T4 Colon Cancer - Current Management.

Colorectal cancer is the third most often encountered type of cancer and represents the third leading cause of cancer related deaths, on both sexes. One of the most important prognostic parameters is the tumor's stage at the time of the diagnosis. T4 cancers represent advanced tumors associated with penetration of the visceral peritoneum (T4a) and/or direct invasion in adjacent structures (T4b). Preoperative diagnosis is influenced by the inability of the existent imaging modalities to accurately differentiate the true invasion from the simple, inflammatory adherence to the neighboring structures. As a consequence surgical treatment must follow the principle of en bloc resection; however the ability of achieving an R0 resection depends on the tumor location, invaded organ, and the type of the surgical procedure required. Neoadjuvant treatment for advanced colon cancer it may be very difficult to be applied. This review is focused on preoperative workup, therapeutic strategies and subsequent results in advanced T4 colon cancers.

The Association between Nod2 R702w Polymorphism and Susceptibility to Colorectal Cancer in Romanian Patients.

It is well recognized that the inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). More susceptibility IBD genes have been reported, NOD2 being one of the most extensively investigated. The aim of this study was to evaluate a possible correlation between NOD2 rs2066844 C>T (also known as Arg702Trp or R702W) variant and CRC risk in a Romanian population. A total of 373 Romanian subjects (108 patients diagnosed with sporadic CRC and 265 controls) were enrolled in this hospital-based case-control study. The NOD2 R702W variants were detected by Real-time PCR using a predesigned TaqMan Genotyping Assay. The association between the genetic risk variant and CRC was expressed as odds ratios (OR) with 95% confidence intervals (CI). We did not find any statistically significant difference when we compared CC genotype with CT genotype (OR 1.1, 95% CI: 0.46-2.61; p=0.83) between CRC patients and controls. No TT homozygous genotype was detected. Also, we compared allele frequencies and no correlation was found (OR 1.09, 95% CI: 0.47-2.56; p=0.84). No association was found in the stratified analysis by tumor site, Dukes' stage and histological subtype. Our study suggests that the NOD2 R702W variant is not associated with CRC risk in the Romanian population. Further data from different and larger populations is required to determine whether NOD R702W SNP has effects on susceptibility to CRC.

Immunohistochemical Study of Sentinel Lymph Node in Colon Cancer.

Identification of sentinel lymph node (SLN) in colon cancer is very important in order to increase the accuracy of lymph node staging. The number of examined lymph nodes represents a significant predictor of survival. This study aims to show the importance of SLN histological and immunohistochemical examination in adjuvant oncological treatment. The study includes 23 patients with colon cancer (44% women and 56% men) who came in our clinic for surgical intervention. In all cases, the SLN was identified and prepared for histological examination. In 13 of the cases, micrometastases were found onhaematoxylin-eosin (HE) staining, there were 5 cases with positive immunohistochemistry using antibodies anti-p53, anti-VEGF-C, anti-CD34, and 5 cases with SLN negative both for HE and immunohistochemistry. Altogether we had a detection rate of 92%, an accuracy of 78,2%, a sensitivity of 90%, a false negative rate of 10% and a negative predictive value of 71,4%, good values according to the literature. Four (17,3%) patients had micrometastases exclusively in the sentinel lymph node, after performing additional histological examination, using multilevel section and immunohistochemistry. After assessing the SNL on our patients, we concluded that it is a reproducible practice for lymph node analysis.

Upper Gastrointestinal Bleeding - Initial Manifestation of Pancreatic Head Carcinoma.

Pancreatic head carcinomas are a rare cause of upper digestive bleeding and the diagnosis and the treatment of these pose particular problems. We selected 6 cases from a number of 283 patients who were hospitalized for surgery between January 2014 and December 2016 with signs of upper digestive bleeding with no varicose origin who were subsequently diagnosed with pancreatic head carcinomas. The diagnosis was established by endoscopic and surgical methods. The evolution of these patients was influenced by whether there was active digestive bleeding or history of digestive bleeding and the possibility of tumor resection. Four patients needed emergency surgery due to continuous bleeding or rebleeding. The resectability of the cephalo-pancreatic tumor was determined and then subsequently performed in two patients who had a favorable postoperative outcome, while in two patients the tumor resection was impossible. The other two patients with upper digestive haemorrhage responded favorable to drug therapy, and digestive endoscopy and CT explorations were negative. After a 5-month interval they presented with clinical signs of a pancreatic neoplasm with invasion into the common bile duct, unwanted weight loss, abdominal pain, and icterus of the sclera and skin. The surgical intervention resulted in the confirmation of locally advanced pancreatic head carcinomas and the performing of bilio-digestive derivations. Pancreatic head carcinomas may be associated with upper digestive tract haemorrhage due to duodenal or bile duct invasion. The clinical picture of these patients can vary from occult haemorrhage to severe upper digestive tract haemorrhage accompanied by hypovolemic shock.

Update on Endoscopy-Based Imaging Techniques in the Diagnosis of Esophageal Cancer.

The early diagnosis of esophageal cancer is necessary for improving the surviving of patients with this disease. To ensure an accurate staging, there are necessary imaging tests to establish the local and regional extension, as well as excluding the metastases. Computed tomography (CT), endoscopic ultrasonography (EUS), and positron emission computed tomography (PET-CT) constitute standard methods for esophageal cancer staging. These techniques are complementary; using only one of these tests is not suitable for correct staging. The role of EUS has improved the doctors' ability to evaluate and select the patients to undergo surgery, radiotherapy, or chemotherapy.

Local surgical treatment with curative intent in rectal cancer.

The surgical treatment of rectal cancer includes radical resection techniques and local excision procedures. Radical resection techniques are still the golden standard in the management of rectal cancer, but the increased postoperative morbidity and mortality led to the idea that less traumatizing procedures of local excision may have the same oncologic results, in selected cases. Yet, the significantly higher local recurrence rate after local excision in comparison to radical resection has been certified by most studies; that points out the need of clearly defined guidelines for local excision. In the present review the following aspects were taken into consideration, when considering local surgical excision as a radical procedure for rectal cancer: the clinico-pathological features of the tumours, the various types of surgical techniques used in local excision, the need for an adjuvant or neoadjuvant oncological treatment, the variety of results obtained in a large number of studies, making this particular issue a topic that is currently subject to debate.

Intestinal perforated malignant melanoma: diagnostic and therapeutic difficulties.

The intestinal malignant melanoma is a rare occurrence in the daily surgical practice, with difficult diagnosis (even on usual pathologic examination) and therapeutic attitude. Most of the lesions are secondary to a cutaneous primary melanoma, but there are cases in which the original site may not be discovered, and are considered as primitive intestinal melanomas. This paper presents the case of a 50 year old male patient, diagnosed and operated as emergency with acute abdomen caused by a tumoral perforation of the small bowel; several tumors, in different stages of local evolution, were discovered during laparotomy. A triple enterectomy with end-to-end entero-enteral anastomosis was performed, with uneventful postoperative recovery. The later postoperative evolution was marked by the occurrence of multiple subcutaneous recurrences and a bulky metastasis in the mediastinum; 18 month after the initial surgery, the patient died due to the melanoma recurrence. Diagnostic and therapeutic difficulties are discussed in this paper, related especially to the differential diagnosis of the origin of the intestinal lesion (a metastatic melanoma with unknown primary site or a primary malignant melanoma of the small bowel), since no other sites of origin were discovered after a thorough examination.

The prognostic value of the immunohistochemical aspects of tumor suppressor genes p53, bcl-2, PTEN and nuclear proliferative antigen Ki-67 in resected colorectal carcinoma.

UNLABELLED: This study aim was to identify the relations between tumor suppressor genes (p53, bcl-2, PTEN), nuclear proliferative antigen Ki-67 and epidemiologic, morphologic and histologic patient related factors, in colorectal cancer. MATERIALS AND METHODS: Twenty-two prospectively collected colorectal cancer resection specimens were histologically prepared, using standard paraffin-embedded and Hematoxylin-Eosin staining method; for immunohistochemical study, the Streptavidin-Biotin (sABC)/Horseradish Peroxidase (HRP) method was used. RESULTS: P53 was positive in 86.36% of cases, more intense (>50%) in rectal cancer and in women 59.16 ± 9.49-year-old; the G1/2 adenocarcinoma was dominant. Bcl-2 was positive in 18.18% of the cases, in distal colorectal cancer, only in men, 63.5 ± 13.2-year-old. PTEN was positive in 95.45% of the cases; intense positivity was recorded in 12 men and six women, 61.47 ± 11.67-year-old, in rectal topography. Ki-67 was positive in 86.36% of the cases, more intense in four men and four women, 63.45 ± 12.22-year-old, in proximal and advanced colorectal cancers (pT3N1/2 - 62.5%). CONCLUSIONS: Tumor suppressor genes mutations are often present in colorectal cancer; the intensity of the expression of these mutations varies, which could explain the different prognosis for these patients.

The value of the histopathologic examination in the diagnosis and management of the actinic keratosis.

Actinic keratosis, considered lately as an intraepithelial squamous cell carcinoma in evolution, are powerful predictors of the risk for developing a cutaneous carcinoma and melanoma. The aims of the study were to establish the value of the histopathologic examination as a confirmation method for the actinic keratosis diagnosis, to assess the percentage of these lesions that suffer a malignant transformation, and also the frequency of the association between actinic keratosis and cutaneous carcinomas. This is a retrospective study, performed on 208 patients diagnosed with different types of cutaneous precancers, hospitalized in Dermatology Clinic of Craiova, Romania, between 2006 and 2010. Actinic keratosis represented 37.93% (79 cases) of all cutaneous precancers (the most frequent cutaneous precancer). Patient's age ranged from 17 to 85 years, 54.8% of the patients being from rural environment; 86.07% of the lesions were located on the solar exposed skin (head and face). 72.16% of the actinic keratosis was clinical subdiagnosed. The most frequent form was hypertrophic actinic keratosis (89.06%); in 18.98% of cases, malignant transformation in squamous cell carcinoma was noticed. Actinic keratosis represent 86% of the precancers that associate a carcinoma, basal cell carcinoma being diagnosed the most frequent. In conclusion, actinic keratosis are the most frequent cutaneous precancer, diagnosed in chronic sun-exposed patients, and manifest a tendency to progress into a squamous cell carcinoma without a proper treatment. Pathologic evaluation is mandatory to an accurate assessment of the actinic keratosis prevalence, and for the right management of these lesions.

Pancreatic true cysts--diagnosis and treatment difficulties.

Pancreatic true cysts represent a rare, heterogeneous group of pancreatic tumors; therapeutic strategy is based on patient's general status, cyst topography, and especially the estimated risk of malignancy. This paper aim is to present 7 cases of pancreatic true cysts, operated on a six years period (January 2004-January 2010) in our surgical clinic: 2 men and 5 women, aged between 24-61 years old; cyst diameter varies between 3.5-15 cm, tumor location being pancreatic head in two cases and the distal pancreas in 5 cases. Surgical treatment consisted in cyst enucleation (two cases), splenopancreatectomy (three cases), duodenopancreatectomy (one case), and subtotal splenopancreatectomy (one case). Histology was represented by serous cystadenoma (one case), mucinous cystadenoma (2 cases), intraductal papillary mucinous cystadenoma (one case), and papillary cystadenocarcinoma (3 cases).Postoperative results were good in all cases, with 3 postoperative pancreatic external fistulas, resolved conservatory; no case of post-pancreatectomy diabetes mellitus was registered. In conclusion, surgical removal of the pancreatic cystic tumors is necessary, especially due to the risk of malignancy, at least in the absence of rigorous histological proofs of benignancy. Postoperative results are favorable in terms of postoperative morbidity and mortality.

Carcinoid tumour of the appendix: problems of diagnosis and treatment.

Carcinoids (neuroendocrine tumours) are considered the most common primary appendiceal neoplasm. Primary appendiceal tumours are uncommon. Routine histopathological examination of appendicectomy specimens is justified given the not infrequent incidental finding of appendiceal tumours. In cases of appendicitis in the elderly, the index of suspicion for epithelial tumours of the appendix should be raised. Moreover, once the diagnosis of an adenomatous lesion is made, colonoscopic examination of the entire large bowel is mandatory given the frequency of synchronous colorectal neoplasia in our population. In our study, we review 3 cases of carcinoid tumor of the appendix and describe their presentation, treatment and outcome. They are often diagnosed incidentally after histopathological examination of the vermiform appendix submitted in the course of the management of another clinical diagnosis. Appendectomy is appropriate for lesions < 1 cm but for lesions over 2 cm in diameter there is a significant increase in metastatic spread and thus right hemicolectomy is required in such cases. Appendiceal carcinoid tumours are found in 0,3 - 0,9 per cent of patients undergoing appendicectomy. Controversy exists over the management following appendicectomy, especially with regard to the role of right hemicolectomy in patients with tumours smaller than 2 cm in diameter.

Sentinel lymph node study in colorectal cancer using serial sectioning and Hematoxylin-Eosin staining: importance and limitations.

The lymph node involvement represents an important predictor for survival in colorectal cancer; consequently, the best pathologic evaluation is necessary in order to adequately assess the lymph node status. This study aims to evaluate the impact of sentinel lymph node technique in colorectal cancer in lymphatic basin staging. The study included 43 consecutive operated cases, in which the identification of sentinel lymph node was performed during surgery (in vivo procedure - colon cancer) or immediately after the removal of the resection specimen (ex vivo procedure - rectal cancer). These cases were matched with 45 control cases. The identified sentinel lymph node was separately examined using multiple sections and Hematoxylin-Eosin staining method. The detection rate, accuracy, sensitivity and false negative rate were better for colon cancer (86.36%; 84.21%; 66.66%; 23.07%) vs. rectal cancer (61.9%; 84.61%; 50%; 18.18%), but there are no arguments for the feasibility of the technique in every day practice. Further studies and methods are mandatory in order to improve the staging of the pN status in colon and rectal cancer.

Parietal abdominal endometriosis following Cesarean section.

Endometriosis is a pathological feature induced by the presence and ectopic development of islets of endometrial active cells. The most common site of occurrence is the genital system, causing specific gynecological pathology. The extragenital localization of endometriosis is rare, but it is more severe and it may have a malignant local evolution, although its structures remain benign. The endometrial inclusions in the abdominal wall scar are iatrogenic "implants", created at the same time with the surgical operation, performed on patients with genital endometriosis. The only curable treatment of this topography of endometriosis is the surgical removal of all the pathological tissue, through a large excision. The hormonal therapy is adjuvant. Our study presents three cases treated in our clinic; the most important objective was to establish the etiological diagnosis and, subsequently, the large excision of the lesions.

[Postoperative enteral feeding in digestive anastomosis with proximal oesophageal partner]. / Nutritia enterala postoperatorie în anastomozele digestive ce au ca partener proximal esofagul.

This paper aim is to discuss the advantages of enteral postoperative feeding on patients submitted to surgery finalized through an eso-digestive anastomosis; in these cases enteral feeding is often delayed 5-8 days after the surgery, and in case of an anastomotic dehiscence may be even impossible. Also, the paper promotes duodenostomy as an important enteral feeding way, and discusses the indications and contraindications of different enteral nutrition pathways in such cases. There were studied 230 cases, 149 cases submitted to cancer surgery and 81 cases with benign condition surgery followed by an eso-digestive anastomosis, in which the following enteral nutrition pathways was practiced: nasogastric or naso-esojejunal feeding tube (55 cases); Witzel jejunostomy (28 cases); gastrostomy (79 cases); duodenostomy (68 cases). Postoperative morbidity induced exclusively by the enteral nutrition pathway was encountered in 36% of patients. On patients with an eso-gastric cervical anastomosis or esogastric thoracic anastomosis we used jejunostomy as enteral feeding path and a gastric tube passed by pyloric canal for gastric decompression. In cases of esophageal reconstruction for benign esophageal strictures gastrostomy remains the best feeding method. Duodenostomy was practiced as a feeding pathway in cases of total gastrectomy with esojejunal anastomosis, with closure of the duodenal stump.

[Soft tissue sarcoma--problems of diagnosis and treatment]. / Sarcoamele de parti moi--probleme de diagnostic si tratament.

Soft tissue sarcomas are a rare group of cancers compromising 1% of all malignancies and there has been a slight increase in incidence. We present 3 cases of soft tissue sarcomas (the tumors were located to the right axilary region, perianal and dorsale face of the left leg) hospitalized in 2nd Surgical Clinic of Emergency Hospital of Craiova and we discuss the difficulties of diagnosis and treatment. The classification and characterization of soft-tissue sarcomas have evolved as the information supplied by histologic analysis has been supplemented with that provided by immunohistochemical analysis. Surgical resection involving wide margins, with or without radiotherapy, offers the best chance of cure in the absence of metastatic disease. There is little evidence that local recurrence increases the likelihood of metastatic spread, although debate on this point continues. Except for rhabdomyosarcomas and Ewing's sarcomas, the use of adjuvant chemotherapy generally does little to influence the natural history of the disease. In conclusion surgical treatment is mainstay of treatment for soft-tissue sarcomas and is usefull the prompt diagnosis for decrease the risk of local recurrence and metastatic disease.

Axillary and perianal leiomyosarcoma: report of two cases.

Soft tissue leiomyosarcoma is a relatively rare malignant tumor. It may be difficult to be distinguished from gastrointestinal stromal tumors and Schwann cell neoplasms. To make a correct identification of soft tissue leiomyosarcoma, immunostaining with several smooth muscle differentiation markers (actin, calponin and desmin), and negative staining results with S100 (to rule out Schwann cell neoplasm), c-kit and CD34 (to rule out gastrointestinal stromal tumors) is needed. Prompt diagnosis and referral are desirable, since the size of the tumor at presentation is a continuous variable for the risk of local recurrence and metastatic disease. Chemosensitivity varies according to the tumor subtype, and the tumor grade, the patient's age, performance status, and the timing of metastatic disease further influence the likelihood of a response and survival. Chemotherapy is palliative for most patients with unresectable or metastatic disease. Ifosfamide and doxorubicin are routinely used in this setting; doxorubicin as a single agent is considered the drug of choice.

Synchronous squamous esophageal carcinoma and urothelial renal cancer.

Synchronous development of a second primary cancer in patients with esophageal squamous cell carcinoma was reported in 2.73%-11% of the cases. Although the synchronous association between esophageal and renal cancer is very rare, an increasingly number of cases is reported in medical literature. This study's aim is to report a case of synchronous esophageal squamous cell carcinoma and an urothelial carcinoma of the right kidney. Patient G.D. was admitted in our clinic with esophageal cancer diagnosis; during the preoperative work-up protocol, an asymptomatic right renal mass was discovered. A nephroureteroscopy with biopsy was performed and the urothelial renal cancer diagnosis was established. The patient is proposed for seriate surgery: nephroureterectomy on the first stage, then esophagectomy with gastric reconstruction was performed. Postoperative evolution was unfavourable, patient being finally discharged, on his request, with severely altered status.

[Esophago-digestive anastomosis dehiscence]. / Dehiscenta anastomozelor esofagodigestive.

This paper aim is to discuss the main etiopathogenic aspects responsible for eso-digestive anastomotic leakage, as well as prophylactic and therapeutic measures of this postoperative complication. There were studied 173 consecutive eso-digestive anastomosis: 103 anastomosis performed for malignancy and 70 anastomosis for benign conditions. Surgical operations followed by an eso-digestive anastomosis were: esophageal reconstruction for benign esophageal caustic strictures (n=67); total gastrectomy (n=55); total esophagectomy (n=13); total esophagectomy plus total gastrectomy (one case); eso-gastrectomies (n=34); upper gastric pole resection (n=2); distal esophageal resection (n=1). Eso-digestive anastomosis topography were cervical (n=81), intrathoracic (n=37) and abdominal (n=57). There were 30 eso-gastrostomies, 81 eso-jejunostomies, and 62 eso-colostomies. There were recorded 24 eso-digestive anastomotic dehiscences (13.8%): 14 in the cervical region (17.2% out of 81 cervical anastomosis); 5 intrathoracic leakages (14.2% out of 35 anastomosis); 5 intraabdominal anastomotic dehiscences (8.7% out of 57 intraabdominal anastomosis). Four patients died as an anastomotic leakage consequence: two patients died after cervical eso-gastrostomy dehiscences, one patient died after an intrathoracic eso-jejunostomy leakage, and one patient died after intraabdominal eso-gastrostomy leakage. In conclusion, we analyze postoperative results, emphasizing the role of discovering and removal of predisposing factors which may lead to an eso-digestive anastomotic leakage.

Loco-regional advanced colorectal cancer: diagnostic and therapeutic features.

The objective of this study is to analyze the main diagnostic and therapeutic aspects in locally advanced colorectal cancers, related to recent advances published in the medical literature. The paper analyzes 2nd Surgical Clinic cases of advanced colorectal cancers over a five year period: 224 such patients operated on, with 79.9% tumor resectability (64.4% with radical intent); in 12.94% extended resections were necessary in order to achieve primary tumor removal. Overall morbidity and mortality rate were 52.23% and 7.14%, respectively. In conclusion it has been emphasized that improvements are necessary to be made in order to achieve a good staging of disease and, as therapeutic feature, in locally advanced cases extended resections may be perform with acceptable risks for the patients.

[Rectal cancer--diagnostic and therapeutic difficulties]. / Cancerul de rect--probleme de diagnostic si tratament.

This paper aim is to analyze the main diagnostic and therapeutic aspects in rectal cancer; for this purpose we analyzed the Craiova's Surgical II Clinic statistics and we report them to the present literature. There were 179 rectal cancers, diagnosed over 10 years period (between 1995 and 2004); 163 cases were operated on, in 62 cases (38.03%) the surgical intervention aim being curative; global resection of tumor was 84.66%. The operation was preceded by preoperative radiotherapy in 82 cases; all cases diagnosed in the last four years in curative stage of disease were treated by preoperative radiotherapy. The postoperative mortality was 3.68% (6 cases) and the morbidity rate (55 cases - 33.74%) is still important, mainly because of the associated diseases. In conclusion we emphasize the importance of untimely diagnosis and the obligatorily sequential treatment: preoperative radiotherapy curative surgical resection - postoperative adjuvant treatment.