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.

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.