Outcome and Factors Related to Isolated Liver Metastasis due to Breast Cancer.

OBJECTIVE: To determine the associated risk factors for isolated liver metastasis in breast cancer patients and to detect the prognostic factors related to survival. STUDY DESIGN: Analytical study. Place and Duration of the Study: Department of General Surgery, The University of Health Sciences, Istanbul, Turkiye, from January 2011 to November 2020. METHODOLOGY: Patients with breast cancer liver metastasis who experienced surgery were retrospectively analysed for breast cancer and metastases-related characteristics. Descriptive statistical methods were used in the evaluation of data. Survival analyses were estimated by the Kaplan-Meier method. Log-rank and univariable Cox regression tests were utilised to search for prognostic factors' impact on survival. RESULTS: Out of 12 patients, 11 had recurrent disease after a median of 36 months of disease-free survival (DFS) and one patient had de novo metastasis. Grade 3 tumours and increased expression of Ki-67 had a negative effect on DFS. The median follow-up period was 66 months. Survival analysis showed 2- and 3-year progression-free survival (PFS); overall survival rates were 82%, 69%, 92%, and 82%, respectively. Development of liver metastasis in 3 years following breast cancer treatment was linked to worse PFS (p = 0.040). CONCLUSION:  Long-term survival is possible for breast cancer survivors with liver metastasis. Disease-free interval is an important determinant. Longer progression-free survival was detected in patients who had developed metastasis after three years of breast cancer treatment. KEY WORDS: Breast cancer, Liver metastasis, Hepatic surgery.

Evaluation of immunohistochemical expression of novel neuroendocrine marker INSM1 and histological tumor growth pattern in well-differentiated neuroendocrine tumors of the appendix: 15-year single tertiary center experience.

INTRODUCTION: Well-differentiated neuroendocrine tumors of the appendix (A-WDNET) are the most common neoplasms of the appendix but are rare and incidental. INSM1 is a novel transcription factor marker with high sensitivity and specificity for neuroendocrine differentiation. It may display architecturally diverse tumor growth patterns including solid, nest, insular trabecular, and acinar. AIMS: The aim of this study was to determine the staining expression of INSM1 in A-WDNETs and detail the morphological tumor growth patterns. MATERIALS AND METHODS: INSM1 immunohistochemistry was performed on 35 A-WDNET patients. Tumors were histologically classified according to their growth patterns. RESULTS: Thirty-five patients, 60% of whom were male, had a mean age of 30 years at diagnosis and a mean tumor size of 0.9 cm. Eight percent of the tumors invaded the mucosa/submucosa, 34.3% showed invasion into the muscularis propria, 57.1% showed invasion into the subserosa or mesoappendix, LN metastasis was observed in two patients, lymph-vascular invasion in two patients, and perineural invasion in five patients. Ninety-four percent of the tumors were grade 1, the mitotic rate was >2% in two cases, and Ki-67 PI was >3% in two cases. INSM1 was positive in all cases (100%), 1+ 8.6%, 2+ 5.7%, 3+ 17.1%, 4+ 68.6%, weak staining in 11.4%, moderate staining in 22.9%, and strong staining in 67.7%. Type A histological growth pattern was observed in 54.3%, type B in 31.4%, and type C in 14.3% architecturally. CONCLUSIONS: INSM1 was positive in all A-WDNET morphological patterns and was 100% sensitive. INSM1 IHC can be used as an alternative to traditional neuroendocrine markers or in combination with the diagnosis of neuroendocrine tumors.

What should be done in patients diagnosed with xanthogranulomatous cholecystitis? Case-control study.

OBJECTIVE: In this study, we aimed to compare development of complications, malignancy and confusion rates in the preliminary diagnosis in patients with xanthogranulomatous cholecystitis identified. METHODS: In this study, 2803 patients undergone cholecystectomy between January 2010 and December 2016 were retrospectively evaluated. Patients with xanthogranulomatous cholecystitis identified in the histopathological examination were classified as Group 1 and patients with cholelithiasis, cholecystitis, and malignancy detected were classified as Group 2. RESULTS: Forty-five patients with xanthogranulomatous cholecystitis were classified as group 1 and 2758 patients as group 2. of group 1, 18 were male and group 2 consisted of 2758 patients with 707 (26%) being male (p=0.04). In the ultrasonographic examination, the wall thickness was increased in 40 patients in Group 1 and 662 patients in Group 2 (p<0.0001). The operation was converted to the open type in 24 patients in Group 1 and 61 patients in Group 2 (p<0.0001). Five patients in Group 1 and 32 patients in Group 2 developed complications in the postoperative period (p<0.0001). CONCLUSION: Xanthogranulomatous cholecystitis should be considered for the differential diagnosis and the operation should be performed, especially by carefully exposing the anatomy in these patients.

Evaluation of the gastrointestinal stromal tumors for clinical features, histopathological findings and prognostic criteria: A case-control study.

OBJECTIVE: In this study, we reviewed GISTs with all morphological and immunohistochemical findings and assessed the prognostic parameters of these tumors. METHODS: Files of 40 cases with GIST operated between 2002 and 2008 were retrospectively examined in this study. Patients were grouped as patients with and without recurrence within postop 1 year. The patients were grouped based on their localization, gender and age. The cases were stratified as the risk grades based on risk categorization table developed by Fletcher et al. according to the tumor diameter and number of mitoses. The cases were immunohistochemically investigated for CD117, CD34, S100, and Ki-67. RESULTS: Male/female ratio was 25/15. The mean age was 61.55. Mean tumor diameters were statistically significantly higher in the recurrence (+) group than in the recurrence (-) group (p=0.048). The mean number of mitoses was statistically significantly higher in the recurrence (+) group than in the recurrence (-) group (p=0.038). No statistically significant difference was found in histological distribution of the recurrence (-) and recurrence (+) groups (p=0.8795). No statistically significant difference was found in CD34, S100, and Ki-67 distribution of the recurrence (-) and recurrence (+) groups (p=0.862, p=0.609, and p=0.023, respectively). All patients in the recurrence (+) group were in the high-risk group. CONCLUSION: GISTs are studied in a wide range from benign, incidental tumors to malignant tumors with the risk for recurrence and metastasis concerning biological behaviour. GISTs have prognostic parameters, such as tumor localization, tumor diameter, mitotic index, cellularity, and pleomorphism grade.

Primary neuroendocrine carcinoma of the breast: a 5-year experiences.

PURPOSE: Breast neuroendocrine carcinomas constitute approximately 0.3-0.5% of all breast cancers. In this study, we aimed to evaluate the data of patients diagnosed with primary breast neuroendocrine carcinoma. METHODS: Patients with more than 50% neuroendocrine differentiation identified in the histopathological examination between January 2010 and January 2015 and who had no other focus on imaging were evaluated retrospectively from the hospital registry system. Patients with secondary neuroendocrine tumor of the breast and male patients were excluded from the study. All patients gave informed consent. Patients were staged according to TNM classification. RESULTS: During the study period, 425 patients were operated for breast cancer. Eleven patients were included in the study. The mean age of the patients was 68 (range 49-86). Immunohistochemical examinations revealed positive staining with neuron-specific enolase, synaptophysin and chromogranin in all patients. Ten patients had strong positive estrogen and progesterone receptors and receptor status was not specified in one patient. Distant organ metastasis was detected in 1 patient during the follow-up period, no local recurrence and mortality were seen in any patient. CONCLUS ON: The most widely used specific markers of neuroendocrine differentiation are chromogranin and synaptophysin. There is no standard treatment protocol for primary breast neuroendocrine tumors. Most of the treatments reported in the literature and in this study are breast sparing surgery or mastectomy, followed by anthracycline and taxanebased chemotherapy and/or hormonotherapy, similar to the treatment of ductal carcinoma. The distinction of primary metastases in breast neuroendocrine tumors is important, so the presence of neuroendocrine tumors should be investigated in other organs. In this case the treatment is changed. The issue of how neuroendocrine differentiation affects clinical outcome is yet to be debated. KEY WORDS: Chromogranin, Neuroendocrine tumor, Synaptophysin.

Non-operative management of civilian abdominal gunshot wounds.

BACKGROUND: In this study, we aimed to evaluate the results of selective non-operative management in patients with civilian abdominal gunshot wounds. METHODS: Patients hospitalized and monitored in our clinic due to civilian abdominal gunshot wounds between January 2009 and January 2018 were retrospectively examined. Patients were studied concerning age, gender, mechanism of injury, anatomic injury site, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), Revised Trauma Score (RTS), treatment method, time to operation, days of hospitalization and mortality. RESULTS: Of the patients, 84 (89.4%) were male, and 10 (10.6%) were female with a mean age of 32.7 (range 4-60). The mean ISS, RTS and PATI values of all patients were 17.05, 7.27 and 9.21, respectively. Immediate laparotomy and/or thoracotomy were performed in 21 (22.3%) of the patients due to hemodynamic instability and in 27 (28.7%) of the patients because of peritonitis findings. The remaining 46 (48.9%) patients were managed non-operatively. Among these patients, early laparotomy was performed in five (5.3%) and late laparotomy in eight (8.5%) patients who developed peritonitis symptoms. The other 33 (35.1%) patients were treated non-operatively. Of these patients, 61.1% of the patients with flank injuries, 50% of the patients with right thoracoabdominal injuries, 44.4% of the patients with posterior abdominal injuries, 42.1% of the patients with pelvic injuries and 27.8% of the patients with left thoracoabdominal injuries were successfully treated non-operatively. Non-therapeutic or negative laparotomy was performed on six (6.4%) patients. Mortality was 10.6% (n=10) in all patients. CONCLUSION: Some patients with a civilian abdominal gunshot wound in certain anatomical localization who are hemodynamically stable and have no peritonitis symptoms can be non-operatively managed just as in patients with abdominal stab wounds. Success rates of selective non-operative management are high, especially in gunshot wounds of flank, posterior abdominal, thoracoabdominal and pelvic regions.

Risk factors for complications after endoscopic retrograde cholangiopancreatography A referral Center experience.

AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic tool in patients with hepato-pancreatobiliary diseases. In the present study, we sought to determine predictors of post-ERCP complications at our institution. METHODS: A retrospective analysis of patients who underwent ERCP in between January 2010 and November 2011 was done. Demographics, indications, ERCP findings, success rate, complications and the need of repeat procedure were evaluated with special emphasis on the difficulty in cannulation procedure, the primary etiology of the disease (benign/malign) and age. Chi-square analysis was applied for statistical analysis. The differences were considered statistically significant, if the p value was less than 0.05. RESULTS: A total of 112 ERCP was performed in 81 patients. Thirty-eight were male (46.9 %) and 43 were female (53.1%). Mean age was 61.3 (range 17-88), and 31 patients was seventy years and older (38.3 %). Complications were detected in 28 patients (34.6 %). Nine cases with difficult or unsuccessful cannulation (69.2 %) had complications (p=0.001). Patients with benign diseases showed less complications (21/70), in comparison with those with malignancies (7/11) (30 % vs. 63.6 %, respectively; p<0.05). Complication rate in patients 70 years and older was 32.2 % (n=10) compared to 35.3 % in patients younger than 70 (n= 18) (p<0.05). CONCLUSION: Risk factors such as difficult or incomplete cannulation and malignancy are considered as possible predisposing factors for complications. Age is an independent factor. KEY WORDS: Endoscopic cholangiopancreatography, Risk factors.

Misleading findings of liver-specific MR contrast agent for radiological diagnosis of cysto-biliary communication in hydatid cysts.

OBJECTIVE: To investigate the effectiveness of gadoxetic acid-enhanced magnetic resonance cholangiopancreatography (CE-MRCP) and T2-weighted half-Fourier acquisition single-shot turbo spin-echo (T2W HASTE) sequences for diagnosis of cysto-biliary communication in hydatid cysts compared to surgical results. METHODS: Preoperative abdominal magnetic resonance imaging examinations of patients who underwent surgery for hepatic hydatid cysts were reviewed by two radiologists retrospectively. A total of 45 patients with hydatid cysts were included. Of 45, 27 also had CE-MRCPs. T2W HASTE sequences and CE-MRCPs were investigated separately for cysto-biliary communication. The relationship between radiological and surgical results was analyzed. The interobserver agreement was evaluated. RESULTS: Of 45 hydatid cysts, there were surgically proven 21 cysts without biliary communications and 24 cysts with biliary communications. All cysts with biliary communications were shown on T2W HASTE sequences. There was no leakage of gadoxetic acid into these cysts (n = 24). Sensitivity, specificity, negative predictive value, positive predictive value (PPV), and accuracy of diagnosis of cyst with biliary communication on T2W HASTE sequences was 100%, 63.64%, 100%, 66.67%, and 78.95%, respectively. Specificity (77.78%), PPV (87.50%), and accuracy (91.30%) were increased in ≥ 10 cm cysts. There was almost perfect interobserver agreement (K = 0.81-1.00). CONCLUSION: Leakage of gadoxetic acid inside the cyst indicates biliary communication. However, the lack of leakage does not rule out cysto-biliary communication. When biliary communication is clearly shown on T2W HASTE sequences, it should be reported as cysto-biliary communication even if there is no leakage of gadoxetic acid into the cyst on CE-MRCP.

An incidental giant preperitoneal fibrolipoma diagnosed during laparoscopic cholecystectomy.

Preperitoneal lipomas are rare in clinical practice. Here we report an unexpected diagnosis of a giant preperitoneal fibrolipoma detected intraoperatively during laparoscopic cholecystectomy in a 56-year-old woman. The mass was excised and a histopathological examination confirmed fibrolipoma. No recurrence was found on follow-up. In the literature, there have been many cases with unexpected diagnoses during laparoscopy. Here, we present an incidental giant preperitoneal fibrolipoma, which was overlooked by ultrasound and physical examination, but was detected during laparoscopic cholecystectomy.

Lumbar (Petit's) hernia: A rare entity.

Lumbar hernias are rare and diagnostically challenging for surgeons. We present the case of a middle-aged patient who presented with swelling in the left back. Subcutaneous lipoma was included in the differential diagnosis. Following diagnostic studies, computed tomography confirmed left lumbar hernia. Elective surgery was performed, and the results revealed Petit's hernia. The hernia was repaired with mesh.

Sinistral Portal Hypertension Due to Pancreatic Hydatid Cyst.

Hydatid disease is caused by Echinococcus granulosus. Hydatid cysts are commonly located in the liver and lungs. The occurrence of pancreatic hydatid cysts is very rare, even in endemic areas. Sinistral portal hypertension, which is rarely seen, occurs when a pathological process causes splenic vein occlusion. A 26-year-old male patient presented with abdominal pain. He had a history of operation for hydatid cyst of the lung 15 years ago. A left thoracotomy incision scar was observed during his physical examination. Laboratory findings revealed no abnormalities. Abdominal ultrasonography revealed a 96×69-mm lobular, contoured, well-circumscribed cystic lesion with thickened septation. Abdominal magnetic resonance imaging revealed a 100×76-mm smooth, bordered cystic lesion containing septations in the body and tail of the pancreas compressing the splenic artery and vein, causing sinistral portal hypertension. Dilatation was noted in the left gastroepiploic vein. The patient underwent cystotomy. Pancreatic fistula developed during the postoperative follow-up. The patient was discharged in 20 days without postoperative complications. No complications were observed during the follow-up period of 7 months. Surgery should be considered as a more conservative approach.

Intraoperative diagnosis of cecal diverticulitis during surgery for acute appendicitis: Case series.

OBJECTIVE: Cecal diverticulum is a rare entity, and can cause acute abdomen by the way of diverticulitis and perforation of diverticulitis. In this study, we aimed to perform an analysis of patients that have cecal diverticulitis, and presented with acute abdomen. MATERIAL AND METHODS: Patients who were admitted to emergency clinic between 2009-2012 and had acute abdomen due to cecal diverticulitis were included into study retrospectively. RESULTS: Six patients were included in the study with a mean age of 34 years (range 24-43). Four patients were male and two were female (male/female: 2). All six patients presented with abdominal pain, additional symptoms were nausea in five patients, and vomiting in one patient. The mean white blood cell count was 11.900/mm(3) (5850-17.400/mm(3)), while the remaining laboratory results were normal. There were no specific findings on abdominal X-ray or ultrasonography. The surgical exploration revealed an inflamed cecal diverticulitis and normal appendix in all patients. Five patients underwent appendectomy and diverticulectomy. Right hemicolectomy was performed in one patient due to suspicion of malignancy. The early postoperative period was uneventful in all patients. The mean length of hospital stay was 4.5 days with a range of 2-6 days. Histopathological examination showed acute perforated diverticulitis with underlying true diverticulum in three patients, and true diverticulum with acute diverticulitis in the remaining three patients. CONCLUSION: Pre-operative diagnosis of cecal diverticulitis is challenging due to symptoms and signs that resemble acute appendicitis. Diverticulectomy and incidental appendectomy is the treatment of choice in uncomplicated cases.

Review of clinical experience with acute cholecystitis on the development of subsequent gallstone-related complications.

BACKGROUND/AIM: Recently, surgery during admission has been advocated for acute cholecystitis, rather than delayed surgery after conservative treatment. This study was designed to perform early surgeries and analyze the criteria used for conservative management followed by delayed surgery. MATERIALS AND METHODS: After implementation of a study with the aim of performing early surgery, a retrospective review using a prospective database during the period of June 2009 to June 2011 was established. Early surgery during index hospitalization was offered to all patients, except those having criteria for conservative management. RESULTS: There were 118 patients admitted for acute cholecystitis. Early and delayed surgeries were performed for 18 (15%) and 23 (20%) patients, respectively. Percutaneous cholecystostomy was performed for 10 (8%) patients with a success rate of 90% and significantly higher length of hospital stay (P = 0.001). Gallstone-related complications developed in 33 (28%) patients, causing significantly higher readmission rates (P = 0.001). Ofthe patients, 34 (29%) were neither operated on nor had complications. The subsequent cholecystectomy rate was calculated as 35%. The overall mortality rate was 1.7% for all groups. CONCLUSION: Although surgical treatment of acute cholecystitis, either by early or delayed surgery, has some specific morbidity and mortality, it should be kept in mind that conservative treatment modalities have a higher rate of recurrences and subsequent complications, which all cause additional morbidity and mortality in patients.

Spontaneous remission of sclerosing mesenteritis.

Sclerosing mesenteritis is a rare fibroinflammatory disorder mostly affecting the small bowel mesentery with unknown etiology. Its clinical presentation varies according to the pathologic stages of sclerosing mesenteritis. In the early stages, nonspecific abdominal symptoms are usually seen, whereas severe small intestinal obstructive symptoms predominate in late stages. Diagnosis is usually obtained with the use of imaging techniques like computerized tomography and magnetic resonance imaging. Sclerosing mesenteritis is a self-limiting disease, and complete remission is seen in most patients. Medical and surgical treatment is reserved for symptomatic and complicated cases, respectively. In this paper, we describe a case of sclerosing mesenteritis in a 31-year-old male patient who presented with abdominal pain and weight loss. He was diagnosed as sclerosing mesenteritis with the help of two consecutive computerized tomographys. The mass spontaneously and completely disappeared in one month.

Laparoscopic excision of a retroperitoneal ganglioneuroma.

OBJECTIVE: Ganglioneuromas are rare benign tumors originating from ganglion cells. Ganglioneuromas are detected incidentally because they are asymptomatic. We report a case of laparoscopic excision of a retroperitoneal ganglioneuroma. CASE DESCRIPTION: A 49-y-old female was admitted to our medical center with the complaint of abdominal pain. Abdominal ultrasound showed a hypoechoic solid lesion at the level of the liver hilum, adjacent to the pancreas. Computerized tomography scan confirmed the presence of a thin walled mass 44 mm in diameter, adjacent to the pancreas and liver. Laparoscopic excision of the retroperitoneal mass was planned. The tumor was removed en bloc, and the pathologic diagnosis was ganglioneuroma. The patient was discharged from the hospital on the third postoperative day without any complications. CONCLUSION: Minimally invasive surgery has been shown to be safe and reliable in patients with retroperitoneal tumors.