INTRODUCTION:Anticancer chemotherapy causes irreversible damage to the endothelial wall of small vessels. This is the reason why long-term (more than 3 months) central venous devices are essential to administer chemotherapy drugs to cancer patients and antibiotics for chronic or severe infections and in patients requiring long-term parenteral nutrition. We report our experience with the percutaneous implantation of central venous devices in a radiology department.MATERIAL AND METHODS:March, 1993, to August, 1997, eighty-seven consecutive patients (26 men and 61 women, mean age: 55 years) were examined. The indications for central venous catheter placement included anticancer chemotherapy in 82 cancer patients, repeated blood transfusion in one patient with bone marrow aplasia and nutritional support in four cancer patients. Eighty-four central venous devices (75 totally subcutaneous systems--Port-a-cath Dome--, and 9 partially tunneled catheters--Groshong) were inserted. The average follow-up was 6.5 months (range: 1-18). All procedures were performed in the radiology department and venous access was achieved with fluoroscopy using the Seldinger technique. Chest radiography with the patient standing was routinely performed after the procedure and repeated the day after to assess the catheter position and the presence of pneumothorax. The venous catheters were placed in the subclavian vein in 68 cases (12 in the right side and 56 in the left side), internal jugular vein in 12 cases (9 in the right side and 3 in the left side) and right femoral vein in 4 cases. We prefer the subclavian vein (80.9%) for better cosmetic results, wider catheter angulation and easier fixation to the deep plane.RESULTS:The first access failed in 6 cases (6.8%). A pneumothorax occurred in 4 patients (4.7%) and late complications were seen in 15 patients (17.8%) after a mean of 15.7 weeks (range: 2-48). Catheter-related infections developed in 6 patients (7.1%) after a mean of 20 weeks (range: 5-48). The microorganisms cultured from these catheters was the Staphylococcus epidermidis. After two weeks' specific antibiotic therapy, all the devices were removed. Deep venous thrombosis occurred only in one patient after 10 months and was successfully treated with direct thrombolytic infusion. The catheter was displaced in the right atrium in two patients after 11 and 12 weeks, respectively: both catheters were removed by transfemoral catheterization.CONCLUSIONS:The percutaneous implantation of--long-term central venous devices is a safe and tolerable procedure. In our experience, the radiology-assisted placement of these devices offers many advantages over surgical implantation. In particular, fluoroscopy allows direct visualization of the catheter position while insertion and positioning are essentially "blind" at surgery, which complicates venous access and increases the risk of catheter malpositioning. Radiologic follow-up is also useful to depict and correct complications.

The diagnostic features of 225 consecutive cases of cancer recurrence (186 true recurrences, 39 new primary cancers) in the conserved breast were reviewed. The sensitivity of palpation, mammography, ultrasonography or fine needle aspiration cytology was 69.8, 66.1, 73.3 and 77.8%, respectively. The sensitivity was not significantly influenced by previous radiotherapy, type of recurrence (new primary or true recurrence), or patient age. Although the sensitivity of mammography was lower (60.6 vs 69.3%) in the presence of dense compared with fatty breasts, this did not explain most of the mammographic false negatives, some of which were likely to be due to the masking effect of surgical scar and distortion. In the study period suspicion of breast recurrence following diagnostic evaluation resulted in 34 unnecessary benign biopsies, giving a positive predictive value for biopsy of 86.8%. Of 171 recurrences undergoing a triple diagnostic approach (palpation, mammography/ultrasonography, cytology), recurrence was suspected by at least one, two or three tests in 99.3, 81.8 or 40.3% of cases, respectively. A multimodal diagnostic approach is necessary to maximize the sensitivity of detecting breast cancer recurrence after conservation therapy, and should be employed routinely.

Positive margins (PM) may have an important role in predicting intramammary recurrences after conservative treatment of breast cancer (BC). We analyzed a variety of preoperative and pathologic factors to determine their association with the occurrence of PM. 1148 BC cases observed from 1980 to 1994 were reviewed. All patients had undergone wide excision of the tumour and 1108 had axillary dissection. Age ranged from 23 to 87 (mean 56). pT category was pT1 in 908, pT2 in 225, and pT4b in 15 cases, respectively. pN category was pN0 in 799, pN1 in 309, and pNx in 40 cases, respectively. PM were observed in 94 (8.2%) cases (intraductal = 56, invasive = 38). PM were significantly associated with a variety of factors, namely: a) age P = 0.03); b) microcalcifications vs. opacities at mammography (12.9% vs. 6.6%, P = 0.001); c) pT2 vs. pT1 (11.5% vs. 7.3%, P = 0.04); d) pN1 vs. pN0 (11.6% vs. 7%, P = 0.01); e) extensive intraductal component (EIC) or multifocality (24.2% or 17.5% vs. 3.3%, P Our experience suggests that in younger patients with microcalcifications at mammography, T2, EIC and multifocality, a wider excision of the tumour is necessary to obtain tumor free resection margins.

Between 1986 and 1995, 965 patients with T1 breast cancer were treated with wide excision (796 pts) or mastectomy (138 pts). Axillary dissection was performed in 934 patients. Nodal positivity was 8.7% for T1a, 15.6% for T1b and 37.7% for T1c. 68.5% of cases had one to three positive nodes, 18.3% four to ten and 13% more than ten nodes. No differences were observed in the frequency of lymph nodes involved according to the age of patients, menopausal status, pattern at mammography, histology and receptor status. Favourable histology (tubular, cribriform, papillary, colloid) shows a significant difference when compared with all the others histotypes. On the basis of data collected it is impossible to anticipate the axillary status and avoid axillary dissection.

Preoperative radio-chemotherapy is currently employed to reduce local recurrences of rectal cancer (RC). We reviewed a consecutive series treated with this modality, in order to evaluate the frequency of complications. 47 patients with localized RC were observed from 1990 to 1994. 19 patients (mean age = 62; T2 = 3, T3 = 14, T4 = 2) received preoperative irradiation (45 Gy in 5 weeks) and chemotherapy (5-FU + Leucoverin, refused by one patient), whereas 28 patients (mean age = 66.5; T1 = 1, T2 = 9, T3 = 17, T4 = 2) were treated by surgery alone. All patients had radical surgery, immediately or after (mean = 5 weeks, range 3–18) preoperative treatment. Grade 3+ toxicity during preoperative treatment was observed in 8 cases (42.1%), being accounted for skin, blood, bladder, and bowel toxicity in 6, 2, 2, and 3 cases, respectively. 8 patients had radiotherapy/chemotherapy interrupted for major toxicity. One patient in the preoperative treatment group died (mortality 5.2%) for postoperative pulmonary embolism. Complications of surgery were observed in 31.5% of cases in the preoperative treatment group, and in 21.4% of cases in the immediate surgery group (P = 0.3). Anastomotic dehiscence developed in 15.7% and 7.1% respectively; but none of them required second intervention. No difference was observed between the two groups as far as ileus time or hospitalization time were concerned. Considering the expected therapeutic benefits of preoperative treatment its side effects were relatively moderates and clinically acceptable. Preoperative radio-chemotherapy is currently employed to reduce local recurrences of rectal cancer (RC). We reviewed a consecutive series treated with this modality, in order to evaluate the frequency of complications. 47 patients with localized RC were observed from 1990 to 1994. 19 patients (mean age = 62; T2 = 3, T3 = 14, T4 = 2) received preoperative irradiation (45 Gy in 5 weeks) and chemotherapy (5-FU + Leucoverin, refused by one patient), whereas 28 patients (mean age = 66.5; T1 = 1, T2 = 9, T3 = 17, T4 = 2) were treated by surgery alone. All patients had radical surgery, immediately or after (mean = 5 weeks, range 3–18) preoperative treatment. Grade 3+ toxicity during preoperative treatment was observed in 8 cases (42.1%), being accounted for skin, blood, bladder, and bowel toxicity in 6, 2, 2, and 3 cases, respectively. 8 patients had radiotherapy/chemotherapy interrupted for major toxicity. One patient in the preoperative treatment group died (mortality 5.2%) for postoperative pulmonary embolism. Complications of surgery were observed in 31.5% of cases in the preoperative treatment group, and in 21.4% of cases in the immediate surgery group (P = 0.3). Anastomotic dehiscence developed in 15.7% and 7.1% respectively; but none of them required second intervention. No difference was observed between the two groups as far as ileus time or hospitalization time were concerned. Considering the expected therapeutic benefits of preoperative treatment its side effects were relatively moderates and clinically acceptable.

Diagnostic features of 102 consecutive cases of cancer reoccurrence in the conserved breast are reported. The sensitivity of palpation, mammography, cytology or ultrasonography was 75.5%, 58.7%, 77.4% and 77.8%, respectively. Mammography failures were not due to natural breast density and could probably be explained by the masking effect of surgical scar and distortion. Most failures at cytology were due to inadequate sampling. Palpation should always be associated with mammography in the follow-up of the conserved breast. Aspiration cytology should.be performed incase of any abnormality seen at palpation or mammography.

From January 1988 to June 1990 one-hundred-twenty-four orthotopic liver transplantation (OLT) were performed in pigs, using a surgical procedure already described in the literature but with two major modifications. One of these modifications was the end-to-end microsurgical anastomosis of the proper hepatic arteries of the donor and recipient; the second one was the reduction in length of the donor suprahepatic vena cava to 1-2 mm before anastomosing it with the recipient suprahepatic vena cava at the level of the diaphragm. The first 24 transplants were used to develop the surgical technique. The latter was then applied to all subsequent 100 transplants, and results are herein presented. Good outcome of surgery appeared to depend on the modifications adopted in surgical technique, use of a pump-driven veno-venous bypass during the anhepatic phase of surgery, administration of cyclosporin A postoperatively, and training of the operator.