Total Parathyroidectomy with Subcutaneous Parathyroid Forearm Autotransplantation in the Treatment of Secondary Hyperparathyroidism: A Single-Center Experience.

Abstract Introduction Secondary hyperparathyroidism is common in chronic kidney disease. Parathyroidectomy is indicated in refractory hyperparathyroidism when medical treatments and so the parathyroid hormone levels cannot be lowered to acceptable values without causing significant hyperphosphatemia or hypercalcemia. The aim of this study is to compare the efficacy and safety of total parathyroidectomy with subcutaneous forearm autotransplantation with total parathyroidectomy with intramuscular forearm autotransplantation. Materials and Methods A single-center retrospective cohort study of total parathyroidectomy with forearm autotransplantation from January 2002 to February 2013 was performed. According to the surgical technique, patients were divided into an intramuscular group (Group 1) and a subcutaneous group (Group 2). 38 patients with secondary hyperparathyroidism were enrolled; 23 patients were subjected to total parathyroidectomy with parathyroid tissue replanting in the subcutaneous forearm of the upper nondominant limb, while 15 patients were subjected to replanting in the intramuscular seat. Results A total of 38 patients (56 ± 13 years) were enrolled. In both groups, the preoperative iPTH value was markedly high, 1750 ± 619 pg/ml in the intramuscular autotransplantation group and 1527 ± 451 pg/ml in the subcutaneous autotransplantation group (p = 0.079). Transient hypoparathyroidism was shown in 7 patients, and 1 patient showed persistent hypoparathyroidism (p = 0.387). 2 patients showed persistent hyperparathyroidism (p = 0.816), and in 2 others was found recurrent hyperparathyroidism (p = 0.816); 3 of them underwent autograftectomy. The anterior compartment of the forearm nondominant limb was sacrificed in 1 case of intramuscular autotransplantation with functional arm deficit. Conclusions The efficacy and safety of parathyroid tissue autotransplantation in the subcutaneous forearm of the upper nondominant limb is confirmed with a good rate of tissue engraftment and with a comparable number of postsurgical transient and persistent hypoparathyroidism and hyperparathyroidism incidence in both techniques. Furthermore, this technique preserves arm functionality in the case of autograftectomy. Consequently, it is our opinion that total parathyroidectomy with subcutaneous forearm autotransplantation is currently the best choice

Surgical treatment of hepatic metastases from gastric cancer

The purpose of the study was to investigate the clinical factors influencing the prognosis of patients submitted to hepatectomy for metastases from gastric cancer and their clinical role. We conducted a retrospective multicentre review. We evaluated how survival from surgery was influenced by patient-related, tumour-related and treatment-related prognostic factors. We analysed data on 144 patients submitted to hepatectomy for metastases from gastric cancer, in the synchronous and metachronous setting. In 117 cases, an R0 resection was achieved, while in 27 an R\u2009+\u2009hepatic resection was performed. Chemotherapy was administered to 55 patients. Surgical mortality was 2.1% and morbidity 21.5%. One-, 3-, and 5-year OS rates after surgery were 49.9, 19.4 and 11.6%, respectively, with a median OS of 12.0 months. T4 gastric cancer, H3 hepatic involvement, non-curative resection, recurrence after surgery, and abstention from chemotherapy were associated with a worse prognosis. Factor T and H displayed a clear (p\u2009<\u20090.001) cumulative effect. Our data show that R0 resection must be pursued whenever possible. The treatment of T4 gastric cancer with hepatic bilateral and diffuse metastasis (H3) should be considered carefully or it should be probably avoided. Finally, a multimodal treatment associating surgery and chemotherapy offers the best survival results

Conversion gastrectomy for stage IV unresectable gastric cancer: a GIRCG retrospective cohort study

Background: The aim of this study is to report the experience with conversion surgery from six Gruppo Italiano Ricerca Cancro Gastrico (GIRCG) centers, focusing our analysis on factors affecting survival and the risk of recurrence. Methods: A retrospective, multicenter cohort study was performed in patients who had undergone conversion gastrectomy between 2005 and 2017. Data were extracted from a GIRCG database including all metastatic gastric cancer patients submitted to surgery. Only stage IV unresectable tumors/metastases which became resectable after chemotherapy were included in this analysis. Results: Forty-five resected M1 patients were included in the analysis. Reasons for being deemed unresectable at diagnosis were peritoneal involvement (PCI > 6) (n = 38, 84.4%), distant metastatic nodes (n = 3, 6.6%) and extensive liver involvement (n = 4, 8.8%). Median follow-up was 25 months (IQR 9-50). Median overall survival from surgery was 15 months and 1-, 3- and 5-year survivals were 57.2, 36.1 and 24%, respectively. Median progression-free survival was 12 months with 1- and 3-year survival of 46.4 and 33.9%, respectively. At cox regression analysis the only independent prognostic factor for OS was the presence of more than one type of metastasis (HR 4.41, 95% CI 1.72\u201311.3, p = 0.002). A positive microscopic resection margin was the only risk factor for recurrence (HR 5.72, 95% CI 1.04\u201331.4, p = 0.045). Conclusions: Unresectable stage IV GC patients could benefit from radical surgery after chemotherapy and achieve long survivals. The main prognostic factor for these patients was the presence of more than one type of extra-gastric metastatic involvement

Serum levels of VCAM-1 are associated with survival in patients treated with nivolumab for NSCLC

Background High circulating levels of cellular adhesion molecules (CAMs) in non-small cell lung cancer (NSCLC) have been supposed to act as a negative prognostic factor. Here, we explored the predictive role of pre-treatment levels of CAMs in previously treated patients receiving nivolumab for NSCLC. Materials and methods Seventy one patients with advanced NSCLC, treated with nivolumab at the dose of 3 mg/kg every 14 days, were enrolled. Maximum follow-up time was 3 years. Serum levels of Vascular Cell Adhesion Molecule-1 (VCAM-1) and Intracellular Adhesion Molecule-1 (ICAM-1) were measured at baseline and before each nivolumab administration. Endpoints of the study were a composite outcome of survival >= 2 years or absence of disease progression at the end of the follow-up, and the overall survival. Results Composite outcome and overall survival were positively associated with VCAM-1 baseline levels and with the reduction of VCAM-1 during the treatment. After adjustment for potential confounders, the change in VCAM-1 serum levels during the treatment was an independent predictor of overall survival. Conclusions High baseline serum levels of VCAM-1 are associated with a longer survival in patients treated with nivolumab as second line treatment for NSCLC. Surviving patients experience also a significant reduction in CAMs expression during the treatment. Hence, CAMs might be promising prognostic factors in patients with NSCLC underoing immunotherapy

An unusual case of a well-differentiated neuroendocrine tumour of the ileum with peritoneal carcinomatosis: A case report

Neuroendocrine tumours (NETs) are a family of neoplasms that come from neuroendocrine cells and express neural markers, such as synaptophysin or chromogranin A.The current classifications of these tumours are presented by the WHO 2000 classification, based on histological parameters, and the WHO 2010 classification, based on the proliferative index, that divides the NETs into a neuroendocrine tumour of a low grade, neuroendocrine tumour of a intermediate grade and neuroendocrine carcinoma (NEC) of a high grade.We are reporting a very rare case of a G1 low-grade neuroendocrine tumour (NET) of the ileum with a peritoneal carcinomatosis.This case is challenging because the tumour expresses low proliferative index as G1 tumours, but it has an aggressive clinical behaviour such as node metastasis and peritoneal carcinomatosis.The peritoneal carcinomatosis is not actually considered by the current classifications of NETs, so it is difficult to predict the prognosis of this patient

The new TNM staging system for thyroid cancer and the risk of disease downstaging

In October 2016 the American Joint Committee on Cancer (AJCC) published the 8th edition of the AJCC/TNM cancer staging system and it has been introduced in clinical practice since 1st January 2018. The effect of most of the changes in the new edition was the downstaging of a significant number of patients into lower stages, reflecting their low risk of thyroid cancer-related death. One of the most relevant modification refers to the role of the microscopic extra-thyroidal tumor invasion, which is no longer considered as criterion for the classification of T3 tumors. With the present study we want to assess the impact of the changes of the new staging system and therefore we analyzed or casistic of 84 T1-T3 thyroid-cancer patients. The results of our analysis show that he downstaging of patients according to the 8th TNM edition does not necessarily reflect less aggressive disease: we actually reported 2 lymph-nodal recurrences (40%) in the five patients that were downstaged from pT3 to pT2 and the lypmh-nodal recurrence rate for stage I rises from 0% with the 7th TNM edition to 5.3% with the 8th edition

Follow-up after surgery for gastric cancer: how to do it

There is no consensus on follow-up after gastric surgery for cancer, nor evidence that it improves outcomes. We investigated the impact of intensity of follow-up, comparing the regimens adopted by two centres, in Italy and in the UK. Patients who underwent surgery for gastric and junctional type-3 adenocarcinoma, between September 2009 and April 2013, at the Surgical Clinic, University of Brescia (Italy), and at the Department of Upper Gastrointestinal Surgery, University College London Hospital (UK), were identified. Patients' demographics, stage, recurrence rates, modality of detection and treatment were recorded. Overall survival and costs were compared between the two protocols. A total of 128 patients were included. Recurrence rates were similar (p = 0.349), with more than 70% diagnosed during regular follow-up appointments in both centres. At univariate and multivariate analysis, stage I and treatment of recurrence were associated with a better survival. Patients treated for recurrence at the Italian centre showed an almost significant better survival (p = 0.052). The intensive Italian surveillance protocol was associated with significant higher costs per year. Follow-up and early detection of recurrence did not affect survival in the analysed series, focused on periods in which chemotherapy was ineffective towards recurrence. However, intensive follow-up allowed a greater number of patients to receive a treatment for recurrence; this might prove useful in the next few years, when more effective chemotherapy combinations are expected to become available. The costs could be reduced by adopting a less intensive surveillance programme

How could we identify the ‘old’ patient in gastric cancer surgery? A single centre cohort study

To analyze the population submitted to gastric cancer surgery in our Institution in order to find those characteristics which could help in the identification of the elderly high-risk patient. In a cohort of 263 patients (>65 y) we selectively investigated the risk factors for medical and surgical complications and postoperative mortality, focusing on the variable “age”. All the significant variables were used to find predictors of complications with Clavien-Dindo>2. Age>75 (AUC 0.61; 95% 0.55–0.67, p = 0.003) and ASA score >2 (AUC 0.60; 95% CI 0.54–0.67, p = 0.01) were significantly associated with an increased risk of medical complications. Operative time >330 min (OR 1.00; 95% CI 1.00–1.01; p = 0.0001- AUC 0.62, 95% CI 0.56–0.68, p = 0.01) was the only significant predictor of surgical complications. In-hospital mortality (6/263 patients) was significantly associated with preoperative albumin ≤2.95 g/dl (OR 0.15; 95% CI 0.04–0.93, p = 0.041 – AUC 0.74 95% CI 0.68–0.80; p = 0.003) and additional procedures (OR 7.05; 1.23–40.32, p = 0.03). Stepwise multivariate analysis showed that albumin ≤2.95 g/dl (OR 3.43; 95% CI 1.06–11.13 p = 0.033), ASA>2 (OR 9.51; 95% CI 1.23–72.97; p = 0.042) and additional resections (OR 3.39; 95% CI 1.36–8.45; p = 0.045) were independent risk factors for complications Clavien Dindo >2. Our work demonstrated that, in our institution, 75 years of age could identify the elderly in gastric surgery as those patients were at higher risk of medical complications. ASA >2, preoperative serum albumin ≤2.95 g/dl and the need of additional procedures could increase the risk of severe postoperative adverse events