Hamartochondroma arising from a tracheal bronchus.

Tracheal bronchus is a congenital abnormality rarely described in the literature. It is mostly completely asymptomatic. This condition may rarely be associated with inflammatory diseases. Exceptional are those cases in which the condition is associated with malignancy. We describe a case of a 45-year-old man in whom a 3-month history of non-productive cough and chest pain led to a diagnosis of a solitary pulmonary nodule associated with a tracheal bronchus. The histopathological examination after VATS enucleation showed the presence of a hamartochondroma. To the best of our knowledge this is the first case in which a hamartochondroma has been found to be associated with a tracheal bronchus.

Distinct molecular patterns based on proximal and distal sporadic colorectal cancer: arguments for different mechanisms in the tumorigenesis.

BACKGROUND AND AIMS: Colorectal cancer (CRC) ranks as the fourth most frequently diagnosed cancer worldwide. CRCs that arise proximally or distally to the splenic flexure show differences in epidemiologic incidence, morphology, and molecular alterations, suggesting the existence of two categories of CRC based on the site of origin. The aim of the present work is to investigate the histological and molecular differences between CRCs located proximally and distally to the splenic flexure, and their potential involvement in tumor prognosis and therapeutic strategies. METHODS: We evaluated 120 patients affected by sporadic CRC for clinicopathologic features, microsatellite instability (MSI), loss of heterozygosity (LOH) of chromosomes 18q, 8p, and 4p; they were also investigated for hMlh1, hMsh2, Fhit, p27, and Cox-2 immunostaining. RESULTS: The mucinous histotype was more frequent in the proximal than in the distal CRCs (p<0.004). The frequency of MSI phenotype was higher in proximal than in distal tumors (p<0.001); moreover, reduced or absent hMlh1, Fhit, p27 immunohistochemical expressions were more frequent in proximal than in distal tumors (p<0.001 and 0.01 for p27). In contrast, the frequency of LOH in 18q was higher in distal than in proximal tumors (p=0.002). No significant differences were observed between proximal and distal tumors in the frequency of LOH in 8p and altered expression of hMsh2 and p53 protein. CONCLUSION: These different features may reflect different genetic pathways of carcinogenesis and support the hypothesis of a different mechanism of cancer development between the proximal and the distal colon, with potential implications in the therapeutic approach.

Loss of p27 expression and microsatellite instability in sporadic colorectal cancer.

BACKGROUND: The role of the loss of p27 protein expression in the oncogenesis of colorectal cancer is still in debate. In this study, we prospectively examined the immunohistochemical expression of p27 in 108 consecutive colorectal cancers, and we analysed the relationship with the results, the clinicopathological data, microsatellite instability (MSI) and other genetic alterations of tumours. METHODS: Unselected patients (108) who underwent curative colorectal resection for sporadic colorectal cancer in a three-year period were evaluated for MSI using 6 microsatellite markers, and for the presence of p27, p53, Fhit, Mlh1 and Msh2 proteins by means of immunostaining. The relationships between these markers were analysed. p27 protein expression was examined for association with disease recurrences and survival. RESULTS: Lack of p27 expression was noted in 33 out of 108 (30.5%) colorectal cancer cases (P<0.05). This altered expression was significantly higher in proximal cancers (P<0.05), mucinous tumours (P<0.001), poorly differentiated histology (P<0.01), cancers with MSI (P<0.05), tumours with altered expression of Mlh1 (P<0.01), of Msh2 (P<0.05), and of Fhit (P<0.01). Overall survival was better in the patient group with altered level of phenotypic p27 expression, although the difference does not reach statistical significance (P=0.069). The analysis performed only for patients with tumour at stage II showed significantly better survival when the tumour exhibited altered p27 expression (P<0.02). CONCLUSIONS: The results of the present study support the hypothesis that altered expression of p27 may be part of the genetic pathway involving MSI, which is responsible for the development of some colorectal cancers.

Hypovolemic shock caused by a true aneurysm of the pancreatico-duodenal artery: case report and review of the literature.

True pancreatico-duodenal artery aneurysm (PDAA) is a rare condition that since 1973 has been described in only 54 cases. It is frequently associated with celiac axis stenosis and often present with rupture. Even if most PDAAs that are not ruptured are asymptomatic and are diagnosed during investigation for other diseases, they may have some symptoms, such as chronic abdominal discomfort and an abdominal pulsating mass, that can be helpful for diagnosis. The treatment of this condition has evolved in time from a merely surgical one to an angiographic noninvasive approach. We present a case of a PDAA that manifested with sudden hypovolemic shock requiring an emergency operation, and through a review of the literature, we discuss the different diagnostic/therapeutic protocols to use in different situations.

Giant fibroma of the lesser omentum: report of a rare case.

UNLABELLED: We report a case of a 43 years old male that presented to emergency room for epigastric and mesogastric pain associated with a palpable abdominal mass. Explorative laparotomy showed a well capsulated tumour of the lesser omentum, sized 20 x 16 x 10 cm. Histologically the mass was charaterized by thick fibrous capsula, with areas of moderate cellularity alternated to areas of sclerosis, spots of hemorragies and infartual necrosis, spindle-shaped cells within collagen bundles that did not present mitotic activity or atipies and showed a low proliferation index with Ki 67 and histochemical positivity for CD 34 and negativity for C-Kit, anti-smooth cell and S100 antigen. FINAL DIAGNOSIS: solitary fibroma of the lesser omentum. To our knowledge only one case of lesser omentum fibroma has been reported in litterature.

Brunner's gland hamartoma: 'over-treatment' of a voluminous mass simulating a malignancy of the pancreatic-duodenal area.

CONTEXT: Brunner's gland hyperplasia is rarely associated with clinical symptoms. Most of the lesions are less than 1 cm in diameter and accounts for about 6.8% of all endoscopically removed duodenal polyps. When symptoms occur, this hyperplasia can be effectively treated with endoscopy. However, when the lesion is too large to pass through the endoscopic snare, endoscopic treatment is not possible and surgical treatment is necessary. This treatment may vary from local excision to more complex operations. When Brunner's gland hyperplasia does not have common dimensions, it may also mimic a malignancy of the duodenal-pancreatic area. In this case, a biopsy is indicated even though its result may be not informative. CASE REPORT: We report the case of a 60-year-old man with a large Brunner's gland hyperplasia mimicking a malignancy and in which the impossibility of a correct diagnosis by pre-operative and intra-operative biopsy led to 'over-treatment' involving a duodenocephalopancreatectomy. CONCLUSION: This 'over-treatment' may be justified since nowadays the consequences of leaving an undiagnosed pancreatic cancer are much worse than the risk of undergoing a major pancreatic operation.

[Diagnostic and therapeutic management of choledocholithiasis associated with gallstone disease: nine years' experience]. / Il percorso diagnostico- terapeutico nella coledocolitiasi associata a calcolosi della colecisti: nove anni di esperienza.

Different approaches are described in the literature for the detection and treatment of common bile duct stones in patients undergoing laparoscopic cholecystectomy (pre-, intra- or postoperative treatment; combined endoscopic and laparoscopic or total laparoscopic management). No particular "gold standard" treatment can be identified, since too many variables and too many techniques need to be compared. Since it is impossible to establish any single protocol, the reviewing of different large experiences is useful to identify the pros and cons of each procedure. We present the evolution of our own experience over the period 1991-2000 in 1741 patients treated by laparoscopic cholecystectomy for gallbladder stones. We have chosen to assess and treat patients with symptomatic common bile duct stones preoperatively, whereas in the asymptomatic cases we have adopted a protocol that has been modified over the years, consisting first in routine intravenous cholangiography and then in the use of a scoring system which, with the aid of ultrasound data, has allowed us to assess the risk of choledocholithiasis and to administer selective preoperative treatment for common bile duct stones.

Calf metastasis of colorectal cancer: report of a case.

Colorectal cancer metastases rarely develop outside liver, lungs and lymph nodes, and only exceptionally in skeletal muscle. The very low incidence of such metastasis sites may be due either to underestimation of the problem or to their intrinsic rarity. We report a case of metastasis from colorectal cancer that developed in the left calf and manifested itself as a painful non-fluctuating mass. The relevant literature is also reviewed.

Abnormal Fhit protein expression and high frequency of microsatellite instability in sporadic colorectal cancer.

The role of Fhit protein in the oncogenesis of colorectal cancer is still in debate. Recent studies have revealed that reduced Fhit protein expression is associated with a deficiency of the mismatch repair protein. One hundred and twenty unselected patients who underwent curative resection for sporadic colorectal cancer in a three-year period were evaluated for microsatellite instability (MSI) using six microsatellite markers, and for the presence of Fhit and mismatch repair (MMR) proteins (Mlh1 and Msh2) by means of immunostaining. The relations between these markers were analysed. Reduced or absent Fhit expression was noted in 18 out of 118 patients. This altered expression was significantly higher in right-sided cancer (P = 0.005), mucinous tumours (P = 0.005) and in poorly differentiated histological types (P = 0.0001). MSI was found in 22 out of 109 patients, more so in right-sided cancer (P = 0.0001), poorly differentiated histology (P = 0.0001), and mucinous tumours (P = 0.0001). No association was found with TNM stage. MSI was present in 66.7% of tumours with altered Fhit expression and in only 10% of tumours with preserved or intermediate Fhit expression (P = 0.0001). Of the tumours with reduced or absent Fhit expression, 72.2% had loss of nuclear Mlh1 or Msh2 expression compared with only 14% of the preserved or intermediate Fhit expression tumours (P = 0.0001). These results support the hypothesis that deficiency in a MMR gene could be a cause of the high frequency of alterations in Fhit expression, and they permit the suggestion that FHIT gene alteration may be part of the genetic pathway involving MSI through which some colorectal cancers arise.

The rationale for cecorectal anastomosis for slow transit constipation.

The most usual reconstruction after subtotal colectomy is ileo-rectal anastomosis, which requires the removal of the caecum. We propose the treatment of chronic slow-transit constipation with subtotal colectomy and antiperistaltic caecoproctostomy. The sparing of the caecum, the ileo-caecal valve and the distal ileal loop, leaving a physiologic reservoir, allowing the presence of colic bacterial flora which metabolizes the undigested starch and produces short chain fatty acids, should guarantee a normal stool consistency, normal absorption of water, sodium and vitamin B12 and the prevention of renal and gallbladder lithiasis. In 1992, we started a study on the outcome of 19 patients who had undergone subtotal colectomy and antiperistaltic caeco-rectal anastomosis for slow-transit constipation. The surgical procedure was carried out without any serious complications and without mortality. The mean clinical follow-up was 64 months (range 5-132). Six months after surgery, 13 patients reported normal bowel movements with solid stool consistency, 5 reported diarrhoea and the need for antidiarrhoeal agents, and one reported constipation easily controlled with laxatives. Fifteen patients considered their quality of life as having improved compared with that before surgery. Selection of patients justify such very satisfying results. It is well known that colic resection is effective only in the case of slow transit constipation, and thus a careful physiologic assessment is needed to rule out other causes of constipation, such as outlet obstruction syndrome.

[Prognostic significance of chromosome and microsatellite instability in colorectal cancer]. / Significato prognostico dell'instabilità cromosomica e microsatellitare nel cancro colorettale.

The prediction of recurrence and the prognosis of colorectal cancer have always been related to the stage of the disease. Clinical pathological classifications are unable to predict the individual risk of recurrence and the prognosis which would also appear to be linked to additional factors, which have yet to be properly assessed, such as the genetic endowment of the tumour. In this study we assessed how microsatellite and chromosomal instability may help us to stratify two classes of risk of recurrence in patients at the same stage. From July 1996 to June 1999 we prospectively collected data on 112 patients (59 male, 53 female) affected by colorectal cancer and undergoing surgery with a radical intent. Biopsies of normal and tumor tissue were submitted to DNA extraction and amplification to evaluate the presence of chromosomal instability (loss of heterozygosity) and microsatellite instability. Analysis of the data revealed that loss of heterozygosity in the long arm of chromosome 18 is associated, in patients with stage III colorectal cancer, with a higher risk of recurrence and therefore with a worse prognosis. Microsatellite instability proved to be associated with a better prognosis even in cases of recurrence.