Incidental small ampullary somatostatinoma treated with ampullectomy 2 years after diagnosis.

Somatostatinomas are rare tumors; ampullary somatostatinomas are very rare. We report a case of a small pure somatostatin-producing neuroendocrine tumor of ampulla of Vater in a 54-year-old woman with neither neurofibromatosis nor somatostatinoma syndrome, "incidentally" discovered during an abdominal computed tomography. The patient initially refused other adjunctive exams but after 2 years she was admitted, presenting with itch, night sweats, severe fatigue, and unintentional weight loss. The size of the tumor (1.5 cm) and the other radiologic findings had not changed since the abdominal CT scan 2 years before. The somatostatin, gastrin, glucagons, serotonin, vasoactive intestinal peptide, dopamine, norepinephrine, epinephrine, and calcitonin plasma levels were normal. ERCP-obtained biopsies revealed a neuroendocrine tumor with psammoma bodies; immunohistochemical profile was positive for chromogranin and somatostatin. The patient underwent surgery; intraoperative histologic examination of lymph nodes sampling of perihepatic and periduodenal lymph nodes was negative for metastasis. We performed, therefore, a transduodenal ampullectomy. The patient continues to do well at 3 years' follow-up with no evidence of local or distance recurrence of disease.

Evolution of the changes of the ileal pouch mucosa over a long follow-up period.

BACKGROUND/AIMS: The mucosa of the ileal pouch after restorative proctocolectomy develops relevant adaptative changes but the real mechanisms and the evolution over time of these alterations are still unclear. The aims of the present work were to study the distribution of the mucosal changes at different levels in the reservoir and to evaluate the evolution of these alterations over a long follow-up period. METHODOLOGY: The severity of chronic and acute inflammation, villous atrophy, colonic-type mucins production and proliferative index were evaluated in the bioptical specimens from 46 patients (30 males, 16 females, mean age 38 years) with functioning pouch. We compared the histology of the upper pouch mucosa with the lower one. Then we divided the 46 patients into Group A-24 patients with a median follow-up of 11 years (range 9-16); Group B-22 patients with a median follow-up of 4 years (range 2-8), comparing the results from the two groups. Finally we performed a prospective evaluation in the 24 patients who were controlled in 3 subsequent follow-ups (1993-1994, 1996-97, 1999-2000). RESULTS: At the topographic evaluation only the acute inflammation was significantly more pronounced in the lower pouch area (p = 0.031). All the morphological changes showed a trend of greater severity in the group A patients, in particular villous atrophy (p = 0.005) and colonic-like mucins secretion (p = 0.006). At the prospective evaluation, the chronic inflammation showed a significant progressive worsening over time (p = 0.011). CONCLUSIONS: Our experience showed that the transformation of the mucosa represents an "organ" response to the luminal environment and may progress over time.

[Surgical treatment of differentiated thyroid carcinoma]. / Il trattamento chirurgico del carcinoma tiroideo differenziato.

Being the excellent prognosis, the extension of the thyroidectomy in the surgical management of differentiated thyroid carcinomas is still controversial: some authors recommend total thyroidectomy for all patients, others suggest a conservative approach, that guarantee the same good prognosis but is associated with fewer complications. Even the cervical lymph node dissection is discussed, both regarding to the indications and the extension. The authors reported a retrospective review of their experience of the last 10 years on 75 patients operated for differentiated thyroid cancer, 61 for papillary carcinoma and 14 for follicular carcinoma; 18 of them were men and 57 females, with a mean age of 48.2 years. We performed a total of 85 operations: 60 total thyroidectomy, 15 lobus-isthmusectomies and 10 completion thyroidectomy. Lymphadenectomy was performed in 17 patients with clinically or intraoperative evidence of enlarged lymph nodes. There was no surgical mortality. Permanent hypoparathyroidism occurred in 5 patients (5.8%) and permanent accidental laryngeal recurrent nerve injury, both monolateral, occurred in 2 cases (2.35%). The mean follow up was 53 months (4.5 years): 71 patients are still alive (94.7%), 68 of them disease free (90.6%) and 3 with recurrent disease (4%). Our results suggest that total thyroidectomy still represent the choice procedure for the treatment of differentiated carcinomas and that modified radical neck dissection is necessary in these patients with pre or intraoperative evidence of palpable lymph nodes. Some patients go well even undergoing more conservative surgery (lobectomy) but most problem is the impossibility to preoperatively identify these patients.

Parietal seeding of unsuspected gallbladder carcinoma after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (VALC) represents the treatment of choice for the symptomatic gallstones. However the occurrence of an adenocarcinoma of the gallbladder results a controindication for this surgical technique. We present a case of a 52 years old woman who underwent a VALC; histology revealed a gallbladder adenocarcinoma. For this reason the patient underwent a second operation that is right hepatic trisegmentectomy. Six months later the patient presented with a parietal recurrence at the extraction site of the gallbladder. We discuss the possible mechanism responsible for carcinomatous dissemination during laparoscopic surgery and we raccommend the use of some procedures in order to limit the risk and eventually to treat a neoplastic parietal seeding. These complications suggest the problem about the utility and the future played by video assisted laparoscopic surgery in the diagnosis and treatment of intraabdominal malignancies.