Surgical treatment of cauda equina compression as a result of metastatic tumours of the lumbo-sacral junction and sacrum.

PURPOSE: We performed a retrospective analysis of all cases of lumbo-sacral or sacral metastases presenting with compression of the cauda equina who underwent urgent surgery at our institution. Our objective was to report our experience on the clinical presentation, management and finally the surgical outcome of this cohort of patients. METHODS: We reviewed medical notes and images of all patients with compression of the cauda equina as a result of lumbo-sacral or sacral metastases during the study period (2004-2011). The collected clinical data consisted of time of onset of symptoms, neurology (Frankel grade), ambulatory status and continence. Operative data analysed were details of surgical procedure and complications. Post-operatively, we reviewed neurological outcome, ambulation, continence, destination of discharge and survival. RESULTS: During the 8-year study period, 20 patients [11 males, 9 females; mean age 61.8 years (29-87)] had received urgent surgery for metastatic spinal cauda compression caused by lumbo-sacral or sacral metastases. The majority of patients presented with symptoms of pain and neurological deterioration (n = 14) with onset of pain considerably longer than neurology symptoms [197 days (3-1,825) vs. 46 days (1-540)]; all patients were Frankel C (n = 2, both non-ambulatory), D (n = 13) or E (n = 5) at presentation and three patients were incontinent of urine. Operative procedures performed were posterior decompression with (out) fusion (n = 12), posterior decompression with sacroplasty (n = 1), decompression with lumbo-pelvic stabilisation with (out) kyphoplasty/sacroplasty (n = 7) and posterior decompression/reconstruction with anterior corpectomy/stabilisation (n = 2). Post-operatively, 5/20 (20 %) patients improved one Frankel grade, 1/20 (5 %) improved two grades, 13/20 (65 %) remained stable (8 D, 5 E) and 1/20 (5 %) deteriorated. All patients were ambulatory and 19/20 were continent on discharge. The mean length of stay was 7 days (4-22). There were 6/20 (30 %) complications: three major (PE, deep wound infection, implant failure) and three minor (superficial wound infection, incidental durotomy, chest infection). All patients returned back to their own home (n = 14/20, 70 %) or a nursing home (n = 6/20, 35 %). Thirteen patients are deceased (mean survival 367 days (120-603) and seven are still alive [mean survival 719 days (160-1,719)]. CONCLUSION: Surgical intervention for MSCC involving the lumbo-sacral junction or sacral spine has a high but acceptable complication rate (6/20, 30 %), and can be important in restoring/preserving neurological function, assisting with ambulatory function and allowing patients to return to their previous residence.

Synchronous and metachronous adenocarcinomas of the large intestine.

BACKGROUND AND AIM: The synchronous and consecutive (metachronous) development of two or more primary adenocarcinomas accounts for 3 to 5% of cases of colorectal cancer. Aim of this study is to review our experience in the management of patients with synchronous and metachronous lesions, and reach conclusions regarding their optimal diagnosis, treatment and follow-up. PATIENTS AND METHODS: Between 1987 and 2004, 12 patients (seven men and five women, mean age 67.5 years, range 47-83 years) with synchronous (three patients) and metachronous (nine patients) lesions were treated, comprising 4.3% of all patients submitted to surgery for colorectal cancer. The diagnosis lag for metachronous lesions ranged from 1.5 to 14 years. All three patients with synchronous cancers had two lesions. RESULTS: Staging colonoscopy and abdominal CT was conducted in 10 patients while the remaining two underwent only abdominal CT due to their critical condition at presentation. Surgery had curative intent in 10 patients and palliative in two. The mean postoperative hospital stay was 21 days (10-49 days). The postoperative mortality was zero. Patients survival after curative procedures was 80% for the first year, 60% for the third and 50% for the fifth year. After palliative surgery, survival was 50% for the first year, and zero for the third. CONCLUSIONS: Patients with colorectal cancer must be followed up regularly after surgery. Follow up aims at early diagnosis and treatment of metachronous lesions that can appear many years after diagnosis of the primary lesion. Preoperative colonoscopy is an invaluable diagnostic (biopsy) and staging (exclusion of synchronous lesions, localization of the primary) modality, dictating the surgical approach. Additionally, it contributes to cancer prevention allowing the discovery and removal of small polyps before their transformation.

The prevalence of hepatitis C and hepatitis G virus infection in patients with B cell non-Hodgkin lymphomas in Greece: a Hellenic Cooperative Oncology Group Study.

Our aim was to investigate the association between chronic hepatitis C virus (HCV) infection and B cell non-Hodgkin lymphoma (NHL) in the Greek population. We studied 120 patients (70 men and 50 women, mean age 59 years) diagnosed with NHL. One hundred and eight had B cell NHL (90%) and 12 had T cell NHL (10%). The presence of anti-HCV antibodies in patients and controls was investigated using the monoclonal enzymatic immunoassay (MEIA) method. The detection of HCV RNA and hepatitis G virus (HGV) RNA in patients with B cell NHL and anti-HCV-positive controls was performed using an RT-PCR technique. Anti-HCV antibodies were present in only 2 of the 108 patients with B cell NHL (1.9%), while the prevalence of HCV infection in the healthy population was 0.6%, and in patients with various solid tumors treated with chemotherapy, it was 0.99%. Ten of the 108 B cell NHL patients (9.26%) were diagnosed as HGV RNA positive, while the prevalence of HGV infection in 285 Greek blood donors was 0.7%. Our findings do not confirm a strong association between HCV infection and B cell NHL for Greek patients. The increased prevalence of HGV infection detected in patients with NHL could imply the potential participation of HGV in the pathogenesis of NHL.

Large bowel obstruction in women with pelvic malignancies. What is the primary?

BACKGROUND: Large bowel obstruction is occasionally the mode of presentation of advanced colorectal or pelvic malignancies, and a prognostic of poor survival. The choices of treatment range from palliative tube decompression to curative or palliative surgery. METHODS: Twelve out of 500 women with various malignancies and symptomatology of large bowel obstruction were studied. All patients required urgent exploratory laparotomies. RESULTS: The primary site was established intra-operatively to be the colon (2 cases), stomach (2 cases) and ovaries (2 cases). In the remaining 6 cases there was uncertainty about the origin of primary disease. Routine histology and immuno-histochemistry of the specimens revealed the origin of primary malignancy in all cases. CONCLUSIONS: Meticulous histological examination is essential for the establishment of correct diagnosis and selection of the best available treatment in women with pelvic malignancies, presenting with acute bowel obstruction.

Spontaneous rupture of the rectosigmoid with small bowel evisceration through the anus.

Spontaneous rupture of the rectosigmoid with small bowel evisceration through the anus is a rare and acute condition of the gastrointestinal tract. After Brodie's first description, only 52 such cases have been reported in the literature. An 83-year-old woman experienced a sudden, spontaneous rectosigmoid rupture and protrusion of small bowel loops, through the ruptured colon and out of the anus. After an immediate management, an emergency operation was performed, and a small bowel resection and suturing of the ruptured rectosigmoid were carried out for restoration of bowel continuity. On the 41st postoperative day, a massive cerebro-vascular accident (CVA) was the cause of the patient's death. Discussion of the aetiology and treatment of this rare condition.

Metachronous breast carcinoma (second malignancy), following "cure" from colorectal carcinoma.

Metachronous or synchronous breast carcinoma following or co-existing with colorectal carcinoma are well recognised clinicopathological entities, and the risk of developing both possibly underlines the similarities in carcinogenesis pathways for these carcinomas. We present a 60-year-old housewife with a history of a treated primary colon carcinoma (Duke's C) 15 years previously. Six months ago, during the follow-up care a small sub-areolar lesion was determined in a mammogram. A lumpectomy was performed under local anaesthesia, which revealed an infiltrating ductal carcinoma (6 mm in greatest diameter). Immuno-histochemical assays for oestrogen and progesterone receptors and c-erb B2 ongoprotein were performed. Axillary lymphadenectomy showed 1/11 positive node. She received adjuvant radiotherapy and hormone manipulation. To date, seven months later she is disease free. The aim of this report is to emphasise the risk of metachronous second malignancy of breast or colorectal carcinoma following colorectal carcinomas. A second primary colonic malignancy following breast primary carcinoma is more frequent than inverse clinical form.

A case of mucinous adenocarcinoma arising in long-standing multiple perianal and presacral fistulas.

Chronic anal fistulas are not rare; however, the development of a carcinoma in long-standing, perianal fistulas is rare. We describe a case of an 85-year-old man with multiple, recurring, perianal fistulas, extending to the natal cleft. The patient underwent en bloc resection of the fistulas which were in direct continuity with the middle rectum. Histological examination revealed a mucinous colonic adenocarcinoma. Abdominal CT and colonoscopy revealed an extramural residual rectal mass. The patient refused a radical colorectal operation. Three years later, because of fistula recurrence, he underwent loop sigmoidostomy and radical en bloc excision of the perianal fistula and rectum, with immediate reconstruction by bilateral gluteal flaps. The patient was discharged on the 12th postoperative day, refusing adjuvant radiotherapy. We present this rare malignant entity, successfully treated by staged operations and without any adjuvant therapy.

Serum levels of bcl-2 in patients with colorectal cancer.

BACKGROUND: Many recent studies focus on the immunohistochemical evaluation of Bcl-2 expression, and its prognostic significance in colorectal cancer (CRC). Our aim was to investigate the presence of bcl-2 protein in the serum and to examine the association between its levels, stage and tumour load, in patients with CRC. METHODS: A commercially available ELISA was used for the estimation of bcl-2 levels, in 94 patients with different stages of CRC. Forty-eight healthy blood donors served as controls. Concentrations ranging 2SD above and below the controls median were accepted as "normal". RESULTS: bcl-2 was detected in the serum of patients with CRC. A significantly higher proportion of patients with non-metastatic disease (61%), had high serum bcl-2 values, compared to patients with metastatic disease (28%, p<0.0001). CONCLUSIONS: Serum bcl-2 in patients with CRC may reflect the degree of Bcl-2 expression in cancer tissue. Serum bcl-2 is easily determinable, and could be useful as a prognostic marker in CRC.

Serum concentrations of soluble ICAM-1 and VCAM-1 in patients with colorectal cancer. Clinical implications.

BACKGROUND: In colorectal cancer (CRC), serum levels of adhesion molecules ICAM-1 and VCAM-1 increase with progressing disease. Our aim was to investigate the effect of treatment in serum ICAM-1 and VCAM-1. METHODS: Serum levels of ICAM-1 and VCAM-1 were determined in 154 patients with CRC. Patients with non-metastatic disease had been treated with "curative" resections, and those with advanced disease were receiving chemotherapy. A group of 48 healthy blood donors served as control. Serum concentrations ranging 2SD above and below the controls median were accepted as "normal". RESULTS: Significantly more patients with advanced disease demonstrated high serum ICAM-1 and VCAM-1 (p<0.001, p=0.043 respectively). However, in some of them serum ICAM-1 and VCAM-1 were below "normal". CONCLUSIONS: Serum ICAM-1 and VCAM-1 may be valuable markers of residual or biologically aggressive disease after curative resections. In advanced disease, they could be useful predictors of response to chemotherapy.