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Malignant pleural effusion (MPE) is a common, debilitating complication of several types of advanced malignancy, which may significantly reduce the quality of life of patients. There are several options to treat MPE, including thoracentesis, placement of a long-term indwelling pleural catheter and chemical pleurodesis. The best treatment is still debated, but talc remains the agent of choice to achieve pleurodesis. Forty-six patients (28 men and 18 women; median age 67 years, range 47-82 years) with MPE related to different malignancies underwent video-assisted thoracoscopy talc pleurodesis. There were 26 (56.5%) patients with non-small cell lung cancer, 8 (17.4%) with breast cancer, 7 (15.2%) with pleural mesothelioma and 5 (10.9%) with other malignancies. The average operative time was 28±8 minutes, and the duration of chest tube drainage was 9.4±4.1 days. Side-effects were mild (temporary pain, fever for 2-3 days), affecting only three (12%) patients. Two patients (8%) died during hospitalization, due to progression of disease. Overall, pre- and postoperative Karnofsky performance index (KI) and Medical Research Council (MRC) dyspnea score were 62.1±12.2 vs. 71.3±13.2 (p=0.014), and 4.2±0.8 vs. 2.7±1.0 (p<0.001), respectively. A significant relationship between total amount of preoperative pleural effusion and both KI (R=-0.54, p=0.002) and MRC (R=0.64, p=0.0001) was found. No correlation (p=NS, log-rank test) was found between preoperative KI or MRC and underlying malignancy related to MPE. In conclusion, thoracoscopic large-particle talc pleurodesis is a feasible and effective treatment for MPE, significantly improving quality of life of patients.

Splenic hamartoma (SH) is a very rare benign vascular lesion, usually asymptomatic. Although infrequent, it must be differentiated from malignant lesions, such as lymphoma or metastases, or other vascular neoplasms of the spleen. We present the case of a solid lesion of the spleen discovered incidentally in a 42-year-ol women, characterized by an unusual rapid expansive growth during four-month follow-up. The lesion, isoechoic and close to the hilum, was initially suspected to be an accessory spleen, measuring 3.5 cm in size. Four months later, magnetic resonance imaging revealed a 9-cm expansive nonhomogeneous mass in the antero-superior margin of the spleen, dislocating the stomach. The lesion exhibited central necrosis with hyper- and hypointense signal both in T1 and T2-weighted images. Due to the risk of spontaneous rupture and because malignancy could not be ruled out, the patient underwent hand-assisted laparoscopic splenectomy. Macroscopically, the spleen measured 15×12×4 cm and weighed 890 g. Cut sections revealed a single nodule of dark-red tissue sized 8.5 cm. The lesion exhibited a network of irregularly arranged and tortuous vascular channels lined by endothelium similar to splenic sinus lining cells, surrounded by aggregates of lymphocytes and macrophages resembling the pulp cords. On immunohistochemical staining the tissue was CD34 - and CD8 + and the final diagnosis was SH. In conclusion, when SH is suspected and malignancy cannot be ruled out, hand-assisted splenectomy should be considered the procedure of choice. Partial splenectomy should be preferred in children, to avoid potential risks of total splenectomy.

The aim of this study was to analyse whether preoperative serum levels of CEA and CA 15-3 correlate with oestrogen (ER) and progesterone (PR) receptor rate and MIB-1 score in elderly (>65 years) women with breast cancer (BC). Data from a series of 349 women (median age 61 years, range 26-89) with pT1-2 BC who underwent curative surgery were reviewed. Patients were divided into two groups: Group A, 237 (60.2%) women <65 years, and Group B, 157 (39.8%) women >64 years. Size of the tumour, ER, PR, CEA and CA 15-3 preoperative serum levels were higher in older patients, while the MIB-1 rate was lower. In both groups, a significant (p<0.05) inverse correlation between ER and MIB-1 was found, while there was a relationship between MIB-1 and both PG and CA 15-3 only in younger patients. These data suggest that only MIB-1 index should be considered an effective parameter for assessing tumour proliferation.

Background: Morbid obesity is frequently accompanied by serious co-morbidity, enclosed obstructive sleep apnea and hypoventilation syndrome, and thus many morbidly obese patients require surgical interventions. The aim of this study was to evaluate the relationship between arterial oxygen (pO₂) and carbon dioxide (pCO₂) partial pressure, age, loss of excess weight, and body mass index (BMI) in obese patients scheduled to undergo bariatric surgery., Patients and Methods: A group of 11 patients (4 men, 7 women, median age 38 years, range 23-58 years) with extremely severe obesity (BMI>50 kg/m²) underwent laparoscopic Roux-en-Y gastric bypass. Preoperatively, BMI, pO₂, and pCO₂ were 52.7±2.4 kg/m², and 70.9±5.3 and 43.1±6.5 mmHg, respectively. Hypoxemia (pO₂<75 mmHg) was present in all patients, but no relationship between BMI and age (R=-0.24, p=0.44) or between BMI and pO₂ (R=0.09, p=0.77) was found., Results: As expected, there was a significant correlation between age and both pO₂ (R=-0.58, p=0.04) and pCO₂ (R=0.85, p=0.0004), while no relationship between BMI and age (R=-0.24, p=0.44), nor between BMI and pO₂ (R=0.09, p=0.77) was found. Finally, there was a significant correlation between pO₂ and loss of excess weight (R=-0.69, p=0.02). No intra- or postoperative complications were observed, and 12 months after surgery BMI decreased to 32.5±2.7 kg/m² (p<0.001) and pCO₂ to 37.9±5.3 mmHg (p=0.05), while pO₂ reached 85.8±6.8 (p<0.001) mmHg., Conclusions: In obese patients, the severity of hypoxemia is mainly related to age. The amount of weight reduction, rather than lower baseline BMI values, may justify the significant postoperative pO₂ improvement.

This study investigated whether preoperative carcinoma-associated antigen (CA) 15-3 and carcinoembryonic antigen (CEA) serum levels are predictive markers of reduced disease-free (DF) survival in women with breast cancer (BC) who have undergone curative surgery A series of 363 consecutive postmenopausal women (median age 63 years, range 47-89 years) with pT1-2, N0-1 and M0 BC who underwent curative surgery and were followed-up for at least 36 months after lumpectomy or mastectomy were reviewed retrospectively. Two groups of patients were considered: Group 1 (age 47-64 years), 203 (55.9%) patients; Group 2 (age >64 years), 160 (44.1%) patients. None of the parameters (age, size of the tumour, CA 15-3 and CEA baseline serum levels, ER and PgR rate, MIB-1 labelling index) differed between the groups. During follow-up (36-60 months) 62 (17.1%) patients developed relapse (DR) of the disease (41 and 21 among Groups 1 and 2, respectively), while 301 (82.9%) were DF. The differences were as follows (DF vs. DR): Group 1: CA 15-3 (25.0+/-11.4 vs. 31.4+/-14.6 U/l; p=0.003) and CEA serum levels (5.7+/-4.8 vs. 7.4+/-6.4 ng/ml; p=0.048). Group 2: CA 15-3 (27.9+/-13.2 vs. 20.4+/-6.5 U/l; p=0.012) and CEA serum levels (6.6+/-5.2 vs. 3.7+/-2.5 ng/ml; p=0.013). Surprisingly, in the subgroup of patients aged >65 years who developed relapse, both CA 15-3 and CEA baseline serum levels were lower than in the subgroup of DF patients. In conclusion, although serum tumour markers levels may be useful during follow-up, their baseline levels are not useful in predicting relapse in elderly patients with BC.

Background: The objective of this study was to evaluate the relationship between oxygen partial pressure (pO(2)), awake oxymetric saturation (SpO(2)), body mass index (BMI), and percentage of excess weight loss (EWL) in extremely severe obesity (BMI >50 kg m(-2)) and hypoxemia, before and after laparoscopic Roux-en-Y gastric bypass., Patients and Methods: A group of 11 obese patients aged 41.2 + or - 10.2 years (4 men, 7 women, median BMI=52.3 kg/m(2), range 50.2-57.1) were prospectively enrolled in the study. BMI, arterial blood gas measurements, and spirometry were obtained before and after (6 and 12 months) surgery., Results: The main preoperative parameters were SpO(2)=88.3 + or - 3.9%, predicted forced vital capacity (FVC)=84.5 + or - 8.3%, predicted forced expiratory volume exhaled in one second (FEV1)=79.9+/-10.1%. No relationship (p>0.01) was found between BMI, SpO(2), and FEV1. A significant correlation between SpO(2) and both paO(2) (R=0.74, p=0.009) and EWL (R=-0.75, p=0.008) was found. Three, 6, and 12 months after surgery EWL was 18.9%, 26.4%, and 39.6% (p<0.001), respectively. At one-year follow-up SpO(2), FVC, and FEV1 were 96.2 + or - 3.2% (p<0.001), 112.3 + or - 9.9% (p<0.001), and 101.6 + or - 18.8% (p=0.003), respectively., Conclusion: In patients with extremely severe obesity, bariatric surgery may improve significantly both SpO(2) and spirometric parameters, and EWL represents the factor that impacted the results.

The aim of this study was to compare the incidence of lymphoedema after different treatments of the axilla in patients with breast cancer (BC). Medical records of 205 women (median age 61 years, range 26-72 years) who underwent curative surgery for primary BC were reviewed. According to the treatment of the axilla, the study population was divided into four age- and stage-matched groups of patients: Group A (N=54 patients), sentinel node biopsy (SLNB) alone; Group B (N=48 patients), SLNB followed by axillary node (AN) sampling using ultrasound scissors (harmonic scalpel); Group C (N=53 patients), AN dissection using ultrasound scissors; Group D (N=50 patients), traditional AN dissection. The median follow-up was 22 months (range 18-28 months). The intraoperative frozen section of SLNB (Groups A and B) showed 32 out of 102 (31.4%) patients with metastasis to AN, while final pathology showed AN metastases in 20, 17, 16 and 17 patients of groups A, B, C and D, respectively (p=NS). The sensitivity of SLNB alone was 80% and that of SLNB followed by AN sampling was 95% (p=NS). At follow-up patients with lymphoedema were 2 (3.7%), 2 (4.2%), 3 (5.6%) and 8 (16%) in groups A, B, C and D, respectively (p=NS). In conclusion, AN sampling is a sensitive and low-morbidity procedure which, in conjunction with the use of harmonic scalpel, may reduce the onset of arm lymphoedema.

There is conflicting evidence on the duration of action of atracurium in obese patients. Cisatracurium is one of the stereoisomers of atracurium. We investigated the neuromuscular effects of cisatracurium in morbidly obese patients. Twenty obese female patients (body mass index >40) were randomized in two groups. Group I (n = 10) received 0.2 mg/kg of cisatracurium on the basis of real body weight (RBW), whereas in Group II (n = 10) the dose was calculated on ideal body weight (IBW). In a control group of 10 normal weight female patients (body mass index 20-24), the dose of cisatracurium was based on RBW. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis, and anesthesia was induced and maintained with remifentanil and propofol. Onset time was comparable between Group I and the control group (132 s versus 135 s; P = ns). The duration 25% was longer in Group I than in the control group (74.6 min versus 59.1 min; P = 0.01) and in the control group compared with Group II (45.0 min; P = 0.016). In conclusion, the duration of action of cisatracurium was prolonged in morbidly obese patients when dosed according to RBW compared with a control group of normal weight patients. Duration was also prolonged in the control group patients compared with morbidly obese patients to whom the drug was administered on the basis of IBW.

We investigated the pharmacodynamic effects of rocuronium on morbidly obese patients. Twelve morbidly obese female patients (body mass index >40 kg/m(2)) admitted for laparoscopic gastric banding were randomized into two groups. Group 1 (n = 6) received 0.6 mg/kg of rocuronium based on real body weight, whereas Group 2 (n = 6) received 0.6 mg/kg of rocuronium based on ideal body weight. In a control group of six normal-weight female patients admitted for laparoscopic surgery, rocuronium was dosed on the basis of their real body weight. Neuromuscular transmission was monitored by using acceleromyography of the adductor pollicis; anesthesia was induced and maintained with remifentanil and propofol. The onset time tended to be shorter in Group 1 and the control group compared with Group 2, but this did not achieve statistical significance. Duration of action to 25% of twitch tension was more than double in Group 1 (55 min) compared with the other two groups (22 and 25 min; P < 0.001). Duration of action was similar between Group 2 and control. Recovery index tended to be longer in Group 1, but without a significant difference. In conclusion, in morbidly obese patients, the duration of action of rocuronium is significantly prolonged when it is dosed according to real body weight. Therefore, the dosage should be assessed on the basis of ideal rather than on real body weight in clinical practice.