Abdominal aorta aneurysm with hostile neck: Early outcomes in outside instruction for use in patients using the treovance® stent graft.

PURPOSE: The efficacy and safety of endovascular aneurysm repair (EVAR), in patients outside instruction for use (IFU), is very challenging and widely debated. The aim of this study was to evaluate the placement of the Treovance® abdominal aorta stent-graft in patients with hostile proximal necks considered outside IFU. MATERIALS AND METHODS: Between May 2013 and August 2014, 5 patients with outside IFU underwent EVAR with the Treovance® stent-graft. Technical and clinical successes were evaluated. All 5 patients underwent clinical and imaging follow-up. RESULTS: Technical and clinical successes were achieved in all 5 patients without adjunctive endovascular procedures or surgical conversion. During the mean follow-up of 21 months, no type I/III endoleaks, stent-graft migration nor kinking/occlusion were observed. In all 5 patients, a reduction of the proximal neck angle was observed. CONCLUSION: In our small series of selected outside IFU patients, EVAR with the Treovance® stent-graft was technically feasible and safe, with satisfactory short-term follow-up results, when performed by experienced operators. Long-term follow-up will be necessary to confirm the durability of our preliminary promising results.

Endovascular treatment of a symptomatic thoracoabdominal aortic aneurysm by chimney and periscope techniques for total visceral and renal artery revascularization.

Conventional endovascular therapy of thoracoabdominal aortic aneurysm with involving visceral and renal arteries is limited by the absence of a landing zone for the aortic endograft. Solutions have been proposed to overcome the problem of no landing zone; however, most of them are not feasible in urgent and high-risk patients. We describe a case that was successfully treated by total endovascular technique with a two-by-two chimney-and-periscope approach in a patient with acute symptomatic type IV thoracoabdominal aortic aneurysm with supra-anastomotic aneurysm formation involving the renal and visceral arteries and a pseduaneurismatic sac localized in the left ileopsoas muscle.

Endoscopic treatment of ganglioneuroma of the colon associated with a lipoma: a case report.

INTRODUCTION: Ganglioneuromas are rare benign peripheral neuroblastic tumors characterized by hyperplasia of ganglion cells, nerve fibers, and supporting cells. They are not usually localized in the colon. CASE PRESENTATION: A 61-year-old Caucasian man was admitted to our department for colon cancer screening. A colonoscopy revealed a lipoma of 5cm in diameter, two micropolyps of less than 1cm, and one sessile polyp of 0.6cm in diameter. The polyps were removed with hot biopsy forceps. A histological examination revealed two hyperplastic polyps and one ganglioneuroma polyp. A follow-up colonoscopy showed no signs of recurrence after 16 months. CONCLUSIONS: Although a few cases of lipomas associated with ganglioneuromatous syndrome have been reported, the association of an intestinal lipoma with an isolated ganglioneuroma polyp has not been described. The implications of this association are unknown.

Prevention of Peritoneal Metastases from Colon Cancer in High-Risk Patients: Preliminary Results of Surgery plus Prophylactic HIPEC.

The study compared the outcome in patients with advanced colonic cancer at high risk of peritoneal metastases (mucinous or signet-ring cell) without peritoneal or systemic spread, treated with standard colectomy or a more aggressive combined surgical approach. The study included patients with colonic cancer with clinical T3/T4, any N, M0, and mucinous or signet ring cell histology. The 25 patients in the experimental group underwent hemicolectomy, omentectomy, bilateral adnexectomy, hepatic round ligament resection, and appendectomy, followed by HIPEC. The control group comprised 50 patients treated with standard surgical resection during the same period in the same hospital by different surgical teams. Outcome data, morbidity, peritoneal recurrence rate, and overall, and disease-free survival, were compared. Peritoneal recurrence developed in 4% of patients in the experimental group and 22% of controls without increasing morbidity (P < 0.05). Actuarial overall survival curves disclosed no significant differences, whereas actuarial disease-free survival curves showed a significant difference between groups (36.8 versus 21.9 months, P < 0.01). A more aggressive preventive surgical approach combined with HIPEC reduces the incidence of peritoneal recurrence in patients with advanced mucinous colonic cancer and also significantly increases disease-free survival compared with a homogeneous control group treated with a standard surgical approach without increasing morbidity.

[Local excision of giant rectal polypoid neoplasms]. / Escissione locale delle neoplasie polipoidi giganti del retto.

Local excision is the best therapeutic option for giant adenomas of the rectum. Parks technique for lower rectal lesions and the T.E.M. technique for lesions localised in the middle and upper rectum offer exceptionally good exposure, allowing radical excision in the case of early low-risk T1 adenocarcinomas (well or moderately differentiated [G1/2] without lymphovascular invasion [L0]). From July 1987 to March 2006, 224 patients were treated by local excision for rectal lesions in our department. In 48 patients (21.4%) a large sessile benign lesion was diagnosed preoperatively. In 3 patients with a preoperative diagnosis of severe dysplasia (Tis) final pathology showed adenoma and for this reason they were included in our study group. A total of 51 patients with giant preoperative benign lesions were treated by local excision (Parks technique, T.E.M. or both). Twenty-five (49%) patients had a definitive diagnosis of adenocarcinoma: in situ (pTis) in 22 patients (88%), pT1 in 2 patients (8%) and pT2 in 1 patient (4%). In 26 patients (51%) the diagnosis was adenoma. The overall local recurrence rate was 9.8% (5/51); the recurrence rate was 7.6% (2/26) for adenomas and 12% (3/25) for carcinomas. The median hospital stay was 7 days (range 3-39). There was no operative mortality. Giant sessile polypoid lesions localized in the middle and upper rectum are best treated with T.E.M., while Parks technique is a good option in lower rectal tumours. These techniques, if correctly indicated and well performed, offer great advantages in terms of safety and radicality. In our experience the operative mortality was nil and the morbidity and recurrence rates were low.

Axillary and subcutaneous breast metastases from rhinopharyngeal carcinoma: a case report and literature review.

The incidence of rhinopharyngeal carcinoma is fewer than one person per 100,000 population but it is one of the most common types of cancer in Southern China. The mechanisms often implicated suggest an important role of genetic, ethnic and environmental factors. Lung metastases are the most frequent, accounting for 66% of distant metastases. Other metastatic sites include bone (22%) and liver (10%). We report a case with breast skin and axillary nodes involvement.

Pleomorphic hyalinizing angiectatic tumour of the mesorectal soft tissue. A case report and review of the literatre.

Pleomorphic hyalinizing angiectatic tumours are rare stromal lesions histologically resembling both neurilemoma and malignant fibrous histiocytoma and occurring in the subcutaneous soft tissue of the lower and upper limbs and, less frequently, in the chest wall. The case reported here is one of 22 cases published in the medical literature and describes a pleomorphic hyalinizing angiectatic tumour which was localized in a body cavity and developed in the pelvis. The present report is the first of its kind to date. A 53-year-old asymptomatic woman was treated via an open laparotomy. The lesion arising from the left mesorectal tissue was entirely resected. The postoperative course was uneventful and the patient was discharged on postoperative day 3. The patient is still disease-free 58 months after the operation. A review of the literature shows that pleomorphic hyalinizing angiectatic tumours are locally aggressive. A 20% recurrence rate has also been observed in long-term follow-up. These patients should therefore be treated by wide local excision and require long-term surveillance.

Role of desmoplasia in recurrence of stage II colorectal cancer within five years after surgery and therapeutic implication.

BACKGROUND: Colorectal cancer (CRC) metastasis is enhanced in patients with venous embolization increasing the risk of recurrence and therefore mortality rate. Several evidences indicate that stage II patients have an abrupt recurrence within five years from surgery. This fact, led us to investigate the role played by different histological variables on CRC invasiveness. AIM: To demonstrate if quantitative and qualitative desmoplastic response and lymphocytic infiltration are prognostic factor involved in the recurrence of CRC within five years from surgery, considering possible clinical and therapeutical implications. METHODS: Thirty-four patients with CRC underwent colectomy and the UICC-TNM classification was applied for disease staging. Histological variables were semi-quantitatively evaluated. Qualitative evaluation of desmoplasia was obtained with the hematoxillin-eosin method. RESULTS: Survival rate arose 88% at stage II, at five years of follow-up, and the 12% not treated with adjuvant chemotherapy developed metastasis. Desmoplasia is strongly associated with venous neoplastic invasiveness (OR: 21.93; 95%CI: 1.012-475.26, p = 0.02), and therefore, with mortality rate (OR: 14.33; 95%CI: 0.67-304, p = 0.04). Moreover, mortality rate was significantly higher in patients with immature desmoplasia compare to mature stromal tissue (OR: 15.61, 95%CI: 0.69-343.38, p = 0.04). CONCLUSIONS: These observations should prompt a future evaluation of desmoplasia to extent more suitably the use of adjuvant chemotherapy in II stage patients. Further clinical trials are needed to determine if these findings will be able to reduce mortality rate, in stage II CRC patients.

Correlation between genetic and biological aspects in primary non-metastatic breast cancers and corresponding synchronous axillary lymph node metastasis.

This study investigated the changes, if any, in the level of expression of a well defined panel of cell proliferation, differentiation and apoptosis markers between the primary breast tumor and the corresponding synchronous lymph node metastasis from a population of patients with a comparable disease status, in terms of clinical features, and natural history.Ninety pure invasive ductal carcinomas with 10 or more axillary lymph nodes involved and without evidence of distant metastasis were included in this study. Primary tumor and corresponding metastatic lymph node tissue specimens were evaluated for the expression of Cyclin B1, MMP1 metalloproteinase, ICAM-1, RARbeta, Ki67, ER, PgR, p53, bcl-2 and c-erbB2 by immunohistochemistry using standard methods. The bivariate Pearson correlation analysis demonstrated a close relationship between primary and matching corresponding metastatic node. A high grade of correlation has been maintained even when staining results where categorized as positive/negative according to each one marker cut-off level of staining expression. We report the most extensive immunohistochemical analysis of biological determinants in a well defined population of patients with invasive ductal carcinomas and involvement of 10 or more axillary nodes and no distant metastasis. We found a close correlation between the primary tumor and corresponding metastatic node in terms of the expression of all 10 of the markers investigated in this study. The not complete concordance observed could be explained by the gene expression modulation by extrinsic factors and by the microenvironment in which the cancer cells reside.

Accuracy rates of US-guided vacuum-assisted breast biopsy.

A prospective study designed to measure the accuracy of mammography (MRx), ultrasound (US), fine-needle aspiration cytology (FNAC) and one of the most recently introduced techniques, vacuum biopsy (VB), in the diagnosis of breast cancer is reported. A sample of 146 breast lesions on 135 patients were examined. The design of the study made it possible to compare MRx, US, FNAC and VB directly, because it excluded several confounding variables. Statistical indicators--sensitivity, specificity, predictive values (PPV and NPV), false-negative and false-positive rates (FN and FP), suspicious plus indeterminate rate and likelihood ratios (LR)--were calculated. The NPV of MRx and US were remarkably high (92.4% and 97.9%, respectively), confirming previous reports. The complete sensitivity of FNAC was 80%, while specificity was 99.1% and LR of positive tests 88.8. The combined score of FNAC, US and MRx resulted in a good increase in complete sensitivity (97.1%), when compared with the results of the single diagnostic tests evaluated separately. The absolute sensitivity of VB was 97.1% and specificity was 100%. In conclusion, considered together, MRx, US and FNAC appear to be reliable diagnostic procedures and, when they are all negative, the possibility of a cancer is extremely low, although it cannot be completely ruled out. The VB test had the highest absolute sensitivity among all the methods compared. Therefore, this technique could be considered conclusive in diagnostically doubtful cases, avoiding open surgical biopsy.

Relationship between beta-catenin expression and epithelial cell proliferation in gastric mucosa with intestinal metaplasia.

AIM: To investigate beta-catenin expression in patients with intestinal metaplasia, and to look for a possible relationship between beta-catenin expression and either epithelial proliferation values or Helicobacter pylori (H pylori) infection. METHODS: Twenty patients with complete type intestinal metaplasia were studied. beta-Catenin expression and epithelial cell proliferation in antral mucosa were assessed using an immunohistochemical analysis. H pylori infection was detected by histology and a rapid urease test. RESULTS: Reduced beta-catenin expression on the surface of metaplastic cells was detected in 13 (65%) out of 20 patients. Moreover, in eight (40%) patients intranuclear expression of beta-catenin was found. When patients were analyzed according to H pylori infection, the prevalence of both beta-catenin reduction at the cell surface and its intranuclear localization did not significantly differ between infected and uninfected patients. Cell proliferation was higher in patients with intranuclear beta-catenin expression as compared to the remaining patients, although the difference failed to reach the statistical significance (36+/-8.9 vs 27.2+/-11.4, P = 0.06). On the contrary, a similar cell proliferation value was observed between patients with reduced expression of beta-catenin on cell surface and those with a normal expression (28.1+/-11.8 vs 26.1+/-8.8, P = 0.7). H pylori infection significantly increased cell proliferation (33.3+/-10.2% vs 24.6+/-7.4%, respectively, P = 0.04). CONCLUSION: Both cell surface reduction and intranuclear accumulation of beta-catenin were detected in intestinal metaplasia. The intranuclear localization of beta-catenin increases cell proliferation. H pylori infection does not seem to play a direct role in beta-catenin alterations, whilst it significantly increases cell proliferation.

Is desmoplasia a protective factor for survival in patients with colorectal carcinoma?

BACKGROUND & AIMS: The role of desmoplasia in colorectal carcinoma progression is unclear and the presence of collagen stroma may represent a barrier against cancer diffusion and vascular invasion or a stroma to build up and support the tumor. The aim of this study was to evaluate the effect of desmoplastic response on long-term survival of patients who underwent radical resection for colorectal carcinoma. METHODS: The study included 429 patients who underwent radical colorectal resection for cancer with a median follow-up period of 72.8 months. RESULTS: At univariate analysis significant associations were observed between desmoplasia and histologic type, parietal infiltration, growth pattern, and staging. No associations were found between desmoplasia and the other clinical and histologic parameters. The multivariate analysis stratified for tumor stage revealed that the factor showing the most favorable influence on time to death was desmoplasia. The presence of desmoplasia was likely to decrease the failure rate to a third of the rate experienced by patients without desmoplasia. Parietal infiltration was associated with an increased risk for a shortened time to death. CONCLUSIONS: Our results favor the view that desmoplasia is a protective factor for survival in patients with colorectal carcinoma. This finding is consistent with the hypothesis that desmoplasia may prevent cancer invasiveness by building a barrier against tumor diffusion.

Epithelial splenic cysts.

BACKGROUND: Epithelial splenic cysts (ESC) are uncommon lesions of the spleen. The etiopathogenesis of these cysts is controversial, even if Burrig's theory is the most accredited. The histological distinction between epidermoid and mesothelial cysts may be difficult, particularly for monostratified epithelium. PATIENTS AND METHODS: In the period between January 1986 and February 2004, 11 patients with ESC were studied. The history, physical findings, all relevant diagnostic studies and treatment were reviewed. All histological material was reviewed in detail with immunohistochemistry for CEA, CA 19-9, cytokeratin and calretinin. RESULTS: Epidermoid cysts were positive for CEA, CA 19-9, and cytokeratin, but negative for calretinin. Mesothelial cysts were positive for cytokeratin and calretinin, but negative for CEA and CA 19-9. CONCLUSION: Immunohistochemistry allows differential diagnosis between epidermoid and mesothelial cysts. With regard to etiopathogenesis, these data could mean that epidermoid and mesothelial cysts have distinct origins, though at variance with Burrig's theory. Although the ESC in this series were treated by open splenectomy, the recent approach by conservative and laparoscopic techniques offers great promise.

Alteration of E-cadherin expression in gastric mucosa: role of intestinal metaplasia and Helicobacter pylori infection.

BACKGROUND: Although E-cadherins have been involved in gastric carcinogenesis, their role in precancerous lesions, such as intestinal metaplasia, is still unclear. This study aimed to assess the role of both intestinal metaplasia and H. pylori infection on E-cadherin expression in gastric mucosa. PATIENTS AND METHODS: Twenty-one consecutive patients with intestinal metaplasia were enrolled to assess E-cadherin expression in metaplastic areas. Twenty further patients without intestinal metaplasia, with and without H. pylori, were enrolled to evaluate the role of the infection on E-cadherin expression. All patients underwent upper endoscopy and gastric biopsies were taken for histological and immunohistochemical assessment. RESULTS: A substantial reduction of E-cadherin expression in metaplastic areas was observed in 14 (67%) of the 21 patients, similarly in H. pylori-infected and uninfected patients (64% vs 71%, p=0.3). In the group without intestinal metaplasia, no reduction in E-cadherin expression was detected either in infected patients or in those without H. pylori infection. CONCLUSION: The data showed that intestinal metaplasia is associated with E-cadherin down-regulation, whereas H. pylori infection does not seem to play a direct role in this process.

Evaluation of CD44 variant 6 expression and clinicopathological factors in pulmonary metastases from colon carcinoma.

Although relatively little is known about the molecular mechanisms underlying tumor progression, recently CD44 glycoproteins and the c-Met receptor tyrosine kinase have been identified as potentially important components of the metastatic cascade. CD44 is a family of transmembrane receptors generated from a single gene by alternative splicing and differential glycosylation. Important biological processes involving CD44 glycoproteins include cell adhesion, lymphocyte homing, hematopoiesis, tumor progression and metastasis. The precise mechanism via which CD44 promotes tumorigenesis have not yet been elucidated. We evaluated the expression of adhesion molecule CD44 variant 6 in pulmonary metastases from colorectal carcinomas and its correlation with clinicopathological parameters. Twenty patients were randomly selected from the patients who had undergone a resection of pulmonary metastasis from colorectal cancer. Formalin-fixed, paraffin-embedded archival specimens of tumor tissues and adjacent normal mucosa from these patients were the subjects of the present study. Immunoreactivity for CD44 was quantified. Specimens were considered positive if almost 25% of the neoplastic cells were stained. CD44 v6 expression was related to the interval between colon resection and metastases diagnosis, the number of pulmonary metastases, and the survival after lung resection. No statistical correlation was found between CD44 v6 positivity and disease-free interval after colon resection, number of metastases or 2-year survival after lung resection. Probably CD44 v6 is necessary and sufficient to confer metastatic potential to carcinoma cells increasing the migration capacity and participating in invasion via changes in adhesion to the extracellular ligands, but is not necessary to modify the clinical history of the metastases. Therefore the evaluation of CD44 v6 expression in lung metastases does not influence the therapeutic scheme.

Squamocellular carcinoma and chondrosarcoma: a true pulmonary carcinosarcoma. Report of a case.

BACKGROUND: Carcinosarcoma is one of the less common tumors of the lung and is composed of a mixture of malignant epithelial and mesenchymal elements of the type ordinarily seen in malignancies of adults. The carcinomatous component is mostly epidermoid and sometimes adenomatoid or undifferentiated. The mesenchymal part is mostly a spindle cell sarcoma and sometimes a polymorphocellular sarcoma. Differentiation as osteosarcoma and chondrosarcoma is rare. CASE REPORT: This report describes the case of a patient with carcinosarcoma of the lung composed of epidermoid carcinoma and chondrosarcoma. A left hilar mass was incidentally diagnosed. The patient was submitted to surgical exploration and a left lower lobectomy with dissection of local lymph nodes was performed. At microscopy the tumor was composed of both epithelial and stromal malignant component. The epithelial component consisted of poorly-differentiated squamous cell carcinoma and the stromal component consisted of chondrosarcoma. He remains well 30 months later. CONCLUSION: The prognosis of patients with carcinosarcoma is not always unfavourable. Potentially curative surgical resections should always be attempted. Pathologists should be aware of a wrong diagnosis of undifferentiated small cell lung carcinoma which eliminates the patient from surgery.

Chemotherapy-induced radiation recall myositis.

Myofasciitis syndrome encompasses a group of disorders characterized by chronic inflammation and/or fibrosis of the subcutaneous septa and muscular fascia. We report on a patient in whom myositis was diagnosed in the areas previously irradiated for papillary thyroid carcinoma and anal canal carcinoma respectively 21 and 3 years after radiotherapy. We are not able to explain why myopathy developed at the same time in two different sites at a different interval from the two radiotherapic schemes. We can suppose that the patient developed a subclinical regional myopathy after the first radiotherapic scheme. Radiation induced heritable mutations within surviving cells that were unable to tolerate the second damage by systemic chemotherapy. It is unclear how radiosensitization correlates with an ability to reactivate latent effects in normal tissue. Physicians using chemotherapic radiosensitizers should be aware of their potential to induce a delayed form of radiosensitization. We report this case to encourage physicians to be alert to the knowledge of the clinical, histologic and morphologic characteristics of radiation myositis in order to distinguish it from an infectious or immune fasciitis or myositis.

Papillary solid and cystic pancreatic tumor. Genetic prediction factors for malignancy: report of three cases.

BACKGROUND: Papillary solid and cystic pancreatic tumor (PSCPT) is a rare neoplasm of unknown pathogenesis, with an excellent overall prognosis after complete resection. The malignant potential of this tumor remains unclear and was the object of our investigation. PATIENTS AND METHODS: We report three cases of PSCPT submitted to radical resection in which histological and immunohistochemical studies, as well as genetic analysis of Kirsten-ras (K-ras) oncogene mutations, p53 and Fragile Histidine Triad (FHIT) gene expression, were evaluated. RESULTS: Low expression of Ki 67 was consistent with a low karyokinetic index of these tumors. Mutations of the K-ras gene were not present. Low-grade variations of p53, K-ras and FHIT genes were detected by immunohistochemistry. CONCLUSION: PSCPT is a rare neoplasm with low malignancy. Further genetic analysis is required to predict the potential malignancy of this tumor; nevertheless combined multimodality approaches may play a suitable role in identifying more aggressive forms.

P53 as a marker of differentiation between hyperplastic and adenomatous parathyroids.

Primary hyperparathyroidism is the clinical result of parathyroid adenoma or hyperplasia, rarely of carcinoma. Clinical, serologic, and radiologic data are unable to discriminate a single parathyroid adenoma from an enlarged hyperplastic gland. Morphologic features also overlap in adenoma and small hyperplastic gland. Studying immunohistochemical expression of fatty acid synthase (FAS), p53, Ki67 and bcl-2, we found that among 21 adenomas 19 (90.5%) were positive for FAS, 12 (57.2%) for Ki67, 11 (52.4%) for p53, and 16 (76.2%) for bcl-2; among 12 hyperplasias, 12 (100%) were positive for FAS, 6 (50%) for KI67, 8 (66.7%) for p53, and 8 (66.7%) for bcl-2. Statistical analysis showed that FAS was associated with parathormone (PTH) (P =.001), Ki67 (P =.01), and p53 (P =.01). Moreover, FAS was associated with hyperplastic (P =.0001) and adenomatous glands (P =.0001). Ki67 was associated with both adenomatous (P =.02) and hyperplastic glands (P =.005). P53 protein were associated only with hyperplastic glands (P =.01). The different occurrence of p53 in parathyroids adenoma and hyperplasia may enable a different management and follow-up of the patients with primary hyperparathyroidism, stratifing them into two groups. The first, with a "false" adenoma having a high risk of relapse, may necessitate exams like serum calcium levels, PTH concentrations, urinary calcium levels for 24 hours, kidney functional tests, and radiology and ultrasound every 3 to 6 months, whereas the second with "true" adenoma, at low risk of relapse, may be checked less frequently with serum calcium levels and PTH concentrations.