Gastrointestinal Seed Bezoars: A Systematic Review of Case Reports and Case Series.

Seed bezoars are a distinct subcategory of phytobezoars, caused by indigestible vegetable or fruit seeds. The aim of our study was to present a comprehensive review on seed bezoars, focusing on epidemiology, symptomatology, diagnosis and treatment options. A systematic review of the English literature (1980-2018) was conducted, using PubMed, Embase and Google Scholar databases. Fifty-two studies fulfilled the inclusion criteria, with a total of 153 patients, the majority of whom (72%) came from countries around the Eastern Mediterranean and the Middle East. Patients complained primarily about constipation (63%), abdominal/rectal pain (19%) or intestinal obstruction (17%). Most seed bezoars were found in the rectum (78%) and the terminal ileum (16%). Risk factors were recognised in 12% of cases. Manual disimpaction under general anaesthesia was the procedure of choice in 69%, while surgery was required in 22% of cases. Seed bezoars appear to represent a different pathophysiological process compared to fibre bezoars. Seeds usually pass through the pylorus and ileocaecal valve, due to their small size, and accumulate gradually in the colon. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. History and digital rectal examination are the mainstay of diagnosis, with manual extraction under general anaesthesia being the procedure of choice.

Synchronous Colonic Adenocarcinoma and Metastatic Lobular Carcinoma in a Colectomy Specimen: A Rare Finding.

Invasive lobular carcinoma is the second-most-common subtype of invasive breast carcinoma. Its metastatic pattern is different compared to invasive carcinoma-no special type. It metastasizes more often to the gastrointestinal tract, peritoneum, pleura, and ovaries. The extrahepatic gastrointestinal tract metastases occur mostly in the stomach and small intestine and less often in the colon and rectum. We present a case description of an 87-year-old woman admitted to our hospital with hematochezia, abdominal discomfort, fatigue, and weight loss. A colonoscopy revealed an exophytic tumor of the sigmoid colon. Metastatic disease was not found in imaging studies. A low anterior resection was performed. The pathologic examination revealed a collision tumor consisting of a poorly differentiated adenocarcinoma of the colon and metastatic lobular carcinoma. The diagnosis was challenging due to the lack of a previous history. Also, the diffuse architectural pattern and signet ring cells found may be in primary signet ring carcinoma of the colon as well as in carcinomas from other anatomical sites. Immunohistochemistry was helpful in making the diagnosis. A review of the literature revealed that this is the fourth case of metastatic breast carcinoma coexisting with colonic adenocarcinoma.

Multiplex RT-PCR-based detections of CEA, CK20 and EGFR in colorectal cancer patients.

AIM: To develop a multiplex reverse transcription polymerase chain reaction (RT-PCR) method detecting circulating tumor cells in the peripheral blood of colorectal cancer (CRC) patients. METHODS: Peripheral blood samples were collected from 88 CRC patients and 40 healthy individuals from the blood donors' clinic and subsequently analyzed by multiplex RT-RCR for the expression of carcinoembryonic antigen (CEA), cytokeratin 20 (CK20) and epidermal growth factor receptor (EGFR) mRNA. The analysis involved determining the detection rates of CEA, CK20 and EGFR transcripts vs disease stage and overall survival. Median follow-up period was 19 mo (range 8-28 mo). RESULTS: Rates of CEA, CK20 and EGFR detection in CRC patients were 95.5%, 78.4% and 19.3%, respectively. CEA transcripts were detected in 3 healthy volunteer samples (7.5%), whereas all control samples were tested negative for CK20 and EGFR transcripts. The increasing number of positive detections for CEA, CK20 and EGFR transcripts in each blood sample was positively correlated with Astler-Coller disease stage (P < 0.001) and preoperative serum levels of CEA (P = 0.029) in CRC patients. Data analysis using Kaplan-Meier estimator documented significant differences in the overall survival of the different CRC patient groups as formed according to the increasing number of positivity for CEA, CK20 and EGFR transcripts. CONCLUSION: These data suggest that multiplex RT-PCR assay can provide useful information concerning disease stage and overall survival of CRC patients.

Dermatofibrosarcoma protuberans: a case series of 16 patients treated in a single institution with literature review.

BACKGROUND: Dermatofibrosarcoma protuberans is an uncommon skin tumour with a low to intermediate-grade of malignancy, characterized by progressive growth and a propensity for local recurrence. PATIENTS AND METHODS: A retrospective study of a series of 16 consecutive patients with dermatofibrosarcoma protuberans who were treated in the host Institution over the last seven years was performed, with special emphasis on the outcome and disease-free interval, as well as recurrence rate over a mean follow-up period of 43.65 months. RESULTS: The clinicopathological features and results were reviewed. The primary treatment consisted of wide local excision with or without radiotherapy on 13 patients with primary and 3 with recurrent disease, and all patients remained free of disease recurrence during the mean follow-up period. CONCLUSION: The results of this study and a review of the literature support the notion that aggressive, wide surgical resection with disease-free margins, with or without radiotherapy decreases local recurrences and offers an excellent probability of cure. The accumulated data also confirm that all patients with dermatofibrosarcoma protuberans should be followed up for an extended period, beyond the usual recommended 5-year follow-up, because late recurrences may occur.

Histologically malignant solitary fibrous tumour of the anterior thoracic wall: a case report and review of the literature.

Solitary fibrous tumour (SFT) is a rare oncological entity that most often arises in the pleura. Over the past 10 years, the tumour has been described at numerous extrapleural locations. We present the case of a 42-year-old female Caucasian patient with an extrapleural SFT located at the anterior thoracic wall for 22 years, with atypical histological characteristics and clinical features of malignancy. Management consisted of a wide surgical resection, plastic reconstruction, and postoperative radiotherapy. Although extrapleural SFT usually behaves as a benign soft tissue tumour, it can also present with a more aggressive local behavior, including locoregional recurrence or metastasis. In that case, a multidisciplinary approach is required for accurate diagnosis and proper management.

Functional results of speech and swallowing after oral microvascular free flap reconstruction.

PURPOSE: To study speech and swallowing in patients who underwent microvascular free flap reconstruction after major surgery of the oral cavity. PATIENTS AND METHODS: Twenty patients, 17 men and 3 women, with a mean age of 58.5 years (range 27-79 years) were included in the study. Squamous cell carcinoma was the most common malignancy. Swallowing assessment was performed through videofluoroscopy, using three consistencies of barium meal. The recorded swallows were assessed for the ability to hold the bolus during the oral phase, lip seal, tongue movement, residue in the floor of the mouth, laryngeal penetration and aspiration. Speech function regarding intelligibility and articulation was objectively assessed. RESULTS: Fifteen out of 20 patients (75%) had a good lip seal. Fourteen patients (73.6%) had adequate control of bolus, while in 89.4% the neotongue motility was satisfactory. Vallecular residue was noted in 25% of patients, laryngeal penetration in two (10%), while three patients (15%) continued to have significant aspiration, which necessitated continuous feeding through a gastrostomy. Postoperative speech intelligibility and articulation was satisfactory in 75 and 62.5% of the patients, respectively. CONCLUSIONS: Microvascular free flap reconstruction of major defects after oral resections rehabilitates the functions of swallowing and speech in acceptable levels, improving quality of life in these patients.

Giant Basal cell carcinoma: clinicopathological analysis of 51 cases and review of the literature.

BACKGROUND: Giant basal cell carcinoma (GBCC) is an aggressive malignant neoplasm. Because of the rarity of the tumor and its recognized high risk of recurrence, there are no guidelines for its treatment. PATIENTS AND METHODS: Published articles in PubMed Central were carefully reviewed. Data from 48 patients obtained from 30 individual articles were added to our 3 cases, producing a total number of 51 cases of GBCC. A clinical database was established in order to define the behavior of this tumor, prognostic factors and optimal treatment. RESULTS: GBCC mostly occurs in elderly male patients, with a peak incidence in the seventh decade of life. It develops as long-standing dermal tumor with mean disease duration of 14.5 years and is most commonly located on the back, followed by the face and upper extremity. The most common histological subtype is nodular. The average size at presentation is 14.77 cm in its largest diameter. The presence of metastasis at the time of presentation represents the most significant adverse prognostic factor. Local recurrence or metastasis develops in 38.3% of patients despite optimal therapy. The overall reported cure rate is 61.7% by a mean follow-up of 2 years. Wide local excision of the tumor with or without postoperative radiochemotherapy represents the optimal treatment. CONCLUSION: Optimal management of GBCC consists of wide local excision with histologically confirmed tumor-free margins, frequently followed by adjuvant therapy. In cases of lymphatic spread, a regional lymphadenectomy is also necessary. In addition, consideration should be given to a close and long-term follow-up because of the high rate of locoregional recurrence.

Successful en bloc resection of primary hepatocellular carcinoma directly invading the stomach and pancreas.

Multivisceral surgical resection for cure was successfully performed in a 70-year-old man suffering from a primary hepatocellular carcinoma (HCC) associated with direct invasion to the stomach and pancreas. The patient presented with gastric outlet obstruction, upper abdominal pain and a history of chronic liver disease due to hepatitis B virus (HBV) infection. Upper gastrointestinal (GI) endoscopy revealed an infiltrating tumor protruding through the gastric wall and obliterating the lumen. Computer tomograghy (CT) and magnetic resonance imaging (MRI) scan demonstrated a 15-cm tumor in the left lateral segment of the liver with invasion to the stomach and pancreas. Alpha-foetoprotein (AFP) levels and liver function tests were normal. The patient underwent an en bloc left hepatectomy, total gastrectomy, distal pancreatectomy with splenectomy and radical lymphadenectomy. Pathology revealed a poorly differentiated, giant cell HCC involving the stomach and pancreas. Disease-free margins of resection were achieved. The patient's postoperative course was uneventful. Sixteen months after surgery, he has no recurrence or distal metastasis. Direct invasion of HCC into the GI tract is rarely encountered. Complete surgical resection should be considered in selected patients with an appropriate hepatic functional reserve.

Solitary fibrous tumor of the liver expressing CD34 and vimentin: a case report.

A case of a successfully treated solitary fibrous tumor (SFT) of the liver is reported. An 82-year-old female presented with left upper abdominal discomfort, a firm mass on palpation, and imaging studies revealed a large tumor, 15 cm in diameter, arising from the left lobe of the liver. A formal left hepatectomy was performed. Microscopic evaluation showed spindle and fibroblast-like cells within the collagenous stroma. Immunohistochemistry disclosed diffuse CD34 and positive vimentin, supporting the diagnosis of a benign SFT. The patient remained well 21 months after surgery. SFT of the liver is a very rare neoplasm of mesenchymal origin. In most cases it is a benign lesion, although some may have malignant histological features and recur locally or metastasize. With less than 30 reported cases in the literature, little can be said regarding its natural history or the benefits of adjuvant radiochemotherapy. Complete surgical resection remains the cornerstone of its treatment.

Primary malignant melanoma of the duodenum: aggressive management and long-term survival of an unusual oncologic entity.

Primary malignant melanoma originating in the small bowel is extremely rare. We report the case of a 55-year-old man who presented with a preoperative bleeding duodenal tumor. A standard pancreaticoduodenectomy was performed. Histopathological examination ascertained the diagnosis of a duodenal malignant melanoma with locoregional lymphatic spread. A thorough postoperative investigation did not reveal any primary melanotic lesions. Thus, the diagnosis of a primary melanoma originating from the duodenum was suggested. Fourteen months after surgery, the patient had no evidence of recurrence. Primary malignant melanoma of the duodenum is an existing, though unusual, oncologic entity. Aggressive surgery remains the treatment of choice offering both symptom palliation and long-term survival.

Pre-operative chemoradiotherapy with oral capecitabine in locally advanced, resectable rectal cancer.

PURPOSE: The aim of the study was to evaluate the efficacy and tolerance of pre-operative chemoradiotherapy with oral capecitabine in Greek patients with locally advanced, resectable rectal cancer. MATERIALS AND METHODS: Thirty patients, 16 men and 14 women with a median age of 58 years (range, 21-75 years), with potentially resectable T3NO (30%), T3N1 (53%) and T4NO-1 (17%) rectal cancer, were treated with capecitabine (825 mg/m(2), twice daily for 7 days/week) and concomitant radiotherapy (50.4 Gy/28 fractions) for 5.5 weeks. Patients underwent surgery with total mesorectal excision 4-6 weeks later followed by 4-months of post-operative treatment with capecitabine. The primary end-point was to determine the clinical and pathological response, safety profile, preservation of the sphincter mechanism and rate of peri-operative complications. RESULTS: The median distance of rectal tumors from the anal verge was 7 cm. All patients had curative resection. Downstaging rate was 84% (25/30) on endorectal ultrasonography and 75% (22/30) on pathology findings. Pathological complete response rate was 23% (7/30). No patient had grade 4 toxicity. Grade 3 toxicity occurred in 3 patients (10%) and consisted mainly of leucopenia (6%) and hand-foot syndrome (4%). Mild or moderate toxicity was frequent, but always reversible. Twenty-four patients (80%) received sphincter-preserving surgical procedures. Peni-operative complications were seen in 6 (20%) patients and included mechanical ileus (3%), delayed wound healing (7%), wound infection (7%) and anastomotic leakage (3%). CONCLUSION: Pre-operative chemoradiotherapy with oral capecitabine in locally advanced, resectable rectal cancer achieves significant rates of tumor downstaging and sphincter preservation with a favorable safety profile.

Mechanical deterioration underlies malignant behavior of aneurysmal human ascending aorta.

OBJECTIVE: The human ascending aorta becomes markedly prone to rupture and dissection at a diameter of 6 cm. The mechanical substrate for this malignant behavior is unknown. This investigation applied engineering analysis to human ascending aortic aneurysms and compared their structural characteristics with those of normal aortas. METHODS: We measured the mechanical characteristics of the aorta by direct epiaortic echocardiography at the time of surgery in 33 patients with ascending aortic aneurysm undergoing aortic replacement and in 20 control patients with normal aortas undergoing coronary artery bypass grafting. Six parameters were measured in all patients: aortic diameter in systole and diastole, aortic wall thickness in systole and diastole, and blood pressure in systole and diastole. These were used to calculate mechanical characteristics of the aorta from standard equations. Aortic distensibility reflects the elastic qualities of the aorta. Aortic wall stress reflects the disrupting force experienced within the aortic wall. Incremental elastic modulus indicates loss of elasticity reserve. RESULTS: Aortic distensibility falls to extremely low levels as aortic dimension rises toward 6 cm (3.02 mm Hg(-1) for small aortas versus 1.45 mm Hg(-1) for aortas larger than 5 cm, P < .05). Aortic wall stress rises to 157.8 kPa for the aneurysmal aorta, compared with 92.5 kPa for normal aortas. For 6-cm aortas at pressures of 200 mm Hg or more, wall stress rises to 857 kPa, nearly exceeding the known maximal tensile strength of human aneurysmal aortic wall. Incremental elastic modulus deteriorates (1.93 +/- 0.88 MPa vs 1.18 +/- 0.21 MPa, P < .05) in aneurysmal aortas relative to that in normal aortas. CONCLUSION: The mechanical properties of the aneurysmal aorta deteriorate dramatically as the aorta enlarges, reaching critical levels associated with rupture by a diameter of 6 cm. This mechanical deterioration provides an explanation in engineering terms for the malignant clinical behavior (rupture and dissection) of the aorta at these dimensions. This work adds to our fundamental understanding of the biology of aortic aneurysms and promises to permit future application of engineering measurements to supplement aneurysm size in clinical decision making in aneurysmal disease.

Intravascular papillary endothelial hyperplasia (Masson's hemangioma) presenting as a soft-tissue sarcoma.

Intravascular papillary endothelial hyperplasia (Masson's hemangioma) is an unusual benign, non-neoplastic, vascular lesion characterized histologically by papillary fronds lined by proliferating endothelium. It may appear as a primary or pure form developing in a distended vessel, or it can be associated with hemangiomas, pyogenic granulomas, or lymphagiomas. Nearly all lesions are intimately associated with a thrombus in various stages of organization. The main significance of intravascular papillary endothelial hyperplasia is its clinical and histological resemblance to soft-tissue sarcoma and possible misinterpretation as such. A case of intravascular papillary endothelial hyperplasia clinically diagnosed and treated as a low-grade angiosarcoma, in a 60-year-old man, presenting with a mass in the left thigh, is reported.

Full-term gestation and transvaginal delivery after wide resection of an abdominal desmoid tumor during pregnancy.

A 29-year-old female was diagnosed with a symptomatic, extra-abdominal desmoid tumor during the first trimester of pregnancy. Computerized tomography (CT) and transabdominal ultrasound (US) noted a mass within the left rectus sheath measuring up to 15 cm in greatest diameter, with mild compression of the uterus. Preoperative diagnosis was confirmed by core-needle biopsy of the lesion. At 20-weeks gestation, wide local resection of the tumor with disease-free margins, as well as abdominal wall reconstruction with polytetrafluoroethylene (PTFE) mesh was successfully undertaken. Histological examination of the tumor ex vivo confirmed that the lesion was a desmoid tumor consisting of spindle cells with dense infiltrating collagenous fibers. Subsequent to her resection, the patient completed a full-term pregnancy without complication, and proceeded with a complication-free transvaginal delivery at 39 weeks. This case illustrates the probable contribution of estrogens towards desmoid tumor development, the durability of abdominal wall reconstruction when subjected to the extraordinary strain of both a gravid uterus and labor, as well as the safety and efficacy of aggressive surgical therapy during pregnancy.

Increased tissue microarray matrix metalloproteinase expression favors proteolysis in thoracic aortic aneurysms and dissections.

BACKGROUND: Little information is available regarding the role of matrix metalloproteinases (MMPs) in thoracic aortic aneurysms and dissections. We applied tissue microarray analysis to determine MMP profiles in a large group of surgically resected thoracic aneurysms and dissections. METHODS: Specimens from 47 patients undergoing a variety of surgical procedures for thoracic aneurysm (n = 30) and dissection (n = 17) were included. Expression of MMP-1, MMP-2, and MMP-9 and tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) were assessed by aortic tissue microarray immunostaining. Matrix metalloproteinase and TIMP expression in aortic tissue was compared with seven control aortic specimens, free of any vascular disease. RESULTS: Expression of MMP-1 and MMP-9 was significantly increased in aneurysm and aortic dissection patients compared with control specimens (p < 0.05). Expression of TIMP-2 was significantly increased in the entire patient group, compared with control specimens (p < 0.05). Aortic dissection patients had higher MMP-2 and MMP-9 expression than aortic aneurysm patients in areas of disease. Compared with control patients, the MMP-9 to TIMP-1 ratio (a relative index of proteolytic state) was increased in both the aortic aneurysm and dissection groups (p < 0.05). CONCLUSIONS: The increased MMP expression in aortic aneurysms and dissections indicates a metamorphosis in the aneurysm wall toward increased proteolysis compared with the normal aorta. Furthermore, we find even higher MMP-2 and MMP-9 presence in aortic dissection. In both aneurysms and dissections, this transformation to a proteolytic state likely plays an important pathophysiologic role in the development and progression of the aortic disease. The recognition of this pathophysiologic mechanism raises the potential for drug therapy to interrupt the cascade of events.

Tissue microarray detection of matrix metalloproteinases, in diseased tricuspid and bicuspid aortic valves with or without pathology of the ascending aorta.

OBJECTIVE: The degeneration of bicuspid aortic valve and its frequent association with ascending aortic pathology, point to a still unidentified genetic tissue defect with unknown mediators. Metalloproteinases (MMPs) are lytic enzymes that have been strongly implicated in aneurysm formation. The purpose of this study was to detect the presence of these enzymes in aortic valvular tissue in healthy and diseased aortic valves with or without the presence of synchronous ascending aortic pathology. METHODS: Aortic valve specimens from 26 aortic valve replacement patients as well as 4 healthy control tricuspid aortic valves were included. 10 patients had bicuspid aortic valves, and 16 had tricuspid aortic valves. Half of our patient population had a concomitant aortic procedure for aortic pathology. The study detected MMPs 1,2 and 9 as well as their Tissue inhibitors (TIMPs) 1 and 2. MMP and TIMP detection was accomplished with the construction of a tissue micro array and immunohistochemistry. CONCLUSIONS: MMP-9 expression was significantly higher in bicuspid aortic valves compared to normal valves (P<0.05). When compared to the tricuspid valve group, MMP-9 mean value was significantly higher in bicuspid valves (P<0.05). When the entire rest of the valve group (n=4+16, i.e. control and tricuspid valve groups) was compared to the bicuspid valve group, bicuspid valves had significantly higher MMP-2, and MMP-9 (P<0.01) expression. TIMP expression also changed in diseased valves, among different patient groups. This increased proteolytic presence in bicuspid aortic valves may attribute to the observed decreased elastin and collagen content, and their resultant functional failure.

Current assessment and management of spontaneous pneumomediastinum: experience in 24 adult patients.

OBJECTIVES: Spontaneous pneumomediastinum (SPM) is an uncommon, benign, self-limited disorder that usually occurs in young adults without any apparent precipitating factor or disease. The purpose of this study was to review our experience in dealing with this entity and detail a reasonable course of assessment and management. METHODS: A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in a single institution between 1993 and 2000. RESULTS: Twenty-four patients were identified who included 18 men and 6 women with a mean age of 17.5 years. Acute onset chest pain was the predominant symptom at presentation. Only half of the patients developed clinically evident subcutaneous emphysema. The most frequent precipitating factor was a history of illegal drug abuse seen in 25% of patients. Other factors included asthmatic bronchospasm, physical activity and violent coughing or vomiting. Chest radiography and computerized tomography (CT) were diagnostic in all cases with CT scan revealing six cases with associated pulmonary abnormalities. Esophagogram and flexible bronchoscopy were selectively used. Twelve patients (50%) were admitted to the hospital. Their mean hospital stay was 2 days. All patients were conservatively treated. In a follow-up of 3-10 years no complications or recurrences were observed. CONCLUSIONS: SPM follows alveolar rupture in the pulmonary interstitium. It shows a rising incidence in young drug users. It has a wide range of clinical features necessitating a high index of suspicion. Chest X-ray and CT scan should be always performed. Hospitalization and aggressive approach should be limited. SPM responds well to conservative treatment and follows a benign natural course.

A novel antioxidant non-steroidal anti-inflammatory agent protects rat liver against ischemia-reperfusion injury.

Liver ischemia followed by reperfusion is an important and common clinical event. A major mechanism is leukocyte adhesion to endothelium followed by release of reactive oxygen metabolites. The aim of this study was to determine the effects of a novel antioxidant ethylenediamine derivative with anti-inflammatory properties (compound IA) on an imitated clinical setting of acute hepatic ischemia-reperfusion injury. Eight groups of rats were subjected to a model of hepatic ischemia that was produced by occluding for 30 min the portal vein and hepatic artery. At the end of ischemia, compound IA was administered intravenously and the clamps were removed allowing reperfusion for 60 min or 24 h. The effect of compound IA was evaluated by histopathological examination, lipid peroxidation and plasma levels of liver enzymes. Administration of compound IA resulted in significantly less histological damage in liver tissue after 30-min ischemia followed by 60-min and 24-h reperfusion. Ischemia followed by 60 min of reperfusion increased lipid peroxidation compared to the sham-operated and the non-ischemic group. This increase was attenuated in the group treated with compound IA. Serum enzyme levels were significantly higher in the reperfusion groups compared to the non-ischemic groups and diminished after treatment. Compound IA exerted a protective effect on hepatic reperfusion injury in rats. Compound IA is believed to act by means of its potent antioxidant and anti-inflammatory activities.

Immunohistochemical testing for Helicobacter pylori infection in ascending aortic aneurysms and penetrating aortic ulcers.

Evidence implicating Helicobacter pylori (H. pylori) in coronary artery disease and aneurysmal lesions is controversial. No published data have related H. pylori infection to ascending aortic aneurysms and penetrating ulcers, although both of these lesions may have an infectious components in their initiating process. We sought to investigate possible H. pylori infection in 54 human specimens of 42 aortic aneurysms and 12 penetrating ulcers. No evidence of H. pylori was found in these specimens.