We analyzed 824 patients treated by thyroidectomy in our Institute from January 1995 to December 2000. We observed the presence of cervicomediastinal goiter in 117 patients (14.9%), 92.7% of whom presented euthyroidism. Sternotomies were performed in 15 patients (10 midline and 5 hemi-clamshell). On the basis of our own experience and the reports in the literature, we analyse the diagnostic and surgical approach to the therapy of cervicomediastinal goiter.

Background: Lymph node metastases are present in only about 15% of patients with early gastric cancer (EGC) and for this reason, the majority of these patients do not require lymphadenectomy. In Japan, EGC patients undergo less invasive treatment (endoscopic mucosal resection, wedge resection, laparoscopy). However, the indications for and results of these types of treatment are still uncertain. Methods: In a multicentre retrospective study, we analysed the clinicopathological data referring to 584 early gastric cancer patients who underwent D2 gastrectomy. A comparison was made between patients with and without lymph node metastases in relation to numerous pre- and postoperative variables. Long-term survival and risk factors for lymph node metastases were analysed. The primary aim was to compare our results with those of Western and Japanese authors; we also evaluated the possibility of identifying a subset of patients at low risk of lymph node metastases who may be candidates for endoscopic treatment. Results: The incidence of lymph node metastasis was 14.4%. Univariate and multivariate analyses showed that submucosal infiltration, diffuse histotype, tumour size and Kodama Pen A type were all related to the presence of lymph node metastases. Patients with types I, IIa and IIb mucosal tumours did not present lymph node metastases. Postoperative mortality was 2.2%. Five-year survival in relation to lymph node groups was 95% in N0 patients, 77% in N1 patients and 60% in N2 patients (p = 0.0001, Japanese N-stage). The number of positive lymph nodes also had a prognostic value. Patients with three or fewer positive lymph nodes presented a better 5-year prognosis (83%) than those with more than three positive lymph nodes (48%) (p = 0.0001). Conclusions: Our study confirms that lymph node involvement is an extremely important prognostic factor. For this reason, the therapeutic strategy of our surgical units is as follows: 1) D2 gastrectomy is the standard treatment even in early gastric cancer (EGC); 2) endoscopic mucosal resection (EMR) could be considered first in types I, IIa and IIb tumours that are diagnosed as limited to the mucosal layer.

Folli, Secondo MDa,*; Morgagni, Paolo MDb; Bazzocchi, Francesca MDb; Dell’Amore, Davide MDa; Vio, Antonio MDb Author Information

The pattern of recurrence following curative surgery for gastric cancer was analyzed in 306 patients observed in two surgical Departments of Italy. Intestinal type and diffuse type of Lauren classification showed different patterns of dissemination, above all in the incidence of peritoneal carcinomatosis (9.8% vs. 30.1%). Multivariate analysis revealed that in intestinal type, nodal status, depth of invasion and male sex increase the risk of recurrence, whereas lymph node dissection (D2-D4 vs. D1) reduces such risk. In the diffuse type, depth of invasion, nodal status and tumor size was associated with higher recurrence rates; super-extended lymphadenectomy (D3-D4 vs. D1-D2) considerably reduced the risk of relapse, whereas no preventive effect was found for D2 vs. D1 dissection. These results suggest the use of different surgical and adjuvant treatment strategies for the two histotypes of gastric carcinoma.

The adrenal glands are often the site of metastases. However, there is much discussion as to the benefits of surgical resection. Personal experience of surgical treatment in 4 patients, one of whom died postoperatively after bilateral adrenalectomy for metachronous metastases, is reported. Surgery achieved pain relief in all patients, average survival was 30 months and 1 patient is still alive after 68 months. The present study shows that surgery is advisable in patients who present the following characteristics: 1) the primary tumor has been resected or is radically resectable, 2) there is no evidence of other metastatic lesions, 3) the adrenal metastasis is unilateral and complete resection is possible, 4) the patient's general physical condition is good.

Long-term clinical outcome was analysed in a series of 337 patients with early gastric cancer (EGC) at a median follow-up of 8 years. Tumours were classified according to the macroscopic and microscopic criteria proposed by the Japanese society of gastroenterological endoscopy (JSGE) and Lauren, respectively. Type of penetration (PEN) was classified according to Kodama. Overall survival rate was 92% at 5 years and 88% at 8 years and was significantly related to depth, type of penetration, lymph node status and tumour size. A significantly lower 5-year survival (p<0.05) was observed for patients with lymph node metastases and PEN A type EGC (55%) or for those with node-positive tumours and submucosal wall penetration (58%) than for the other pathologic subgroups. Therefore, these two subgroups should be considered as advanced gastric cancer patients from the prognostic point of view. Moreover, multivariate analysis by Cox regression model showed the degree of lymph node involvement and Kodama's type PEN A as the only independent prognostic factors.

DNA flow cytometry was performed on 128 non tumoral gastric mucosa and 133 tumors. None of the 128 samples from the non tumoral mucosa showed aneuploidy and the overall median of the S-phase faction was 10.29. The overall median of S-phase fraction for tumors was 16.55 with a significative difference (p=0.0001) between diploid (14.71%) and aneuploid (17.41%) tumors.Eighty-seven out of 133 tumor samples (65.41%) gave an aneuploid histogram. There was no significant difference in frequency of DNA ploidy and S-phase fraction in terms of age, sex; tumor location, clinical stage: histologic grade, histologic sade, invasion depth and in vitro tritiated thymidine labeling index. The 3.5-year survival rate was 60% in patients with diploid and near diploid (DNA Index=1.05-1.30) and only 30% in those with aneuploid tumors (p=0.005).

From 1976 to 1994, 337 patients underwent curative gastric resection for Early Gastric Cancer (EGG) in this Department. Lymph node metastases were present in the dissected lymph nodes of 44 patients (13 per cent). associated: in the univariate analysis, with larger sized, submucosal invasion, diffuse histological and Pen-A types (P<0.001). Multivariate analysis showed that the independent risk factors for lymph node metastases were large tumour size (P=0.02), Pen-A type (P=0.006), diffuse histological type (P<0.001), submucosal invasion (P<0.002). long-term survival for N+ patients was lower than N- ones (P<0.001). We think that the best treatment for EGC is D2-resection and conservative treatment should be reserved for high surgical risk patients.

A retrospective study of 223 patients treated for early gastric cancer (EGC) is reported, representing 21.2 per cent of the 1051 patients with gastric cancer treated over the same period. Two main types of surgical procedure were used: subtotal resection of the stomach for EGC of the two lower thirds and total gastrectomy for lesions of the upper third. A lymphadenectomy of groups 1 and 2, according to the procedure of the Japanese Research Society for Gastric Cancer (R2 resection), was performed in all patients. The mean duration of follow-up was 7.5 years. Univariate analysis showed a significant difference in survival rates only between patients with and without involved nodes (log rank = 6.05, P = 0.0139). Other prognostic factors were not identified. A bivariate analysis was performed to evaluate the joint effect of node status and the Kodama classification: survival rates for patients with EGC of the penetrating (Pen) A type and node positive falls to around 57 per cent within 6 years. This group of patients has a tumour that should probably be considered as a 'non-early' lesion. To improve the survival of patients with a Pen A, node positive lesion, adjuvant chemotherapy may be appropriate.

This multicenter, prospective, randomized, open, long-term study compared the efficacy of sucralfate (1 g twice daily) versus ranitidine (150 mg once daily) versus no therapy in patients with gastric ulcer. The results at the end of the first of a scheduled 3-year follow-up are reported. Two hundred ninety patients with healed GU entered the 3-year, open study. Ninety patients were randomly assigned to receive sucralfate, 105 to receive ranitidine, and 95 to receive no treatment. The three groups proved well matched in terms of standard clinical data. Fifty patients were withdrawn from the study during the first year; a gastric neoplasm was diagnosed in four patients. At months 3, 6, and 12 of therapy, the remission rates were, respectively, 94.8%, 86.2%, and 79.6% with sucralfate; 98.9%, 91.6%, and 82.5% with ranitidine; and 89.3%, 80.7%, and 66.9% with no treatment. Sucralfate was as effective as ranitidine (P = NS), and both drugs produced higher cumulative remission rates than no treatment (P < 0.06 and P < 0.01, respectively). We conclude that 1 g of sucralfate twice daily was as effective as 150 mg of ranitidine once daily in maintaining GU remission for 1 year; both treatments led to a better outcome than no treatment.

Objective: To evaluate the safety and efficacy of nizatidine 150 mg as a maintenance therapy for gastric ulcer. Design: A 1-year prospective, multicentre, randomized, double-blind study versus placebo. All patients were examined every 3 months with endoscopy, clinical check-ups and blood tests. Setting: Outpatients followed-up by 22 endoscopic units in north-eastern Italy. Patients: Adult patients with an endoscopically documented healed gastric ulcer, obtained within 8 weeks by nizatidine 300 mg. Two hundred and forty-one patients entered the study: 123 treated with nizatidine 150 mg, 118 with placebo; one was excluded. Thirty-eight patients withdrew during follow-up, 202 concluded the study. Main outcome measures: Age, gender, height, weight, family history of ulcer disease, smoking habit, alcohol consumption, length of gastric ulcer history, previous ulcer treatment, number of ulcers, ulcer size and location, current drug therapy and common laboratory tests were taken into account. Results: Nizatidine proved significantly better than placebo in preventing gastric ulcer relapse, i.e. remission rate was 94 versus 79%, 81 versus 68%, 79 versus 640/o and 77 versus 52% after 3, 6, 9 and 12 months, respectively (P = 0.001). Antacid consumption, symptoms, compliance and adverse events were comparable in both groups; cigarette smoking was the major relapse risk factor in both treatment groups. Conclusion: Long-term nizatidine 150 mg per day proved safe and effective in containing gastric ulcer relapse compared with placebo: smoking habit is the most important risk factor in gastric ulcer relapse.

This multicenter, prospective, randomized, open, long-term study compares sucralfate (2 g daily) with ranitidine (150 mg daily) and no treatment in gastric ulcer (GU). We report the results of the second year of a scheduled 3-year follow-up, the outcome of the 1 st year has been reported earlier. The 24-month follow-up was completed by 142 patients who were continuously either treated with the drug randomly assigned at the beginning of the study or left untreated (i.e. 32 patients took 150 mg ranitidine at bedtime, 29 took 1 g sucralfate twice daily and 81 were left untreated, 23 of whom came from the ranitidine group, 19 from the sucralfate group and 39 from the untreated group). Seven patients dropped out and 26 subjects relapsed (5 under ranitidine, 4 under sucralfate and 17 untreated cases). Ranitidine versus previous ranitidine, sucralfate versus previous sucralfate and each one versus no treatment showed comparable relapse rates. An additional study, using Cox's models, showed that three variables have a significant correlation with relapse during the 1 st year of follow-up: therapy carried out (p = 0.0025), symptoms (p = 0.0047) and family history of ulcer (p = 0.0392). In conclusion, both ranitidine 150 mg and sucralfate 2 g proved effective in reducing GU relapse as compared with no treatment, an effect which does not seem to persist during the 2nd year of therapy, when the 'no treatment' option may be taken into account.

UNLABELLED:A substantial number of duodenal ulcer (DU) patients relapse despite maintenance treatment with antisecretory drugs. The influence of certain risk factors and the heterogeneity of the disease could explain such behavior. The present prospective, open study compares the one-year clinical outcome (with upper GI endoscopy at the beginning of the study, at 6 and 12 months, and at every symptomatic relapse) of four groups of DU subjects, consecutively recruited from December 1987 to December 1988, separated in accordance with whether or not a bleeding DU episode had previously occurred, and whether or not an evaluation of gastric acid secretion had been made. Thus, Group I (17 patients; 12 males, 5 females) included heavy smokers and/or gastric acid hypersecretors; Group II (13 patients; 12 males, 1 female) non- or light smokers non-hypersecretors; Group III (34 patients; 22 males, 12 females) subjects with unknown gastric acid secretion; Group IV (33 patients; 30 males, 3 females) previously bleeding DU patients. All patients, except those in Group II (who were left untreated), were given ranitidine 150 mg at bedtime. The outcome of Groups I+II was compared with that of Group III (considered as "standard therapy") and Group IV patients, the latter presumably with a low risk of relapse because of the low prevalence of smokers.STATISTICS:Chi-square test, Fisher's exact test, analysis of variance and the logrank test. During the year of follow-up, 27/97 patients withdrew from the study, while 18 had a DU relapse (remission rates 82.1% +/- 7.4% in Groups I+II, 70.5% +/- 8.4% in Group III, 87.5% +/- 5.9% in Group IV).(ABSTRACT TRUNCATED AT 250 WORDS)

In order to evaluate the relevance of protooncogene alterations in gastric cancer and to specifically relate these alterations to types and stages of the neoplasia, we studied oncogenes of possible interest in gastric tumors with different clinical parameters. Fifty DNAs from primary gastric adenocarcinoma were analyzed, by the Southern blotting technique, for the presence of amplification or rearrangements of seven different protooncogenes: c-myc, c-erbB2, c-Ki-ras, c-Ha-ras, c-N-ras, hst, and c-mos. All the tumors analyzed were histologically classified and staged. Amplification of the following genes was found: c-myc (2 of 50), hst (3 of 50), c-erbB2 (3 of 50), and c-Ki-ras (5 of 50). The simultaneous amplification of hst (3 cases), c-myc (1 of 3), or c-Ki-ras (2 of 3) was observed. Analysis of DNAs from atrophic and metaplastic gastric mucosa (which can be regarded as preneoplastic lesions) of the 10 patients showing gene amplification demonstrated that this was limited to neoplastic cells. Considering protooncogene amplification in general (i.e., involving different genes and occurring to different degrees) and clinical parameters of tumors, we found a statistically significant association between amplification and both tumor progression and presence of metastases. Therefore, at least for the genes analyzed, amplification is a relatively infrequent phenomenon and represents a late event in the temporal development of gastric cancer.

Cystic lesions of the spleen are unusual. They are classified essentially as: parasitic or nonparasitic, based on their etiology, and true or pseudo based on the presence or absence of lining epithelium. The pathogenesis of true cysts is unknown and numerous hypotheses are given by different Authors. After a short review of the literature, the Authors describe the clinical and pathological data of a case of epithelial (epidermoid) splenic cyst occurs in a 12-year-old woman. The Authors put forward some personal observations on pathogenesis, still doubtful, by means of histochemical and immunohistochemical study.