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Introduction: Neuroendocrine bladder cancer is extremely rare, with an estimated incidence of 0.35-0.70% of all bladder tumors. The small-cell carcinoma represents the most frequent histologic variant described. Small-cell carcinoma is an epithelial tumor associated with a more aggressive behavior and poorer prognosis than transitional cell bladder carcinoma. The overall survival rate at 5 years does not exceed 8%. At the time of presentation 59% of patients have clinical stage >T2 and 56% show metastatic disease. In 50% of the patients, fatal progression occurs within 6 months. Local recurrence after radical surgery occurred in 50-70% of cases., Patients and Methods: We report three cases of pure neuroendocrine small-cell bladder cancer. Hematuria was the most common presenting symptom. Local advanced disease was present in all the cases with stage >T2, metastatic disease in 1 case, lymph node involvement and ureteral bilateral obstruction in 2. Two patients were treated by radical cystectomy, bilateral pelvic limph node resections and urinary derivation. Platinum-based adjuvant chemotherapy was proposed but only two patients received the treatment. One patient with liver metastasis was managed only by extensive TUR and support regimen., Results: In 2 patients residual or relapsed cancer reappered within 2 months after surgery. All of the three patients died of metastatic disease at 5, 7, and 13 months. Median overall survival was 7 months. The most common site of relapse and spread of disease was the peritoneum and intestinal tract, and the reason of death was uncontrolled acute hemorrhage from gastro-intestinal district., Conclusions: In the absence of a prospective study, and because of the rarity of the disease, the best treatment for small-cell bladder cancer remains uncertain. Neoadjuvant chemotherapy with platinum regimen plus aggressive surgical approach will be the treatment of choice. The association of chemotherapy and radiotherapy should also be considered.

Small bowel tumours are rare, representing 0.3% of all cancers. The main problem with these tumours is that they induce vague, non-specific symptoms, causing a delay in diagnosis, which is often reached in cases of acute complications such as intestinal obstruction. Moreover, the small bowel is often involved secondarily by tumours that actually start from adjacent organs or by processes of peritoneal carcinomatosis, conditions which are responsible for a distinct worsening of the prognosis (up to 70% mortality). The aim of the study was to define the indications and the most appropriate surgical treatment modalities depending on the presentation of the small bowel tumour. At the Emergency Surgery Unit of the Vittorio Emanuele, Ferrarotto and S. Bambino Hospital in Catania 21 cases of intestinal obstruction caused by small bowel tumours were observed out of a total of 335 patients affected by intestinal occlusion (1.6%). Thirteen patients (62%) had already undergone abdominal surgery for a malignant neoplasm. All patients underwent plain abdominal X-ray which showed air-fluid levels; 14 (66%) were additionally studied by CT scans. Thirteen patients were operated on immediately on the day of admission, while the other 8 were initially treated conservatively. The small bowel was the primary site of the neoplasm only in 3 cases; in the other 10 it was secondarily involved by tumours originating from adjacent organs or by peritoneal carcinomatosis. In 8 cases an intestinal resection was accomplished together with removal of the involved organs, while in the 5 cases of carcinomatosis simple diverting procedures were carried out. Of the 8 patients initially treated conservatively, 6 were subsequently submitted to diverting operations because of persistence of the occlusive status. Nine patients had postoperative complications (47%) and another 3 died (14%). In conclusion, intestinal obstruction is a frequent complication of small bowel tumours, especially if they are in the final stages. Intestinal resection offers a good chance of recovery in cases--unfortunately rare--of confined tumours; in the other instances it is preferable to perform diverting procedures and subsequently refer the patient to the oncologist in order to plan adjuvant therapy, if possible.

The authors report on their experience in the treatment with self-expanding enteral stent for acute left-sided large bowel obstruction and believe that this procedure is effective as a "bridge to surgery". From January to November 2005 3 patients have been treated with colorectal stents in obstructing left-sided large bowel carcinoma: over the following 24 hours we observed canalization and consequent disocclusion of the colonrectum. Stented patients were treated with elective colonic resection with primary anastomosis avoiding decompressive stoma and Hartmann's procedure.

Objective: The Authors report their experience in diagnosis and treatment of one case of mesenteric cystic lymphangioma; recent international literature review., Experimental Design: Complete clinical report. Diagnostic, clinical and prognostic indication, evaluation of effectiveness of radical surgical treatment and follow-up., Setting: Operative Unit of General and Thoracic Surgery. University "Paolo Giaccone" of Palermo., Intervention: Radical surgical treatment, according to international guide-lines., Results: Complete recovery with "restitutio ad integrum". No relapse were recorded at short follow up., Conclusions: Even when asymptomatic and discovered incidentally, LCM must be treated surgically because of the potential to grow, invade vital structures, and develop life-threatening complications. The best and only radical treatment is the total removal of the lesions with microscopically clear borders, when it is available.

Lung carcinoma is the first cause of death for tumors; in Italy there are from 35,000 to 40,000 new cases a year, with a global survival to 5 years from the diagnosis in 13% of cases. The gastric and small bowel metastases are rare, respectively 0.4% and 1.1% and the cases reported in the literature are rare. There is often a poor symptomatology and diagnosis is usually based on post-mortem examination. Yet, sometimes, the first and only demonstration of the secondary illness is a surgical complication, whether it be a haemorrhage, a perforation or an occlusion. The authors report their experience, from April 1999 to March 2003, of 3 cases of small bowel metastases, presented in 1 case with a perforation and in 2 cases with an occlusion and of 1 case of gastric metastasis, which presented with a haemorrhage. These patients were treated by emergency surgery, with 1 case only of postoperative mortality. The 1st patient died 6 months after surgery, and the 2nd patient 6 days after, the 3rd patient 4 months after the 1st operation and the 4th patient is still in follow-up after 6 months. The authors present a review of the literature and some considerations of diagnosis and surgical treatment.

We report the case of a patient with von Recklinghausen's disease, who was admitted with a diagnosis of acute abdomen due to small bowel neurofibromatosis. The patient was submitted to an abdominal CT scan that showed a homogeneous round lesion, with a regular margin, probably belonging to the small bowel and with the appearance of a benign lesion that probably caused an intestinal intussusception. The patient was submitted to a surgical procedure that mainly consisted in multiple small bowel resections. The histopathological examination confirmed the benign nature of the lesions. About one third of patients affected by von Recklinghausen's disease present involvement of the bowel, but only 5% of them are symptomatic. The intestinal tumours are usually neurofibromas and are mainly localized in the jejunum. However, there have also been reports of stromal, nervous and endocrine tumours and even other tumours not belonging to these categories, including adenocarcinoma. The overall incidence of intestinal malignancy in patients with von Reckilnghausen's disease is about 10%. The surgical operation, as well as the histopathological and immunochemical examination of the intestinal lesions are of crucial importance for the treatment of the complications of intestinal neurofibromatosis and for the treatment and diagnosis of malignancy.

Celiac disease (CD), a gluten-induced enteropathy, is characterized by typical intestinal involvement with classical clinic features in childhood and less frequent features in adult patients. Recognizing pauci- and asymptomatic patients is a critical point in the clinical management of CD because of the high mortality associated with the onset of complications. Among these, malignant diseases are the most severe, particularly squamous cell carcinoma and lymphoma, the latter accounting for 50% of all malignancies occurring in CD patients. The authors describe a 57 years old patient with CD and Enteropathy-Associated-T-Cell Lymphoma, who had no intestinal symptoms but only severe pruritus and hypereosinophilia.

We report a case of metaplastic ossification occurring within a tubulovillous adenoma of the large bowel. To our knowledge, only two cases of this process have been previously described. The pathogenesis is unclear, but the phenomenon seems to be a morphologic curiosity with no clinical significance.

Forty-eight patients aged 80 or more were operated on for intestinal obstruction mainly due to incarcerated hernias (39.6%) and colonic neoplasms (27.1%). The morbility rate was 27.1% and the mortality rate was 8.3%. The study of the variables frequently related to the risk of postoperative complications (cancer, intraoperative contamination, emergency and blood transfusion) showed statistical significance only for blood transfusion. The others (emergency included) did not have a prognostic significance in this series.

The clinical consequences of intestinal malabsorption are extremely variable and a dissociation between malabsorption, malabsorption syndrome and enteropathy is often noted. Enteropathy does not always results in malabsorption and in an alteration of the tests exploring the absorptive function. The following have particular relevance in clinical practice: coeliac disease, malabsorption induced by microbiologic agent (including Whipple's disease), post-surgical malabsorption and selective carbohydrate malabsorption. In particular, coeliac disease has been analyzed in its various aspects, from studies with organ cultures to immunological hypotheses, from the classical variety to subclinical forms and to serious complications, such as enteropathy-associated T cell lymphoma. Malabsorption syndromes are dramatically underdiagnosed: in the typical case of coeliac disease, enteropathy represents a clinical iceberg, and the discovery of the submerged portion, represented by the polymorphous subclinical varieties, has just started. As far as intestinal malabsorption is concerned, the main clinical problem regards diagnosis.

The authors describe a case of intestinal invagination caused by leiomyoma of the small intestine. They make the diagnostic difficulties of the disease apparent and stress the importance of abdominal echography in cases of acute abdominal disorders.

After reviewing the literature on this topic, the authors examine all patients admitted to the Institute of Surgical Pathology in Pavia with a diagnosis of intestinal occlusion from 1-1-1974 to 31-12-1990. Of these, only those aged over 65 were included in the study and were in turn subdivided into 3rd and 4th age groups. The etiopathogenesis of this disorder is also discussed, stressing that it may be non-neoplastic (Group I) or neoplastic (Group II). The treatment used is also examined (surgical in the majority of cases) together with postoperative complications occurring in these patients. From the results obtained it is concluded that the method used in the pre-, intra- and postoperative stages provided satisfactory results, also in relation to the postoperative mortality rate which relatively low compared to other published reports.

The authors reports a case of massive digestive hemorrhage produce by a carcinoid of the small intestine. Having reviewed the most frequent causes of primary hemorrhage of the mesenteric small intestine, attention is focused on the difficulties o making an etiological and topographical diagnosis, in spite of using the most advanced instrumental research methods. The paper concludes that explorative laparotomy is the sole method for making a precise diagnosis and performing appropriate surgical treatment.

Three cases of lymphoma of the small intestine accompanied by numerous aspecific signs related to probable paraneoplastic syndromes are reported. All patients presented watch glass nails and drumstick fingers. These were associated, in the first patient, with initial pruritus followed by a picture of ichthyosis and, in the second, with a polyneuritic syndrome localised initially at the nerves of the lumbosacral plexus, later extended to the right facial nerve. The practical importance of such signs, which often precede and dominate, at least initially, symptomatology in the gastroenteric apparatus, is pointed out. Their early recognition may lead to a suspicion of the fundamental condition, thus avoiding diagnostic errors and permitting earlier diagnosis and faster treatment.

Cardiac involvement is commonly seen in the carcinoid syndrome (C.S.). However echocardiographic observations in this condition are still very scanty. In two patients with the C.S. and clinical signs of tricuspid insufficiency (plus mild pulmonic stenosis in one case) two-dimensional echocardiography showed: 1) right ventricular overload with normal left heart valves and chambers; 2) a peculiar aspect of the tricuspid valve, whose three leaflets were markedly thickened and retracted. The anterior leaflet was almost fixed in a semi-open position while the septal and posterior leaflets appeared as rigid structures fixed in an open position, extending from the annulus into the right ventricular cavity. In both cases only the posterior cusp of the pulmonary valve could be visualized. The afore-mentioned changes exactly reproduce the pathological features of the tricuspid valve in the carcinoid heart disease and so far, have not been observed in other conditions.

The Authors report an investigation on 42 patients with large bowel occlusions for neoplastic lesions. Obstruction complications were localized in 69% in sigmoid colon and recto-sigmoid junction. This pathology involved old patients with one or more associated affections. The Authors explain reflections on surgical treatment, on necessity of therapeutic approach in high-risk patients, and of large bowel surgery with oncologic radical treatment.

A case of serious, recurrent enterorrhagia is reported. The cause could not be identified with normal diagnostic tools and was discovered only after explorative laparotomy. The finding was benign ulcerated tumour of the small intestine, histologically defined as fibroma with fluorishing cellularity.

Primitive gastrointestinal lymphomas constitute a rare pathological event, may involve any part of the gastrointestinal tube, and normally belong to the non-hodgkin variety. They do not present characteristic symptoms as compared with what can be found in other gastrointestinal lesions whether neoplastic or inflammatory. Radiologically and endoscopically they do not evidence any particular aspects, so that they can be confused with other diseases (gastroduodenal ulcer, benign tumours, epithelial malignant tumours). For such primitive forms, radical surgical treatment constitutes the first treatment and undoubtedly the fundamental form, with which radiotherapy and chemotherapy may be associated. In addition to a review of the literature, the Authors examine a case of intestinal lymphoma complicated by a picture of subocclusion.

Vaginal elimination of stool due to sigmoid-uterine fistula was the first symptom in a case of neoplasia of the sigma. Few instances of a similar fistula appear in the literature. Bouskela, Chérisié, Yourde and Taieb observed one case starting from the uterus. McGregor & Bacon have described a fistula starting from the colon due to diverticulitis, as have Colceck & Staumann, Smalley et al., and Johnston & Stubbs. No previous example of tumour of the large intestine as the cause of a fistula with the corpus uteri could be found. On examination, the patient presented losss of stool via the vagina and a sigmoid-uterine fistula. Her condition was poor. Blood glucose was high, the protein picture was altered with a los of albumin, and infection was present. Radical management was impossible. Left colostomy reduce the causes of infection and permitted devitalisation of the fistula. Subjective and objective improvement followed, though further enlargement of the tumour engulfing the sigma and uterus led to death some months later due to the onset of renal block.

A case of intestinal occlusion due to jejunal leiomyosarcoma is reported. Attention is drawn to the unusualness of the picture and the absence of an indicative symptomatology. Early diagnosis is desirable if surgery is to be successful.

A case of ileo-colic invagination caused by lipoma of the last loop of the small intestine is reported. The anatomo-clinical features of this neoformation are illustrated and stress is laid on certain special aspects: the rarity (about 300 cases have been described in the literature), the lack of symptomatology and its insidious development without pathognomonic sign up to the occurrence of occlusive episodes. The surgery carried out and the result obtained are reported.

The observation of a case of Hodgkin's disease primarily localized in the small bowel and with clinical picture of free perforation prompts the AA. to report the unusual enteric symptoms of this disease and to examine its pathologic and clinical features. Although Hodgkin's disease of the small intestine as a cause of perforation is extremely rare, the AA. describe the prominent frequency of abnormal serum proteins and of long lasting diarrhea with syndrome of florid malabsorption as primary manifestations of ileum involvement. Moreover the AA. indicate that while diagnosis of this peculiar location is rarely made clinically, it requests laparotomy and its confirmed by histologic specimen. The AA. suggests radical surgery and extensive radiotherapy in the treatment of primary Hodgkin's disease of the small bowel.

Intestinal occlusion with the characteristics of an atresia proved to have been caused by leiomyoma of the jejunum.

A case of cancer of the small bowel associated with Crohn's disease with onset 21 years after the first clinical signs of the latter is reported. The patient survived for 20 months after cancer diagnosis. After noting the rare association between the two conditions, the aetiopathogenetic relations that can be called on to explain relations of causality are analysed and it is emphasised that it is impossible to distinguish symptoms from those of cancer due to the renewed inflammatory activity. Finally it is considered that to clarify unequivocably the relations between the two conditions further studies are required.

An unusual case of intestinal obstruction due to ileal metastatic melanoma is reported. An ileocolic intussusception led to intestinal obstruction. The patient underwent palliative surgery to re-establish intestinal continuity.

Starting from a case of pure fibroma of the small intestine, which led to ileo-ileo-colic invagination, the Authors review the literature on the subject. The great rarity both of the type of neoplastic pathology found and the type of induced intestinal invagination is stressed. It is concluded by asserting that correct diagnosis, adequate selection of the type of surgery and its efficient performance allow a favourable prognosis in the overwhelming majority of cases.

The authors review a total of 132 cases of acute neoplastic obstruction of the large gut seen in their clinical material over the last twenty years. In the light of the results obtained they discuss the indications and limitations of the various surgical strategies adopted (radical surgery, derivative surgery, and palliative resection); they conclude that radical procedures are best for the majority of cases.

The Authors have examined the problem concerning the presence of "Double malignancies" in the same patient, on the basis of a review of the literature and of an investigation of their own case material (nine patients: six with double solid tumours and three with a solid tumour and an associated haematologic neoplasia). The Authors discuss the time sequence of the two neoplastic processes and the immunological pattern (T and B lymphocytes) of all cases.

The Authors after having paid considerable attention on the contemporary existence of numerous carcinoid tumours of the intestine and of other abdominal organs, as well as on the frequent multicentricity exhibited by the very same at the level of the last tract of the ileum, explain this by considering the recent research performed on the APUD cells and on the cells of the diffuse endocrine system (DES) of the intestine. They present a carcinoid case, where it is understood that the product of secretion of the same, still not completely identified in its structure and mode of action, produces an arterial vascular alteration even at considerable distance from the tumour, hence bringing about an intestinal ischemic symptomatology which they hypothesize is the case for all the cells of the intestinal diffuse endocrine system, a type of self-regulatory feed-back hormonal system.

Ten cases of serious complications requiring emergency surgery in patients with tumours of the small intestine are presented: 3 cases of peritonitis due to perforation of a fibroleiomyoma, a jejunal adenocarcinoma, and an ileal lymphosarcoma; 3 invaginations (1 ileocolic due to an ileal polyp, and 2 ileoileal due to lymphoma and polypoid metastasis of melanoma; 3 stenosis (ileal owing to metastasis of melanoma, and duodenal and of the duodenojejunal flexure due to histologically unascertained neoplasias); 1 massive enterorrhagia from ileal anaplastic carcinoma. The frequency of such pictures is not negligible when assessed in terms of emergency surgical pathology and compared with other emergency situations arising in patients with tumours. Preoperative diagnosis is difficult even from the clinical history. Tumours of the small intestine appear to give rise to such complications in their initial stages.

The authors describe 9 cases of primitive tumors of the small gut (3 adenocarcinomas, 2 lymphosarcomas, 1 fibroma, 1 angioma, and 2 leiomyosarcomas, one being the cause of active hemorrhage). In all cases the tumors were diagnosed only at operation, which was invariably necessitated by complications. Seven patients underwent emergency surgery for intestinal obstruction; one underwent an exploratory laparotomy for recurrent intestinal bleeding caused by an angioma of the ileum; and the last of this series (exceptional enough to warrant separate reporting elsewhere) was operated upon as an emergency case when the tumor, precisely a leiomyosarcoma, was perforated and actively bleeding.