Recurrent oncocytic adrenocortical carcinoma: implementing diagnostic criteria in a case report with the longest survival.

INTRODUCTION: Oncocytic adrenocortical tumors represent a subtype of the adrenal cortex neoplasms. These tumors can be divided into oncocytomas, oncocytic neoplasms of uncertain malignancy and carcinomas (OACs). To date, only 34 cases of OAC have been reported. CASE EXPERIENCE: We reported a case of a 54-year-old male patient with a history of laparoscopic right adrenalectomy for an OAC and subsequent chemotherapy for a recurrence. He was referred to our emergency room for diffuse abdominal pain, vomit, change in bowel habits, fever, asthenia. He underwent a laparotomy and a complete excision of the known bilobate lesion. The histopathological findings matched the features of a recurrent OAC. No chemotherapy was administered after surgery and the patient was disease-free after a follow-up of twenty-eight months. RESULTS - DISCUSSION: The most questionable issue in treating adrenocortical oncocytic neoplasms is the determination of malignancy. According to the Helsinki Score, which is the best prognostic system, the primary lesion was an OAC. We also implemented the score systems to the recurrent lesion, that seemed to be malignant. We believe that the adjuvant treatment can delay a recurrent lesion development, but finally, radical surgical excision is necessary. Moreover, we reported the longest survival after the primary adrenalectomy. CONCLUSIONS: This study described the first case of recurrent oncocytic adrenocortical carcinoma with the longest followup. Adrenocortical oncocytoma is an extremely rare tumor of the adrenal gland with variable biological behavior without definitive consensus about diagnostic criteria. This was also the first case in which different histopathological criteria have been implemented in a recurrence. KEY WORDS: Oncocytic adrenocortical carcinoma, Surgical oncology, Survival.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades.

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic fluid collections (PFCs) due to the better experience and significant progress using newer stents and access devices during last decade. This study aimed to evaluate the role of the evolving experience and possible influence of new technological devices on the outcome of patients evaluated for PFCs and submitted to EUS-guided drainage during two different periods: the early period at the beginning of experience when a standardized technique was used and the late period when the increased experience of the operator, combined with different stents quality were introduced in the management of PFCs. METHODS: We retrospectively analyzed the clinical data of a cohort of 91 consecutive patients, who underwent EUS-guided drainage of symptomatic PFCs from October 2001 to September 2017. Demographic, therapeutic results, complications, and outcomes were compared between early years' group (2001-2008) and late years' group (2009-2017). RESULTS: Endoscopic treatment was successfully achieved in 55.6% (20/36) of patients in the early years' group, and in 96.4% (53/55) in the late years' group. Eighteen patients (12 in early years' and 6 in the late year's group) required additional open surgery. Procedural complications were observed in 5 patients, 4 in early years' and 1 in late years' group. Mortality was registered in two patients (2.2%), one for each group. CONCLUSIONS: During our long-term survey using EUS-guided endoscopic drainage of PFCs, significantly better outcomes in term of improved success rate and decrease complications rate were observed during the late period.

Over-the-catheter precut to gain access to the biliary duct during ERCP rendezvous.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) rendezvous during laparoscopic cholecystectomy is an efficient and safe method to treat cholecystocholedocholithiasis. Advancing a guidewire through the cystic duct into the duodenum and withdrawing it in the accessory channel of duodenoscope may be, however, laborious. Moreover, rendezvous performed in the typical manner needs the use of several costly accessories. We herein describe a simpler and cheaper method to gain access to the biliary duct at rendezvous. METHODS: Twenty-four consecutive patients undergoing ERCP rendezvous during laparoscopic cholecystectomy were considered. A catheter was introduced in the cystic duct and advanced into the duodenum. Access to the bile duct was than achieved by means of a precut sphincterotomy performed over the catheter emerging from the papilla. RESULTS: Cannulation was successful in all but two patients, in whom ERCP was performed in the conventional manner. The only complication was a case of mild post-sphincterotomy bleeding. In comparison with the typical rendezvous technique our procedure allowed savings of about 250, since its performance only requires a catheter and a knife sphincterotome. CONCLUSIONS: Over-the-catheter precut during ERCP rendezvous is a feasible and safe method which avoids the need for the manipulation of several accessories and guidewires, and thus results in money and time savings.