Voluminous oesophageal bronchogenic cyst treated with thoracoscopic approach.

AIM: Bronchogenic cysts are congenital lesions deriving from the primitive foregut, and are usually located in close relation to tracheobronchial tree or oesophagus. We report a case of an oesophageal bronchogenic cyst appearing at preoperative examinations as a benign fibromuscular tumour (leiomyoma). CASE REPORT: A 62 years old male patient in good general conditions, was admitted to our Institution because of moderate dysphagia and upper post-prandial abdominal pain. Conventional imaging, endoscopy and echo endoscopy detected a parietal oesophageal wall mass looking like a solid formation, determining extrinsic compression and narrowing of the lumen. RESULTS: The mass has been radically removed with thoracoscopic approach. Postoperative stay was uneventful and the patient was discharged three days after the operation. At histological examination the mass appeared as a cystic formation with fibromuscular wall and ciliated epithelium (so-called disembriogenetic bronchogenic cyst). CONCLUSION: The case we have reported describes a very unusual case of a voluminous symptomatic intramural oesophageal disembriogenetic cyst whose characteristics had not been defined at preoperative examinations. Surgical removal of the mass has been achieved with a minimally invasive approach.

A typical behaviour of thymic carcinoma.

AIM: To describe the case of a thymic carcinoma with atypical clinical behavior that has arisen with a voluminous metastasis at the right hemidiaphragm while the primitive thymic neoplasm was initially occult. CASE REPORT: A 42 years female patient came to clinical observation for a voluminous thoraco-abdominal mass located in right side, infiltrating the diaphragm. The patient was submitted to surgical excision of the mass; definitive histological examination: non-keratinizing spinocellular carcinoma suggestive for neoplasia on ectopic thymic tissue or metastasis from carcinoma of the thymus. Three 3 months after surgery MR and CT-scan restaging identified the presence of anterior mediastinal mass of about 3 cm of diameter, compatible with thymical origin; thymectomy was performed (histology: Lymphoepithelial thymoma). Eight months after the first surgical procedure a restaging by CT, MR and PET CT showed the presence of disease recurrence at the right diaphragmatic level. The patient underwent surgical exploration, with right thoracotomic approach: a metastasis in the hepatic segment VII was found and radically removed. Six months after liver metastasis resection, CT scan showed disease progression in mediastinum, with involvement of pericardium and aorta; the patient died for disease recurrence five months later, 22 months after the first surgical procedure. CONCLUSION: Thymic neoplasms are the most common tumors of the mediastinum; a small percentage of these tumors are however extremely aggressive carcinomas. Rare but not exceptional findings are also cancers arising from ectopic thymic tissue.

Metachronous solitary left adrenal gland metastasis of right colon cancer treated with laparoscopic approach.

AIM: Adrenal gland metastasis are the second most common type of adrenal mass lesions after adenomas and they could be related to numerous malignancies; Literature shows that adrenal metastasis deriving from colorectal cancer are very rare. MATERIAL OF THE STUDY: A 71-year old - male patient, treated two years before with right colectomy and adjuvant chemotherapy for right colon cancer, came to our attention after the diagnosis at follow up, of a left adrenal gland mass; CT scan and CT - PET did not show other pathological findings. RESULTS: The patient underwent left adrenalectomy with trans-peritoneal laparoscopic approach: the definitive histological examination diagnosed metastatic tissue of colonic cancer in left adrenal gland. CONCLUSIONS: Adrenal gland metastases are common clinical entities, but which of them arise starting from colonic cancer are very rare and they are generally discovered about 1 year after the first diagnosis of cancer. Early diagnosis, laparoscopic radical excision when feasible and eventual adjuvant radio-chemotherapy are actually the proper clinical management of adrenal gland metastases finalized to better outcomes in terms of longer survival rate and quality of life. KEY WORDS: Adrenal gland, Colorectal cancer, Laparoscopic, Metastasis.

Hepatocellular cancer arising from ectopic liver tissue on diaphragm. Case report.

AIM: Ectopic liver tissue is a rare clinical entity; very few cases of extra peritoneal localization have been described in Literature. MATERIAL OF STUDY: A 54 years old male patient was admitted to our Institution because of thoraco - abdominal pain (lower left chest, left hypochondrium), and fever; CEA and CA 19-9 were in range, but alpha fetoprotein levels were high (880 IU / L); CT scan and NMR showed a thoraco - abdominal mass developing from the left hemidiaphragm, with infiltration of the cranial part of the spleen; no primitive liver tumors have been detected. A jejunal mesentery mass (6 cm in diameter) was also incidentally diagnosed. RESULTS: The patient underwent surgical resection of the thoraco - abdominal tumor and of the mesenteric mass. HISTOLOGY: hepatocellular carcinoma arising from ectopic islet of liver tissue on left hemidiaphragm; mesenteric desmoid tumor. CONCLUSIONS: The case we have observed showed a coexistence of two very rare tumors; carcinogenesis on ectopic liver should be suspected in this patient with a thoraco-abdominal mass with high alpha fetoprotein levels, in absence of primitive liver chronic diseases and cancer.

KRAS mutational analysis in ductal adenocarcinoma of the pancreas and its clinical significance.

Mutations of KRAS are detectable in 70-90% of pancreatic duct adenocarcinomas (PDAC), using direct sequencing. We used a highly sensitive molecular method in order to investigate: (a) the frequency and prognostic significance of different KRAS mutations and, (b) whether the presence of KRAS mutations in histologically-negative resection margins of PDAC could explain local tumor recurrence after surgery. Twenty-seven patients with histologic diagnosis of PDAC, radical pancreaticoduodenectomy and histologically-negative margins were evaluated. KRAS mutations were searched for mutant-enriched PCR in tumor and negative resection margins. KRAS mutations were detected in 85.2% of the cases; the most frequent mutation was G12D (48.1%). Shorter OS was found in patients with G12D (25 months; 95% CI, 20.5-29.5), vs patients with other mutations (31.5 months; 95% CI, 25.6-37.1) (N.S.). KRAS mutation in histologically-negative margins was detected in one patient who died of locoregional recurrence; six patients had tumor recurrence but no mutations in surgical margins. The high frequency of KRAS mutations suggests a search for KRAS status to improve the diagnosis in suspected cases; the G12D mutation could be related to poor prognosis, but without statistical significance. No correlation was found between the frequency of cancer recurrence and KRAS mutations in surgical margins.

[Early stoma closure in colorectal resections after endoscopic monitoring of the anastomosis. Clinical results]. / Chiusura precoce di stomia dopp dopresezione del retto previo controllo anastomotico endoscopico. Risultati clinici.

The need for a protection of a colo-colonic or colorectal anastomosis (by a colostomy or ileostomy) does not always encounter a general consensus except in selected clinical settings such as a low or ultra-low colorectal anastomosis or a colo-colonic or colorectal anastomosis after resection for acute disease. Commonly, a protective stoma is closed within 3-6 months after x-ray or endoscopic monitoring of the anastomosis. We believe in the importance of an open debate on the timing of bowel reconstruction and on the ways of monitoring the anastomosis. The aim of our study was to confirm the feasibility of early closure of stomas without specific increased risks, and especially to demonstrate the usefulness of early endoscopic monitoring of the anastomosis. We present 26 consecutive patients who underwent a left colonic resection or a colorectal resection with a stoma constructed for protection. In these patients the early restoration of bowel continuity was achieved between postoperative days 8 and 15 after endoscopic monitoring. There have been no specific complications related to the endoscopic manoeuvre. The morbidity rate after early bowel continuity restoration was 4.1%, which is lower than the rates encountered in the literature (6-8.6%). We consider as innovative the concept of early endoscopic monitoring, which is commonly not indicated in the presence of a recent anastomosis. We believe that in selected conditions the risk of perforation due to this manoeuvre can be eliminated.

Relationships between gastric development and anatomic bases of radical surgery for cancer.

The aim of this study was to determine with all possible accuracy the processes of embryologic development of the stomach and its lymphatics in order to confirm their supposed link with the modern anatomic bases of gastric cancer surgery. The knowledge of the anatomic behavior of the peritoneal folds and of the lymphatic drainage of the stomach is, in fact, considered the essential basis for the comprehension of the oncologic dissection of the stomach. The study was based on reconstruction of serial histologic sections of 9 human embryos and 8 human fetuses regarding the mesogastric area, as well as anatomic microdissection of 2 9-month fetuses. The proximal part of the stomach is not involved in the rotation mechanism of the other portions; the lesser sac development follows cranial migration of the spleen; the cardiac (pars cardiaca gastris) area is in continuity with the zone of paraaortic lymph node development; lateral and posterior lymph nodes of the hepatoduodenal ligament do not take origin in the dorsal mesogastrium: they develop together with the common bile duct and the ventral pancreas inside the mesoduodenum; the fusion of the dorsal mesogastrium and the gastric fundus with the posterior abdominal wall appears late in development. The embryologic study of the mesogastric area clarifies the real mechanism of development of the stomach and its lymphatic pathways with some differences from classic reports; these results agree with the more recent modification of the lymph nodes classification used in the radical treatment of gastric cancer.