Cytoreduction and HIPEC in the treatment of "unconventional" secondary peritoneal carcinomatosis

BACKGROUND: Peritoneal metastasis (PM) is considered a terminal and incurable disease. In the last 30 years, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) radically changed the therapeutic approach for these patients and is regarded as the standard of care for pseudomyxoma peritonei from appendiceal cancer and peritoneal mesotheliomas. Improved survival has also been reported in treating PM from ovarian, gastric, and colorectal cancers. However, PM often seriously complicates the clinical course of patients with other primary digestive and non-digestive cancers. There is increasing literature evidence that helped to identify not only the primary tumors for which CRS and HIPEC showed a survival advantage but also the patients who may benefit form this treatment modality for the potential lethal complications. Our goal is to report our experience with cytoreduction and HIPEC in patients with PM from rare or unusual primary tumors, discussing possible "unconventional" indications, outcome, and the peculiar issues related to each tumor. METHODS: From a series of 253 consecutive patients with a diagnosis of peritoneal carcinomatosis and treated by CRS and HIPEC, we selected only those with secondary peritoneal carcinomatosis from rare or unusual primary tumors, excluding pseudomyxoma peritonei, peritoneal mesotheliomas, ovarian, gastric, and colorectal cancers. Complications and adverse effects were graded from 0 to 5 according to the WHO Common Toxicity Criteria for Adverse Events (CTCAE). Survival was expressed as mean and median. RESULTS: We admitted and treated by CRS and HIPEC 28 patients with secondary peritoneal carcinomatosis from rare or unusual primary tumors. Morbidity and mortality rates were in line with those reported for similar procedures. Median survival for the study group was 56 months, and 5-year overall survival reached 40.3 %, with a difference between patients with no (CC0) and minimal (CC1) residual disease (52.3 vs. 25.7), not reaching statistical significance. Ten patients are alive disease-free, and eight are alive with disease. CONCLUSIONS: Cytoreduction and HIPEC should not be excluded "a priori" for the treatment of peritoneal metastases from unconventional primary tumors. This combined therapeutic approach, performed in an experienced center, is safe and can provide a survival benefit over conventional palliative treatments

Prognostic factors influencing infectious complications after cytoreductive surgery and HIPEC. Results from a tertiary referral center

Background. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. High morbidity restrains its wide application. The aim of this study was to report postoperative infectious complications and investigate possible correlations with preoperative nutritional status and other prognostic factors in patients with peritoneal metastases treated with CRS and HIPEC. Methods. For the study we reviewed the clinical records of all patients with peritoneal metastases from different primary cancers and treated by CRS and HIPEC in our Institution from November 2000 to December 2017. Patients were divided according to their nutritional status (SGA) in group A (well-nourished), B/C (mild or severely malnourished). Possible statistical correlations between risk factors and postoperative complications rates have been investigated by univariate and multivariate analysis. Results. Two hundred patients were selected and underwent CRS and HIPEC during the study period. Postoperative complications occurred in 44% of the patients, 35.3% in SGA-A patients and 53% in SGA-B /C patients. Cause of complications was infective in 42, non-infective in 37 and HIPEC related in 9 patients. Infectious complications occurred more frequently in SGA-B /C patients (32.6% vs. 9.8% of SGA-A patients). The most frequent sites of infection were Surgical Site Infections (SSI, 35.7%) and Central Line Associated BloodStream Infections (CLABSI, 26.2%). The most frequent isolated species was Candida (22.8%). ASA score, blood loss, performance status, PCI, large bowel resection, postoperative serum albumin levels and nutritional status correlated with higher risk for postoperative infectious complications. Conclusions. Malnourished patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are more prone to post-operative infectious complications and adequate perioperative nutritional support should be considered, including immune-enhancing nutrition. Sequential monitoring of common sites of infection, antifungal prevention of candidiasis, and careful patient selection should be implemented to reduce complications rate

L'evoluzione normativa dei distretti industriali

CAP. 1. Prefazione; CAP. 2. Il percorso giuridico dei criteri di definizione dei Distretti; CAP. 3. Le politiche Industriali statali a sostegno dei Distretti Industriali; CAP. 4. Attuazione della normativa nazionale nelle Regioni italiane; 4.1 - Campania; 4.2 - Emilia Romagna; 4.3 - Lombardia; CAP. 5. - La proposta del CNEL sui Distretti Industriali; 6 - Considerazioni conclusive; 7 - Bibliografi

Dal government alla governance: un percorso per l'area PIT Penisola sorrentina amalfitana

INDICE Capitolo I Il governo della complessita'  Introduzione 1 Governance e sviluppo 2 New Public Management: un nuovo approccio alla gestione della cosa pubblica 3 La governance europea tra coesione sociale e ricerca dell'efficienza 4 Brevi considerazioni sulla riforma della Pubblica Amministrazione in Italia 41 La riforma del pubblico impiego 42 Il decentramento amministrativo 43 La riforma del Titolo V della Costituzione 5 Il modello reticolare Capitolo II Pratiche di Governance Introduzione 1 I documenti delle Istituzioni locali 2 La programmazione negoziata 3 Il programma Leader plus 4Il Progetto Integrato Rurale ambito Salerno 1 Costiera Amalfitana Monti Lattari 5 I Progetti Integrati Territoriali 6 PIT Campania 7 PIT penisola sorrentina-amalfitana Capitolo III Analisi Territoriale Introduzione 1 Penisola sorrentina-amalfitana: incrocio di storia e cultura 2 Accessibilita' 31 Analisi territoriale: struttura geomorfologia 32 Ambiente 33 La costa 34 L'erosione costiera 35 Le aree protette: esempio di biodiversita'  e serbatoio di opportunita'  36 La Riserva Marina Statale Punta Campanella Il Parco Regionale Monti Lattari 4 Il clima 5 Analisi demografica 61 Analisi economica 62 Turismo 7 Agricoltura 8 Imprese 9 Commercio e servizi alle imprese 10 Il sistema amministrativo 11 Strumenti di programmazione negoziata 12 Il Piano urbanistico territoriale (PUT) 13 Analisi Field 14 Analisi SWOT Capitolo IV Idea Forza 1L'idea complessa di ambiente come idea forza 12Lo sviluppo sostenibile da Stoccolma ad oggi 13 L'Agenda 21 locale 14 Articolazione del Processo 15 Criticita' riscontrate in Italia 2 Dalla teoria alla pratica 21 Caso Calvia  22 Local Agenda 21 di Calvia  23 Gli obiettivi della Local Agenda 21 24 Le proposte della Local Agenda 21 a Calvia  25 Risultati ottenuti 26 L'esperienza in cifre 27 La Spezia e le cinque Terre 28 Il ruolo di Agenda 21 all'interno della pianificazione strategica 3 Logical framework analysis 31 analisi stakeholder 32 analisi dei problemi e degli obiettivi 33 Quadro logico 4 Idea Progetto: ufficio operativo Agenda 21 41 Dal piano di azione ai piani operativi 42 Piano delle attivita' 43 Piano delle attivita' e progetto dei costi Allegato 1 cronogramma delle attivita'Â

Prevention of Peritoneal Metastases from Colon Cancer in High-Risk Patients: Preliminary Results of Surgery plus Prophylactic HIPEC

The study compared the outcome in patients with advanced colonic cancer at high risk of peritoneal metastases (mucinous or signet-ring cell) without peritoneal or systemic spread, treated with standard colectomy or a more aggressive combined surgical approach. The study included patients with colonic cancer with clinical T3/T4, any N, M0, and mucinous or signet ring cell histology. The 25 patients in the experimental group underwent hemicolectomy, omentectomy, bilateral adnexectomy, hepatic round ligament resection, and appendectomy, followed by HIPEC. The control group comprised 50 patients treated with standard surgical resection during the same period in the same hospital by different surgical teams. Outcome data, morbidity, peritoneal recurrence rate, and overall, and disease-free survival, were compared. Peritoneal recurrence developed in 4% of patients in the experimental group and 22% of controls without increasing morbidity (P < 0.05). Actuarial overall survival curves disclosed no significant differences, whereas actuarial disease-free survival curves showed a significant difference between groups (36.8 versus 21.9 months, P < 0.01). A more aggressive preventive surgical approach combined with HIPEC reduces the incidence of peritoneal recurrence in patients with advanced mucinous colonic cancer and also significantly increases disease-free survival compared with a homogeneous control group treated with a standard surgical approach without increasing morbidity

Peritonectomy Procedures and HIPEC for Peritoneal Metastasis from Ovarian Cancer

Peritoneal carcinomatosis (PC) is the most impressive and frequent evidence of loco-regional spread of epithelial ovarian cancer (EOC). For most of its natural history, PC remains confined to the peritoneal district, thus representing a target for various combinations of surgery and systemic or loco-regional chemotherapy. PC is observed both in primary settings, i.e. in patients first treated for locally advanced EOC, and in recurrent, previously treated, EOC patients at any FIGO stage. Since 2000s, the use of hyperthermic intraperitoneal chemotherapy (HIPEC) combined with maximum cytoreduction (peritonectomy) has gradually spread in the treatment of PC from ovarian cancer, as well as for gastrointestinal carcinomatosis and primary tumours of the peritoneum. Use of combined peritonectomy + HIPEC in the treatment of ovarian carcinomatosis is the most discussed issue among those concerning peritoneal surface malignancy (PSM). The main criticism concerns the use of HIPEC, since the need for maximal cytoreduction is consolidated and does not raise any doubts. Communities of surgeon and oncologic gynaecologists who believes in the role of HIPEC have started controlled clinical trials aimed at clarifying the role of HIPEC associated to peritonectomy, but these studies are difficult to conduct and time-consuming. At present and pending the results of future prospective trials, the role and limits of application of the procedure are drawn from experiences from three basic study groups: collective reviews, multicentre studies, monocentric case studies produced by high-volume HIPEC centers. A comprehensive literature review and an in-depth analysis of our personal experience, based on the largest monocentric case series (130 cases), have helped to provide an assessment on the role of peritonectomy + HIPEC in about 2000 patients treated for initial and recurrent PC from ovarian cancer. Comparison of the overall results drawn from these studies, indicates that peritonectomy + HIPEC is able to guarantee in these patients better overall survival (OS) and higher progression-free survival (PFS) rates than those derived from traditional treatments, with acceptable morbidity and mortality. Notwithstanding, some specific aspects, including the role of chemoresistance and neoadjuvant and adjuvant treatments, should be clarified by further experience and the results of on-going trials

Transplastomic tobacco plants expressing a fatty acid desaturase gene exhibit altered fatty acid profiles and improved cold tolerance

The possibility of altering the unsaturation level of fatty acids in plant lipids by genetic transformation has implications for the stress tolerance of higher plants as well as for their nutritional value and industrial utilisation. While the integration and expression of transgenes in the plastome has several potential advantages over nuclear transformation, very few attempts have been made to manipulate fatty acid biosynthesis using plastid transformation. We produced transplastomic tobacco plants that express a Delta9 desaturase gene from either the wild potato species Solanum commersonii or the cyanobacterium Anacystis nidulans, using PEG-mediated DNA uptake by protoplasts. Incorporation of chloroplast antibioticinsensitive point mutations in the transforming DNA was used to select transformants. The presence of the transcript and the Delta9 desaturase protein in transplastomic plants was confirmed by northern and western blot analyses. In comparison with control plants, transplastomic plants showed altered fatty acid profiles and an increase in their unsaturation level both in leaves and seeds. The two transgenes produced comparable results. The results obtained demonstrate the feasibility of using plastid transformation to engineer lipid metabolic pathways in both vegetative and reproductive tissues and suggest an increase of cold tolerance in transplastomic plants showing altered leaf fatty acid profiles. This is the first example of transplastomic plants expressing an agronomically relevant gene produced with the ‘‘binding-type’’ vectors, which do not contain a heterologous marker gene. In fact, the transplastomic plants expressing the S. commersonii gene contain only plant-derived sequences, a clear attraction from a public acceptability perspective

Premature Ejaculation patients and their partners: arriving at a clinical profile for a real optimization of the treatment.

The aim of the study is to extrapolate clinical features of Premature Ejaculation (PE) patients and female partners of men affected with PE, in order to get a profile that can be of assistance for physicians within the dynamics of a couple, one of which is a PE patient. An observational, non-interventional, cross-sectional epidemiological study entitled IPER (Italian Premature Ejaculation Research) was conducted and included two different cohorts of subjects that were randomly sampled from a patient dataset of selected General Practitioners: 1. IPER-M sub-cohort (1.104 subjects) was made of male subjects in which they were then distinguished patients with or without PE based on the score of the PEDT questionnaire; IPER-F sub-cohort (1.109 subjects) was made of female subjects from an independent sample of women (therefore not the partners of the IPER-M males) in which they then distinguished those partners of a male subject with PE or not. In addition to an identical general questionnaire to explore demographic aspects and habits, each subcohort was then evaluated using validated questionnaires. No differences were noted between PE+/PE- patients in terms of alcohol consumption, smoking habits, physical activity nor stress condition in everyday life, employment, socio-economic class and marital status. While the prevalence of PE proportionally increased with age, excluding the 50-59 and 70-80 years decades, in the IPER-M group an overall statistically significant difference for the mean age between the PE+ and PE- groups (p = 0.002) was detected, but without reaching any difference amongst the different age classes in the IPER-F group. The PE+ patients reported a significantly lower frequency rate of sexual intercourse, worse QoL (p = 0.006 and p < 0.0001, respectively), and increased anxiety status (p < 0.0001 for both subgroups). This study shows that, rather than talking with a patient affected by PE it would be advisable to introduce the concept of couple counseling with the person patient and his partner, because it is only through classification of both partners as one couple and a full understanding of their mutual sexual experience that PE treatment can be optimized and its results measured accurately

Tre Lettere Di Ipomonetico Filopatrido Ad Eritimo Proselito, Colle quali si dáa contezza del critico Scrutinio sopra l' Etáa, e la Patria di San Prospero Vescovo di Reggio, inserito nell' Opera intitolata: Ad Monasterii Divi Prosperi Regiensis Commentaria Historica Appendix seu Pars Tertia

TRE LETTERE DI IPOMONETICO FILOPATRIDO AD ERITIMO PROSELITO, COLLE QUALI SI DÁA CONTEZZA DEL CRITICO SCRUTINIO SOPRA L' ETÁA, E LA PATRIA DI SAN PROSPERO VESCOVO DI REGGIO, INSERITO NELL' OPERA INTITOLATA: AD MONASTERII DIVI PROSPERI REGIENSIS COMMENTARIA HISTORICA APPENDIX SEU PARS TERTIA Tre Lettere Di Ipomonetico Filopatrido Ad Eritimo Proselito, Colle quali si dáa contezza del critico Scrutinio sopra l' Etáa, e la Patria di San Prospero Vescovo di Reggio, inserito nell' Opera intitolata: Ad Monasterii Divi Prosperi Regiensis Commentaria Historica Appendix seu Pars Tertia (1) Titelblatt (1) Lettera Prima (3) Lettera Seconda (33) Lettera Terza (65) Prospectus Monastery (105