Biomedical subjects
Publications and source records attributed to T Testa.
The authors review nosologic problems related to the infarction of the greater omentum on the ground of two cases (one idiopathic, the other by torsion) recently observed. Omental infarction, far from being a real diagnostic or surgical problem, is an unusual cause of acute abdomen; resection of the affected omentum is curative in 100% of cases.
The TNM System as originally proposed by Denoix in 1946, provides a consistent, reproducible description of the anatomic extent of disease in cancer patients at a specific time in the life history of the cancer. C.F. Mountain first adapted this classification to lung cancer in 1973 on behalf of AJCC. In 1986 he presented the "New Intl. Staging System for Lung Cancers" mainly based on a 13 yr experience of the previous one, which was accepted world-wide through a round of international consensus meetings held in 1985. Clinical Staging is the best estimate of disease extent made prior to the institution of any therapy; Surgical-pathological Staging is the classification of disease extent as determined from pathological examination of resected specimens. Accordingly, once the diagnosis is made, it is necessary to stage accurately the tumour determining the size and location of the tumour (T status), the presence or absence of lymphnode involvement (N status), and whether the tumour is metastatic to distant sites (M status). Moreover the uniform staging criteria for lung cancer will assure for each patient the better selection of treatment, the evaluation of operability, the need for adjuvant therapy, as well as the estimation of prognosis. Equally important is the resultant ability to compare the outcome of treatment protocols from different centres. More recently C.F. Mountain has added to the Staging System a new standard logic or "convention" for classifying infrequently observed presentations of lung cancer with which the standard rules of Staging System itself don't fit. These conventions are based on empiric expectation for treatment selection and survival that are similar to those for the Staging definitions, which are based on actuarialsurvival data. Many different types of tumour such as multiple masses, synchronous multiple primitives, discontinuous tumour foci in visceral or parietal pleura as well neoplastic involvement of various mediastinal structures, could be now staged with a major benefit for their treatment protocols. In conclusion the Staging System represents today a standard clinical methodology which basically helps in a better clinical approach to lung cancer even if it cannot fully cover and consider all the innumerable manifestations of the tumor. Therefore, if it is true that in the near future the new molecular predictors of prognosis are expected to measure more deeply the extent of disease, for the present time the International Staging System still continues to act as the best common method for measuring prognosis.
Preceded by an international overview on the surgical approach to the peripheral higher stage NSCLC, the cumulative clinical experience from ten Italian University Departments and Teaching Hospitals, is analyzed in the light of the corresponding international contributions. Accordingly, the clinical records of 470 patients affected by such Stage III tumors and surgically treated, were collected and retrospectively reviewed. 43 out of 120 patients belonging to the group of apical invasive Pancoast's tumour underwent an en-bloc chest-wall resection, while an extrapleural dissection was performed in the remaining 77. Combined segmentectomy was prevalent (54%), while lobectomy/bilobectomy was performed in 38%, wedge resection in 5% and pneumonectomy in 3% of all cases respectively. Preoperative high-voltage radiation was given in 70% of them; while adjuvant RT was requested in 17% of cases, mainly because of N1-2 status. Actuarial 5-year survival was 14% with a range of 0% in N2 cases to 21% in NO-1 ones. When considering surgical modes, the en-bloc chest-wall resection had a 5-year survival of 20% while the more limited extrapleural dissection yield only a 9% survival. Compared with the international experience the 14% 5-year survival is standing at the bottom of the scale. On the other hand, 350 patients belong to the other two main groups of peripheral tumors taken in consideration: the ones which, even apical, are yet lying anteriorly far enough from the costo-vertebral angle (apical non Pancoast tumor), and the other ones which are lower placed along the thoracic cage. The majority of these patients (213) were treated by an extrapleural dissection, while the remaining minority (123) received an en-bloc chest-wall resection with 1-2 ribs resected in 46%, 3 ribs in 38% and 4 ribs or more in 16%, respectively. Combined lobectomy/bilobectomy was prevalent (64%), while pneumonectomy was performed in 16%, more limited resections in 16% and exploration alone in 4% respectively. 5-year survival was 18% ranging from 0% in N2 patients to 23% in the NO-1 ones. The extrapleural dissection had a 5-year survival rate of 24.5%, while the en-bloc chest-wall resection yield a lower rate of 15.6%. This overall survival can be indeed considered nearer the international one, even if both surgical approach and the related 5-year survival rates are in full discordance with the compared international references.
Such a novel surgical project is supported by a large basic knowledge on molecular biology of solid tumours progression as well as the already assessed clinical experience in the parallel field of surgery for lung, brain and liver metastases. While pathology and the clinical work up have for a long time pointed out the steady rate of adrenal metastatic involvement from lung cancer (from 25 to 28% of all cases at the autopsy and, on clinical grounds, the most important site of extrapulmonary tumour spread just after the first one represented by the mediastinal lymphatic groups), the surgical approach to the problem is still very limited and the few operated cases previously reported in world literature (summing up to a total of 21) are not truly homogeneous and even largely scattered in time. The Authors report on their personal contribution in this field with four consecutive cases who underwent surgery during the last five years. The most important clinical features together with the initial remarkable result obtained in one patient who is still free of disease more than 3 years after the sequential radical resection of the primary lung tumour and the metastatic ipsilateral adrenal gland, are presented. In the light of this preliminary positive experience, the Authors are planning a sound clinical research based on the combined resection of those NSC Lung Cancers which appear surgically resectable but already included in an unresectable Stage IV Disease only because of the contemporary adrenal metastases (M1). An adjuvant chemotherapy in usually added.