AIM OF THE STUDY:To evaluate the indications for open surgical biopsy of breast lesions resulting in a benign histologic report.METHODS:A consecutive series of 754 benign breast biopsies was collected from six Italian centers previously participating in a multicenter study on the benign/malignant biopsy ratio. Histologic diagnosis, diagnostic tests performed, final clinical diagnosis and the indication for surgical biopsy were compared.RESULTS:Fibrocystic alterations represented the most frequent histologic type (43.2%), followed by fibroadenomas (34.5%). Atypical hyperplasia, phyllode tumors and cancer-like lesions (radial scar, sclerosing adenosis) accounted for a minority of cases. The diagnostic approach was different among centers, with mammography, ultrasonography or cytology being underused in some of them. Suspicion of cancer was an indication for surgical biopsy in 66.7% of cases. In the remaining cases the final report was negative or benign, but biopsy was advised for growing lesions (11.3%) or for cosmetic (3%) or psychological reasons (8.2%). In 4% of cases surgical biopsy was presumably advised for the concurrent influence of high-risk conditions such as previous breast cancer (0.7%), family history of breast cancer (2%) or contralateral synchronous breast cancer (1.3%). In 6.8% of the cases biopsy was advised elsewhere for unknown reasons. The indications for biopsy differed among centers, with one center having a low rate of suspicious cases (37%) and a high rate of reported "cosmetic" or "psychological" reasons (47%).CONCLUSIONS:Leaving aside differences in diagnostic approach and aggressiveness, two thirds of all lesions were biopsied in order to exclude cancer. The routine use of a more complete diagnostic protocol and/or alternative methods to obtain a histologic diagnosis (e.g. core biopsy) might substantially reduce the need for open surgical biopsy.

A 67 year old man presented with non-invasive thymoma, associated aplastic anemia and important hypogammaglobulinemia; the postoperative course has been characterized, three months later, by thrombocytopenia (kept under control with steroid therapy) and, two years later, by squamous lung cancer, not susceptible of surgical treatment. The patient died five years after operation because of progression of the lung cancer. Anemia improved only partially after operation; there where no effects on hypogammaglobulinemia. Thymoma has been reported in literature in 50% of patients with aplastic anemia, 7-13% of adult patients with hypogammaglobulinemia is affected by thymoma, in 21% of patients that presented with thymoma other tumors have been discovered through clinical history.

The diagnosis of traumatic hernia of the diaphragm can be obtained at the time of injury or months-years after the trauma. The Authors report a case of traumatic hernia of the diaphragm, diagnosed 3 years after a blunt thoracic trauma in a 47-year-old man. The patient was admitted to the hospital for a pneumothorax caused by perforation of the herniated colon. He underwent colonic resection and reduction of the herniated viscera but unfortunately he died of septic shock on the 40th postoperative day. Pneumothorax is a very rare complication of traumatic diaphragmatic hernia and few cases are reported in literature. The diagnosis in the delayed phase is not easy since the correlation with the trauma is not always clear.

Over the last few years, estrogen receptor determinationby means of immunohistochemistry has been extensively used.The aim of this study was to comparethis technique with estrogen receptor determination by meansof dextran-coated charcoal, and to evaluate whether oneof the two methods is more predictive ofprognosis. Estrogen receptors were determined by means ofboth the dextran-coated charcoal method and immunohistochemistry in405 patients with primary breast cancer; age, pathologicaltumor size, nodal status, and progesteron receptors bydextran-coated charcoal method were also recorded. The disease-freeand overall survival probabilities were estimated using theproduct-limit method; Cox's proportional hazard model was usedto evaluate the prognostic role of estrogen receptorsas determined by the two methods.There appears to be a close association betweenestrogen receptor determination by the two methods (81.5%of concordant results) and their prognostic role wassimilar, even when the patients were divided intodifferent groups (on the basis of their estrogenreceptor status) and adjustments for the effect ofother prognostic variables were taken into account. Ourstudy shows that the two methods can beused indifferently to evaluate estrogen receptor status asa prognostic factor in breast cancer patients.

AIM:Retrospective evaluation of 19 diaphragmatic ruptures due to blunt trauma.MATERIALS AND METHODS:We collected all patients with thoracic and/or abdominal blunt trauma who were admitted to the department of surgery (Clinica Chirurgica and Chirurgia generale C) from 1970 to 1995. We selected patients with ascertained diaphragmatic rupture.RESULTS:We considered 17 cases of TDR (15 males and 4 females). Mean age was 38 years (range 16-67). Radiologic findings were consistent with TDR in 10 cases out of 17 (58.8%). Right hemidiaphragm was injured in 6 cases (31.6%). 10 patients (52.6%) presented at operation with intrathoracic visceral herniation. 8 patients underwent laparotomy, 7 both laparotomy and thoracotomy, 4 thoracotomy alone. Perioperative mortality was 15.7% (3 patients).DISCUSSION AND CONCLUSIONS:The clinical features were complicated by a large number of associated lesions; radiologic diagnosis is comparatively easy if visceral herniation into the thorax is present, repeated radiologic examinations facilitate diagnosis. The surgical access is determined by concomitant associated injuries which may require urgent operation.

AIMS AND BACKGROUND:Although they have been decreasing over time due to improved specificity of diagnostic assessment, benign biopsies of the breast are still common. Benign biopsies should be regarded as negative events, due to their economical and psychological cost and their possible negative impact on cosmesis and on further diagnostic evaluation. METHODS:Retrospective data on benign/malignant breast biopsies ratio (B/M) were collected in 9 Italian centers for a period of 10-15 years. The time trend of B/M and its association to age or to single centers was evaluated. RESULTS:Overall 31,001 cases were considered. A strong association of B/M to age was evident (average B/M values were 5.0, 1.3, 0.6, and 0.2 for women aged < 40, 40-49, 50-59, and > 59 years). A significant trend of decreasing B/M over time was observed only for one center. Age standardized B/M was significantly different (P < 0.000001) between centers, ranging between 0.34 and 1.69. Multivariate analysis confirmed an independent significant association of age and center to B/M. CONCLUSIONS:Marked differences in B/M are evident between centers, which cannot be explained by the confounding effect of age or by any apparent difference in the diagnostic protocol. The observed differences are likely ascribed to individual variations in diagnostic aggressivity. A progressive increase of the predictive value of calls for surgical biopsy may be achieved over time and centers with a high B/M should make every effort to optimize their performance. Acceptable (< 40 = 5, 40-49 = 1.5, 50-59 = 0.75, > 59 = 0.3) and desirable (2.5, 0.75, 0.35, 0.15) age specific reference standards for B/M are proposed.

The authors consider 88 cases of mastectomy and immediate breast reconstruction mainly performed using the skin expander plus prosthesis method or latissimus dorsi myocutaneous flaps. At the same time, 53 patients underwent contralateral mastopexy for symmetry. The mean follow-up was 21 months (range 2-102). Progressive disease was observed in nine cases: one patient presented scar relapse, one axillary relapse, two contralateral tumor, two contralateral tumor and distant metastasis, three distant metastases and one death from distant metastasis. Reconstruction complications were capsular contracture in 12 cases, infection in nine, skin necrosis in two, skin expander breakage in three and implant dislocation in one. The final result was judged good in 54 cases, fair in nine, poor in 11 and unevaluable in 14. In conclusion immediate breast reconstruction does not seem to interfere with the disease or oncological therapy. After analysing separately, and comparing the results and complications of the two main techniques used, latissimus dorsi seems to be the most reliable method in the majority of cases but skin expanders can be a good technique in patients with small and firm breasts and without complicating risk factors.

The results of 50 latissimus dorsi myocutaneous flaps are presented. The majority of reconstructions were assessed by the patients as excellent or good. There were few major complications and these were more common in patients having delayed reconstruction.

ER were determined on 405 primary b.c. by both biochemical and immunoistochemical methods. The aim of this study was to evaluate if one of the two methods is more predictive of prognosis. We considered ERDCC + if ≥ 10 f mol/mg and ERICA+ if ≥ 45% of cells were stained. Product-limit method and Cox's proportional hazard model were used for the statistical analysis. The median follow-up was 40 months (range 4–95); 98 pts relapsed and 48 died. There is a close association between ERICA and ERDCC (concordance: 81.5%). ERICA status was significantly associated with both DFS and OS (higher in ERICA+); ERDCC status was significantly associated only with OS (higher in ERDCC+). Similar results were obtained when adjustments for the effect of other prognostic variables (pT, pN, age) were considered. A comparison of DFS and OS when ERICA and ERDCC status were jointly evaluated showed that these methods gave quite similar information on prognosis, so that it is possible to use only one technique. ER were determined on 405 primary b.c. by both biochemical and immunoistochemical methods. The aim of this study was to evaluate if one of the two methods is more predictive of prognosis. We considered ERDCC + if ≥ 10 f mol/mg and ERICA+ if ≥ 45% of cells were stained. Product-limit method and Cox's proportional hazard model were used for the statistical analysis. The median follow-up was 40 months (range 4–95); 98 pts relapsed and 48 died. There is a close association between ERICA and ERDCC (concordance: 81.5%). ERICA status was significantly associated with both DFS and OS (higher in ERICA+); ERDCC status was significantly associated only with OS (higher in ERDCC+). Similar results were obtained when adjustments for the effect of other prognostic variables (pT, pN, age) were considered. A comparison of DFS and OS when ERICA and ERDCC status were jointly evaluated showed that these methods gave quite similar information on prognosis, so that it is possible to use only one technique.

Four cases of iatrogenic rupture of the oesophagus are presented. The site of the lesion was in the cervical tract in 1 case and in the thoracic tract in the other 3 cases. Their etiology was pneumatic endoscopic dilatation for achalasia in 2 cases, endoscopic insertion of a Celestin tube for carcinoma of the thoracic tract of the oesophagus in 1 case, and diagnostic endoscopy in the last one. Instrumental findings were relevant in all cases. All patients underwent surgery. In the patients suffering from achalasia, the rupture was repaired by a patch of the gastric fundus. The patient suffering from carcinoma underwent an oesophageal resection, the one with cervical perforation underwent a mediastinal drainage. There were no deaths or considerable post operating complications. In a patient suffering from achalasia gastro-oesophageal reflux was demonstrated after some months following the operation.

OBJECTIVE To present our experience of 10 patients with extra-adrenal retroperitoneal paragangliomas, and assess prognostic tests. DESIGN Retrospective study of casenotes. SETTING University hospital, Italy. SUBJECTS 10 Patients who presented with paragangliomas between 1970 and 1991. MAIN OUTCOME MEASURES Histological and immunohistochemical results, and outcome. RESULTS All tumours were completely resected and there was no operative mortality. Of the 8 patients who had no metastases at presentation 3 died of recurrence 3, 5, and 10 years later, respectively; 4 were alive and free of disease 2-7 years after diagnosis. The 2 patients with synchronous bone metastases at presentation died 1 and 4 years later. Immunohistochemical analysis of type I cells (chromogranin A and neurone-specific enolase) showed little correlation with progression of disease, but there was a correlation between the presence of type II cells (S100 protein) and good prognosis. CONCLUSIONS Excision is the treatment of choice for paraganglioma. Immunohistochemical techniques may provide useful information about prognosis, in particular about those patients who are at increased risk of recurrence. Long term follow up is essential, because successful management of recurrence is dependent on early recognition.

9 patients (8 males 1 female, middle age 24.3 years, range 20-41) affected by primary mediastinal germ cell tumor were surgically treated in our department. They were 4 seminomas, 2 embryonal carcinomas, 1 malignant teratoma and 2 benign teratomas. Three patients were asymptomatic; cough, dyspnea and chest pain were the most frequently observed symptoms. The staging work-up did not show signs of metastatic disease in the malignant types. Benign teratomas underwent complete excision. In one patient suffering from seminoma radiotherapy and chemotherapy caused complete remission of the disease. In the others cases remission of the neoplasm was obtained by resection and adjuvant therapy in 3 cases, by neoadjuvant treatment and excision of the residual mass in 3 cases. Among the patients suffering from seminoma, 2 are dead at 60 months since initial treatment and 2 are alive at 132 and 120 months respectively. Among the patients with malignant nonseminomatous tumours, 2 are alive at 60 and 36 months and 1 patient is dead at 13 months. Two patients with benign teratoma are alive at 189 and 168 months respectively. At present a multimodality treatment including surgery, radiotherapy and cisplatin-based combination chemotherapy, give the most satisfactory results in the treatment of malignant mediastinal germ cell tumours.

27 patients suffering from carcinoid of the lung (18 females and 9 males, middle age 52 years, range 26-68) underwent surgery in our department. The neoplasms were located at the pulmonary hilum in 21 cases. The diagnosis was occasional in 6 cases, cough (51.8%) and recurrent bronchitis (37%) were the most frequent symptoms. No instances of carcinoid syndrome were detected. Preoperative staging ruled out pathologic mediastinal lymph nodes or hematogenous metastases. 26 patients underwent complete excision of the neoplasm (11 lobectomies, 9 pneumonectomies, 4 bilobectomies, 1 segmental resection, 1 bronchial wedge resection). Histologically, 4 cases were categorized as atypical carcinoids. Two patients died within 1 year, one suffering from atypical carcinoid because of disease progression, and an other one (suffering from atypical carcinoid) who underwent only at exploratory thoracotomy followed by chemotherapy. A patient suffering from typical carcinoid died within 1.5 years because of gallbladder carcinoma. From our experience and from the literature review it appears that carcinoids has to be considered as malignant neoplasms and treated according to.