[Surgical management of rectovaginal septum endometriosis from a continuous series of 50 cases]

OBJECTIVES

To assess the value of MRI and ano-rectal endosonography (ARES) for the diagnosis and surgical prognosis of rectovaginal septum endometriosis and to analyse the surgical management in order to evaluate its functional results and complications.

PATIENTS AND METHODS

Retrospective study of 50 consecutive patients operated for a clinical presumption of endometriosis nodule of the recto vaginal septum. Thirty-nine patients had a MRI, 31 an ARES and 28 both exams. All the patients had a complete dissection of the rectovaginal septum and all lesions were excised.

RESULTS

For the diagnosis of rectovaginal septum endometriosis nodule, MRI results are: sensitivity 73%, specificity 50%, positive predictive value (PPV) 89%, negative predictive value (NPV) 25%; for uterosacral ligaments involvement: sensitivity 84%, specificity 95%, PPV 94%, NPV 86% and for rectal wall infiltration: sensitivity 53%, specificity 82%, PPV 69%, NPV 69%. The ARES results for diagnosis of rectovaginal septum endometriosis nodule are: sensitivity 93%, specificity 100%, PPV 100%, NPV 50% and for rectal wall infiltration: sensitivity 100%, specificity 71%, PPV 81%, NPV 100%. ARES appeared more sensitive than MRI for the detection of rectal wall infiltration (P = 0.002) and for rectovaginal septum endometriosis nodule diagnosis (P = 0.03). Eighty-nine percent of the patients had a coelioscopy in first intention and 15 laparoconversions were performed, 11 in order to perform a digestive resection: 45 nodules were found. In 43cases the nodule was excised, associated to 19 digestive resections, 30 colpectomys, and 22 uterosacral ligaments resections. Three patients required an additional surgical treatment by Hartman's procedure with Mickulicz's drainage for peritonitis. Forty-one nodules were endometriosis nodules: the two other cases were fibrosis nodules. Thirty-three patients were interviewed about the evolution of their pains over a mean history of 20 months: 90% of the patients were satisfied with the management results.

DISCUSSION AND CONCLUSIONS

Our data support the efficiency of MRI for rectovaginal septum endometriosis nodule and uterosacral ligaments involvement diagnosis; accord ARES to rectovaginal septum endometriosis nodule diagnosis and its reliability in establishing a diagnosis of rectal wall involvement. The surgical cure of rectovaginal septum nodules without digestive infiltration is performed by coelioscopic or coelio-vaginal procedure, but in case of associated digestive affliction, laparotomy is actually the standard procedure in order to achieve a complete cure of the lesions. Complications, in particular peritonitis, are not frequent. Our data support the efficiency of radical surgical treatment for the improvement of pain symptoms. Results on fertility seem to be satisfactory, but complication risks suggest being careful in this indication. Clinical examination during a catamenial period is essential in order to evoke the diagnosis. MRI yields a complete map of the sub-peritoneal and peritoneal lesions and ARES allows for the diagnosis of an infiltration of the rectal wall. Pre-operative association of those two exams is actually indispensable for the surgical management of those patients, which consists of complete excision of endometriosical lesions and is efficient at treating pain symptoms and fertility. Complications are rare but severe, therefore, justifying a cure in specialised centres.

[Pancreatic metastasis of renal cell carcinoma: report of three cases]

INTRODUCTION

The pancreas is an uncommon site of metastasis from renal cell carcinoma.

EXEGESIS

Three observations are described in this review which is aimed at reporting recent data on diagnosis, prognosis and therapeutic features of this kind of metastasis 0: The average space of time between nephrectomy and the diagnosis of the metastasis was 16 years. They have been fortuitously discovered in 2 cases, in patients who did not complain of any pancreatic symptom, during abdominal ultrasonography done for another reason. In the third case, pancreatic symptoms led to the diagnosis. Endoscopic ultrasonography (EUS) was useful to diagnose multiple lesions misdiagnosed on CT-scan or MRI imaging. EUS patterns are characteristic, but histological and cytological examinations of EUS-guided needle biopsies are difficult to study according to the hypervascularized character of these metastasis.

CONCLUSION

The diagnosis of pancreatic metastasis must be suggested for patients suffering from a pancreatic mass with a previous medical history of late renal cell carcinoma. According to their hypervascularized character, the negativity of EUS-guided needle biopsies could strongly direct the diagnosis. When surgery is possible, the survival rate is better than in primary pancreatic adenocarcinoma and is even better than in pancreatic metastasis from other sites.

Intraductal papillary and mucinous pancreatic tumour: a new extracolonic tumour in familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is characterised by the development of numerous colorectal adenomatous polyps. Other extracolonic benign or malignant lesions have been reported previously in association with FAP but precancerous lesions in the pancreas have never been described. We report the first case of intraductal papillary and mucinous pancreatic tumour (IPMT) in a patient with FAP. A 48 year old man with a well documented past history of FAP was admitted for epigastric pain, weight loss, and new onset diabetes mellitus. Spiral computed tomography scan revealed a large tumour in the pancreatic head with upstream main pancreatic duct dilatation. Endoscopic ultrasonography confirmed these data. Mucous secretion was seen at duodenoscopy and a lesion in the main pancreatic duct was confirmed by retrograde pancreatography. The patient underwent a pancreaticoduodenectomy for suspected IPMT. Histological examination of the resected specimen confirmed an IPMT with in situ carcinoma. Twelve months after resection, the patient remained free of tumour relapse. Genetic analysis showed loss of the wild allele of the adenomatous polyposis coli gene in IPMT, causing inactivation of both alleles and demonstrating that IPMT was not incidental in this patient. IPMT should be included in the extracolonic localisation of FAP.

Assessment of complications of EUS-guided fine-needle aspiration

BACKGROUND

EUS-guided fine-needle aspiration (EUS-FNA) permits both morphologic and cytologic analysis of lesions within or adjacent to the GI tract. Despite increasing use of this technique, the safety and overall complication rates remain poorly defined.

METHODS

During a period of 20 months, 322 consecutive patients underwent EUS-FNA in 2 centers. All procedures were performed with the patients under general anesthesia. All complications (including local complications resulting from endoscopy/aspiration or clinical complications after the procedure) were evaluated. Potential risk factors for the development of complications were also analyzed including site and nature of the lesion, presence of portal hypertension, and number of needle passes.

RESULTS

A total of 345 lesions were aspirated in 322 patients. EUS-FNA involved the pancreas in 248 cases. Pancreatic lesions included solid (134) and cystic (114) types, which required a mean of 2.5 and 1.4 needle passes, respectively. Complications were observed in 4 (1.2%) patients after aspiration of pancreatic cystic lesions (acute pancreatitis, n = 3; aspiration pneumonia, n = 1) and all cases of pancreatitis resulted from FNA of lesions in the head/uncinate process. No complications resulted from FNA of solid pancreatic lesions. Complications were not observed after FNA of lymph nodes (n = 62) and one case of aspiration pneumonia was observed after FNA of a stromal tumor. EUS-FNA was performed without complication in 16 patients (5%) with portal hypertension. The number of needle passes was not predictive of complications.

CONCLUSIONS

Because the overall risk of complications from EUS-FNA was relatively low (1.6%) with no severe or fatal incidents and although the risk appears slightly higher than that for standard EUS alone, the safety of EUS-FNA appears acceptable based on this analysis from an experienced center.

Anal carcinoma: prognostic value of endorectal ultrasound (ERUS). Results of a prospective multicenter study

BACKGROUND AND STUDY AIMS

The classification of anal carcinoma is based on the clinical examination and the estimation of the tumor height (Union Internationale Contre le Cancer (UICC) 1987 Classification). This classification has a direct therapeutic application since tumors which are designated T1 and T2 are generally treated by radiotherapy whereas T3, T4 or N+ lesions are treated by concomitant radiation and chemotherapy. The aim of this prospective multicenter study was to evaluate endorectal ultrasound (ERUS) and to define an ERUS-based classification.

PATIENTS AND METHODS

Between January 1994 and May 1997, 146 patients (42 men and 104 women; mean age, 63) from eight different centers were studied prospectively. The ERUS classification incorporates disease of the anal canal and the perirectal lymph nodes, thus: usT1 describes involvement of the mucosa and submucosa with sparing of the internal sphincter; usT2, involvement of the internal sphincter with sparing of the external sphincter; usT3, involvement of the external sphincter; usT4, involvement of a pelvic organ; N0 describes no suspicious perirectal lymph nodes, and N+, perirectal lymph nodes fulfilling endosonographic criteria for malignancy (e.g. round, hypoechoic). Tumors classified as UICC T1-T2 (<4cm) N0 were treated by radiotherapy alone, whereas lesions with a UICC classification of T2 (> 4 cm), T3-T4, N0-N1-2-3 received combined radiochemotherapy.

RESULTS

Data concerning the treatment and follow-up were available for 115/146 patients (78.7%). We compared the prognostic importance of the two classification schemes for treatment response and the rate of local relapse (chi-squared test). A significantly greater proportion of T1-T2N0 lesions classified by ERUS had a complete response to treatment than those classified by conventional UICC staging (94.5% vs. 80%, respectively; P = 0.008). The ERUS T and N stage were significant predictors of relapse (P=0.001 and P=0.03, respectively) whereas the corresponding clinical (UICC) stages were not (P = 0.4 and P = 0.5, respectively). Using a Cox model, usT stage was the only significant predictive factor for patient survival.

CONCLUSION

This muticenter prospective study demonstrated the superiority of ERUS-based staging over traditional clinical staging in the prediction of important outcomes such as local tumor recurrence and patient survival.

Predictive factors for regression of gastric MALT lymphoma after anti-Helicobacter pylori treatment

BACKGROUND AND AIMS

Discrepant remission rates (41-100%) have been reported for patients with localised low grade gastric mucosa associated lymphoid tissue (MALT) lymphoma after eradication of Helicobacter pylori. The aim of this study was to explain these discrepancies and to determine the predictive factors of gastric lymphoma regression after anti- H pylori treatment.

PATIENTS AND METHODS

Forty six consecutive patients with localised gastric MALT lymphoma (Ann Arbor stages I(E) and II(E)) were prospectively enrolled. All had gastric endoscopic ultrasonography and H pylori status assessment (histology, culture, polymerase chain reaction, and serology). After anti-H pylori treatment, patients were re-examined every four months.

RESULTS

Histological regression of the lymphoma was complete in 19/44 patients (43%) (two lost to follow up). Median follow up time for these 19 responders was 35 months (range 10-47). No regression was noted in the 10 H pylori negative patients. Among the 34 H pylori positive patients, the H pylori eradication rate was 100%; complete regression rate of the lymphoma increased from 56% (19/34) to 79% (19/24) when there was no nodal involvement at endoscopic ultrasonography. There was a significant difference between the response of the lymphoma restricted to the mucosa and other more deep seated lesions (p<0.006). However, using multivariate analysis, the only predictive factor of regression was the absence of nodal involvement (p<0.0001).

CONCLUSION

In H pylori positive patients with localised gastric MALT lymphoma, carefully evaluated and treated without any lymph node involvement assessed by endoscopic ultrasonography, complete remission of lymphoma was reached in 79% of cases.

Intraductal acinar cell carcinoma of the pancreas

We describe a purely intraductal acinar cell carcinoma involving branch ducts of the pancreas in a 74-year-old man, which presented as recurrent episodes of acute pancreatitis. Endoscopic ultrasound examination revealed an intraductal mass bulging into the main pancreatic duct suggesting, pre-operatively, an intraductal mucinous papillary tumour. Gross examination showed several dilated branch ducts that contained haemorrhagic tumour material without any solid or true cystic formation within the pancreatic parenchyma. Using histology, a purely intraductal acinar cell carcinoma was observed, involving branch ducts only, associated with foci of carcinoma in situ in adjacent exocrine parenchyma. The main pancreatic duct was free of disease except for its communication with a cancerous branch duct. A concomitant neuroendocrine microadenoma was incidentally found during slide screening. Immunohistochemistry performed on the intraductal proliferation confirmed zymogen secretion with positive staining for alpha-1 anti-chymotrypsin and anti-trypsin and the persistence of diastase-periodic acid-Schiff positive granules in the apical pole of the tumour cells. Neuroendocrine markers were negative in the acinar cell carcinoma and positive in the neuroendocrine microadenoma. To our knowledge, this is the first report of an intraductal acinar cell carcinoma of the pancreas involving branch ducts and sparing the main pancreatic duct.