Solitary pulmonary nodules: Morphological and metabolic characterisation by FDG-PET-MDCT [Nodulo polmonare solitario: Caratterizzazione morfologico-metabolica mediante imaging integrato TCms/FDG-PET]

Purpose. This study was done to analyse the additional morphological and functional information provided by the integration of [18F]-2-fluoro- 2-deoxy-D-glucose positron emission tomography ([18F]-FDG-PET) with contrast-enhanced multidetector computed tomography (MDCT) in the characterisation of indeterminate solitary pulmonary nodules (SPNs). Materials and methods. Fifty-six SPNs, previously classified as indeterminate, were evaluated using a Discovery ST16 PET/CT system (GE Medical Systems) with nonionic iodinated contrast material and [18F]-FDG as a positron emitter. Images were evaluated on a dedicated workstation. Semiquantitative parameters of [18F]-FDG uptake and morphological, volumetric and densitometric parameters before and after contrast administration were analysed. Results were correlated with the histological and follow-up findings. Results. Twenty-six SPNs were malignant and 30 were benign. Malignant lesions at both PET/CT and histology had a mean diameter of 1.8±1.2 cm, a volume doubling time (DT) of 222 days, a mean standardized uptake value (SUV) of 4.7 versus 1.08 in benign lesions and a mean postcontrast enhancement of 44.8 HU as opposed to 4.8 HU in benign nodules. Malignant lesions had a significantly shorter doubling time and significantly greater postcontrast enhancement compared with benign nodules. Based on the SUV and using a cut-off value of >2.5, PET/CT had a sensitivity of 76.9%, specificity of 100%, diagnostic accuracy of 89.2%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 83.3%. Based on doubling time (cut off <400 days), it had a sensitivity of 76.9%, specificity of 93.3%, accuracy of 85.7%, PPV of 90.9% and NPV of 82.3%. Based on postcontrast enhancement (cut off >15 HU), it had a sensitivity of 92.3%, specificity of 100%, accuracy of 96.4%, PPV of 100% and NPV of 93.7%. Conclusion. PET/CT allows accurate analysis of anatomical/morphological and metabolic/functional correlations of SPN, providing useful data for identifying and locating the disease, for differentiating between malignant and benign nodules and for establishing the aggressiveness and degree of vascularity of pulmonary lesions. Therefore, partly in view of the considerable reduction in time and cost of the single examinations, we believe that PET/CT will gain an increasingly dominant role in the diagnostic and therapeutic approach to lung cancer, especially in the preclinical phase. © 2007 Springer-Verlag

3-Tesla MR spectroscopy in patients subjected to bone marrow transplantation: clinical correlations.

PURPOSE: This study evaluated the usefulness of 3-Tesla magnetic resonance (MR) spectroscopy in patients with non-Hodgkin's lymphoma (NHL) undergoing bone marrow transplantation (BMT). MATERIALS AND METHODS: Twelve NHL patients who were candidates for BMT underwent three MR examinations of the lumbosacral spine: before ablative therapy for BMT, 15±4 days and 54±24 days after BMT. The MR study was supplemented by spectroscopic analysis. The lipid content was calculated and expressed as a percentage of lipid signal intensity relative to total signal intensity [fat fraction (FF)]. RESULTS: In the first MR study, the FF was 62.5±7%, in the second it was 70.75±5% and in the third it was 75±1%. We observed a statistically significant difference between FF values calculated at the various MR studies (p=0.02) and between red blood cell count (p=0.017), platelet count (p=0.003) and haematocrit (p<0.001) at the three MR studies. FF had a statistically significant correlation with the number of circulating platelets (p<0.01) CONCLUSIONS: MR spectroscopy of the bone marrow of NHL patients undergoing BMT is noninvasive and highly sensitive for characterising and monitoring bone marrow after BMT

Anomalous development of the inferior vena cava: Case reports of agenesis and hypoplasia

we reported the cases of two adult male patients who were admitted to our emergency room with abdominal pain and dyspnea caused by gallstones and pulmonary embolism respectively. during the radiological investigations, as collateral findings, we found two anomalous development of the inferior vena cava. these conditions affect about 4% of population and, although asymptomatic or mildly symptomatic, are associated with thrombotic manifestations as deep vein thrombosis and pulmonary embolism. the prompt recognition of these anomalies is necessary in order to prevent the complications associated with these conditions and to set the best therapy for patients

Oesophagus Cancer : wich treatment ? Personal experience using a Multidisciplinary Therapeutic Approach.

BachGround :Actually the oesophageal and cardias carcinoma is a high morbility and mortality disease too.The main reason is a underestimated disphagic disease with a delayed clinical evaluation. The result is a very low quality of life and severe mortality. The purpose of this study was to reduce the high grade of the disphagia and improve the quality of life in patients affected by oesophagus cancer stenosis using a MultiDisciplinary Therapeutic Approach. Materials & Methods :In our last Universitary Endoscopic Ambulatory,during 10 years, we observed 135 patients affected by oesophageus disease .The grave or severe disphagia was the more frequent symptom.Sometime,there were other symptoms linked to disphagia (tab.1). The 89% cases arrived to our evaluation without an adeguate clinical-endoscopic-radiological documentation.All had previously been treated with anti H2 and pro-kinetic drugs for several months.We observed 1)Primitive Neoplasm (78/120 p.=65%) 2)Secondary Neoplasm(12/120 p.= 10%) 3)Neoplastic Recurrences (17/120 p.=14.5%) 4)Flogistic Disease (5/120p.=4.16%) 5)Achalasia (5/120p.=4.16) 6)Barrett’s Disease (3/120p.=2.5%) (tab.2-3).Male/female ratio was 2.5/1.Various risk factors were classified (smoke=60%,Alchohol intake over 1000cc/die=60%,Obesity=25%,Barrett =2.5%)(tab.4) All the patients were valued with accurate clinical evaluation using a Multianalises Score System (tab.5-6-7-8-) In evaluating operability,we considered several parameters concerning the General Clinical Status and the Neoplasm Stage (TNM) (tab.9-10-11) Surgical treatment was established for only a few patients (15/135) which might gain advantages one-step open-surgical oesophagectomy,alone or combined to chemo-radio therapy,in according to international leterature. The others 120 patients with disphagia (III°rd level=80 p., IV°th level = 40 p.) were valued no-responders to classic open-VLS Surgery (tab.12-13).They were treated with ELS (Endoscopic Laser Surgery) alone or combined to others treatments (EGDS Savary Dilatation,Endoprosthesis, X-Rays Therapy). Flexible fibre CO2 Laser and single-use pinches were employed to perform this kind of treatment.The Endoscopic Laser Energy was administered with a continuous power flow (20-40 Watts) and mixed Technique.We used a specific treatment to single patient and disease.The single dose ranged 800-2000 Joules.The procedure was cyclically repeated every 15-60 days.The Total Dose ranged 2000-6000 Joules.In general ,we prefered the EGDS Savary Dilatation before the LES and positionating self expanding covered or non-covered stents (102)after ELS according Radiologist collegues. If necessary ,RadioTherapy (mean dose 39 Gy) was associated too. Results : we obtained a total recanalisation in flogistic disphagia disease.We obtained an important recanalisation in the first 12 months in the 85% of the neoplastic stenosis and an enough recanalisation in the 60% of the cases between 12-24 months from the first treatment.After 24 months ,we obtained an useful canalisation only in the 30% of the cases(tab.14).We registered some complications link to the treatment.(tab.15).The only one intra-operative death was in a 78 y.old patient affected by cardiomegaly.Probably ,the cause was an arrest hearth because of the fatality laser energy propagation.So,the mortality for this laser-surgery treatment was lower than 1% and also the morbidity was reduced when compared to the other centers ‘dates.We registered oesophagus Iatrogenous perforations (3) too.These healed spontaneously after specific therapy (2) using thoracic drainage,antibiotic drugs,total parenteral nutrition).It has been necessary to place only one covered endoprosthesis. Our protocol provided a 3-years follow-up with long term survival ranging 30-900 days. Conclusions :ELS could be considered the main treatment to inoperable oesophageal cancer.According our dates we think that the Treatment don’t influence the survival ,reduces absolutely the disphagic symptoms and improve the quality of life. The Cost/Benefit is profitable too.(tab.16) Tab.1 Symptom % Dysphagia 78 Epigastric pain 6 Heatburn 3 Weight loss only 3 Odinophagia 2 Vomiting/Regurgitation 2 Fatigue 2 GastroIntestinal bleeding 1 Nausea 1 Indigestion 1 Sore throat 1 Tab.2 Patology Diagnosis n.patients % Primitive Cancer 78 65 Secondary Cancer 12 10 K. Recurrences 17 14.5 Flogistic disease 5 4.16 Achalasia 5 4.16 Barrett’esophagus 3 2.5 Tab.3 Primitive Cancer n.patients % Cervical esoph. 10/78 12.8 Thoracic 17/78 21.7 Cardias 51/78 66.5 Tab.3 Secondary Cancer n.patients % Cervical esoph. (from laringeal K.) 7/12 58.2 Cardias (from lung-mediastinic K.) 5/12 39.7 Tab.4 Risk Factors Smoke 70 % Alcohol 60 % Obesity 30 % Barrett’s esophagus 2.5 % Tab.5 Clinical Evaluation General Status Pulmonary Function Cardio-Vascular Function Hepatic Function Renal Function Neurological Function Diabetes Tumor Stage Tab.6 Clinical Evaluation - General Status Sex Age Karnofsky Index Alcohol Abuse Tobacco Abuse Weight loss Dispepsia Mental Cooperation Blood examination Tab.7 Clinical Evaluation - Pulmonary/Renal Function Vital Capacity V.C Focal Expiratory Volume FEV 1 Peak Flow PaO2 mm/Hg PaCO2 mm/Hg Creatinine Clearance mg/ml Tab.8 Clinical Evaluation - Cardiac/Hepatic Function ECG X-rays Chest Cardiologist Visit Serum Albumin Bilirubin P.T- P.T.T Aminopyrine Breath Test Cirrhosis Tab.9 Clinical Evaluation - Mental cooperation / Risk Karnofsky Index > 80 & good cooperation / Normal Karnofsky Index < 80 & good cooperation/ Compromised Karnofsky Index < 80 & bad cooperation/Severely impaired Tab.10 Clinical Evaluation - Cardiac Function / Risk Normal Normal Compromised Increased Severely impaired Highest Tab.10 Clinical Evaluation -Pulmonary Function / Risk VC > 90% PaO2 >70 mm/Hg Normal VC < 90% PaO2< 70 mm/Hg Compromised Tab.11 Clinical Evaluation –Hepatic Function / Risk ABT > 0.4 Normal ABT < 0.4 no Cirrhosis Compromised Cirrhosis Severely Impaired Tab.12 Conditions for inoperable patients III th Stage Neoplasm T3 N2 M0-1 Age over 75 Cardio-Vascular disease Coagulopaties Weight loss Immuno Compromised Tab.13 Pre-Operative Disphagia Patients III grade IV grade 120 80 40 Tab.14 Post-Operative Disphagia grade % n.patients Follow-up/months I 85 102/120 <12 I 60 72/120 >12 <24 II 30 36/120 >24 Tab.15 Intra-Peri Operative Complications n.patient % Exitus 1/120 0.83 Iatrogenous perforation 3/120 2.5 Re – Stricture (after RadioTherapy) 2/120 1.66 Tab.16 Cost effectiveness in the management of oesophageal K. Surgery RadioTherapy Laser Stents No Treatm. Median Cost $ 8070 4720 3520 2450 1390 Range 2540-39780 3364- 6687 2530- 6340 1647- 5550 1132- 2348 Cost /month Survival 457 364 342 / / References : 1. Palliative therapy for patients with unresecable esophageal. Freeman R.K.,Ascioti A.J.,Muhidara R.J. Surg Clin North Am 2012 Oct;92(5):1337-51 2. The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer. Eroghu A.,Turkylmaz A.,Subasi M.,Kareoglanoghu N Dis Esophagus 2010 Jan;23(1):64-90 3. Advanced esophageal carcinoma recanalization. Molna’rova’ A Klin Onkol 2008;21(5):309-312 4. Inoperable esophageal cancer and out come of palliative care. Besharat S.,Jabbari A.,Semnani S.,Keshtkar A.,Marjanis World J GastroEnterol 2008 June 21;14(23):3725-8 5. Causes and treatment of recurrence dysphagia after self-expanding metallic stent placement for palliation of esophageal carcinoma. Homs MY.,Steyerberg E.W.,Knipers E.J.,Van der Goost A.,Haringsma J.,Van Blankenstein M.,Siersema P.D. Endoscopy 2004 Oct;36(10):880-6 6. Endoscopic Laser Surgery in Flogistic Disease and non operable cancer of oesophagus. Fiorito R.,Bellanova G.,Milito G.,Filingeri V.,Venditti D.,Casciani C.U. Atti 7mo Congresso Nazionale della Societa’ Italiana di Chirurgia Endoscopica;Urbino 9-11 Sett/2001 7. Neoplasie inoperabili del cardias : degenerazione e dislocamento di self expanding covered stents dopo RadioTerapia. Fiorito R. , Moraldi A. , Pocek M.,Sergiacomi G.L.,Bellanova G.,Filingeri V.,Casciani C.U. Atti 101°Congresso Societa’ Italiana di Chirurgia; Catania 10-13 Ott./1999 Abstrac book p.129-130 8. Palliation of inoperable oesophageal carcinoma treated by self expanding stents. Guemes A.,De Gregorio M.A., Salinas J.C., Torcal J.,Sousa R.,Burdio F.,Fernandez J.and Lozano R. Br J Surg 1998;85,supp.2:182-184 9. Restenting malignant oesophageal strictures LaGattolla N.R.F., Rowe H., Anderson H.,Dunk A.A Br J Surg 1998;85:261-263 10. Management of malignant oesophageal obstruction with self-expanding metallic stents. Cowling M.G., Hale A., Grundy A. Br J Surg 1998;85:264-266 11. Advances in the surgical treatment of oesophageal cancer. Sugimachi K. Br J Surg 1998;85:289-290 12. Palliative treatment of neoplastic oesophageal strictures by self-expanding metallic stents. Pocek M., Iascone C., Fiorito R. Atti 6 th World Congress of the International Society for Disease of the oesophagus; Milan Aug.23-29/1995:vol.I ,pag.501-504 13. Esophageal cancer and palliation of dysphagia. Massey S. Clin J Oncol Nurs 2011 June:15(3):327-

FedCohesion: Federated Identity Management in the Marche Region

Federated identity management is a set of technologies and processes supporting dynamically distribute identity information. Its adoption in Public Administrations maintains organizations autonomy giving at the same time citizens support to access the services that are distributed across security domains. In this paper, we propose the Marche Region experience for what concern federate identity management focusing on the regional authentication framework, named FedCohesion. It is bases on Security Assertion Markup Language standard and it results from Cohesion re-engineering. It is the old style legacy authentication framework. We first present resulting architecture showing supported identification process and pilot applications. Lessons learned and opportunities have been also presented

Percutaneous kyphoplasty: New treatment for painful vertebral body fractures

Aims and Background: The purpose of this study was to assess the effectiveness and safety of Percutaneous Kyphoplasty as a new method of treatment for pain deriving from vertebral compression firactures (VCF). Patients and Methods: We treated sixteen patients with unremitting pain over spine, which increased particularly when pressure was applied over the spinous process, in absence of neurological signs and refractory to conventional medical therapy. Results: The method demonstrated swift pain relief associated with an evident augmentation in the resistance and restoration of the vertebral body's physiological shape. Polymethylmethacrylate (PMMA) leakages were not observed in the epidural space or foraminal area. The presence of complications such as pulmonary embolism involving the venous plexus, toxicity due to PMMA and infection due the procedure did not occur. Conclusion: Kyphoplasty is an effective, alternative, simple and safe treatment of vertebral collapse consequent to osteoporosis, aggressive haemangiomas, myelomas and metastases

Idiopathic Pulmonary Fibrosis (IPF) incidence and prevalence in Italy

Background: Studies of Idiopathic Pulmonary Fibrosis (IPF) epidemiology show regional variations of incidence and prevalence; no epidemiological studies have been carried out in Italy. Objective: To determine incidence and prevalence rates of IPF in the population of a large Italian region.Methods: in this cross-sectional study study data were collected on all patients of 18 years of age and older admitted as primary or secondary idiopathic fibrosing alveolitis (ICD9-CM 516.3) to Lazio hospitals, from 1/1/2005 to 31/12/2009, using regional hospital discharge, population and cause of death databases. Reporting accuracy was assessed on a random sample of hospital charts carrying the ICD9-CM 516.3, 516.8, 516.9 and 515 codes, by reviewing radiology and pathology findings to define cases as IPF “confident”, “possible” or “inconsistent”. Results: Annual prevalence and incidence of IPF were estimated at 25.6 per 100,000 and 7.5 per 100,000 using the ICD9-CM code 516.3 without chart audit while they were estimated at 31.6 per 100,000 and at 9,3 per 100,000 for the IPF “confident” definition after hospital chart audit. Conclusion: The data provide a first estimate of IPF incidence in Italy and indicate that incidence and prevalence in southern European regions may be similar to those observed in northern Europe and North America. (Sarcoidosis Vasc Diffuse Lung Dis 2014; 31: 191-197

MRI of the lung (3/3)-current applications and future perspectives

BACKGROUND: MRI of the lung is recommended in a number of clinical indications. Having a non-radiation alternative is particularly attractive in children and young subjects, or pregnant women. METHODS: Provided there is sufficient expertise, magnetic resonance imaging (MRI) may be considered as the preferential modality in specific clinical conditions such as cystic fibrosis and acute pulmonary embolism, since additional functional information on respiratory mechanics and regional lung perfusion is provided. In other cases, such as tumours and pneumonia in children, lung MRI may be considered an alternative or adjunct to other modalities with at least similar diagnostic value. RESULTS: In interstitial lung disease, the clinical utility of MRI remains to be proven, but it could provide additional information that will be beneficial in research, or at some stage in clinical practice. Customised protocols for chest imaging combine fast breath-hold acquisitions from a "buffet" of sequences. Having introduced details of imaging protocols in previous articles, the aim of this manuscript is to discuss the advantages and limitations of lung MRI in current clinical practice. CONCLUSION: New developments and future perspectives such as motion-compensated imaging with self-navigated sequences or fast Fourier decomposition MRI for non-contrast enhanced ventilation- and perfusion-weighted imaging of the lung are discussed. Main Messages • MRI evolves as a third lung imaging modality, combining morphological and functional information. • It may be considered first choice in cystic fibrosis and pulmonary embolism of young and pregnant patients. • In other cases (tumours, pneumonia in children), it is an alternative or adjunct to X-ray and CT. • In interstitial lung disease, it serves for research, but the clinical value remains to be proven. • New users are advised to make themselves familiar with the particular advantages and limitations

Oesophagus Cancer : wich treatment ? Personal experience using a Multidisciplinary Therapeutic Approach.

BachGround :Actually the oesophageal and cardias carcinoma is a high morbility and mortality disease too.The main reason is a underestimated disphagic disease with a delayed clinical evaluation. The result is a very low quality of life and severe mortality. The purpose of this study was to reduce the high grade of the disphagia and improve the quality of life in patients affected by oesophagus cancer stenosis using a MultiDisciplinary Therapeutic Approach. Materials &amp; Methods :In our last Universitary Endoscopic Ambulatory,during 10 years, we observed 135 patients affected by oesophageus disease .The grave or severe disphagia was the more frequent symptom.Sometime,there were other symptoms linked to disphagia (tab.1). The 89% cases arrived to our evaluation without an adeguate clinical-endoscopic-radiological documentation.All had previously been treated with anti H2 and pro-kinetic drugs for several months.We observed 1)Primitive Neoplasm (78/120 p.=65%) 2)Secondary Neoplasm(12/120 p.= 10%) 3)Neoplastic Recurrences (17/120 p.=14.5%) 4)Flogistic Disease (5/120p.=4.16%) 5)Achalasia (5/120p.=4.16) 6)Barrett’s Disease (3/120p.=2.5%) (tab.2-3).Male/female ratio was 2.5/1.Various risk factors were classified (smoke=60%,Alchohol intake over 1000cc/die=60%,Obesity=25%,Barrett =2.5%)(tab.4) All the patients were valued with accurate clinical evaluation using a Multianalises Score System (tab.5-6-7-8-) In evaluating operability,we considered several parameters concerning the General Clinical Status and the Neoplasm Stage (TNM) (tab.9-10-11) Surgical treatment was established for only a few patients (15/135) which might gain advantages one-step open-surgical oesophagectomy,alone or combined to chemo-radio therapy,in according to international leterature. The others 120 patients with disphagia (III°rd level=80 p., IV°th level = 40 p.) were valued no-responders to classic open-VLS Surgery (tab.12-13).They were treated with ELS (Endoscopic Laser Surgery) alone or combined to others treatments (EGDS Savary Dilatation,Endoprosthesis, X-Rays Therapy). Flexible fibre CO2 Laser and single-use pinches were employed to perform this kind of treatment.The Endoscopic Laser Energy was administered with a continuous power flow (20-40 Watts) and mixed Technique.We used a specific treatment to single patient and disease.The single dose ranged 800-2000 Joules.The procedure was cyclically repeated every 15-60 days.The Total Dose ranged 2000-6000 Joules.In general ,we prefered the EGDS Savary Dilatation before the LES and positionating self expanding covered or non-covered stents (102)after ELS according Radiologist collegues. If necessary ,RadioTherapy (mean dose 39 Gy) was associated too. Results : we obtained a total recanalisation in flogistic disphagia disease.We obtained an important recanalisation in the first 12 months in the 85% of the neoplastic stenosis and an enough recanalisation in the 60% of the cases between 12-24 months from the first treatment.After 24 months ,we obtained an useful canalisation only in the 30% of the cases(tab.14).We registered some complications link to the treatment.(tab.15).The only one intra-operative death was in a 78 y.old patient affected by cardiomegaly.Probably ,the cause was an arrest hearth because of the fatality laser energy propagation.So,the mortality for this laser-surgery treatment was lower than 1% and also the morbidity was reduced when compared to the other centers ‘dates.We registered oesophagus Iatrogenous perforations (3) too.These healed spontaneously after specific therapy (2) using thoracic drainage,antibiotic drugs,total parenteral nutrition).It has been necessary to place only one covered endoprosthesis. Our protocol provided a 3-years follow-up with long term survival ranging 30-900 days. Conclusions :ELS could be considered the main treatment to inoperable oesophageal cancer.According our dates we think that the Treatment don’t influence the survival ,reduces absolutely the disphagic symptoms and improve the quality of life. The Cost/Benefit is profitable too.(tab.16) Tab.1 Symptom % Dysphagia 78 Epigastric pain 6 Heatburn 3 Weight loss only 3 Odinophagia 2 Vomiting/Regurgitation 2 Fatigue 2 GastroIntestinal bleeding 1 Nausea 1 Indigestion 1 Sore throat 1 Tab.2 Patology Diagnosis n.patients % Primitive Cancer 78 65 Secondary Cancer 12 10 K. Recurrences 17 14.5 Flogistic disease 5 4.16 Achalasia 5 4.16 Barrett’esophagus 3 2.5 Tab.3 Primitive Cancer n.patients % Cervical esoph. 10/78 12.8 Thoracic 17/78 21.7 Cardias 51/78 66.5 Tab.3 Secondary Cancer n.patients % Cervical esoph. (from laringeal K.) 7/12 58.2 Cardias (from lung-mediastinic K.) 5/12 39.7 Tab.4 Risk Factors Smoke 70 % Alcohol 60 % Obesity 30 % Barrett’s esophagus 2.5 % Tab.5 Clinical Evaluation General Status Pulmonary Function Cardio-Vascular Function Hepatic Function Renal Function Neurological Function Diabetes Tumor Stage Tab.6 Clinical Evaluation - General Status Sex Age Karnofsky Index Alcohol Abuse Tobacco Abuse Weight loss Dispepsia Mental Cooperation Blood examination Tab.7 Clinical Evaluation - Pulmonary/Renal Function Vital Capacity V.C Focal Expiratory Volume FEV 1 Peak Flow PaO2 mm/Hg PaCO2 mm/Hg Creatinine Clearance mg/ml Tab.8 Clinical Evaluation - Cardiac/Hepatic Function ECG X-rays Chest Cardiologist Visit Serum Albumin Bilirubin P.T- P.T.T Aminopyrine Breath Test Cirrhosis Tab.9 Clinical Evaluation - Mental cooperation / Risk Karnofsky Index &gt; 80 &amp; good cooperation / Normal Karnofsky Index &lt; 80 &amp; good cooperation/ Compromised Karnofsky Index &lt; 80 &amp; bad cooperation/Severely impaired Tab.10 Clinical Evaluation - Cardiac Function / Risk Normal Normal Compromised Increased Severely impaired Highest Tab.10 Clinical Evaluation -Pulmonary Function / Risk VC &gt; 90% PaO2 &gt;70 mm/Hg Normal VC &lt; 90% PaO2&lt; 70 mm/Hg Compromised Tab.11 Clinical Evaluation –Hepatic Function / Risk ABT &gt; 0.4 Normal ABT &lt; 0.4 no Cirrhosis Compromised Cirrhosis Severely Impaired Tab.12 Conditions for inoperable patients III th Stage Neoplasm T3 N2 M0-1 Age over 75 Cardio-Vascular disease Coagulopaties Weight loss Immuno Compromised Tab.13 Pre-Operative Disphagia Patients III grade IV grade 120 80 40 Tab.14 Post-Operative Disphagia grade % n.patients Follow-up/months I 85 102/120 &lt;12 I 60 72/120 &gt;12 &lt;24 II 30 36/120 &gt;24 Tab.15 Intra-Peri Operative Complications n.patient % Exitus 1/120 0.83 Iatrogenous perforation 3/120 2.5 Re – Stricture (after RadioTherapy) 2/120 1.66 Tab.16 Cost effectiveness in the management of oesophageal K. Surgery RadioTherapy Laser Stents No Treatm. Median Cost $ 8070 4720 3520 2450 1390 Range 2540-39780 3364- 6687 2530- 6340 1647- 5550 1132- 2348 Cost /month Survival 457 364 342 / / References : 1. Palliative therapy for patients with unresecable esophageal. Freeman R.K.,Ascioti A.J.,Muhidara R.J. Surg Clin North Am 2012 Oct;92(5):1337-51 2. The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer. Eroghu A.,Turkylmaz A.,Subasi M.,Kareoglanoghu N Dis Esophagus 2010 Jan;23(1):64-90 3. Advanced esophageal carcinoma recanalization. Molna’rova’ A Klin Onkol 2008;21(5):309-312 4. Inoperable esophageal cancer and out come of palliative care. Besharat S.,Jabbari A.,Semnani S.,Keshtkar A.,Marjanis World J GastroEnterol 2008 June 21;14(23):3725-8 5. Causes and treatment of recurrence dysphagia after self-expanding metallic stent placement for palliation of esophageal carcinoma. Homs MY.,Steyerberg E.W.,Knipers E.J.,Van der Goost A.,Haringsma J.,Van Blankenstein M.,Siersema P.D. Endoscopy 2004 Oct;36(10):880-6 6. Endoscopic Laser Surgery in Flogistic Disease and non operable cancer of oesophagus. Fiorito R.,Bellanova G.,Milito G.,Filingeri V.,Venditti D.,Casciani C.U. Atti 7mo Congresso Nazionale della Societa’ Italiana di Chirurgia Endoscopica;Urbino 9-11 Sett/2001 7. Neoplasie inoperabili del cardias : degenerazione e dislocamento di self expanding covered stents dopo RadioTerapia. Fiorito R. , Moraldi A. , Pocek M.,Sergiacomi G.L.,Bellanova G.,Filingeri V.,Casciani C.U. Atti 101°Congresso Societa’ Italiana di Chirurgia; Catania 10-13 Ott./1999 Abstrac book p.129-130 8. Palliation of inoperable oesophageal carcinoma treated by self expanding stents. Guemes A.,De Gregorio M.A., Salinas J.C., Torcal J.,Sousa R.,Burdio F.,Fernandez J.and Lozano R. Br J Surg 1998;85,supp.2:182-184 9. Restenting malignant oesophageal strictures LaGattolla N.R.F., Rowe H., Anderson H.,Dunk A.A Br J Surg 1998;85:261-263 10. Management of malignant oesophageal obstruction with self-expanding metallic stents. Cowling M.G., Hale A., Grundy A. Br J Surg 1998;85:264-266 11. Advances in the surgical treatment of oesophageal cancer. Sugimachi K. Br J Surg 1998;85:289-290 12. Palliative treatment of neoplastic oesophageal strictures by self-expanding metallic stents. Pocek M., Iascone C., Fiorito R. Atti 6 th World Congress of the International Society for Disease of the oesophagus; Milan Aug.23-29/1995:vol.I ,pag.501-504 13. Esophageal cancer and palliation of dysphagia. Massey S. Clin J Oncol Nurs 2011 June:15(3):327-