stones can be the source of serious complications, such as inflammatory masses or abscesses. The authors describe a patient in whom a large retroperitoneal abscess developed as a result of missed stone fragments during cholecystectomy. Although several cases of intraperitoneal abscess have been reported in the literature, retroperitoneal collection is very uncommon. Crushed and infected stones seem to be the essential prerequisite for abscess formation. Therefore, every attempt should be made to avoid stone spillage and intra-abdominally retained stones. Conversion to open surgery has to be considered in the presence of adverse factors, such as primary acute cholecystitis or cholecystitis induced by previous sphincterotomy, or bilirubinate stones believed to be infected. Abdominal abscess treatment requires removal of missed stones by surgical incision or new laparoscopic procedure because simple percutaneous drainage is usually unsuccessful.

We retrospectively studied clinical picture, diagnosis, treatment and complications of patients with cervico-mediastinal goiter who underwent surgery.Sixty-three patients underwent surgical treatment for cervico-mediastinal goiter in the last 10 years. Thirty-two patients (50.8%) had cervico-mediastinal goiter, 24 patients (33.3%) had mediastino-cervical goiter and 7 patients (11.1%) had mediastinal goiter. Forty-seven cases were prevascular goiters and 16 were retrovascular goiters. We performed total thyroidectomy in 25 patients, subtotal thyroidectomy in 31 patients and in 7 cases the resection of residual goiter. In 50 patients we used a cervical approach, in 12 patients the cervical incision was combined with median sternotomy (6 in total) and in 1 patient with transverse sternotomy.Three patients (4.7%) died in the postoperative period (2 cardio-respiratory failure and 1 pulmonary embolism). The histologic study revelead 5 (7.9%) carcinomas. Postoperative complications were: dyspnea in 7 cases (11.1%), transient vocal cord paralysis in 5 patients (7.9%), temporary hypoparathyroidism in 6 patients (9.5%) and kidney failure in 1 case (1.6%).Cervicotomy is the approach of choice but in some limited cases (carcinoma, thyroiditis, retrovascular goiter, ectopic goiter) the sternotomy should be performed. Postoperative mortality and morbidity is very low, independent of surgical techniques.