Different strategies have been used to induce preoperative liver hypertrophy and reduce the risk of postoperative liver failure. Those have included both radiological-interventional and surgical strategies, such as portal and hepatic vein embolization, 2-stage hepatectomy and associated liver partition with portal vein ligation for staged hepatectomy (ALPPS). Herein, we describe the case of a patient with a large right liver hepatocellular carcinoma not amenable to liver transplantation, with HBV-related chronic hepatitis and a small future liver remnant (FLR), who underwent a multistep approach to ensure a safe major laparoscopic resection with an adequate FLR.

Purpose: Despite the notable expansion of both laparoscopic and robotic pancreatoduodenectomy (PD) the optimal surgical approach is yet to be defined. Whilst laparoscopy offers more agility in moving between different quadrants during the resection phase, the robotic approach offers a more precise and easier suturing during the reconstructive phase. Additionally, most of the robotic protocols report a strong dependence on the laparoscopic assistance and tools during the resection phase. It is likely that both technologies will continue to develop to permit a synergetic combined use of each approach. Herein, we show our technique combining both approaches. Method: We herein provide a video demonstration of our proposed Roboscopic approach, consisting in a pure laparoscopic resection and a full robotic reconstruction. In addition, we report our initial experience with the first 14 consecutive cases. The video shows a Roboscopic PD in a 79-years old woman diagnosed with a 33 mm pancreatic head tumor. Results: The operation time was 340 min(laparoscopic and robotic phase: 180 and160 min, respectively), blood loss was 100 ml. The patient was discharged after 5 days, the postoperative period was uneventful. Among 14 Roboscopic-PD patients, median operation time, blood loss, and fistula risk score were 456 minutes (range:310-628), 190 ml (100-400), and 3 (0-6), respectively. Major complication, POPF (grade B/C) and mortality rates were 36%, 14% and nil, respectively. Postoperative median length of stay was 7 days (IQR 4-29). Conclusion: Roboscopic-PD is safe and feasible and combines the benefits of both the laparoscopic and robotic approach.

Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) remains the most frequent complication, potential precursor of more serious events, and mechanisms behind POPF development are not clear. Primary aim of the current study is to investigate correlations between patients’ characteristics, including technical intraoperative data assessed by retrospective video review of laparoscopic DP (L-PD), and development of clinically relevant (CR-)POPF and major complication. Patients undergoing L-DP whose surgery video was available for review were included in this study. Retrospective video review, performed by two surgeons blinded for postoperative outcomes, was focused on pancreatic neck transection and identification of pancreatic capsule disruption (PCD)/staple line bleeding (SLB). Correlation between clinical, demographic, and intraoperative factors and CR-POPF/major complications and assessment of factors associated with PCD and SLB were investigated. Of 41 L-DP performed at our institution (June 2015–June 2020) using a triple-row stapler (EndoGIA™ Reloads with Tri-Staple™), surgery video was available for 38 patients [men/women, 13/25; median age (range) 62 (25–84) years; median BMI (range) 24 (17–42)]. PCD and SLB occurred in 15(39%) and 19(50%) patients and were concomitant in 9(24%). CR-POPF and major complications occurred in 8(21%) and 12(31%) patients, respectively. PCD, SLB, and PCD + SLB rates were significantly higher among patients with CR-POPF, compared to patients without (all p < 0.05). Among patients with PCD, pancreatic thickness at pancreatic transection site was higher (19 mm), compared to non-PCD patients (13 mm, p < 0.001). A directly proportional relation between PCD, CR-POPF, and major complication rate and pancreatic thickness was confirmed by ROC analysis (AUC = 0.949, 0.798, and 0.740, respectively). PCD and SLB close to the staple line detected by retrospective video-review are intraoperatively detectable indicators of severe pancreatic traumatism and a potential precursors of CR-POPF following L-PD. Given the strict correlation between PCD and pancreatic thickness, alternative techniques to stapled closure for pancreatic transection may be recommended for patients with a thick pancreas and modification in postoperative care may be considered in patients with PCD/SLB.

Background: For patients affected by left-sided pancreatic cancer (PC), characterized by high malignant potential and rapid peritumoral diffusion, Radical Antegrade Modular PancreatoSplenectomy (RAMPS) has been proposed in the attempt of improving oncologic outcomes. Herein, we compare the Results of Laparoscopic RAMPS (L-RAMPS) with Open-RAMPS (O-RAMPS) consecutively performed at our center. Material and Methods: Demographic, perioperative, and pathologic data of 19 patients undergoing RAMPS at our center (March 2015-April 2018) were prospectively collected and retrospectively analyzed and compared between patients who underwent L-RAMPS (n=10) and O-RAMPS (n=9). Results: L-RAMPS was attempted in 12 patients, two (16%) of whom underwent conversion to laparotomy and were included among O-RAMPS. Demographic and clinical characteristics were similar among L-RAMPS and O-RAMPS patients. O-RAMPS patients, compared to L-RAMPS, more often underwent additional organ resection and had higher intraoperative blood loss (p=.003 and p=.01, respectively), paralleling a trend among O-RAMPS toward higher rate of malignancy (100%) and higher number of retrieved lymphnodes (n=48), compared to L-RAMPS (60% and n=25, respectively). Among 15 patients operated on for malignancy (PC=14, neuroendocrine tumor=1), R0 resection was achieved in 87% of patients and such rate was similar among L-RAMPS and O-RAMPSS. Rates of overall and major complications and mortality were 58%, 11% and nil in the overall study group and did not differ significantly among L-RAMPS and O-RAMPS patients. Median postoperative hospital stay was shorter among L-RAMPS (10 days), compared to O-RAMPS (16 days, p=.017). Conclusion: this initial experience confirms safety and feasibility of L-RAMPS which, compared to O-RAMPS, offers similar oncologic and postoperative outcomes with shorter postoperative recover.

In the management of symptomatic nonparasitic simple liver cysts (SN-SLC), percutaneous sclerotherapy (PS) and laparoscopic fenestration (LF) represent the treatment options of choice. Recently, European guidelines on Interventional Ultrasound indicated PS as a good alternative to LF, with similar efficacy and lower complication rates. However, the choice of the best treatment options for SN-SLC remains a debated matter. Objective of this manuscript is to review the literature and to report on the short and long-term results of PS and LF for patients affected by SN-SLC. A Medline review of articles (July 1988–July 2019) concerning the over mentioned subject was performed. Papers considering pediatric patients, patients affected uniquely by polycystic liver disease, or less than five patients were excluded from the current analysis. Overall, 62 studies met inclusion criteria: one study comparing results of PS and LF, 40 and 21 studies reporting on results following LF and PS, respectively, accounting for an overall study population of 1,658 patients (1,037 and 621, respectively). Abdominal pain, eventually associated to fullness/ discomfort, was the main symptom at diagnosis. Overall morbidity rate was 8% (7.9% and 9.9% among the LF and PS groups, respectively). Mortality rate was nil among LF patients and 0.2% among PS patients. Following cyst treatment, rapid symptoms relief was observed in the majority of patients. Average follow-up duration was of 49 and 29 months among studies investigating LF and PS results, and symptoms recurrence necessitating for additional treatment was observed in 1.6% and 8.2% of patients treated with LF and PS, respectively. While PS, mainly performed using alcohol/minocycline, seems associated with a lower risk of perioperative complications and higher rate of symptoms recurrence, LF is indicated when differential diagnosis with other condition is necessary, in the presence of biliary communication, or after ineffective PS. However, a multidisciplinary decision is recommended for defining the most appropriate treatment.

BACKGROUND:Due to its technical complexity, laparoscopic (L-) radical antegrade modular pancreatosplenectomy (RAMPS) for left-sided pancreatic ductal adenocarcinoma (PDAC) has been described in a few series.1-4 In addition, splenomesenteric junction tumor involvement is considered a formal contraindication to L-RAMPS.METHODS:The video shows posterior L-RAMPS with a left approach to the superior mesenteric artery (SMA) for a left-sided PDAC with suspected involvement of the splenomesenteric junction.RESULTS:The patient was a 61-year-old woman affected by a cT3N0M0 pancreatic body PDAC. Following dissection of the superior mesenteric vein (SMV), proper/common hepatic artery, and gastroduodenal artery, the pancreatic neck is encircled and the celiac trunk (CT) skeletonized. The treitz ligament is opened, and the SMA is identified and dissected on its left anterior margin. Pancreatic mobilization en bloc with the Gerota fascia and left adrenal gland is followed by splenic artery transection and suprapancreatic lymphadenectomy completion. The mesopancreas is dissected from the right margin of the SMA and CT and the pancreas is transected. The portal vein and SMV are cross-clamped and a venous tangential resection/closure is performed. Cryostate histological examination of the venous and pancreatic stumps showed absence of tumor cells. Final pathology revealed a pT2N0(0+/42)R0G2 PDAC of the pancreatic body.CONCLUSION:During L-RAMPS, periadvential SMA dissection through the left-anterior approach, specular to the right posterior SMA approach described for laparoscopic pancreatoduodenectomy,5,6 has a primary role in maximizing the vascular surgical margin and, allowing for complete mobilization of the specimen before vein resection, may make a splenomesenteric junction tangential resection/closure easier and safer in case of tumor involvement of the splenomesenteric venous axis.

BACKGROUND:Several studies report that practicing Yoga may lead to numerous psychophysiological benefits in patients undergoing treatment for cancer. Moreover, it may result in an effective alternative for coping with sleep disturbances, anxiety, depression and fatigue symptoms. A study based on the "Yoga in Oncology" project of the Foundation Poliambulanza was carried out, and it was designed to explore the benefits of Yoga, therefore corroborating Yoga as a therapeutic activity that can have a beneficial impact on patients diagnosed with cancer.METHODS:Seventy patients were recruited, of whom 20% were males and 80% were females 18 years of age and older. All patients were being treated at the oncology department for gastrointestinal, mammary or genital carcinoma, and the disease was metastatic in 80% of patients. Data were collected between April 2013 and May 2017. The protocol consisted of a weekly 90-minute Yoga lesson for 8 consecutive weeks, and the data collection was carried out in 2 phases: (T0) preprotocol assessment and (T1) postprotocol assessment. Psychophysiological assessment was carried out with the following scales: the (BFI) Brief Fatigue Inventory, (HADS) Hospital Anxiety and Depression Scale and (PSQI) Pittsburgh Sleep Quality Index.RESULTS:Data analysis showed a significant difference between the (T0) and (T1) HADS (Hospital Anxiety and Depression Scale) scores. The constructs of this scale consist of psychological variables for the assessment of anxiety and depression. In contrast, scores from the (BFI) Brief Fatigue Inventory and (PSQI) Pittsburgh Sleep Quality Index did not show significant differences between (T0) and (T1): such scales are relative to psychophysiological variables for an assessment of the perception of fatigue and quality of sleep.CONCLUSION:It is noteworthy that the data, once analyzed, showed a significant difference between preprotocol and postprotocol levels of anxiety and depression but not for the perception of fatigue or the quality of sleep. In accordance with the scientific literature, data from this study highlight that practicing Yoga may promote changes in the levels of perceived anxiety and depression in patients undergoing treatment for cancer, thus positively affecting their (QoL). It is clear that the difference in significance between the psychological and physiological variables considered here and the statistical significance found only in levels of anxiety and depression encourage further studies to account for the nature of fatigue and sleep disturbances and how to address these symptoms in oncological patients. Moreover, other points of interest for future clinical research regard the evaluation of the reason for the possible denial to participate to this kind of study, as well as the social-cultural differences in patients' behavior.

Replaced common hepatic artery (RCHA) constitutes a rare but serious anatomical variation of the hepatic artery during laparoscopic pancreaticoduodenectomy (PD). Hereby, we report a technique to deal with such a situation during laparoscopic PD for cancer.

BACKGROUND:The prognosis of patients affected by pancreatic adenocarcinoma and periampullary tumors is dismal, mainly due to aggressive tumor biology and low rate of resectability at the diagnosis. Among resectable patients, the quality of surgical resection, with a particular focus on the complete resection of the retropancreatic tissue (the so-called "mesopancreas") encircling the superior mesenteric artery (SMA), has a cardinal role. With this assumption, many pancreatic surgeons recommend periadventitial dissection of the SMA in order to obtain a total mesopancreas excision (TMpE), maximizing surgical margin and minimizing R1 resection rate.OBJECTIVE:To introduce our approaches for periadventitial dissection of the SMA, tailored to patient and tumor characteristics and aiming at obtaining a TMpE, during laparoscopic pancreatoduodenectomy (LPD).METHODS:Three different approaches for the SMA periadventitial dissection during LPD are described: the right, the right-left, and the anterior SMA-first approach. Indications, advantages, and technical aspects of each technique are reported, as well as pathologic results, particularly focusing on resection margin status and removed lymphnodes number, safety, and feasibility.RESULTS:Overall, R0 rate and number of lymphnodes retrieved were 86% and 26, respectively, without significant differences according to the SMA approach performed. Rate of conversion to laparotomy due to intraoperative bleeding during SMA dissection step was 6% (3/48) among patients who underwent the right SMA approach and nil among remaining patients.CONCLUSION:During LPD, a tailored approach for periadventitial dissection of SMA makes TMpE feasible, safe, and oncologic valid, when performed by a team experienced with mininvasive approach and pancreatic surgery.

Background: Radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic body or tail adenocarcinoma has been designed to increase the rate of negative margin and to obtain better N1 nodes clearance. However, laparoscopic RAMPS has been rarely reported. Methods: Herein, we describe our technique for laparoscopic RAMPS. Following dissection of the gastro-colic ligament, proximal and distal control of the mesenteric-portal confluence is obtained and a retropancreatic tunnel is developed. Common hepatic artery is dissected from right to left until identification and dissection of celiac axis and of splenic artery, which is ligated. The pancreatic neck is transected, the splenic vein is dissected and divided. At this point, Treitz dissection is performed in order to identify the left renal vein, representing the posterior margin of dissection and the left side of superior mesenteric artery and of celiac axis, which represent the left dissection margin. The splenic artery is then divided and the dissection is continued posteriorly until distal pancreatosplenectomy is completed. Results: The operative time was 368 minutes, estimated blood loss 150 cc. The postoperative period was uneventful and the length of stay was 10 days. Pathologic exam showed complete resection of a pT3N1 (n+ 2/tot 20) adenocarcinoma, all resection margins were >1mm. Conclusion: RAMPS procedure with laparoscopic approach seems to be safe, feasible and effective.

Aims and Background: The main purpose of our psycho-educational groups was to help women with breast cancer, learn how to cope with the physical, emotional, and lifestyle changes associated with cancer as well as with medical treatments that can be painful and traumatic. With this study, we wanted to detect the effects that group action had on the women who participated in it. Methods: We studied a total of 97 patients who participated in 13 psycho-education groups. The whole sample was female patients who had breast cancer with no recurrence or metastases. Results: All patients were evaluated with the Hospital Anxiety and Depression Scale (HADS) and the Body Image Scale (BIS). We found no significant effect on anxiety and body image for the brief psycho-educational group for women with breast cancer in this study. It is possible to highlight a statistical difference and hence an improvement between the results of the HADS depression test at T0 (first evaluation at the first meeting) and T1 (retest in the final meeting). Conclusion: The tests did not show a significant effect on anxiety and body image perception, but the patients reported that the psycho-educational group was an important intervention for their life. Outcome measurement is more complex in psychosocial research because many variables come into play and each phase of treatment is characterized by different types of problems for the patient: physical, relational and psychological aspects are involved.

Introduction: Initially proposed to assess resectability and improve surgical resection margin status of patients undergoing pancreatoduodenectomy for pancreatic head tumors, the superior mesenteric artery (SMA)-first approach may also improve surgical safety allowing better identification of pancreatoduodenal arteries originating from the SMA and easier preservation of aberrant/replaced right/common hepatic arteries (RHA/CHA) originating from the SMA. We describe our experience with SMA-first approach during Open and Laparoscopic pancreatoduodenectomy (OPD and LPD). Methods: We used the SMA-first approach in 63 consecutive patients (June 2015–June 2017), 44 undergoing OPD and 19 LPD. Demographic, clinical-pathological, and perioperative data were prospectively collected and retrospectively analyzed. Results: The SMA-first approach was feasible in all study patients and was useful in the management of RHA/CHA anomalies in 14% of patients. Overall, median intraoperative blood loss was 150 ml, with 16% of patients undergoing intraoperative blood transfusion. OPD patients had higher intraoperative median blood loss (200 ml) and more frequently needed intraoperative blood transfusion (23%), compared to LPD (100 ml and 0%,respectively, p< .05). OPD patients underwent more complex procedures with higher rates of vascular resection/reconstruction (55%) and total pancreatoduodenectomy (43%), compared to LPD (0% and 5%; p< .005 for both comparisons). Among 34 patients affected by pancreatic ductal adenocarcinoma, the rate of R0 resection was 85% overall and similar between LPD and OPD. Conclusion: SMA-first approach is feasible, safe and oncologically sound, allowing for low intraoperative blood loss and high rate of R0 resection, and may be of help when a vascular resection/reconstruction is needed or a LPD is attempted.

Portal annular pancreas (PAP) is a pancreatic congenital anomaly consisting of pancreatic parenchyma encircling the portal vein and/or the superior mesenteric vein. It has been reported that the risk of developing a post-operative pancreatic fistula is higher following pancreaticoduodenectomy in patients with PAP, probably because of the possibility of leaving undrained a portion of pancreatic parenchyma during the reconstructive phase. Few manuscripts have reported a surgical technique of pancreaticoduodenectomy in case of PAP, herein we report the first case of a patient with PAP undergoing laparoscopic pancreaticoduodenectomy.

e23045 Background: Several studies demonstrated that an elevated neutrophil-to-lymphocyte ratio (NLR) correlate with a poor prognosis both in early and advanced stage of NSCLC. The aim of this retrospective analysis was to investigate the correlation between NLR and prognosis in caucasian patients diagnosed with advanced EGFR-mutated NSCLC and treated with tyrosine kinase inhibitors (TKIs). Methods: A retrospective database was used to identify consecutive patients diagnosed with advanced EGFR-mutated NSCLC and treated with TKIs. From January 2011 to December 2015, 63 patients from five Institutions were enclosed in our series. NLR was derived from the absolute neutrophil and the absolute lymphocyte counts of a full blood count.Survival curves were calculated with Kaplan-Meier method and data were compared by log-rank test. Prognostic significance of NLR were assessed using a Cox regression analysis. Results: Sixty-three eligible patients were stratified according to the mean pretreatment NLR value (3.57 ± 2.42). The chosen cut-off for NLR was 3.5. Forty patients had NLR < 3.5 while 23 patients had a value of NLR > 3.5.A statistical significant difference, both in PFS and OS, was found in the NLR < 3.5 group compared with the higher NLR group (PFS: p < 0.01, OS: p < 0.05). According to univariate analysis, histological type (adenocarcinoma vs non-adenocarcinoma) and NLR value correlate significantly with PFS and OS. In Cox multivariate analysis, only NLR ³ 3.5 resulted significantly associated as independent prognostic factor for worse PFS (HR 2.275, 95% CI 1.257-4.116, p < 0.01) and OS (HR 2.699, 95% CI 1.187-6.137, p < 0.05). Conclusions: Pre-treatment NLR seems to represent a reliable, simple, and easy to reproduce, laboratory tool to predict survival and outcome to therapies in western caucasian EGFR-mutated NSCLC patients. Further prospective trials are needed to definitively confirm its prognostic and predictive role.

Purpose Lung cancer is one of the leading causes of cancer-related death worldwide and, although targeted therapy with tyrosine kinase inhibitors has dramatically improved the rates of response and survival in advanced EGFR-mutated adenocarcinoma, the overall outcome remains unsatisfactory. Therefore, new prognostic factors, preferably simple, inexpensive, and easy to reproduce on a large scale, are needed. We performed a retrospective analysis of our database including 63 western Caucasian patients with advanced EGFR-mutated lung adenocarcinoma and receiving gefitinib, erlotinib, or afatinib as first- or second-line therapy. Several studies demonstrated a strong link between elevated neutrophil-to-lymphocyte ratio (NLR) and poor prognosis both in early and advanced stages of non-small-cell lung cancer (NSCLC). Methods From January 2011 to December 2015, 63 consecutive elegible patients with advanced EGFR-mutated NSCLC were included in this analysis from 5 institutions. The NLR was derived from the absolute neutrophil and the absolute lymphocyte counts of a full blood count and the cutoff value was determined according to the mean NLR level. Results Despite the small sample analyzed, we found that NLR has a prognostic role for progression-free survival (PFS) and overall survival (OS), reaching a statistically significant difference with a better PFS and OS in the lower NLR group. Conclusions Pretreatment NLR seems to represent a reliable, simple, and easy to reproduce laboratory tool to predict outcome and response to cancer therapies in this setting of Western Caucasian patients with EGFR-mutated NSCLC.

Background: The retroperitoneal peripancreatic tissue, and particularly the tissue surrounding the superior mesenteric artery (SMA), are often invaded at the time of pancreaticoduodenectomy for pancreatic head tumor, resulting in R1 resection with dismal survival. It is important to remove “enbloc” the head of the pancreas and the retropancreatic tissue, anterior to the inferior vena cava and the left renal vein, and around the SMA, in order to increase the number of R0 resections and to extend the circumferential resection margins. The SMA-first approach, in which the SMA is dissected free during the early phase of operation, seems to be associated with decreased rates of positive resection margins in patients undergoing pancreaticoduodenectomy for periampullar tumor. Herein, we describe our initial experience with the SMA-first approach for open pancreaticoduodenectomy (OPD) and laparoscopic pancreaticoduodenectomy (LPD).

Aims: Recently the superior mesenteric artery (SMA) first approach during open pancreaticoduodenectomy has been reported to be an efficient and safe approach to get the best chance of a negative resection. The feasibility and usefulness of this technique in the early phase of laparoscopic pancreaticoduodenectomy (LPD) is not yet fully elucidate. Methods: This report describes an «artery first» laparoscopic assisted pancreaticoduodenectomy for a pancreatic adenocarcinoma: after the access to the lesser sac and the Kocher maneuver, the retroperitoneum is widely opened and the origin of the SMA is visualized just proximally to the left venous reno-caval confluence. The loose connective tissue that surrounds the origin of the SMA is meticulously dissected and the periarterial connective tissue and nerve plexuses surrounding the SMA are dissected longitudinally downward as far as possible. The preparation continues as previously described in literature. After the transection of the pancreas neck, the pancreas resection is completed with the mobilization of the uncinate process that allows to reach an optimal view of the distal part of the SMA margin which is freed along the right side rejoining the previously dissected proximal part. Results: The operative time has been 8 h 46 min, blood loss less than 100 cc with no need of blood transfusion during hospitalization. The patient has been discharged in 10th post operative day and no severe post-operative complications have been reported (Dindo-Clavien 1). Histologic complete resection of the lesion has been achieved (pT3N1R0 − L + 5/25 − R>1 mm) with progression-free survival 6 months after PD. Conclusions: Although LPD still remains controversial, in our experience the SMA first approach is feasible, safe and effective in LPD. Prospective randomized controlled trials are still needed for confirmation, but the improvement in surgeons' experience and new technological innovations will probably make this technique a standard surgical procedure for the treatment of the pancreatic head diseases.

OBJECTIVE:Recent scientific approaches to cancer patients draw attention to the psychological aspects of the disease and the involvement of their families, who are forced to reorganize themselves in order to manage the patient's illness. Functional responses to a stressful event facilitate open communication between family members and empathy for the patient's children, who need to be involved and informed about the illness in a clear and open fashion. The primary goal of this observational study was to explore the communication styles used by cancer-stricken parents with their children and to identify a correlation with the patient's levels of anxiety and depression and their ability to cope. We also sought to understand whether location, severity, and time from diagnosis influenced communication, coping, anxiety, or depression.METHOD:From September of 2011 to July of 2015, 151 questionnaires were given to patients who had received at least one course of chemotherapy. The instruments that we employed were the Openness to Discuss Cancer in the Nuclear Family Scale, the Hospital Anxiety and Depression Scale, and the Mini-Mental Adjustment to Cancer Scale. Our sample included patients with children aged from 3 to 18 years. The patients had different types of cancer, mainly gastrointestinal and breast cancer. Their disease was at the metastatic stage in approximately 20% of patients.RESULTS:Our results showed statistically significant correlations between higher levels of anxiety and depression and more closed communication styles. The coping styles "hopelessness/helplessness," "cognitive avoidance," and "anxious preoccupation" were associated with a closed communication style that is correlated with higher levels of anxiety and depression. Tumor location, time from diagnosis, and stage of disease did not show statistically significant correlations with anxiety, depression, coping mechanisms, or communication styles.SIGNIFICANCE OF RESULTS:Our study confirmed what has been reported in the literature: high levels of anxiety and depression affect communication among family members. Not surprisingly, the "fighting spirit" coping style engenders open communication.

Background: In recent years, literature has reported an increase in the use of Complementary Alternative Medicine (CAM) by cancer patients to manage symptoms related to the disease or side effects of the treatments. Yoga is one of the most widely used complementary and alternative medicine therapies to cope with the most common symptoms of cancer as anxiety, depression, fatigue and sleep disorders. Recent studies conducted with cancer patients indicate that Yoga is associated with improvement in overall QOL, emotional well-being, physical symptoms and distress. In April 2013 we started the "Yoga project in Oncology " which involved the use of specific exercises of this discipline as a complement of cancer treatments. The aim of this study was to evaluate the impact of Yoga training on mood, fatigue and sleep quality in metastatic cancer patients. Material and methods: The Yoga intervention used the Yoga Ratna approach, consisting of pranayama (breathing exercises), gentle yoga asanas (postures) and meditation. The program includes 8 weekly group meetings lasting 1.5 hours, trained by a Yoga professional teacher with a psychologist. At the beginning (T0) and at the end (T1) of the training we administered the following tests: Hospital Anxiety and Depression Scale (HADS) to evaluate anxiety and depression; Fatigue Symptom Inventory (FSI) to assess fatigue symptoms; Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality. Results: Sample consisted of 35 patients with metastatic cancer receiving chemotherapy. The majority of the patients were women (65.7%), the mean age was 55 years, 62.8% of patients were married and 45.7% were employed with a medium-high level of education (57.1%). All patients had advanced disease: 54.3% breast cancer, 31.4% colorectal cancer; 8.6% others gastrointestinal tumors and 5.7% pancreatic cancer. The preliminary results showed a not statistically significant trend concerning anxiety and depression improvement and a better sleep quality. In addition, we found an increase of fatigue symptoms. Conclusions: These results don't show statistically significant correlations probably because the still small sample treated so far. Moreover patients continued to receive medical treatment (chemotherapy) during Yoga training and this condition could have influenced their fatigue perception. Nevertheless, every participant expressed a very positive evaluation of this experience concerning a better body awareness and anxiety control.