Single-center experience of surgically resected gastrointestinal stromal tumors: A report of six cases, including a rare case involving the lower esophagus.

Gastrointestinal stromal tumors (GISTs) are rare, but remain the most common GI mesenchymal neoplasms. In the present study, six cases of GIST are reported, and one of these cases, a patient with esophageal GIST, is reported in-depth. Certain recent developments in the clinical therapy of GISTs are also discussed. The records of all surgically-resected GI stromal tumors treated at the Al-Hada Military Hospital between January 2007 and December 2012 were reviewed. There were six cases of surgically resected GISTs during this time period, three males and three females, with a mean age of 69.3±16.4 years. The stomach was involved in 66.7% of cases, the small intestine in 16.7% and the esophagus, which is an extremely rare site, in 16.7% of cases. The most common symptom at presentation was abdominal pain, followed by GI bleeding. The mean tumor size was 8.7±6.3 cm. Surgery was indicated by the presence of the aforementioned symptoms or a tumor size >5 cm. All tumors were completely resected with histologically negative margins. The diagnoses were established by immunohistochemistry. Four patients were classified as possessing a high-grade variant, and were administered with tyrosine kinase inhibitors (TKIs). Following a mean follow up of 31 months, no recurrence or mortality was detected. Complete surgical resection with tumor-free margins is the standard treatment for GISTs, and TKIs should be used as adjuvant therapy if the risk of progressive disease is high.

Non-invasive assessment of choledocholithiasis in patients with gallstones and abnormal liver function.

AIM: To find a non-invasive strategy for detecting choledocholithiasis before cholecystectomy, with an acceptable negative rate of endoscopic retrograde cholangiopancreatography. METHODS: All patients with symptomatic gallstones were included in the study. Patients with abnormal liver functions and common bile duct abnormalities on ultrasound were referred for endoscopic retrograde cholangiopancreatography. Patients with normal ultrasound were referred to magnetic resonance cholangiopancreatography. All those who had a negative magnetic resonance or endoscopic retrograde cholangiopancreatography underwent laparoscopic cholecystectomy with intraoperative cholangiography. RESULTS: Seventy-eight point five percent of patients had laparoscopic cholecystectomy directly with no further investigations. Twenty-one point five percent had abnormal liver function tests, of which 52.8% had normal ultrasound results. This strategy avoided unnecessary magnetic resonance cholangiopancreatography in 47.2% of patients with abnormal liver function tests with a negative endoscopic retrograde cholangiopancreatography rate of 10%. It also avoided un-necessary endoscopic retrograde cholangiopancreatography in 35.2% of patients with abnormal liver function. CONCLUSION: This strategy reduces the cost of the routine use of magnetic resonance cholangiopancreatography, in the diagnosis and treatment of common bile duct stones before laparoscopic cholecystectomy.

Malignant extra-adrenal pancreatic paraganglioma: case report and literature review.

BACKGROUND: Pancreatic paragangliomas are rare tumors, with only 16 reported cases to date. One of these cases demonstrates metastasis to lymph node, while another case was functional, however, none of these cases showed malignant and large, pancreatic paraganglioma with marked invasion. Also another unique feature was the age of our patient compared to the average reported ages in published literature (42-85 years). CASE PRESENTATION: A 19-year-old woman presented with a one-year history of intermittent abdominal pain. Physical examination showed a palpable mass in the right upper abdomen, but initial laboratory results were within normal ranges; tumor markers (CEA, AFP, and CA19-9) were negative. An abdominal and pelvic computed tomography (CT) scan showed a well-defined retroperitoneal para-aortic mass. The CT scan revealed that the surrounding lymph nodes were not enlarged, but the liver showed evidence of parenchymal infiltration. Intraoperatively, a large, firm tumor originating from the head of pancreas was found pushing on the caudate hepatic lobe and the inferior vena cava (IVC). The tumor was resected through a pancreaticoduodenectomy, involving segment VI of the liver and a small segment of the IVC. The blood pressure spiked (>220 mm Hg) when the tumor was manipulated during the operation. The final pathology report showed a 9-cm tumor with lymphovascular invasions; immunohistochemistry was positive for synaptophysin and chromogranin. All resection margins were negative and 1/15 lymph nodes was positive for metastasis. Post-operative recovery was unremarkable. One month after discharge, the patient was re-admitted with abdominal pain and found to have an abdominal collection at the resection site, which was drained under CT guidance. She received a therapeutic dose of I131-metaiodobenzylguanidine (MIBG). Follow-ups showed the absence of recurrence, and she has remained disease free. CONCLUSION: This patient was an extraordinary example of a rare tumor. Even more remarkable was that the tumor was malignant with lymph node invasion. To our knowledge, a case similar to that presented here has not been previously reported in the literature.