Collision tumor of the stomach: a case of an adenocarcinoma and a gastrointestinal stromal tumor.

A collision tumor of the stomach is a rare event. We report the case of a collision tumor of the stomach consisting of an adenocarcinoma and a gastrointestinal stromal tumor (GIST). This is, to our knowledge, the second report in the literature of such a case. A 71-year-old man with abdominal discomfort underwent an esophagogastroduodenoscopy which revealed a tumor of the oesophagogastric junction. A total gastrectomy was performed. Histologic examination showed a mixed tumor consisting of a primary adenocarcinoma and multiple nodules of GIST. The adenocarcinoma showed both diffuse and intestinal growth, angio-invasion and metastasis to lymph nodes. The GIST tumor cells were strongly immunoreactive to CD117 and CD34. Based on mitotic index, size and cytonuclear details, the biological behavior of this GIST tumor was supposed to be benign. This case reports the rare finding of a collision tumor consisting of an adenocarcinoma and a GIST with an unknown etiology.

Adolescent melanoma: risk factors and long term survival.

AIMS: To report the adolescent melanomas with focus on differences in clinical characteristics, prognostic factors, disease free (DFS) and overall survival (OS) in comparison with adults. METHODS: A single institution retrospective study in which 49 adolescent patients were compared to an adult group of 972 patients. The 10-year DFS, 10-year OS and prognostic factors were calculated for both groups. RESULTS: The median age for the adolescent patients was 17 (range 12-19) years and 49 (range 20-93) years for the adult patients. Median follow-up time was 92 (range 4-366) months. Adolescent patients presented more often with locally advanced melanoma (p<0.01). The median Breslow thickness was 1.6 vs 2.0mm for the adults (p=0.075). Increasing age, ulceration, Breslow thickness, tumour location, male gender and stage at diagnosis were calculated to be negative prognostic factors for the adult group. In the adolescent group, only the stage at diagnosis was a significant negative predictor. The 10-year DFS and OS for the adolescent patients and adult group were not significantly different regarding AJCC stages I-III. CONCLUSION: Although adolescent patients presented more often with locally advanced disease, there are no significant differences in the 10-year DFS and OS between adolescent and adult patients. In our series, we could not confirm the prognostic factors found in the adult group for the adolescent patients, except for the stage at diagnosis.

Extra nodal growth as a prognostic factor in malignant melanoma.

AIM: Extra nodal growth (ENG) in lymph-node metastases may be an additional indicator for poor prognosis and increased loco-regional recurrence in patients with a cutaneous malignant melanoma (CMM). Most studies analyzing prognostic factors lack a proper definition or description of the histological criteria for extra nodal growth. The objective of this study was to evaluate this factor. METHODS: Retrospectively 94 patients with CMM and clinically lymph-node metastases were analysed. Metastatic lymph-nodes were evaluated for ENG and if present grouped in microscopic (<2 mm) or macroscopic (>2 mm) ENG. ENG was defined as metastatic tumour which clearly extends histologically through the nodal capsule into the perinodal fatty tissue or tumour involvement in the hilar region with interruption of the smooth outline of the (presumed) capsule. RESULTS: Ninety-four patients, median age 52 (6-92) years with CMM, median Breslow thickness 2.8 (0.2-11.0) mm. In 50 patients ENG was present (macroscopic: 32, microscopic: 18). The median follow-up was 59 (range 5-325) months. The number of loco-regional recurrence was 10; 4 in the group with and 6 in the group without ENG (n.s.). Five years survival of patients with ENG was 42% and without ENG 50% (n.s.). There was no significant difference in survival or loco-regional recurrence between microscopic or macroscopic ENG. CONCLUSION: ENG of lymph-node metastases of CMM is of no prognostic value and has no clinical impact.

Continuous leakage measurement during hyperthermic isolated limb perfusion.

BACKGROUND: Continuous measurement of perfusate leakage into the systemic circulation is of the utmost importance and can be performed with the help of radioactive tracers. The purpose of this study was to assess changes in the perfusion leakage rate between two periods: 1977-1990 and 1991-2000, and to determine the factors responsible for these changes. METHODS: During the 1991-2000 period, 119 patients underwent HILP mainly for locally recurrent melanoma or locally advanced soft tissue sarcoma. HILP was performed with melphalan (33%) or in combination with TNFalpha (65%). There were 67 iliacal, 12 femoral, 25 popliteal, and 15 axillary perfusions performed. Leakage into the systemic circulation was monitored continuously with the help of 131I-albumin and a stationary scintillation detector placed above the heart. RESULTS: The median maximum leakage was 2.7% (range 0%-21%) which is significantly less than the previous period (1977-1990) where leakage of 8% (range 0%-30%) was reported (P < .05). A statistical difference in leakage was detected among perfusion locations where the iliac and femoral vessels showed more leakage than the axillary and popliteal vessels (P < .05). Furthermore, there appeared to be significantly less leakage when TNFalpha was used than when melphalan was the sole drug (P < .05). CONCLUSIONS: Nowadays leakage from isolated perfusions into the systemic circulation is further minimized compared with the days when melphalan was the sole drug used. Increased awareness about TNFalpha leakage, continuous external monitoring with 131I-albumin as the main isotope, flow rate regulation in the perfusion circuit, and regulation of the patient's systemic blood pressure have all been major contributors to this improvement.

Hyperthermic isolated regional perfusion of the limb with carboplatin.

AIMS: To investigate the feasibility of hyperthermic isolated regional perfusion (HIRP) with carboplatin in the management of locally recurrent and/or intransit metastases of melanoma or locally advanced soft tissue sarcoma. METHODS: Three patients, two with locally advanced melanoma and one with a low-grade liposarcoma of the lower extremity, were treated with HIRP under mild hyperthermia (39-40 degrees C) with 125 mg carboplatin/l perfused limb volume. RESULTS: No systemic toxicity was observed. Local toxicity consisted of post-perfusion oedema present in all three patients which resolved within 2 weeks. Clinically, a persistent local neuropathy was observed in all three patients, two of which were confirmed by electromyogram and nerve conduction study. Severe motor-sensory neuropathy was located mainly in the peroneal and sural nerves of the perfused limbs. Pharmacokinetic parameters of the carboplatin showed a higher concentration of carboplatin in the skin compared to the muscle. The two melanoma patients showed a complete response but developed local recurrences within 1.5 years after perfusion. The third patient underwent a delayed excision of the sarcoma 8 weeks after perfusion which revealed 50% viable tumour. One of the melanoma patients and the sarcoma patient died from lung metastases 56 and 31 months post-perfusion treatment, respectively. The other melanoma patient is alive 95+ months post-perfusion treatment. CONCLUSIONS: The local neurotoxicity observed did not warrant further research of carboplatin in HIRP.

Aspectos controversiales en el uso del bicaborbonato en la resucitación cardiopulmonar / Controversial aspects in the use of bicarbonate in the cardiopulmonary arrest

A partir de la publicación de los Standards de la American Heart Associatión en 1986 se ha discutido el uso del bicarbonato en el tratamiento del paro cardiorespiratorio. En esta revisión, se presentan las causas fisiológicas y bioquímicas que excluyen su uso rutinario. Así mismo, se describe el balance ácido-base en el paro cardiorespiratorio y poca utilidad de la medición de los gases arteriales para tomar medidas terapéuticas. Se describen los efectos delectéreos de la administración de bicarbonato en esta situación, haciendo énfasis en el metabolismo extra e intracelular y las consecuencias que acarrea sobre la contractilidad miocárdica. Por último, se recomienda la administración de bicarbonato, después de la instauración de otras medidas abanzadas, a dosis de 1 mEq/kg de manera inicial y a 0,5 mEq/kg cada 10-15 minutos si el pH persistentemente permanece por debajo de 7,20