[Intraperitoneal hyperthermic chemotherapy in the management of recurrent peritoneal carcinomatosis. Preliminary results in 5 patients]. / Faisabilité d'une chimiohyperthermie intra-péritonéale itérative après chirurgie de cytoréduction pour récidive de carcinose péritonéale. A propos de 5 cas.

Peritoneal carcinomatosis has been treated by extensive cytoreduction surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). We report here our experience of 5 patients treated twice or three times by recurrent procedure of HIPEC and cytoreduction. The mortality rate was 0% and morbidity one 30%. Three patients have died at 6, 10, 18 months respectively after the second cytoreduction surgery and HIPEC, and two patients are still alive at 40 and 67 months. Our results might suggest that recurrent peritoneal carcinomatosis after cytoreduction and HIPEC, could be usefully treated by another cytoreduction and HIPEC procedure in a curative approach superior to more conventional treatments.

Management of surgical complications of small-bowel diverticulosis.

INTRODUCTION: Diagnosis of complications of small bowel diverticulosis is difficult in the emergency setting and often delays surgical management. The aim of this study was to report our experience with seven patients presenting with a surgical complication of small-bowel diverticulosis. PATIENTS AND METHODS: From January 1, 1995 to June 30, 2001, 7 patients presenting with a complication of small-bowel diverticulosis were included in this retrospective study. The mean age of the patients was 73.1 years. Complications were bleeding in 4 cases and diverticulitis with perforation and abscess formation in 3 cases. RESULTS: The time between complication onset and its management was 20.6 days. Among paraclinical examinations small-bowel barium opacification showed diverticulosis in 4 cases. Other investigations such as endoscopy or CT-Scan imaging studies were used to eliminate other causes of acute abdomen. Patients were operated on in all cases and a segmental small bowel resection was performed in all cases while in one patient, a diversion stomy was performed. One patient died following septic peritonitis treatment. CONCLUSION: Small-bowel diverticulosis is unfrequent. In cases of gastrointestinal haemorrhage or occlusion, diagnosis is performed by eliminating other more frequent causes. If emergency surgery is not required, barium opacification seems to be the most sensitive examination.

[Cytokeratins 7 and 20 immunohistochemistry in ampullary carcinomas]. / Expression immunohistochimique des cytokératines 7 et 20 dans les carcinomes ampullaires.

UNLABELLED: Ampullary carcinomas (AC) account for 33% of all surgically operable pancreatoduodenal tumors. The 5-year relative survival rate is 50% and tumoral stage is the main prognostic factor. However, among the three AC histological subtypes (intestinal, pancreatobiliary and mixed), a favorable prognostic has been reported for the intestinal subtype. BACKGROUND: The aims of this study were to determine the prognostic impact of AC histologic subtype and of cytokeratins (CK) 7 and 20 immunostaining profile in these tumors. PATIENTS AND METHODS: Clinical data of 54 AC were obtained retrospectively. Macroscopic and histologic documents were reviewed and immunostainings for CK7 and CK20 were performed. RESULTS: The classification of tumors, according to histological subtype, was: intestinal 26%, pancreatobiliary 65% and mixed 9%. No correlation was found between histological subtype and tumor stage. The 5-year survival rate varied from 100% for intestinal subtype to 35% for pancreatobiliary subtype. A strong correlation (p < 0.0001) was found between histological subtype and CK7/CK20 immunostaining profile. The 5-year survival rate varied from 100% for CK7-/CK20 + AC to 40% for CK7 + /CK20- AC. CONCLUSION: In our study, the intestinal histological subtype had a favorable prognostic value. CK7/CK20 immunostaining profile was helpful for the identification of histological subtype and appears to provide additional prognostic information.

Colorectal cancer with non-resectable synchronous metastases: should the primary tumor be resected?

OBJECTIVES: In asymptomatic patients presenting with non-resectable synchronous metastatic disease from colorectal adenocarcinoma, the beneficial effect of resecting the primary tumor remains to be documented. The aim of this study was to compare survival of patients with metastatic colorectal cancer who underwent elective resection of the primary tumor to those who did not. METHODS: A retrospective analysis of patients with metastatic colo-rectal cancer treated between June, 1996 and December, 1999 was performed. Overall survival was compared between patients who underwent first-line resection of the primary colorectal tumor (group 1) or those who did not undergo elective resection of the primary (group 2). The probability of surgical resection of the primary tumor for gastrointestinal complications in group 2 was evaluated. RESULTS: Thirty-one and 23 patients were included in groups 1 and 2 respectively. Five patients (21.7%, 95% confidence interval CI95% 4.9-38.5%) in group 2 required surgical treatment for intestinal obstruction due to the primary tumor. Two clinical characteristics were significantly different between groups 1 and 2: rectal localization (9.7% versus 34.7%; P=0.03) and presence of fewer than three metastases (29.0% versus 4.3%; P=0.03). Survival curves were not significantly different (logrank). Median duration of survival was 21 and 14 Months, respectively (P=0.718). CONCLUSION: In patients with non-resectable synchronous metastatic disease, non-surgical management of the primary tumor is a rational alternative if asymptomatic. A prospective randomized trial integrating the quality-of-life factor should be organized.

SMAD4-related Familial Juvenile Polyposis Syndrome with Colon Cancer.

BACKGROUND: Juvenile polyposis syndrome (JPS) is a rare autosomal dominant disorder characterized by the development of multiple hamartomatous polyps in the gastrointestinal tract with an increased risk of malignancy. SMAD4 germline mutations account for about a third of JPS. PATIENTS AND METHODS: We describe, in the same family, the morphological and genetic aspects of two cases of JPS with colon cancer in one patient. RESULTS: Both cases were characterised by diffuse colorectal and gastric involvement by typical juvenile polyps as well as "atypical" multilobulated and densely epithelial polyps with some dysplastic areas. A germline mutation of SMAD4 was demonstrated in both cases. SMAD4 protein and DNA analyses were performed on the colonic adenocarcinoma showing a lack of expression of SMAD4 protein and loss of heterozygosity at the SMAD4 locus. CONCLUSION: These two exceptional familial cases underline the fact that the morphological features of JPS associated with SMAD4 mutations are different from those found in non SMAD4 mutated cases: polyps are more widespread in the upper GI tract with massive gastric polyposis and they have a dense epithelial component. This study also confirmed that SMAD4 genetic analysis is useful for the diagnosis of JPS and may be predictive of an increased risk of malignancy through inactivation of both alleles of SMAD4.

[Cystic mass of the pancreatic region associated with elevated CA 19-9 serum levels revealing a colonic duplication in an adult]. / Tumeur kystique de la région pancréatique avec augmentation du CA 19-9 révélant une duplication colique chez un adulte.

Intestinal duplications are rare embryologic malformations, especially in adults. We report a case of cystic duplication located near the pancreas revealed by unusual symptoms and associated with marked elevation of serum CA 19-9 levels. Although the physiopathology of the expression of CA 19-9 in duplications is unclear, this feature has been recently reported in adults and could be of interest in the diagnosis and management of intestinal duplications.

[Juvenile polyposis coli. The usefulness of a genetic study and the role of surgical treatment]. / Polypose juvénile familiale. Intérêt de l'etude génétique et place du traitement chirurgical.

We report two cases of familial juvenile polyposis coli. SMAD4 gene mutation was found in our two patients, leading to the definite diagnosis. Colonic cancer occurred in the first patient. Long-term outcome was favorable after colectomy. In the second patient, prophylactic total colectomy was performed. Rectal bleeding, diarrhea, stomach obstruction and vomiting developed during the follow-up. Proctectomy, distal partial gastrectomy and total gastrectomy were successively performed.