Prognosis of patients with cirrhosis and hepatocellular carcinoma (HCC) depends on both residual liver function and tumor extension. The CLIP score includes Child-Pugh stage, tumor morphology and extension, serum alfa-fetoprotein (AFP) levels, and portal vein thrombosis. We externally validated the CLIP score and compared its discriminatory ability and predictive power with that of the Okuda staging system in 196 patients with cirrhosis and HCC prospectively enrolled in a randomized trial. No significant associations were found between the CLIP score and the age, sex, and pattern of viral infection. There was a strong correlation between the CLIP score and the Okuda stage. As of June 1999, 150 patients (76.5%) had died. Median survival time was 11 months, overall, and it was 36, 22, 9, 7, and 3 months for CLIP categories 0, 1, 2, 3, and 4 to 6, respectively. In multivariate analysis, the CLIP score had additional explanatory power above that of the Okuda stage. This was true for both patients treated with locoregional therapy or not. A quantitative estimation of 2-year survival predictive power showed that the CLIP score explained 37% of survival variability, compared with 21% explained by Okuda stage. In conclusion, the CLIP score, compared with the Okuda staging system, gives more accurate prognostic information, is statistically more efficient, and has a greater survival predictive power. It could be useful in treatment planning by improving baseline prognostic evaluation of patients with HCC, and could be used in prospective therapeutic trials as a stratification variable, reducing the variability of results owing to patient selection.

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Background Pneumothorax is one of the respiratory toxic effects of cocaine inhalation. The literature counts several cases, some associated to other respiratory conditions such as pneumomediastinum, haemoptysis and others not requiring surgical treatment. Aim We present a series of nonHIV cocaine-inhaler subjects who underwent video-assisted thoracoscopic surgery (VATS) for isolated spontaneous pneumothorax. Design Nine subjects, with a mean age of 24 ± 4 years, admitting cocaine inhalation, developed spontaneous pneumothorax and underwent 10 surgical treatments by means of VATS, at our Institution. Results Previous pneumothorax occurred in six cases episodes ranged from 0 to 5 (mean 1.6 ± 1.6). Chest computed tomography (CT) scan showed abnormalities in seven cases. All subjects underwent lung apicectomy, apical pleurectomy and mechanical pleurodesis. Seven subjects had also bullectomy. In all cases the visceral pleura was partially covered by fibrinous exudate. Histology of the lung showed small foreign body granulomatous inflammation in fibrotic and/or emphysematous pulmonary parenchyma. Relapse of pneumothorax occurred in one subject at 60 days and it was surgically treated. Mean follow-up was 150 ± 38 months (range 120–239). All subjects are now well, with no evidence of pneumothorax. Conclusions Spontaneous pneumothorax in cocaine-inhaler subjects is a reality of which physicians need to be aware. Chest CT scan might not reveal abnormalities. Macroscopically the lung might presents bullae and/or peculiar visceral pleura. Foreign body granulomas observed in the specimens suggest that the particulate component of inhaled substances can injure the lung. Surgical treatment of the bullous disease and mechanical pleurodesis can provide a long-term follow-up without relapse of pneumothorax.

The ability of intrarectal ultrasound to recognize the local extent of disease was investigated in 23 patients with histologically proven adenocarcinoma of the lower two-thirds of the rectum before operation. Two probes, 12 cm long, working at a frequency of 3.5 and 7.5 MHz, were used. The results were compared with those of pre-operative computed tomography (CT) and with the pathological report of the resected specimens. Sonography correctly staged 20 of 23 tumours with two false negatives and one false positive, while CT correctly staged 19 of 23 tumours with two false negatives and two false positives. The results of ultrasound were found to be as accurate as those of CT; the low cost and simple use of ultrasound makes it preferable in the pre-operative assessment of the depth of invasion of rectal cancer. In addition, intrarectal ultrasound was routinely performed in 42 patients, operated on for rectal cancer by means of sphincter-saving procedures, at variable intervals in the first 2 years postoperatively. Eight local recurrences were recognized and confirmed by CT. Based on the low cost, reliability and simple use, intrarectal ultrasound is proposed as first examination for local recurrence detection in the follow-up of patients with low anterior resection for rectal cancer.

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