We reported a case of a breast cancer's skin metastases in a patient that had sustained 3 lines of chemotherapy. At first she received surgical treatment with Madden's mastectomy with dissection of axillary limphnodes and positioning of an expander. After that she underwent to chemo- and radiotherapy. The schedules we performed were: FEC, TC,Vinorelbine and Capecitabine. Only after the FEC there was a clinical remission just for 1 year. After that she underwent to surgery for the removal of a lozenge of skin on the right hemithorax, including also the subcutaneous tissue, a strip of muscular tissue, and a residue of the breast implant. The histology showed a multiple-nodules infiltration involving the dermis, the hypodermis, and the muscle. This pattern was valuated as a G3 breast cancer recurrence with ER 70%, PgR<5%, Ki67 50% Her2neu-. During the second line chemotherapy with TC she developed an high grade LCIS with lymphovascular infiltration on the left breast; on the right hemithorax there were cutaneous metastases with dermis' infiltration. Surgery with local excision was performed, and a cutaneous flap was realized. KEY WORDS: Breast cancer, Chemo-radiotherapy, Cutaneous Flap, Local Excision.

AIMS:

Meckel's diverticulum is a congenital anomaly found in approximately 2% of the general population. The complications caused by Meckel's diverticulum include intussusception, volvulus in adolescents and acute bleeding in adults 3. This is an interesting and unusual case of spontaneous perforation of Meckel's diverticulum, in a Caucasian woman.

METHODS:

A 46-year-old Caucasian woman was admitted because of severe abdominal pain and diarrhoea. A CT (Fig. 1) scan of the abdomen and pelvis was obtained, which demonstrated free air and a moderate amount of free fluid in the pelvis tracking up the gutters. The patient was consented and taken to theatre for diagnostic laparoscopy. A normal appendix was identified during laparoscopic examination of the abdomen. An inflammatory mass was seen with turbid fluid collection in the pelvic area on laparoscopy. The inflammatory mass turned out to be a perforated Meckel's diverticulum (Fig. 2). Wedge resection of the perforated Meckel's diverticulum was performed with endoGIA stapler fired at the base of diverticulum. Histopathology showed heterotopic gastric mucosa within the diverticulum and evidence of acute inflammation with perforation. The patient was followed up for two years and is symptom-free.

DISCUSSION:

The total lifetime rate of complications is widely accepted at 4%, with a male-to female ratio ranging from 1.8:1 to 3:1 4,5. Hemorrhage is the most common presentation in children and is reported in over 50% of cases 10. In adults, hemorrhage occurs often but only in 11.8% is present 5. 90% of bleeding diverticula contain heterotropic mucosa, most often gastric mucosa 13. In one study, 11% of children with complicated Meckel's diverticulum (MD) were initially diagnosed with appendicitis.8

CONCLUSIONS:

The diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis. Laparoscopy has a definite role in patients with symptomatic Meckel's diverticulum, especially when the diagnosis is in doubt and it has proved definitive in facilitating diagnosis. KEY WORDS: Gastric mucosa, Heterotropic mucosa, Merkel's diverticulum.

AIM:

The aim of this report is to analyze how to obtain a truly immediate loading in complete edentulous patients, using a dedicated software that provides beforehand both the information for a guided implant placement and the creation of a temporary prosthesis. MATERIAL OF STUDY: A CT scan was taken with a complete radiopaque scan prosthesis; CT data were imported in the software to plan the exact position of the implants. Following these guidelines a mucosa-supported surgical template was developed. A flapless implant site preparation was performed. 22 implants were placed in a complete edentulous patient. The abutments were positioned and the impressions for the final restoration were taken. The patient received immediately the temporary prosthesis that was prepared prior to the surgery in the dental laboratory.

RESULTS

AND

DISCUSSION:

Due to the flapless surgery, post-operative swelling and pain are limited. The computer-aided planning and the template guided surgery allow us to place a temporary fixed prosthesis within hours and an aesthetic and functional final restoration within some days. KEY WORDS: Computer-aided implantology, Immediate loading, Stereolithographic surgical guide, Surgical template.

AIM:

Laparoscopic Nissen fundoplication represents the gold standard in GERD therapy, although, a frequent failure of this primary repair is represented by the breakdown of the hiatoplasty. Aim of our work is to evaluate if ultrastructural alterations of the diaphragmatic pillars in patients with hiatal hernia, can explain the physiopathology of hernia recurrence. MATERIAL OF STUDY: The patients were divided into two groups: group A comprised 51 patients affected by hiatal hernia and group B (control) included 30 patients not affected by hiatal hernia.. Each patient underwent four biopsies, two from the phrenoesophageal membrane and two from the diaphragmatic pillars during laparoscopic procedures. Three hundred and twenty-four specimens, 204 from the group A and 120 from the group B, were processed and analyzed by transmission electron microscopy.

RESULTS:

No alterations were found in the phrenoesophageal membrane in both groups; samples from the diaphragmatic pillars showed no alteration in the group without hiatal hernia (group B). Instead, 90,2% of the muscular samples from the crura of group A patients presented ultrastructural alterations: in almost 75% of the cases the lesions were considered severe with extended disruption-degeneration of the muscle architecture.

DISCUSSION:

Patients with hiatal hernia have ultrastructural abnormalities of the muscular tissue of the diaphragmatic pillars that are absent in patients with normal gastroesophageal junction.

CONCLUSIONS:

The outcome of GERD surgery could depend not only on a correct technique but also on the underlying status of the diaphragmatic crura. KEY WORDS: Electron microscope, Hiatal hernia, Mesh hiatoplasty.

BACKGROUND:

In the pediatric age, mediastinal teratomas are an infrequent observation, accounting for only 7%-11% of extragonadal teratomas. Mainly located in the anterior mediastinum arising from the thymic gland, or exceptionally, from ectopic thyroid tissue, they may rarely be observed in the posterior mediastinum, sometimes in a paravertebral position, simulating a neuroblastoma. The Authors have extrapolated, from their entire experience of teratomas, 3 cases, mostly operated as emergencies; 1 of them was treated just after birth. Aim of this paper is to report the clinical and pathologic findings, to evaluate the surgical approach and the long-term biological behaviour in these cases, in the light of survival and current insights reported in the literature.

MATERIALS AND METHODS:

The Authors reviewed the most significant clinical, laboratory, radiologic and pathologic findings, surgical procedures, and early and long-term results in 3 children, 2 males and 1 female, suffering from extragonadal teratomas, located in the mediastinum, treated immediately after birth. In 1 of them the lesion was prenatally diagnosed by US scanning between the 2nd and 3rd trimester of pregnancy. All the infants were born by scheduled caesarean section in a tertiary care hospital and were then immediately referred to the N.I.C.U. because of a mostly acute clinical presentation. The 3 patients were referred to the surgical unit at different ages, namely 2 days, 10 years and 12.5 years, respectively. The initial clinical presentation was consistent with the site of the mass and/or its side-effects. The first patient, a female newborn, presented a worsening condition of respiratory distress, immediately after birth, that required mechanical ventilation and stabilization of the vital signs. Likewise, the presentation of case N° 2 was acute with dyspnea associated with an upper airways infection. Instead, the initial symptoms in case N° 3 were subacute and non-specific, characterized by worsening pain at the right shoulder extending to the neck and homolateral arm. The patients underwent laboratory and radiologic investigations that confirmed the clinical diagnosis of teratoma on the basis of elevated AFP values in 2 cases only (Case N° 1 and N° 2), while calcifications were lacking at imaging in all 3 patients. Emergency surgical management was required and, in accordance with recommended practice, the procedure was complete exeresis.

RESULTS:

All the patients underwent close long-term clinical, laboratory and imaging surveillance at shorter intervals during the first 5 years after the exeresis and annually thereafter. At the present time they are alive, disease-free and have not suffered any recurrence and/or distant metastases, with a follow-up of 7, 30 and 3 years respectively.

CONCLUSIONS:

Some extragonadal teratomas of childhood may rarely arise in the mediastinum. Being congenital tumors, prenatal diagnosis by US scan is extremely important in order to organize proper perinatal care in appropriate facilities where it is possible to define the diagnosis, and equipped with appropriate tools to carry out emergency surgery at minimal risk and to prevent severe complications after birth. An emergency procedure is frequently dictated both by complications related to the mass effect, and by the need to define the histology of the whole mass rather than just small biopsy specimens. Some teratomas can hide more or less extensive islands of immaturity or signs of malignant transformation that are clinically evident. It should be noted that calcifications and high levels of AFP and/or beta-HCG, usually pathognomonic elements for diagnosis, may not always be evident during the diagnostic work-up in mediastinal lesions. The prognosis is generally benign, although the AIEOP 2004 guidelines pointed out that high levels of circulating markers, including AFP, in children affected by mature or immature teratomas would indicate the presence of micro-foci of YST, marking them out as at high risk. The UKCCSG II and the SFOP indicated AFP values exceeding 10,000 ng / ml as the threshold identifying a group of patients with a severe prognosis. The treatment indicated is early, complete exeresis, followed by a careful, extensive microscopic examination and associated, if necessary, with adjuvant chemotherapy. Finally, in accordance with recommended practice, close, long-term clinical, laboratory and imaging surveillance is necessary, at shorter intervals during the first 5 years after the exeresis. KEY WORDS: Extragonadal tumors, Germ cell tumor, Mediastinal Teratomas.

Nora's tumor, also known as bizzarre parosteal osteochondromatous proliferation (POPB), is an exophytic outgrowth arising from the cortical surface of the bone that consists of a mixture of bone, cartilage and fibrous tissue. It is a benign lesion with atipical microscopic features and a tendency to recur. It must be distinguishable from parosteal osteogenic sarcoma, parosteal chondrosarcoma, osteochondroma, florid reactive periostitis, turret exostosis, subungueal exostosis, myositis ossificans. The treatment is surgical, but a high rate of local relapse is described. The diagnosis is histological. We report a case of a patient with POPB involving the foot, underwent surgical excision and with no evidence of recurrence at one year. KEY WORDS: Bizarre parosteal osteochondromatous proliferation; Nora's lesion.

The evolving concept of free-style flaps with one or more perforators able to lend support, has been shown to have noteworthy advantages in the context of reconstructive surgery, especially in relation to the distal portion of the lower limb. Among the advantages, an analogy of the covering tissues with pre-existing ones in the compromised area, reduced morbidity of the donor site, less time spent in theatre and a greater flexibility from the surgeons' point of view.Between 2009 and 2012, 18 patients were treated with local free-style flaps for lesions involving the leg and the foot. The median age of the patients, (11 men and 7 women) was 63.2 years. Subsequently, the patients were followed up for 6 months-1 year.In the period following surgery all the free style flaps have survived completely; further surgery has not been warranted. Healing of the donor sites took place by primary intention in 17 cases; in one case, a V-Y advancement flap adapted as a cover for a loss of substance of the calcaneus, it occurred by secondary intention.Lower limb reconstruction, in virtue of the fact that adjacent tissues for reconstruction are scarce and vascularization is an issue, has always constituted a problem which has not been easy to solve for the surgeon. The application of the free-style concept to loco-regional flaps has yielded satisfactory results in our experience, from both a functional as well as an aesthetic point of view. KEY WORDS: Foot reconstruction; Free-style flap; Lower limb reconstruction.

Stenotrophomonas maltophilia (S.M.) is a Gram-negative bacillus, naturally resistant to cephalosporins and carbapenems, which can colonize different sites and may be responsible for serious infections for which treatment is a real challenge. This was rarely reported as cutaneous pathogenic organism causing cellulitis-like lesions, paronychia, mucocutaneous ulcers and ecthyma gangrenosum in immunocompromised individuals. We report a case of non-healing legs ulcer infected with Stenotrophomonas maltophilia. KEY WORDS: Antibiotic resistance Stenotrophomonas maltophilia; Bionect Start ® ointment; Serious infections; Stenotrophomonas maltophilia.

Hemangiomas are proliferative lesions characterized by increased endothelial cell turnover. Lip hemangiomas can distort lip anatomy and are at increased risk of ulceration and/or bleeding, which lead to impaired function and disfigurement. Surgery can provide active treatment but it can be problematic because vermilion tissue is unique and not found elsewhere on the body. Since there is no similar tissue that can easily be used for reconstructing missing vermilion, its preservation is essential for a satisfactory cosmetic result. We present the case of a 74 year old woman suffering from a large hemangioma of the mid-face and particulary with an angiomatous ulcerated lesion at the level of the lower lip. We describe clinical management and surgical treatment of this pathology. KEY WORDS: Bleeding lip hemangioma; Facial hemangioma; Neoplasm embolization; V-shaped full-thickness lip excision.

METHODS:

The authors reviewed 98 selected patients, aged 65 to 90 years, with 149 HCC treated between 2002 and 2011. According to the extent of malignancy, health status and treatment, patients were divided into 3 groups. Sixty-one, submitted to major and minor curative resections, were in group A and B while group C included 37 patients, unsuitable for high-risk procedures and percutaneous ablation, submitted to intraoperative-radiofrequency ablation (IRFA) alone or combined with minor resections. Assessment of safety and therapeutic efficacy of this managment was evaluated.

RESULTS:

A postoperative mortality rate of 1,02% and an overall survival rate at 5 years of 62.3% were observed. Indeeed matched post-operative morbidity and mortality rates of A, B, C groups were 45%, 8%, 16.21% (p < 0.004) and 9 %, 0%, 0% (p= 0.112 ) respectively. 3 years overall-survival was not statistically different (p= 0.585). However 5 years survival rate and disease-free-survival rate were significantly higher in patients of group A and B (p= 0.003; p< 0.001).

CONCLUSION:

Treatment strategies to minimize treatment-related morbidity and mortality have resulted satisfactory for early and late outcomes of an heterogeneous group of elderly patients with HCC. KEY WORDS: Elderly and very elderly patients, First line treatments, Hepatocellular carcinoma.