Treatment of peritoneal carcinomatosis with Pressurized IntraPeritoneal Aerosol Chemotherapy - PIPAC-OPC2.

BACKGROUND: Peritoneal carcinomatosis (PC) is a common endpoint in both gastrointestinal and non-gastrointestinal cancers, and PC is treated as other systemic metastases - unfortunately with disappointing results and considerable side-effects. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a new method of applying traditional chemotherapy, and preliminary data indicate that PIPAC is safe, able to stabilize or improve quality of life, and can induce an objectively measurable reduction in disease burden in PC. METHODS: PIPAC-OPC2 is a prospectively controlled Phase II, single center, one-arm, open-label clinical trial investigating the treatment effect of PIPAC in patients with histological or cytological proven PC from gastrointestinal, ovarian or primary peritoneal cancer. Eligible patients will receive PIPAC in series of three using a combination of doxorubicin (1.5 mg/m2) and cisplatin (7.5 mg/m2) for non-colorectal cancer patients (PIPAC C/D), and oxaliplatin (92 mg/m2) in patients with PC of colorectal origin (PIPAC OX). Patients are monitored by: (1) repeated measurements of the Peritoneal Regression Grading Score (PRGS) in biopsies obtained from metal clips marked areas, (2) Quality-of-Life (QoL) questionnaires, (3) Magnetic Resonance Imaging (MRI) and (4) Prognostic Nutritional Index (PNI). Adverse events and surgical complications will be recorded according to the 30 days definition. RESULTS: The primary outcome of PIPAC-OPC2 is to evaluate if PIPAC can induce major or complete response (PRGS 1 or 2) within a series of three PIPAC procedures. Secondarily this study investigates changes in QoL and MRI as a staging and response evaluation tool. The secondary outcomes will be used to create a model that may predict which of the patients will benefit from PIPAC treatment. CONCLUSIONS: It is expected that PIPAC directed therapy can induce major or complete response in 50 % of patients with PC of colorectal origin and in 30 % of patients with PC of non-colorectal origin - and at the same time stabilize or even improve quality of life. This trial may provide data regarding the utility of MRI as a staging and response evaluation tool in patients with PC. TRIAL REGISTRATION: The study is registered with ClinicalTrials.gov Identifier NCT03287375 and the European Clinical Trials Database (EudraCT) number 2016-003394-18.

The value of contrast-enhanced laparoscopic ultrasound during robotic-assisted surgery for primary colorectal cancer.

AIM: The aim of this study was to assess the potential clinical value of contrast enhanced laparoscopic ultrasonography (CE-LUS) as a screening modality for liver metastases during robotic assisted surgery for primary colorectal cancer (CRC). METHOD: A prospective, descriptive (feasibility) study including 50 consecutive patients scheduled for robotic assisted surgery for primary CRC. CE-LUS was performed by 2 experienced specialists. Only patients without metastatic disease were included. Follow-up was obtained with contrast-enhanced CT imaging at 3 and 12 months postoperatively. RESULTS: Fifty patients were included; 45 patients were available for final analysis. The patients were equally distributed between stage I, II, and III according to the TNM classification system. No liver metastasis was detected during LUS and CE-LUS. CE-LUS was easy to perform and there was no complication. Follow-up revealed no liver metastasis in any of the patients. CONCLUSION: CE-LUS did not increase the detection rate of occult liver metastasis during robotic assisted primary CRC surgery. The use of CE-LUS as a screening modality for detection of liver metastasis cannot be recommended based on this study, but larger controlled studies on high-risk patients seem relevant.

[Polyorchidism is a rare cause of a scrotal mass].

In this case report we present a 14-year-old boy with two testicles in the right hemiscrotum - a case of polyorchidism. He did not have surgery for his condition, and his condition was followed according to the guidelines. In a study, 6.4% of cases with polyorchidism were found to contain neoplasms of which the most were malignant. If the supernumerary testicle is not contributing to the spermatogenesis, it is therefore recommended to remove the testicle. Otherwise, recommendations are a yearly follow-up by Doppler ultrasound, including a physical examination to discover development of cancer.

[Focal hepatic peliosis without evident aetiology].

Hepatic peliosis is a rare vascular disorder of the liver characterized by small cavities containing blood. It is most often asymptomatic but may give rise to portal hypertension and even fatal liver rupture. In this case a 47-year-old woman presented with abdominal pain and elevated alkaline phosphatase. An ultrasonography and additional MRI of the liver detected three lesions suspected of focal nodular hyperplasia. A core needle biopsy revealed that hepatic peliosis was the correct diagnosis. No causative factors were found and the patient was followed by consecutive MRIs.

[Portal vein embolization prior to liver surgery]. / Portal vene-embolisering før leverkirurgi.

Portal vein embolization is performed with the intention to occlude the portal veins to liver segments with malignancies and direct the portal flow to the healthy part (usually the left lobe) of the liver. Thus, hyperperfusion through the non-embolized part of the liver will create hyperplasia and hyperfunction, which allow extensive liverresection at a later stage in patients where it otherwise would have been contradictory to operate because of too small volume of the residual liver.

[Atypical course of Budd-Chiari syndrome with hydrothorax]. / Atypisk forløb af Budd-Chiaris syndrom med hydrothorax.

Budd-Chiari syndrome is a very rare condition with an incidence and a prevalence of respectively 0.8 and 1.4 per million inhabitants per year. Significant large right-sided pleural effusion without significant ascites is well-known in portal hypertension and cirrhosis, where it occurs in 5-10% of the patients. Due to the presence of endometriosis and the dominant symptom in the form of hydrothorax up to 5 l per day delayed the correct diagnosis in a case with a 33 year-old woman. Reviews of the initially performed computed tomographies could have been made shortly after admission thus avoiding long time illness and hospitalization.

[Chronic ileus following iatrogenic reversal of the small intestine]. / Kronisk ileus efter iatrogen reversering af tyndtarmen.

We report a case of inadvertent reversal of the entire small intestine leading to severe complications and long-standing ileus. The clinical diagnosis was confirmed by magnetic resonance imaging and laparotomy. The patient was cured by surgical re-reversal of the bowel. Care should be taken to mark the bowel ends when multiple simultaneous bowel resections are performed.

[Computer tomographic diagnosis of an internal hernia]. / Diagnostik af et internt hernie ved computertomografi.

A case is presented in which a transmesenteric hernia developed four weeks after transperitoneal laparoscopic left nephrectomy. The diagnosis of an internal hernia is best established by computer tomography; however, the signs have low sensitivity, and on suspicion of an internal hernia, early laparoscopy or laparotomy is recommended.

Successful resection of an advanced duodenal gastrointestinal stromal tumor after down-staging with imatinib: report of a case.

The diagnosis of gastrointestinal stromal tumor (GIST) relies on a combination of the following criteria: anatomic location, typical histopathology, and the presence of CD 117-antigen (the tyrosine kinase receptor, c-kit) or CD 34-antigen. Imatinib mesylate, a specific tyrosine kinase inhibitor, is highly efficient against locally advanced or metastatic GIST. We report a case of unresectable duodenal GIST, which we were able to resect with curative intent after down-staging treatment with a dosage of imatinib 400 mg daily for 8 months. We performed Whipple's procedure combined with en bloc resection of the right kidney and adrenal gland. The patient was recurrence free at his 24-month follow-up examination. Down-staging treatment may be worthwhile in selected patients, but further prospective studies of imatinib in this setting are necessary. We think that imatinib should be continued postoperatively, as the risk of recurrence in these patients may be high.

Extreme neutrophil granulocytosis in a patient with anaplastic large cell lymphoma of T-cell lineage.

We describe a 47-year-old male admitted with fever and extreme neutrophil granulocytosis (up to 80 x 10(9)/L). All microbiology tests and test for autoimmune disease were negative. CT scan showed pulmonary infiltrates bilaterally, mediastinal lymphadenopathy and splenomegaly. Conventional pathological examination of bone marrow and lymph node biopsies did not demonstrate malignant cells and inflammatory disease was suspected. The patient died of multiorgan failure 23 days after admission. Autopsy showed neutrophil infiltration of several organs. Immunohistochemistry and cytogenetics postmortem led to a diagnosis of anaplastic large cell lymphoma (ALCL) of T-cell lineage. Involvement of peripheral blood with leukemoid reaction is a rare manifestation of ALCL. This case emphasizes the importance of immunophenotyping in unexplained extreme granulocytosis.

[Perforation of the intestine after ingestion of magnetic items]. / Tarmperforation efter indtagelse af magnetisk legetøj.

The ingestion of magnetic items is a potentially dangerous condition which may result in local necrosis and perforation of the intestine due to incrustation of the bowel wall between two magnetic bodies. We report a case of a 12-year old girl who ingested several magnetic items, causing perforation of the small intestine. We recommend surgical removal if more than one magnetic foreign body is ingested. If imaging results indicate that only one magnet has been ingested, we recommend a control x-ray within a few hours to confirm a secure passage of the foreign body.