Long-term results after proactive management for locoregional control in patients with colonic cancer at high risk of peritoneal metastases.

PURPOSE: A major problem in treating patients with peritoneal spread from colorectal cancer is that at diagnosis wide peritoneal involvement often precludes all curative attempts. A possible solution is to identify those patients at risk for peritoneal metastases and intervene early to prevent locoregional disease spread before it develops and, thus, to improve outcome. METHODS: We analyzed long-term results from a previous study and compared outcomes in 25 patients with advanced colon cancer considered at high risk for peritoneal spread (pT3/pT4 and mucinous or signet ring cell histology) prospectively included and managed with a proactive surgical approach including target organ resection for peritoneal spread plus hyperthermic intraperitoneal chemotherapy (HIPEC) and in 50 retrospectively well-matched controls who underwent standard surgical resection during the same period and in the same hospital by different surgical teams. RESULTS: At 48 months after the study closed, peritoneal metastases and local recurrence developed significantly less often in proactively managed patients than in controls (4 vs 28%) (p < 0.03). Patients in the proactive group also survived longer than control patients (median overall survival 59.5 vs 52 months). Despite similar morbidity, Kaplan-Meier survival curves disclosed significantly longer disease-free and overall survival in the proactive than in the control group (p < 0.05 and <0.04). CONCLUSIONS: In patients with advanced colon cancer at risk for peritoneal recurrence, the proactive surgical approach plus HIPEC seems to achieve good locoregional control preventing peritoneal spread thus improving outcome without increasing morbidity. These advantages merit investigation in a multicentric randomized trial.

Ectopic liver nodules: a rare finding during cholecystectomy.

The ectopic liver (or choristoma) is a rare condition found during autopsy or abdominal exploration for various indications. The authors report two cases of ectopic liver found during laparoscopic cholecystectomy for acute cholestytis. The ectopic liver tissue has been reported to develop in several sites as thoracic cavity, gastrohepatic ligament, adrenal glands, pancreas, esophagus and, above all, gallbladder. The Authors review the literature and report their experience as a contribution to the knowledge of this rare pathological entity.

Cystic duplication of transverse colon: an unusual case of abdominal pain and bowel obstruction.

Gatrointestinal duplications are rare congenital anomalies, usually detected prenatally or in the first two years of life, although they can be diagnosed even in older age. Within the abdomen, a small bowel location is the most frequent (more than 50% of cases), while colonic site accounts for 17% of patients; transverse colonic location is very rare. These lesions can vary in shape, being cystic or tubular, and typically show the same structure of the adjacent normal bowel, with which they can have direct communication. The most of case of intestinal duplication in adults present with acute abdomen and bowel obstruction, and are more common in the ileum than in the colon. When diagnosed these lesions should be surgically resected to avoid future possible complications. The Authors present a case of cystic duplication of transverse colon in a young adult male, cause of acute abdominal pain and intestinal obstruction, thus requiring urgent surgery.

No evidence of involvement of Chlamydia pneumoniae in lung cancer by means of quantitative real-time polymerase chain reaction.

Chlamydia pneumoniae, an obligate intracellular pathogen, is well-known as etiological agent of acute respiratory infections; the repeated or prolonged exposure to chlamydial antigens may promote the persistence of C. pneumoniae in the respiratory tract leading to chronic diseases, such as chronic obstructive pulmonary disease and asthma. The predilection of C. pneumoniae to cause respiratory tract infections combined with its persistent nature suggest that it might play a role in lung cancer. The aim of our study is to evaluate the involvement of C. pneumoniae in pathogenesis of lung cancer. We therefore investigated the presence of C. pneumoniae DNA in tumor lung tissues by using real-time PCR assay. Simultaneously, tumor and healthy tissues from the same patient with primary carcinoma lung were analyzed. C. pneumoniae DNA was not detected in a single lung tumor tissue by means of an highly sensitive, and specific real-time PCR assay based on FRET hybridization probes. In conclusion, this study does not support the involvement of C. pneumoniae in the pathogenesis of lung cancer, suggesting that further investigations are needed to clarify other potential causative factors for the development of this malignancy.

Two synchronous adenocarcinomas of the small bowel in a patient with undiagnosed Crohn's disease of the terminal ileum.

A small but significant excess of deaths for tumors of the digestive system has been described in Crohn's disease. In a study analyzing all cancers of the small intestine within a defined population, Crohn's disease was the major underlying factor for cancer of the small intestine. Areas of the small intestine containing strictures are unusually prone to malignant transformation. We report the rare case of a patient in whom surgery for intestinal occlusion disclosed Crohn's disease of the distal ileum complicated by two adenocarcinomas arising within distinct areas of the inflamed bowel.

Giant GIST of the mesocolon: report of a case.

UNLABELLED: Gastrointestinal stromal tumors are rare neoplasms arising from mesenchymal cells of the gastrointestinal tract, that strongly express a class III receptor tyrosine kinase, called KIT, due to some mutations in the KIT proto-oncogene. Two thirds of GISTs are found in the stomach, 20% to 50% in the small bowel (one third in the duodenum), and 5% to 15% in colon and rectum; GISTs, however, may rarely be found also in the oesophagus, omentum, mesentery or the retroperitoneum. Their treatment is strictly surgical, and only R0 resection can achieve good RESULTS: Treatment with Imatinib seems to be promising in case of unresectable or metastatic GIST, even if some trials are studying its effects after curative resection. GIST of the mesocolon are rare, and as in the other locations, require extensive surgery. The Autohrs report a case of giant malignant GIST arising from transverse mesocolon, treated by en-bloc resection of the tumor with a segment of transverse colon and great omentum.

Intestinal anisakiasis in Italy: a case treated by emergency surgery.

Anisakiasis is a fish-borne zoonotic disease. A case of intestinal anisakiasis in a woman who had consumed raw marinated anchovies was reported. The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment. The histological examination of the eosinophilic granuloma removed from the resected colon revealed the presence of larval nematodes of the genus Anisakis as causative agents.

Characterization of tumoral lesions of the breast: preliminary experience with multislice spiral CT.

The aim of the present study was to validate low dose Multislice Spiral Computed Tomography (MSCT) in the diagnosis of breast lesions. Fourteen patients with mammographic and ultrasound findings suspect of malignant neoplasm underwent dynamic MSCT of the breast under basal conditions and 1, 3, and 6 minutes after intravenous injection of iodinated contrast medium. Both enhancement of the lesion >100% without further increase after 6 minutes, and irregular margins of the lesion were considered signs of malignancy. All lesions were examined cytologically and/or histologically. A correct diagnosis was achieved by MSCT in 7/8 malignant lesions, and in 6/6 benign lesions. The only malignant lesion missed by MSCT was histologically a ductal carcinoma in situ (false negative). In one case the MSCT showed the multifocality of an infiltrating ductal carcinoma, and in another it defined the bilaterality of the malignant lesions. Sensitivity and specificity of MSCT in the diagnosis of malignancy of a lesion were 88% and 100%, respectively. Our results suggest that MSCT is an effective diagnostic method to define suspicious breast lesions, and a valid alternative to Magnetic Resonance Imaging, especially when the latter is not feasible.

Pre-operative assessment of extramural invasion and sphincteral involvement in rectal cancer by magnetic resonance imaging with phased-array coil.

OBJECTIVE: Pre-operative staging of rectal cancer should identify patients with extrarectal spread, who might benefit from pre-operative radiotherapy, and patients with minimal sphincteral involvement, who can avoid permanent colostomy. The aim of this study was to assess the accuracy of Magnetic Resonance Imaging (MRI) to predict tumour stage and sphincter status. PATIENTS AND METHODS: Thirty-three patients with a rectal tumour were pre-operatively assessed by MRI with a phased-array coil. Imaging results were correlated with the final pathological findings. RESULTS: The overall accuracy of pre-operative staging with MRI was 88% (k = 0.75) for extramural tumour invasion and 59% (k = 0.26) for lymph node metastases. MRI correctly evaluated the infiltration of the anal sphincters in 87% of patients (7 of 8 patients with low rectal tumour). CONCLUSION: MRI provides the surgeon with valuable information regarding extramural tumour spread and sphincteral involvement, enabling appropriate selection of patients for pre-operative adjuvant therapy or sphincter-saving surgery.

Intestinal anisakiasis in Italy: case report.

A case of intestinal anisakiasis caused by Anisakis sp. larva type I in a woman from Italy who consumed raw marinated anchovies, is reported. The diagnosis was based on the morphological features characteristic of anisakid larval stages, which were readily recognized in a large granuloma removed after emergency surgical treatment.

Adrenomedullin immunoreactivity tissue distribution in parathyroids of the patients with primary hyperparathyroidism.

Adrenomedullin (ADM) is a new potent vasorelaxant peptide identified originally in extracts of pheochromocytoma, and is widely distributed within the tissue. Although histopathological studies have demonstrated the presence of ADM-immunoreactivity (ir-ADM) in some human neuroendocrine tumors (such as insulinoma, pituitary adenoma, and gastrointestinal neuroendocrine tumors), data on the presence of ADM in normal and pathological parathyroid gland are not available. Plasma AM concentrations were recently reported to be elevated in patients with PHP (primary hyperparathyroidism). The aim of our study was to determine tissue distribution of ir-AM in 34 patients with PHP (27 female and 7 male, mean age 50 +/- 6 years) undergoing surgery. Six normal parathyroid samples incidentally found during thyroidectomy for neoplastic diseases and ten sections of human rectus abdominis muscle tissue were used as controls (C). Adenomatous parathyroids were found in 22 PHP and hyperplastic parathyroids in twelve PHP patients. Four hyperplastic parathyroids were found in three PHP patients and three parathyroids in 10 PHP patients. Eight parathyroids revealed a prevalent diffuse growth pattern and four showed a prevalent nodular growth pattern. Immunohistochemical ADM expression was seen in seven of twelve (58.3 %) hyperplastic parathyroids and in fourteen of twenty-two (66.6 %) adenomatous glands. Parathyroid chief cells showed strong cytoplasmatic staining, whereas oncocytic cells showed a faintly aspecific cytoplasmatic staining. Normal parathyroids were negative for ir-ADM. In conclusion, we found the presence of ADM in parathyroid chief cells of PHP patients using immunohistochemistry in our study.

[Diagnosis and treatment of distal bile duct carcinoma: our experience]. / Diagnosi e trattamento delle neoplasie del coledoco distale: nostra esperienza.

Bile duct carcinomas are known to be difficult to cure, due to frequent locoregional recurrence even after radical resection. The Authors analyze their experience in a study about 53 patients treated between October 1991-January 2002.

Systematic radical gastrectomy and D2 lymphadenectomy in primary gastric B cell lymphoma: impact on diagnosis, classification and long term results. A prospective study.

The role of surgery in the treatment of primary gastric lymphoma has been recently re-evaluated. We report the results of a series of 37 operated patients for primary gastric lymphoma (PGL). All patients underwent gastrectomy with D2 lymphadenectony and bilateral liver biopsies. Postoperative histopathological classification was compared to preoperative staging data. No mortality and low morbidity were observed in this series of patients. We found a high incidence of mixed grading of tumors and a relatively high incidence of lymph node metastases in low grade lymphoma. Relying on preoperative biopsies and imaging techniques could lead to preoperative staging inaccuracy and therefore to inappropriate treatment planning. For these reasons we advocate systematic primary surgery in PGL. Surgery could be useful for staging purposes and seems to be curative in stage IE.

Two twins with teratoma of the ovary. An unusual association: case report.

Teratomas are neoplasms composed of tissue foreign to the area in which it is found. They are considered to be an acquired neoplastic disease and familial incidence has not been reported. Only one occurrence of teratoma between monozygotic twins has been found in the literature. Here we report the case of two heterozygotic twins with benign cystic teratomas of the ovary as a base for future research for efficacy of an accurate familial follow-up in order to diagnose this neoplasm in early stage and for the molecular understanding of pathogenesis of teratoma.

Monodermal highly specialized teratoma of the ovary: a sebaceous gland tumor.

Teratomas are neoplasms that originate in pluripotential cells and contain representations of all three germ layers in a rather mature state. Specialized forms of teratoma with unilateral development of certain tissues, such as struma ovarii, argentaffin tumors, cholesteatoma, primary choriocarcinoma of the ovary, pseudomucinous cystoma and neurogenic cysts are known. In this paper we describe an ovarian teratoma consisting entirely of sebaceous glands.

Vascular prosthetic graft infection: epidemiology, bacteriology, pathogenesis and treatment.

UNLABELLED: Vascular prosthetic graft infection remains a major surgical challenge. Prevention of risk factors and antibiotic therapy can reduced but not eradicate it. Management of infected vascular grafts depends on several factors, including the location of the infected prosthesis, the extent of infection, and the underlying micro-organism. Classic treatment consists of extra-anatomic bypass grafting. The disappointing results due to the high mortality and amputation rate have kindled interest in alternative approaches, such as in situ reconstruction with antibiotic-bonded prostheses, autogenous veins or arterial allografts. PURPOSE: We focused on the treatment of aortic graft infection by means of both fresh and cryopreserved arterial allograft. Here, the experience of the Italian Collaborative Vascular Homograft Group is reported. METHODS: Between March 1994 and December 2000 seventy-nine patients with aortic graft infection were treated. The results of 68 patients are analysed. Eleven patients were treated with fresh, and 57 with cryopreserved homograft. Emergency surgical procedures were performed in 12 patients (17%). Aortoenteric fistula was diagnosed in 22 patients. The mean interval between the first procedure and the insertion of a homograft for patients with infected aortic graft was 3 years (range 1-15). The mean duration of follow-up was 30 months (range 1-68). Clinical and duplex scanning evaluation were routinely performed. Computer tomography (CT), magnetic resonance (MR), or arteriography were performed on the basis of duplex scanning results. RESULTS: The analysis was performed on 68 cases for which there were sufficient reliable data. Eleven deaths occurred during the early postoperative period (30 days), a mortality rate of 16%. There were also seventeen late deaths, a mortality rate of 25%. Eleven patients had graft occlusion; six cases were successfully treated with thrombectomy. In three cases leg amputation was necessary. The results of fresh and cryopreserved homografts were compared. No significant differences of early postoperative mortality, late mortality, homograft-related mortality, graft failure were observed. The presence of aortoenteric fistula is a negative predicting factor of perioperative early mortality, which causes a rapid decline in the survival curve. Thirty-six months after the surgery the actuarial survival of the patients was 57% and the actuarial patency of the allograft was 41%. CONCLUSION: No significant difference in terms of clinical outcome was observed when using fresh, rather than cryopreserved homografts. The only factor that significantly influenced the survival rate appeared to be the aorto-enteric fistula.

Unique pineal gland metastasis of clear cell renal carcinoma: case report and review of the literature.

The metastatic involvement of the pineal gland is an extremely unusual event; it has a 4% incidence in patients with disseminated neoplasias. Most metastatic pineal lesions are asymptomatic. Only in a small number of cases the symptoms produced by metastatic involvement of this organ precede those of the primary tumor or those of another metastatic site. To our knowledge the herein reported case is the first in which the pineal gland was apparently the unique metastatic site of a primitive kidney carcinoma and where the symptoms produced by metastasis in the pineal region were the first sign of the disease.

Solitary splenic recurrence of epithelial ovarian cancer: a case report and review.

The metastatic involvement of the spleen in epithelial ovarian cancer is rare and usually reflects late disseminated disease. Isolated parenchymal metastasis in the spleen is an extremely unusual event, in fact in most cases in medical literature, the spleen was involved as part of diffuse peritoneal carcinomatosis. We report a rare case of epithelial ovarian carcinoma, which recurred in the splenic parenchyma 15 years after initial treatment. The patient underwent a splenectomy followed by six cycles of platinum-based poly-chemotherapy. Currently, 8 years after splenectomy, the patient has no evidence of relapsed disease. In the solitary splenic recurrence of epithelial ovarian cancer our case suggests that accurate surgical resection of the spleen, followed by platinum-based chemotherapy, is correlated with a prolonged survival.

Plasma and tissue prolactin detection in colon carcinoma.

Serum concentrations of prolactin, a trophic hormone produced by the pituitary gland, have been shown to be raised in certain group of patients with cancer. Prolactin was detected in 0-20% of the colon cancer by immunohistochemistry and in plasma in 6-53% of the patients. These conflicting results do not support the hypothesis of an ectopic prolactin production by colon carcinoma. The aim of this study was to confirm the reported incidence of hyper-prolactinemia in colorectal cancer and to find further evidence for an ectopic prolactin production by the tumor. Thirty consecutive patients with colon carcinoma were studied. Before surgery all the patients underwent blood sample collection to assay plasma prolactin levels. All patients underwent colectomy. All the neoplastic specimens were tested with antiprolactin antibody. In none of the patients were significantly high preoperative levels of plasma prolactin found. Prolactin immunostaining was not identified in any of the tumor specimens. We could not confirm previous reports of frequent hyperprolactinemia in patients with cancer. This is the first report in which the incidence of both hyperprolactinemia and prolactin positive immunostaining was 0%. Our study was unable to demonstrate the synthesis of prolactin by colorectal cancers. The tumor is unlikely to be the source of hormone production. Our results suggest that circulating prolactin levels cannot be used as prognostic marker in patients with colon cancer.

Prognostic impact of CD31 antigen expression in anal canal carcinoma.

BACKGROUND/AIMS: CD31 is a platelet endothelial cell adhesion molecule. Thus CD31 immunostaining of vascular endothelial cells can be used to measure degree of angiogenesis. As angiogenesis is necessary for tumor growth and metastasis, microvessels density could be a predictor of prognosis. The purpose of this study was to examine the relationship between CD31 value and standard pathologic parameters and prognosis of anal canal carcinoma. METHODOLOGY: Twenty-four patients with anal canal carcinoma were evaluated. Five-micron sections of formalin-fixed, paraffin-embedded tissue were tested with monoclonal anti-CD31 antibody. CD31 value is considered positive if more than 185 vessels/mm2 were counted. Pearson's chi 2 test was employed to test for association between CD31 value and clinicopathological variables. RESULTS: We found no correlation between CD31 value and histologic type, lymph node involvement, patients age and neoplastic relapse. Significant correlation was found between CD31 score and depth of parietal invasion. CONCLUSIONS: The relapse type could strengthen the hypothesis that increased vascularity promotes neoplastic dissemination. As angiogenesis could be used as prognostic indicator to determine patients who may be at higher risk for relapse, our results warrant further confirmation. Development of markers of angiogenic activity in anal canal carcinoma must be an integral part of proper clinical trials.