Gastrointestinal stromal tumor of the stomach and hepatocellular carcinoma: An unusual association.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are uncommon, potentially malignant tumors, that arise in the wall of the gastrointestinal tract. Up to 50% can develop metastasis, mainly in the liver, but the occurrence of synchronous primary liver tumors is a rare event in these patients. PRESENTATION OF CASE: The authors report a case of the association of gastric GIST and hepatocellular carcinoma (HCC) in a non-cirrhotic liver in a 76 year-old patient. DISCUSSION: The appearance of an hepatic lesion in a GIST patient does not necessarily imply its secondary nature. CONCLUSION: In diagnosed GIST patients, all efforts should be pursued to characterize synchronous hepatic lesions, in order to plan a correct and tailored treatment of the patients.

Frontal totalmente expuesto ¿y ahora? / Frontal bone fully exposed, ¿what now?

Existen pocas publicaciones sobre el uso de terapia de presión negativa en heridas de cabeza y cuello, probablemente por la compleja configuración anatómica de estas áreas, que dificulta el lograr un correcto sellado. Presentamos el caso de un paciente con úlcera extensa de región frontal, con afectación ciliar y exposición ósea. Optamos por una estrategia de estimulación del crecimiento del tejido de granulación con terapia de presión negativa sobre la superficie ósea y posterior cobertura con un injerto cutáneo, logrando excelentes resultados. La utilización de adyuvantes a la terapia de presión negativa posibilitó un cierre eficaz en un área de dificil abordaje. El conocimiento previo de las complicaciones potenciales nos permitió llevar a cabo su profilaxis (AU)

There are few published studies regarding the use of negative pressure therapy in wounds located in the head and neck regions. This probably occurs because of the anatomical complexity of these areas, which may difficult the use of a sealed dressing. We present the clinical case of a patient with a vast ulcer on the frontal region, extending to the eyebrow and with bone exposure. We decided to stimulate the growth of granulation tissue over bone surface through negative pressure therapy and proceed to an autologous skin graft, with excellent results. The use of adjuvants to the negative pressure dressing allowed us to be safe and efficient in an area of difficult approach. The anticipated knowledge of possible complications made it possible to use prophylactic measures (AU)

Gastric stump cancer: more than just another proximal gastric cancer and demanding a more suitable TNM staging system.

BACKGROUND: Considerable controversy persists about the biological behavior of gastric stump cancer (GSC). The aim of this study is to clarify if this cancer is just another proximal gastric cancer or if it emerges as a distinctive clinicopathologic entity. METHODS: This review of a prospectively collected gastric cancer database identified 73 patients with GSC in a single institution between January 1980 and June 2012 and compared them with 328 patients with proximal gastric cancer (PGC) and 291 patients with esophagogastric junction cancer (EGJC). RESULTS: Patients with GSC were predominantly males. Eighty-three percent of GSC penetrated the subserosal or the serosal layers. The median number of lymph nodes retrieved in GSC patients was significantly lower than in PGC patients or in EGJC patients. Cumulative survival curves were not different between GSC, PGC, or EGJC patients. Unlike that observed in PGC and in EGJC, no significant differences in cumulative survival according to the TNM staging system were observed in GSC cases. CONCLUSIONS: The outcome of patients with GSC displayed significant differences when compared to those with other proximal gastric cancers concerning the lack of survival association with the TNM staging system. Therefore a more suitable staging system should be designed for these unique cancers.

Elevated serum C-reactive protein as a predictive factor for anastomotic leakage in colorectal surgery.

BACKGROUND: C-reactive protein (CRP) has been used as an indicator of postoperative complications in abdominal surgery. Its short half-life makes it a reliable marker of the systemic inflammatory response secondary to a surgical procedure or to the appearance of complications, rapidly returning to normal values with the recovery of the patient. AIM: To demonstrate the value of sequential serum determinations of postoperative C-reactive protein (CRP) and white blood cell counts (WBC) in the identification of increased risk of anastomotic leakage after colorectal surgery. METHODS: We reviewed the daily postoperative serum CRP and white blood cell counts in 173 patients who underwent surgery for colorectal disease with anastomosis, between January 2008 and October 2009. Patients with anastomotic leakage (Group A, n = 24) were compared to patients without leakage (Group B, n = 149). Patients with ongoing infections before surgery or with acquired postoperative infections other than leakage were excluded. Mean pre- and postoperative values of CRP and WBC were compared. RESULTS: The diagnosis of anastomotic leakage was made between the 4th and 11th postoperative day (POD; mean 7th POD). The daily average values of serum CRP were significantly higher in group A starting at the 2nd POD and remained significantly elevated until the diagnosis of leakage (p = 0.003). The cut-off value of 140 mg/L on the 3rd POD maximized the sensitivity (78%) and specificity (86%) of serum CRP in assessing the risk of leakage. Comparison of postoperative serum WBC values did not show any significant differences between the two groups until the 6th POD. CONCLUSION: According to these results, an early and persistent elevation of CRP after colorectal surgery with anastomosis, is a marker of anastomotic leakage. A cut-off value > 140 mg/L on POD3 maximizes sensitivity and specificity.

Brunner's gland hyperplasia: an unusual cause of hemorrhagic shock.

Brunner's gland hyperplasia is a very rare lesion of the duodenum, which is usually asymptomatic and diagnosed incidentally during upper gastrointestinal endoscopy. It can cause gastrointestinal bleeding but hemorrhagic shock is a rare clinical presentation of Brunner's gland hyperplasia. The authors present a case of a patient with hemorrhagic shock due to a bleeding Brunner's gland hyperplasia, treated by urgent laparotomy and polypectomy.

Early onset gastric cancer no longer presents as an advanced disease with ominous prognosis.

BACKGROUND: This study aimed to characterize the clinicopathological features and prognosis of early onset gastric carcinomas (EOGCs) in a sample of young Portuguese adults. MATERIAL AND METHODS: A subset of 415 patients submitted to gastric resection was divided into 2 groups: A--patients aged 45 years or less (n = 108), and B--patients older than 45 years (n = 307). The groups were compared for several clinicopathological features and the survival of the patients was analyzed by uni- and multivariate analysis. RESULTS: The surgical resection rate was higher in young patients, in whom tumors more frequently displayed an ulcerative shape (p < 0.001) and diffuse/isolated cell-type histology (p < 0.001). In the elderly, the rate of vascular invasion was significantly higher (p = 0.002). Overall, the survival of young patients was higher than in the elderly (p < 0.001). Survival curves were higher in young patients, except for pT4 and pM1 cases. In the multivariate survival analysis, age (p < 0.001), depth of tumor invasion (p < 0.001), nodal status (p < 0.001), vascular invasion (p = 0.011) and distant metastases (p = 0.007) emerged as independent prognostic factors for gastric carcinoma. CONCLUSION: Young gastric cancer patients no longer present with more advanced disease than the elderly and, overall, survival is better in young patients.

Clinicopathological significance and survival influence of p53 protein expression in gastric carcinoma.

AIMS: Mutations in the gene coding for p53 protein are among the most frequent genetic alterations observed in human cancers. The relevance and biological significance of p53 expression in gastric carcinoma are far from being fully established. The aim of our study was to evaluate the influence of p53 detected by immunohistochemistry in the clinicopathological behaviour of a series of gastric carcinoma cases. METHODS AND RESULTS: Samples from 163 patients treated by gastric resection for gastric carcinoma between 1988 and 1995 were used. Surgical specimens were evaluated for the presence of p53 protein detected by immunohistochemistry with a monoclonal antibody. Cases were classified as positive or negative for p53. Several clinicopathological parameters and c-erb B-2 expression were analysed in the same series and compared with the expression of p53. Cumulative survival was evaluated using univariate analysis and Cox model regression. p53 expression was identified in 41 carcinomas (25.2%) and was significantly associated with venous invasion (P = 0.049), lymph node metastases (P = 0.01) and c-erb B-2 expression (P = 0.003). All the parameters except gender, tumour size and Laurén's classification influenced survival on univariate analysis. p53 expression correlated with overall survival (P = 0.006) and survival in the subgroup of patients with intestinal type carcinoma (P = 0.04). In the subgroup of patients with carcinomas not expressing c-erb B-2, p53 expression significantly influenced cumulative survival (P = 0.02). CONCLUSIONS: p53 expression is associated with the aggressive biological behaviour of gastric carcinomas and is related to cumulative survival.

MUC5B expression in gastric carcinoma: relationship with clinico-pathological parameters and with expression of mucins MUC1, MUC2, MUC5AC and MUC6.

Previous studies have shown that mucin expression can be used to evaluate differentiation patterns of gastric carcinoma: MUC5AC expression is associated with diffuse type and early gastric carcinomas, and MUC2 expression is associated with mucinous gastric carcinomas. The role played by MUC5B in the evaluation of differentiation and biological behaviour of gastric carcinoma is largely unknown. Our aim was to characterise the pattern of expression of mucins MUC1, MUC2, MUC5AC, MUC5B and MUC6 in a series of 50 gastric carcinomas to evaluate whether MUC5B expression was associated with the clinico-pathological characteristics of the cases and/or with the co-expression of other mucins. A panel of six monoclonal antibodies (HMFG1, SM3, PMH1, CLH2, EU-MUC5Ba and CLH5) was used to determine the expression of mucins (MUC1, MUC1 underglycosylated form, MUC2, MUC5B, MUC5AC and MUC6, respectively) using immunohistochemistry. Cases were considered positive if more than 5% of the cells expressed immunoreactivity for the several mucins evaluated. Our results showed that: (a) expression of MUC5B was observed in 11 cases (22.0%) and was associated with the "unclassified" histological type of gastric carcinoma according to Laurén ( P = 0.03) and with the absence of venous invasion ( P = 0.02); (b) in this series, MUC5B expression had no impact on survival of patients with gastric carcinoma; (c) the expression of MUC5B was associated with the co-expression of MUC5AC ( P = 0.02) and (d) none of the cases with the so-called complete intestinal phenotype of mucin expression expressed MUC5B.

Clinicopathologic profiles and prognosis of gastric carcinomas from the cardia, fundus/body and antrum.

BACKGROUND/AIMS: The putative influence of tumor location on the biologic behavior of gastric carcinomas remains controversial. The aim of this study was to investigate if carcinomas arising in the three types of gastric mucosa (cardia, fundus/body and antrum) have different clinical and pathologic profiles and carry a different prognosis. METHODS: Three hundred and two patients with cardia or gastric carcinoma resected between 1984 and 1996 were retrospectively studied. Cases were divided in three groups according to tumor location: cardia (n = 80); fundus/body (n = 60); antrum (n = 162). The three groups were crosstabulated with clinic and pathologic parameters, such as age, sex, macroscopy, histology, desmoplasia, tumor size, depth of tumor wall penetration, nodal status, venous invasion and stage. Survival rates were calculated for the three locations according to the aforementioned parameters. Univariate survival analysis and Cox regression were performed for each location. RESULTS: Cases from the cardia and fundus/body were similar and distinct from antrum cases according to macroscopy, tumor size, depth of wall penetration, venous invasion, nodal status and stage. Cases from fundus/body were similar to antrum cases and distinct from cardia cases according to gender and Laurén's classification. An overall difference in survival between the three locations was observed (p = 0.006). Cumulative survival was better for patients with carcinomas in the antrum than in the cardia (p = 0.04) and in the fundus/body (p = 0.003); no significant differences were observed in survival between cardia and fundus/body carcinoma cases. Cox regression identified stage and venous invasion as prognostic factors for patients with carcinomas in the three locations. In the group of cardia tumors, older patients had a worse outcome and in the group of fundus/body carcinomas, large tumors were associated with a poorer survival. CONCLUSIONS: Our results show that cardia carcinoma and antrum carcinoma are distinct gastric carcinoma entities whereas fundus/body carcinoma shares some characteristics from both entities.