[Immunoproliferative small intestinal disease (IPSID): IPSID-like lymphomas, IPSID equivalents?, in 12 Spanish patients]

BACKGROUND

Immunoproliferative small intestine disease (IPSID) encompasses a primary intestinal lymphoma of underpriviliged populations of North Africa, Middle East, etc. This epidemiological feature strongly implicates environmental and host (genetic) factors in its pathogenesis. IPSID can be distinguished on clinicopathological grounds from "Western-type" intestinal lymphomas. "IPSID-like" lymphomas had been sporadically identified, i.e., patients with original clinico-analytical data of IPSID (chronic diarrhoea, malabsortion, clubbing of fingers, diffuse intestinal involvement, etc.) without its conventional histopathologic (lymphoplasmocytic or plasmocytic infiltration) and immunological (alpha-heavy-chain paraprotein) background.

PURPOSE

The aim of this study has been: 1) to identify, in a series of small intestine lymphomas, a group of patients with a long-lasting history of chronic diarrhoea and a clinico-biologic pattern of "IPSID-like" lymphoma; 2) to analyze its clinicopathological profile; 3) to search for differences with the pattern of the remaining cases ("Western-type" lymphomas) and 4) To suggest a possible epidemiological significance.

PATIENTS AND METHODS

Patients considered were 12 Spanish caucasians with primary intestinal lymphoma and a long-lasting history of chronic diarrhoea vs 31 cases of "Western-type" intestinal lymphomas admitted in our Hospital over a 33-year period. Statistical significance of differences in clinico-biological features (symptoms/signs, analytical data, patterns of involvement, histopathology, immunophenotype and tumor staging) between these two groups was evaluated using X2 test.

RESULTS

The results of this retrospective study allow us to delineate a relatively homogeneous "IPSID-like" group (12 cases) among 43 cases of primary small intestine lymphoma diagnosed between 1960 and 1993. The clinico-pathological behavior of these patients was significantly different from that exhibited by the 31 cases of so-called "Western-type" lymphomas.

CONCLUSIONS

It is suggested that they may represent a group of patients suffering an evanescent "IPSID-equivalent" disorder (last case diagnosed in 1975), that probably has evolved in similar but not identical epidemiological circumstances to those present in the "Third World" countries of our Mediterranean area.

[Post-therapeutic evolution and prognostic factors of intestinal lymphomas, Retrospective analysis of 42 cases]

PURPOSE

To evaluate in retrospect the response to therapy and long-term evolution of a series of primitive intestinal lymphomas.

PATIENTS AND METHODS

The series was comprised of 42 patients diagnosed in our hospital during 1960-1962. The mean age was 34.5 years (range, 3-73), the M/F ratio was 21/21, and the histopathology distributes as follows: high grade (HG), 24 cases, low grade (LG), 12 cases, and mixed (LG/HG), 6 cases. B/T immunophenotype: 40/2. Staging: IE1,29 cases, IIE2-IV, 11 cases. The treatment applied in the series was classified in various types: ample surgical resection (aSR), 21 cases; partial surgical resection (pSR), 9 cases; abdominal radiation therapy (RT), 7 cases; monochemotherapy (MCT), 7 cases, and polychemotherapy (PCT), 28 cases. The correlation of clinicobiological variables with immediate response to treatment was evaluated by means of the chi square test, and the acturial post-therapeutic survival curves in accordance to the life tables, differences being calculated by the log rank test.

RESULTS

Small intestine was the commonest site of involvement, 31 cases; ileocecal region, 7 cases; colon, 2 cases, and colon plus small intestine, 2 cases. Regardless of therapy type, complete remission (CR) was attained in 20 patients (47.5%), partial remission in 5; 11 cases were unresponsive (26.5%) and early death occurred in 6 instances (14.2%). The acturial post-therapeutic survival offered an 8-year expectancy of 47%. The correlation between immediate complete response and 16 clinico-biologic variables showed favourable significance for tumoral proliferation index (i.e., Pc10-positive cells < 15%) and for therapeutic regimens including PCT+aSR. On the other hand, the necessity of emergency surgery for diagnosis was a poor-risk factor. The correlation between a post-therapeutic survival and 19 other variables showed the following as favorable data: female sex, tumour proliferative index (i.e., Pc10-positive cells < 15%), the use of PCT+aSR, and attaining CR. Poor-risk factors were the need of emergency surgery, multicentric lymphomatous involvement and serum LDH rates 350 UI/L. Although immediate response (CR) and long-term results (survival) were better in the patients with favourable histology (LG+LG/HG) and in those with loco-regional disease (stages IE-IE1), the differences had no statistical significance, possibly due to the low number of cases.

CONCLUSIONS

1) Even though these findings should be carefully evaluated, dut to lack of homogeneity of the series and the fact of being a retrospective study, the rate of CR in this series (47.5%) is similar to that of current studies. 2) Female sex, type of therapy, multifocal involvement, the need of emergency surgery and high LDH levels have significant value in univariate analyses.

[Cancer of the middle third of the choledochus: an infrequent diagnosis]

We report the case of an 80-year-old woman with a previous history of HBP, hysterectomy due to cancer of the uterus and cholelithiasis, who was admitted in our hospital because of diffuse abdominal pain, marked jaundice, choluria and acholia during one week, together with anorexia and loss of weight. Blood chemistry results disclosed a total bilirubin of 11 mg/dl, a direct bilirubin of 8 mg/dl, GGTP 826 U/I, alkaline phosphatase 287 U/I, AST 285 U/I, ALT 837 U/I and LDH 242 U/I. The CA 19-9 marker was higher than 500 U/ml. The abdominal ultrasound examination did not show any space-occupying lesions; the extra and intrahepatic bile ducts were very dilated and the gall bladder showed multiple stones within its contents. The endoscopic retrograde cholangiopancreatography (ERCP) showed a homogeneous filiform defect at the middle third of the common bile duct of approximately 1 cm in length and with a marked dilatation of the bile ducts. A percutaneous drainage of the bile tree was performed, but the patient died.

[Eosinophilia and ascites as an expression of a subserous form of eosinophilic gastroenteritis]

Clinical and biological features are discussed on a 50 years old female, who suffered a peritonitis with eosinophilic ascites, together with a bilateral pleural effusion with the same cytologic findings, developing in the course of an hypereosinophilia. The clinical situations in which eosinophilic ascites is associated with blood hypereosinophilia are reviewed. The histopathological findings in this case support the diagnosis of eosinophilic gastroenteritis of subserous type.

[Jaundices in pregnancy]

There are three types of disorders which may produce jaundice during pregnancy: 1) acute or chronic coexistent or pre-existent liver disease (acute and chronic hepatitis, liver cirrhosis etc.), 2) acute and chronic hemolytic disorders, 3) jaundice directly or indirectly related to pregnancy. Among the later group, intrahepatic cholostasis, gravidic hyperemesis with jaundice represent exacerbations of physiologic gravidic cholostasis. Hepatic steatoses of pregnancy are the result of toxic metabolites or drugs on the liver parenchyma. Severe forms of eclampsia may induce jaundice of hemolytic and parenchymal origin. Hypercoagulability may also induce, in the first post-partum days Budd-Chiari's syndrome with accompanying jaundice.

[Immunological and biochemical factors associated with spontaneous bacterial peritonitis]

A prospective study (June 1988-December 1989) of all patients admitted with ascites due to cirrhosis was undertaken: Biochemical and immunological factors which may have significance in the development of spontaneous bacterial peritonitis were determined. Among 56 patients (44 males and 12 females) SBP developed in 16% of the group. No age differences were found and the etiology of the cirrhosis was mainly alcoholic. Patients with SBP had lower alpha-2 globulin concentrations: 0.43 +/- 0.12 vs. 0.60 +/- 0.18 g/dl (p less than 0.05) and a lower prothrombin time: 41 +/- 13% vs. 69.5 +/- 13 vs. 69.5 +/- 21% (p less than 0.001). Patients with SBP had also lower ascitic fluid total protein 0.99 +/- 0.4 vs. 1.64 +/- 1.1 g/dl (p less than 0.01) as well as lower alfa-2 globulin: 0.065 +/- 0.012 vs. 0.096 +/- 0.067 g/dl (p less than 0.05); beta globulin, 0.11 +/- 0.047 vs. 0.2 +/- 0.17 g/dl (p less than 0.05); gamma globulin, 0.32 +/- 0.1 vs. 0.52 +/- 0.4 g/dl (p less than 0.05); IgG, 275 +/- 157 vs. 477 +/- 335 g/dl (p less than 0.05); C3, 9.2 +/- 3.2 vs. 17 +/- 13 mg/dl (p less than 0.01) and C4, 2.83 +/- 1.5 vs. 4.66 +/- 3.9 mg/dl (p less than 0.05) than patients without this complication.

[Presenting forms and diagnostic procedures in gigantic hemangioma of the liver]

We present eleven patients diagnosed of giant hepatic hemangioma in the last 20 years. The diagnosis was confirmed in all the cases during laparoscopy or laparotomy. The mean age of the patients was 44.9 +/- 8.99; nine of them were women. Only two of the patients complained of abdominal pain. Five patients showed abnormal liver function tests; the most common finding was increased levels of alkaline phosphatase. We have reviewed the diagnostic tools employed: isotopic study of the liver with 99Tc, and labeled erythrocytes, abdominal ultrasonography, CAT, hepatic arteriography, laparoscopy, laparotomy and liver biopsy. Usually we employed more than one of these diagnostic methods. In the last years there has been a shift to employ less invasive procedures.

[Prognostic value of fibrinogen measurement in acute pancreatitis]

To evaluate the utility of fibrinogen as a prognostic factor in acute pancreatitis (PA) it was measured within 48 hours of admission in 55 patients with acute pancreatitis studied prospectively. We found that patients with fibrinogen levels above 850 mg/dl. presented a serious evolution in 55.55% of cases as compared to 10.87% of those who had levels below this figure (p less than 0.01). We conclude that fibrinogen measurement can be useful in the early evaluation of the prognosis of acute pancreatitis.