Expression of Smad4, E-cadherin and beta-catenin in advanced colorectal cancer: a retrospective study

PURPOSE

To correlate the expression of E-cadherin and beta-catenin with alterations of expression of Smad4 in advanced colorectal cancer (CRC).

METHODS

Tissue specimens from 75 colorectal cancer cases (Dukes stage C and D) were tested for Smad4, E-cadherin and beta-catenin by the Avidin-Biotin immunoperoxidase method. The results were correlated with patients' clinicopathological parameters.

RESULTS

Smad4 expression was lost or reduced in roughly 1 out of every 3 Dukes C and D CRCs. Association of Smad4 expression with other clinicopathological parameters was not noted. Association of expression of E-cadherin with other clinicopathological parameters was not noted, apart from tumor location. Expression of beta-catenin was not associated with clinicopathological parameters. Lack of expression of Smad4 was associated with lack of expression of both E-cadherin (<0.000) and beta-catenin (p<0.000). As regards the relation between E-cadherin and beta-catenin, the expression of each seemed to parallel the expression of the other (p<0.000). Beta-catenin was overexpressed in 68.5% of the specimens studied.

CONCLUSION

Clinically advanced CRC is associated with a reduced or complete lack of expression of Smad4. Ecadherin and beta-catenin are expressed in parallel with each other and also with Smad4. This tumor suppressor role of Smad4 by affecting both E-cadherin and beta-catenin may indicate a novel pathway for metastatic tumor via cellular reshaping. The precise underlined mechanism(s) and the clinical significance of these findings remain to be determined.

Dermatofibrosarcoma: a rare form of soft tissue. Management and review of the literature

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor of cutaneous origin of intermediate grade malignant potential. The incidence of DFSP is 0.1% of all cancers and 1% of all soft tissue sarcomas. We present the case of a 65years old female with a palpable, painful mass on the right thigh. A surgical excision of the lesion was done and the histopathology, as well as the immunohistochemical analysis with CD-34, confirmed the diagnosis of DFSP. Two years later, the patient is free of disease and no local recurrences or metastases have been found. Wide radical excision is the preferred surgical method for therapy of DFSP without distant metastasis. Furthermore, DFSP resists to conventional chemotherapy and radiation therapy, while, in cases of metastasis, therapy depends on cytogenesis and molecular biology of the tumor, so new therapeutic strategies are under research.

Gastrointestinal carcinoid tumors: diagnosis and treatment

Carcinoid tumors are malignancies originating from neuroendocrine cells, most commonly encountered in the gastrointestinal tract, in a rate of 64%, with the majority affecting the ileum. Certain genetic syndromes sometimes include carcinoid tumors in their phenotype. These malignancies may be rather asymptomatic, although occasionally they behave aggressively. They are typically diagnosed due to the effects of a locally advanced disease, or when producing symptoms because of hormone secretion (carcinoid syndrome). A better understanding of their molecular biology and behavior is demanded so that these tumors to be diagnosed precociously and managed effectively.

Insulinoma: a rare neuroendocrine pancreatic tumor

Insulinomas are functional endocrine tumors originating from the pancreatic b-cells. In 1902 Nicholls described the first adenoma of pancreatic islets, while the first insulinoma was described in 1927 in Mayo Clinic, which was dissected two years later in 1929 in Toronto. The first enucleation of insulinoma took place in a St. Jouis hospital in 1931, and after four years, in 1935, Whipple described the classic diagnostic triad: symptoms of fasting hypoglycemia or fatigue, blood glucose levels under 50 mg/dl and disappearance of symptoms after glucose administration.

Primary adenocarcinoma of the appendix: an update

Adenocarcinoid arising in the vermiform appendix is a rarity. The diagnosis of appendiceal adenocarcinoma has never been made preoperatively and is frequently an incidental finding at the time of operation for unrelated conditions. Because of the rarity of the disease, its natural history is poorly understood. Benefits from adjuvant radiation, chemotherapy, or a combination have not been reported. Most studies emphasize survival outcome based on surgical technique. There are few data and, consequently, much debate on the appropriate management of these lesions. The aim of this article is to review this entity and to assess and report new data, through a study of the literature.

The management of patients with retained foreign bodies in the rectum: from surgeon with respect

BACKGROUND

The introduction of foreign bodies into the rectum is not an uncommon medical problem. The phenomenon has increased in the homosexual population. In a 25-year period we have encountered 34 patients with retained rectal foreign bodies.

MATERIAL AND METHODS

We have performed five laparotomies due to perforation and a laparotomy in order to retrieve a large wooden object.

RESULTS

We have observed only one complication in a woman who developed a retrovaginal fistula.

CONCLUSIONS

In order to obtain successful extraction of the foreign body the surgeon, apart from the well-known techniques, must exercise a high degree of ingenuity. Finally, it should be emphasized that the appropriate respect should be shown to all patients who seek treatment for this problem.

Anthelminthic treatment: an adjuvant therapeutic strategy against Echinococcus granulosus

The main goal of the paper is to clarify anthelminthic treatment as an alternative hydatic cyst therapy, its indications and contraindications. Chemotherapy constitutes a non-invasive treatment and is less limited by the patient's status than surgery or PAIR. Many investigators have employed benzoimidazole carbonates for the management of human hydatid disease. Both, albendazole and mebendazole have, a favourable effect in patients suffering from multiorgan and multicystic disease, in inoperable primary liver or lung echinococcosis, and they can also prevent secondary echinococcosis. Chemotherapy is contraindicated for large cysts that are at risk to rupture and for inactive or calcified cysts. The main adverse events are related to changes in liver enzyme levels. The best efficacy is observed with liver, lung, and peritoneal cysts. Certain various factors influence the therapeutic results of medical treatment. The vast majority of the recurring cysts show good susceptibility to re-treatment.

Hydatid disease of the urinary tract: an update

Hydatid disease constitutes an endemic zoonosis caused by different species of the cestode Echinococcus. The main organs affected are the liver and the lungs. Echinococcosis of the urinary tract is an extremely rare medical condition, met in 2-4% of cases. This pathologic entity has to be included in the differential diagnosis of occupying lesions of the urinary tract at any age, especially among patients in endemic areas. Meticulous laboratory and imaging control when taking into consideration the suspicion for the disease, can guarantee an accurate diagnosis and successful outcome.

Mammary candidiasis. A breast infection difficult to handle

Mammary candidiasis is a disease with significant impact on breast feeding. Early diagnosis and treatment is essential for successful long-term breastfeeding. It constitutes however a significantly rare breast inflammatory entity. A case of a young woman with breast candidiasis properly diagnosed and treated in our clinic is reported.

Superficial parotidectomy under local anaesthesia

The modern tendency of surgery is to perform a constantly rising number of operations under local anaesthesia. Superficial parotidectomy under local anaesthesia has not been widely attempted. However only few reports show that this kind of procedure could be feasible. If this is the case, standard assessment of benign parotid tumors will change radically.

Anorectal incontinence: therapeutic strategy of a complex surgical problem

The anatomophysiological integrity of the pelvic floor and anorectum contributes to the important function of continence and defecation. A variety of causes can cause damage in the anatomy and/or the innervation of the pelvic floor muscles as well as in anorectal sensitivity or stool consistency leading to anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is related to injury of the sphincter muscles after delivery, or anorectal surgery. Anorectal incontinence is a complex problem, often of multifactorial origin. The exact cause of its incidence is unknown. However, the incidence is approximately 2% in the general population and 25-60% in the elderly. Although the condition is considered a problem in the elderly, it is becoming apparent that people are frequently affected from a much younger age. Anorectal incontinence is a severe disability and a major social problem as it produces a feeling of insecurity and pushes the patient towards social isolation. Management of the incontinent patient may be conservative (medicinal, biofeedback training), surgical (sphincter repair, pelvic floor repair, neosphincter formation, artificial sphincter or stoma) or use sacral nerve stimulation. The successful treatment of anorectal incontinence depends on accurate diagnosis of its cause, which is achieved by a thorough patient assessment including patient history, physical examination and selective specialized investigations. A stoma is the final resort when all other therapeutic attempts have failed.

Evaluation and surgical management of the gallstone ileus. A single center experience

Gallstone ileus representing 1-4% of all bowel obstructions cholelithiasis. Impaction of a gallstone in the human of the bowel is a surgical emergency. Relief of the obstruction is the treatment of choice, but controversy exists regarding the repair of the fistula and cholecystectomy. Our experience in the management of gallstone ileus is presented in the following article.

Lower extremity infections by vibrio vulnificus

BACKGROUND

Vibrio vulnificus is a Gram-negative pathogen which is found in seawater and shellfish during warm months and can cause local infections in healthy individuals or septicemia in patients with chronic liver disease.

MATERIALS-METHODS

Clinical and laboratory records of four complicated cases are presented, with a 4.2 mean year follow-up.

RESULTS

Three patients underwent urgent leg amputation because of of irreversible necrotic changes with septic complications and failure of incisional drainage to control the infection. Another one patient underwent only excision of necrotic soft tissue but he developed calcaneus osteomyelitis after three years of the initial fish bone injury.

DISCUSSION

Clinicians must maintain a high index of suspicion, especially in regions endemic for vibrio necrotising fasciitis and antibiotic prophylaxis must be given to swimmers before or during bathing.

Adrenal rupture after blunt abdominal trauma

The case of a patient, victim of a car accident, with rupture of the left adrenal gland associated with splenic rupture and liver laceration is reported. Injury of the adrenal glands is most frequently caused by blunt abdominal trauma and is usually associated with injuries of other abdominal organs. Careful exploration of the upper retroperitoneal space where adrenals are located is considered necessary during laparotomy for severe blunt abdominal trauma. If adrenal lesion has been overlooked continuous hemorrhage may occur, which could be lethal if not promptly treated.

Echinococcal cyst of the subcutaneous tissue: a rare case report

Hydatid disease is an endemic zoonosis caused by the cestode Echinococcus granulosus. The most common affected organs are the liver and the lungs. Echinococcal cyst located in the subcutaneous tissue constitutes an extremely rare manifestation of the hydatid disease. Here we present a case report with a cystic mass in the subcutaneous tissue of the left gluteal area, diagnosed as being a hydatid cyst.

Abdominal compartment syndrome: effects on organ function

Abdominal compartment syndrome (ACS) constitutes a critical clinical situation presenting a remarkable incidence being the causal factor of variable abdominal and extra-abdominal pathology, thus a rising issue of interest in intensive medical care over the past decade. Moreover, ACS as a condition potentially leading to Multiple Organ Failure (MOF), its better understanding could provide more effective management resulting to limitation of MOF incidence and mortality.

Fournier's gangrene: exists and it is still lethal

BACKGROUND

Fournier's gangrene is an aggressive form of necrotizing fascitis of the perineal, perianal or genital regions, caused by a polymicrobial infection that includes virulent organisms.

PATIENTS AND METHODS

Eleven cases of Fournier's gangrene were treated in our department during the last 20 years. Portals of entry were ischiorectal abscess, perirectal abscesses, scrotal abscess and trauma in the perianal area. The documents were analyzed according to clinical and epidemiologic patterns.

RESULTS

We dispensed systemic chemotherapy with broad-spectrum antibiotics, and performed surgical debridement for all patients. In addition, one patient was treated by local use of 100% oxygen, with excellent results in wound healing. All patients made a full recovery, except one who died of sepsis.

CONCLUSION

These cases are presented with some notes underlying the reasons for the persisting incidence and mortality of this disease.

Life-threatening hemorrhage due to cytomegalovirus infection of the gastrointestinal tract

Cytomegalovirus infection of the gastrointestinal tract of normal hosts is very rare. On the other hand, this is a common cause of morbidity in immunocompromised hosts. Herein we describe the case of a 52-year-old male who underwent a gastrectomy due to a severe gastrointestinal hemorrhage. Histological examination showed the characteristic cytomegalovirus inclusion bodies. The diagnosis was confirmed with immunohistochemistry and his immune system revealed no abnormality. We believe that, although it is very rare, cytomegalovirus infection should be kept in mind for non-immunocompromised patients with upper gastrointestinal bleeding or multiple gastric ulcers.

Changes of Bone Turnover Markers after Marathon Running over 245 km

We evaluated bone turn over markers, cortisol and parathyroid hormone (PTH) levels in male athletes after 245 km of marathon running. Sixteen athletes were studied five days before, immediately after, and 1, 3, and 5 days after the run. We used T-test and Pearson correlation for statistical analysis. Osteocalcin levels were significantly decreased from 4.6 microg/lit to 3.8 microg/lit (p < 0.05). Activity of b-ALP was significantly decreased from 66 U/lit to 61.5 U/lit (p < 0.05). PICP levels were also significantly decreased from 168 microg/lit to 153 microg/lit (p < 0.05). Hydroxyproline levels decreased after the run from 70 mmol/min to 65 mmol/min (p < 0.05). ICTP levels increased after the run but without being statistically significant, from 6.62 microg/lit to 7.0 microg/lit. Urine calcium decreased significantly by 68 %, immediately after the run. Cortisol increased from 212 ng/ml to 455 ng/ml, and PTH levels increased from 12 pg/lit to 16 pg/lit immediately after the race (p < 0.05). Cortisol levels were significantly negatively correlated with osteocalcin (r = - 0.61, p < 0.05) and b-ALP (r = - 0.98, p < 0.05). PTH levels were significantly negatively correlated only with serum osteocalcin (r = - 0.8, p < 0.05). These findings suggest a transient suppression in osteoblast function during the marathon run probably due to cortisol and PTH levels elevation.

Spigelian hernia. A rare case of bilateral hernia and presentation of our experience

Spigelian hernia is a relatively rare defect of the abdominal wall. Due to its unspecific and variable clinical presentation, presents a difficult diagnostic challenge. We present a rare case of bilateral Spigelian hernia that was diagnosed and successfully treated with open surgery and hernioplasty. Also we present our experience in management of the disease. In our department the last fifteen years, 12 cases of Spigelian hernia have been treated surgically, using direct reconstruction with excellent results.

Intrahepatic bile duct rupture of hydatid cyst: a severe complication for the patient

In most cases of echinococcal disease the liver is the mainly affected organ. The clinical manifestations are defined by the size and the localization of the hydatid cyst. The appearance of complications, such as purulence and rupture of the cyst, aggravate the patients' clinical condition. Intrabiliary rupture, although rare, carries severe health risks; timely diagnosis and appropriate management of this entity are vital for the patient's survival.

Hydatid disease of the parotid gland: a rare case report

A 40-year-old female suffering from hydatid disease located in the parotid gland is presented. Although Greece remains an endemic area for echinococcosis, this presentation of the disease is rare. Total excision of the cyst with partial parotidectomy was performed. The patient refused to receive general anesthesia and the operation was carried out under local anesthesia. Perioperative adjuvant medical therapy with albendazole was administered. In a two-year follow-up no recurrence has occurred.

The coexistence of carcinoma of the rectum and of ischiorectal abscess: what is the optimal therapeutic approach?

This article deals with the dilemma of the surgeon to choose the optimal surgical procedure in case of coexistence of ischiorectal abscess and a rectal carcinoma. The case of a patient suffering from ischiorectal abscess in association with rectal carcinoma is reported.

Choledochoduodenal anastomosis: a technical tip to ensure the impermeability of the anastomosis

In 1891 O. Sprengel described a successful side-to-side choledochoduodenostomy and since then this has been a method frequently used in dealing with the problem of constriction of the lower third-portion of the bile duct, due to malignant or benign causes. Taking in consideration that the first choledochoduodenostomy was performed by H. Riedel in 1888 and the patient died 9 hours after surgery due to leakage of the anastomosis (disclosed in autopsy), it is evident to conclude that hermetic anastomosis is the main factor for fast and uncomplicated recovery of the patient. In order to ensure intraoperatively a hermetic "bile-proof" anastomosis, we have applied a technical tip, which has been proved to be efficient.

Solitary hydatid cyst in the pelvis: A case report

Hydatid disease mainly affects the liver and the lungs. Pelvic involvement have been rarely reported in the literature. Herein we present a rare case of isolated hydatid cyst of pelvis attached to the urinary bladder.

Complications of thyroid surgery

Thyroid surgery has a history of significant changes in the technique and the incidence of complications. Since then continuous developments in surgical techniques and better understanding of thyroid anatomy and pathology have increased the safety of thyroid surgery and reduced the incidence of complications. Nowadays, the rate of postoperative mortality is extremely low. Nevertheless, the incidence of postoperative complications varies in literature from 7.4% to 53% of the operations performed. The most common and potentially life-threatening complications in thyroid gland surgery are vocal cord palsy and hypocalcemia. Herein we discuss the common complications in thyroid gland surgery and their proper management.

Pancreatic abscess due to perforation of duodenal diverticulum

Duodenal diverticula are usually incidental findings, but some times could be complicated with inflammatory or pressures effects to pancreas tissue. We present a rare case of pancreatic abscess caused by a perforated diverticulum, arising from the distal end of the second part of the duodenum.

Changes of CPK and CPK-MB levels after open and laparoscopic cholecystectomy

According to the World Health Organization, an increased ratio (more than 6%) of CPK-MB to total CPK may indicate the diagnosis of an acute infarction. But false elevation of CPK and CPK-MB levels after noncardiac operation, because of soft tissue damage, may confuse the clinicians in detecting myocardial infarction in early postoperative period. In order to determine the usefulness of CPK-MB to total CPK ratio in detecting myocardial infarction after open and laparoscopic cholecystectomy, we measured the serum levels of these markers in 135 patients, immediately after the operation and for the next five days. Patients were divided into four groups according to type of surgical procedure, as follows: Group I: a right oblique subcostal (Kocher's) incision was performed in 29 patients, Group II: a right paramedian transrectal incision was performed in 52 patients, Group III: a vertical high midline incision was performed in 17 patients, Group IV: laparoscopic cholecystectomy was performed in 37 patients. Although we found increased levels of CPK and CPK-MB after all the types of cholecystectomy, but in any case the CPK-MB exceeded more than 6% of total serum CPK. Furthermore we noticed that the patients who underwent open cholecystectomy with right oblique subcostal incision had the most elevated CPK and CPK-MB levels comparing to the other types of cholecystectomy. In conclusion, tissue damage after elective cholecystectomy is minimal and CPK-MB to total CPK ratio is a secure marker in detection of myocardial infarction during early post-operation period, after cholecystectomy.

Hydatid disease of the seminal vesicle: A rare presentation of hydatid cyst

Seminal vesicle belongs to the unusual sites of the hydatid cyst presentation. Even though the patient had a history of surgically treated hydatid disease of the liver, however, solitary echinococcal cyst of the seminal vesicle is a rare condition. Surgical removal of the cyst intact is the treatment of choice.

Diagnostic and therapeutic aspects in medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) is a rare and particularly aggressive type of thyroid cancer with several distinctive features that distinguish its management from other thyroid cancers. Since MTC was first recognised as a distinct tumour in 1959, it became clear that MTC is more difficult to cure than differentiated thyroid cancer and has higher rates of recurrence and mortality, but it is usually a slow growing tumor compared with other malignancies. In addition, unlike differentiated thyroid cancer, there is no known effective systemic therapy for MTC.

Emphysematous cholecystitis. Review of five cases and report of septic musculoskeletal complications

A variant of acute cholecystitis is emphysematous cholecystitis. Here in we reviewed useful clinical data of five cases of this entity. Clinical outcomes were uncomplicated for three patients who were treated with open cholecystectomy. But on the other hand we faced two septic musculoskeletal complications in two patients who were treated with percutaneous trans gallbladder drainage. We believe that we must be aware of musculoskeletal complications, whenever a patient with emphysematous cholecystitis is treated with percutaneous trans gallbladder drainage.

Multimodality approach towards advanced rectal carcinoma. "Its efficacy and safety"

BACKGROUND/AIMS

To evaluate the efficacy and safety of multimodality approach towards advanced rectal cancer.

METHODOLOGY

In a prospective, randomized trial, two hundred and ten patients with advanced carcinoma of the rectum were studied. Patients were randomly divided in two groups A and B. Patients in group A underwent total mesorectal excision (TME) with adjuvant systemic chemotherapy and radiotherapy. Group B patients underwent TME with adjuvant stop-flow perfusion along with systemic chemotherapy

RESULTS

The five-year survival for Group A patients was 72% and for Group B patients the overall five-year survival was 92% and the disease-free survival was 87%.

CONCLUSIONS

Multimodality approach to advanced rectal cancer leads to substantial prolongation of survival and optimization of quality of life.

Leucovorin and fluorouracil vs levamisole and fluorouracil as adjuvant chemotherapy in rectal cancer

The aim of this study was to evaluate the effectiveness of 6-month therapy with leucovorin (LV) + 5-fluorouracil (5-FU) vs 12 months of therapy with levamisole (LVZ) + 5-FU, as adjuvant chemotherapy in patients with completely resected Dukes' stage B2 or C rectal cancer. One hundred and fifty patients with surgically resected rectal carcinoma, were enrolled in the present study; Dukes' stage B2 (n=70) or C (n=80), were randomly assigned to chemotherapy with 5-FU + LV x 6 months or 5-FU + LVZ x 12 months. Patient characteristics were equally balanced between the examined groups. Adjuvant CT consisted of LV 20 mg/m(2) intravenously (i.v.) plus 5-FU 450 mg/m(2) i.v., on days 1-5 every 4 weeks for 6 cycles or 5-FU 450 mg/m(2) i.v. every week plus LVZ 50 mg t.i.d x 3 days for 1 year. All patients received radiotherapy with a three-field technique to a total dose of 45 Gy, over 5 weeks. After a median follow-up of 7.4 years there were no significant differences between the two treatment groups with respect to the recurrence rates (P=0.821). Moreover, there was no difference in disease-free survival for patients stage Dukes' B2 (log-rank p=0.73); median for LV group 90 (8-131) months, and for LVZ group 86.5 (3-129) months. No difference was noted in disease-free survival for patients stage Dukes' C (log-rank p=0.73); median for LV group 60 (17-128) months, and for LVZ group 64 (2-123) months. There was no difference in overall survival for patients stage Dukes' B2 (log-rank p=0.75); median for LV group 90 (22-131) months, and for LVZ group 86 (10-129) months. For stage Dukes' C (log-rank p=0.73); median for LV group 67 (17-128) months, and for LVZ group 64 (5-123) months. Toxicities were as follows in the 5-FU + LVZ vs 5-FU + LV group; myelosuppression (leucopenia grade 3, 12% vs 4%, p<0.04), diarrhea (grade 0, 60% vs 76%, p<0.02), and liver toxicity (increase of transaminases >3-fold, 12 patients vs 2, p<0.03), were more frequent in LVZ group. None of the patients stopped chemotherapy because of the toxicity, and there were no toxicity-related deaths. In conclusion, adjuvant chemotherapy in RC with LV + 5-FU for 6 months is equally effective and less toxic than LVZ + 5-FU for 12 months.

Changing trends in the management of Klatskin tumor

BACKGROUND/AIMS

To evaluate the long-term outcome of a multidisciplinary approach for advanced Klatskin tumor involving the hepatic hilus.

METHODOLOGY

A retrospective analysis was undertaken in 110 patients between 1993 and 2003. The patients were divided into Group A (n=42) and Group B (n=58). Group A patients underwent local excision of the tumor and Group B patients underwent combined tumor and liver resection with or without resection of the regional vascular structures. On admission, all patients underwent percutaneous transhepatic biliary drainage. Where hepatectomy was planned, portal vein branch ligation and transection was done ipsilateral to the liver lobe where the tumor was present. An arterial catheter was introduced into the hepatic artery at the end of the surgery, for adjuvant locoregional immunochemotherapy, which was carried out in all patients. The second-stage resectional surgery was carried out 35 days later.

RESULTS

The overall mean survival for Group A patients was 29 months (range 14 to 76). The mean disease-free survival was 28 months (range 10-52). Five-year survival rate was 5% and five-year disease-free survival was 0%. The overall mean survival for Group B patients was 39 months (range 28 to 79). The mean disease-free survival was 32 months (range 17-72). Five-year survival rate was 20% and five-year disease-free survival was 10%.

CONCLUSIONS

The concept of a multidisciplinary approach has significantly improved survival in patients with a grave disease like Klatskin tumor.

Haemorrhagic shock from the spontaneous rupture of an adrenal cortical carcinoma. A case report

Adrenal cortical carcinoma is a rare endocrine neoplasm which can be either functioning or non-functioning. Usually, patients refer to the doctor because of abdominal pain or symptoms associated with the mass effect. We present an unusual case of a patient with adrenal cortical carcinoma who was immediately operated due to massive retroperitoneal haemorrhage following the spontaneous rupture of the tumour. Adrenal cortical carcinoma should enter in differential diagnosis of retroperitoneal haemorrhage. Surgeons should be familiar with this clinical entity and attempt complete resection if possible.

Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study

BACKGROUND/AIMS

To evaluate, the early and long-term results of mono-bloc spleno-pancreatic and vascular resection for advanced carcinoma of the head of the pancreas, with portal-mesenteric venous invasion.

METHODOLOGY

In a prospective, randomized trial, fifty-six patients with advanced carcinoma of the head of the pancreas with vascular invasion were studied. Patients were randomly divided in two groups A and B. Group A patients underwent an en-bloc spleno-pancreatic and vascular resection. Group B patients underwent a palliative gastro-biliary bypass. Patients in both groups were subjected to adjuvant locoregional chemoimmunotherapy, through an arterial catheter introduced into the superior mesenteric artery via a jejunal arterial branch.

RESULTS

The 2- and 5-year survival rates for Group A patients were 81.8% and 18.5%. The respective percentages for disease-free survival were 60.6% and 0%. Two-year survival for group B was nil.

CONCLUSIONS

Mono-bloc spleno-pancreaticoduodenectomy and regional vascular resection and reconstruction, with adjuvant locoregional chemoimmunotherapy leads to substantial prolongation of survival and optimization of quality of life.

Two-stage liver surgery for advanced liver metastasis synchronous with colorectal tumor

BACKGROUND/AIMS

To evaluate the efficacy of two-stage surgery and multidisciplinary approach, in the treatment of primary colorectal cancer, synchronous with advanced liver metastases.

METHODOLOGY

Sixty-two patients who underwent two-stage surgery for advanced metastatic liver disease synchronous with colorectal tumor were studied. In the first-stage surgery, the primary colorectal tumor was resected. Depending on the location of the main tumor mass, ligation and transection of the relevant (right or left) main portal vein branch was done. Subsequently, the metastatic nodules in the contralateral lobe were ablated by microwave therapy. An arterial jet port catheter was also introduced into the hepatic artery via the gastroduodenal artery for locoregional chemoimmunotherapy. Two days after the first-stage surgery locoregional transarterial targeting chemoimmunotherapy was given. The second-stage hemihepatectomy was carried out forty to forty-five days after the initial surgery. As an adjuvant treatment locoregional targeting chemoimmunotherapy was carried out in all patients via the arterial chemoport.

RESULTS

Mean survival was 66+/-4 months. There were no operative deaths.

CONCLUSIONS

Two-stage liver surgery including, portal vein branch ligation, microwave ablative therapy and transarterial targeting locoregional chemoimmunotherapy is the best treatment for advanced, synchronous metastatic liver disease of colorectal origin. It results in an increase in the overall survival of these patients with good postoperative quality of life, which encourages the hepato-biliary surgeon to venture upon this herculean task thus increasing the resectability rate of the tumor.

Palliative treatment for bile duct carcinoma

BACKGROUND/AIMS

Extrahepatic bile duct carcinoma remains a very difficult problem for the surgeon. The aim of this study was to evaluate the differences between surgical treatment and endoscopic or transhepatic dilatation and intubation.

METHODOLOGY

Clinical data from 62 consecutive patients with carcinoma of the extrahepatic bile ducts, who underwent palliative treatment during the past 25 years in our department, were retrospectively analyzed. Preoperative assessment defined site, stage and resectability of tumors.

RESULTS

Tumors were located in the upper third of the bile duct in 32 cases, in the middle third in 17 cases and in the distal third in 13 cases. Transtumoral dilatation was performed in 36 patients (Group A) and cholangioenteric bypass in the remaining 26 patients (Group B). The overall mortality rate was 12.9%. The average survival rate was 6.5 months in group A and 7.3 months in group B.

CONCLUSIONS

In conclusion we suggest that the cholangioenteric bypass offers a better quality of life than non-operative techniques.

Metastatic liver disease of colorectal origin: the value of locoregional immunochemotherapy combined with systemic chemotherapy following liver resection. Results of a prospective randomized study

BACKGROUND/AIMS

Liver resection for metastatic liver disease of colorectal origin, although considered as the 'gold standard' of treatment, is associated with limited long-term survival. The aim of this study was to compare overall survival, disease-free survival and the incidence of intra- or extrahepatic recurrence between patients who were randomly assigned to have locoregional chemoimmunotherapy with systemic chemotherapy group A (n = 62 patients) versus those who were treated with systemic immunochemotherapy group B (n = 60 patients).

METHODOLOGY

Group A included patients who, after liver resection, received locoregional immunochemotherapy combined with systemic chemotherapy, while group B included patients who had undergone systemic immunotherapy combined with systemic chemotherapy following liver resection. The two groups were matched in terms of sex, age and stage of the disease. Prognostic factors and their impact on disease-free survival were studied in both groups.

RESULTS

Two-year survival was 92% for group A versus 75% for group B, 5-year survival was 73% for group A versus 60% for group B. During the two-year period, 34% of the group A patients versus 52% of those of group B developed either intrahepatic or extrahepatic recurrence of the disease (P < 0.00212).

CONCLUSIONS

From the analysis of the above results it becomes clear that regional immunochemotherapy combined with systemic chemotherapy leads to a decrease in the incidence of disease recurrence and thus to a significant prolongation of the overall survival and of disease-free survival.

Long-term results following resectional surgery for Klatskin tumors. A twenty-year personal experience

BACKGROUND/AIMS

The purpose of this study was to assess whether long-term survival in patients suffering from cholangiocarcinomas of the porta hepatis is significantly different when comparing results between local and extended procedures in order to justify increased mortality and morbidity following extensive resections.

METHODOLOGY

From November 1991 to May 2000, 46 patients with Klatskin tumor were assigned to two groups. Group A patients (n = 25) had local resection and group B patients (n = 21) had local resection plus hemihepatectomy. On admission, all patients were drained via percutaneous transhepatic biliary drainage. In all patients we proceeded with an internal biliary drainage in order to anticipate jaundice and decompensated liver function. Internal biliary drainage was carried out 35-40 days before surgery. At the end of the operation an arterial catheter was introduced into the common hepatic artery for adjuvant locoregional targeting immunochemotherapy, which was initiated 20 days following surgery in all patients.

RESULTS

Overall survival for group A patients ranged from 14 months to 76 months (mean: 29). Disease-free survival ranged from 10-52 months (mean: 25). Five-year survival rate was 10%. Five-year disease-free survival was 0%. Overall survival for group B patients ranged from 28 months to 79 months (mean: 39). Disease-free survival ranged from 17-72 months (mean: 32). Five-year survival rate was 20%. Five-year disease-free survival rate was 10%.

CONCLUSIONS

Combined tumor and liver resection is associated with significantly better results when compared with those following tumor resection alone.

Surgical treatment of human echinococcosis

Hydatid disease may affect several organs in the human body and thus represents a major challenge for the general surgeon. The aim of this study was to analyze the multiple clinical presentations of hydatid disease and the surgical options according to the involved organ. The medical records of 272 adult patients operated on for hydatid disease in our department during the period 1970-1996 were retrospectively reviewed. The most commonly involved organ was the liver (204 patients; 75%), followed by the lung (42 patients; 15.4%) and the spleen (14 patients; 5.1%). In 12 patients, the cysts were located in uncommon sites: in the pancreas (4 patients; 1.5%), the gallbladder (2 patients; 0.74%), the kidney, the thyroid gland, the breast, the pericardium, the supraclavicular region and the thigh (1 patient in each case; 0.37%). Clinical symptomatology varied according to anatomic location and pre-operative diagnosis was accomplished with plain abdominal films, ultrasound, computerized tomography and serological tests. The surgical procedures performed included simple closure with drainage, unroofing of the cyst with omentoplasty (for liver cysts), marsupialization, cyst excision, excision of the involved organ or combinations of procedures. Postoperative morbidity was mainly due to septic complications (n = 41), postoperative bleeding (n = 2), deep vein thrombosis (n = 2) and fistulae (n = 13). Four patients died in the early postoperative period (mortality rate, 1.5%) secondary to septic complications (n = 3) and pulmonary embolism (n = 1). During long-term follow-up, 14 patients developed recurrent disease. In conclusion, hydatid disease should be included in the differential diagnosis of cystic masses in solid organs or other anatomic sites, especially in endemic countries. Since there is not an effective medical treatment, surgery still remains the treatment of choice, offering a good clinical result and an acceptable recurrence rate.

p53 protein expression and proliferative activity in ductal breast carcinomas

The immunocytochemical expression of p53 protein and Ki-67 labelling index in tumour cells of 100 ductal breast carcinomas of different histological grade and stage was evaluated in cytological material. In order to investigate p53 expression and Ki-67 expression an avidin-extravidin immunocytochemical technique was applied to imprints. Monoclonal antibody (MoAb) DO-p53 and proliferating cell monoclonal antibody were used as primary antibodies. A statistically significant difference was observed between p53 protein expression and grade of malignancy and clinical stage (P = 0.001, P < 0.001, respectively). A statistically significant difference was also observed between Ki-67 LI and histological grade and stage of the tumours (P < 0.001, P < 0.001 correspondingly). A correlation was observed between p53 protein expression and Ki-67 LI (P < 0.001). The immunocytochemical study of p53 protein and Ki-67 expression in cytological material represents a simple method which can be applied in routine cytological laboratories for the investigation of potential malignancy of ductal breast cancer.

Aneurysms of the distal branches of the external carotid artery

Aneurysms of the distal branches of the external carotid artery are rare and usually traumatic in origin. We present two cases which were treated in our clinic. The first case is about a traumatic aneurysm of the left superficial temporal artery (STA) in a young boy 8 years old. The young patient developed a pulsatile mass above his left eyebrow ten days after a bite by a boy of the same age. The second case is referred in a 36-year old woman with a pulsatile mass behind the right ear, which was an aneurysm of the posterior auricular artery. The treatment was ligation and resection under local anesthesia in the first case and under general anesthesia in the latter. Surgeons' familiarity with this entity is important for diagnosis and treatment.

Splenic artery aneurysm rupture

This is the report of a case with an atherosclerotic splenic artery aneurysm ruptured into the peritoneal cavity which presented with hypovolaemic shock. The patient underwent successfully emergency laparotomy and splenectomy. A brief review of the the literature follows.

Surgical treatment for lung hydatid disease

Lung is the second most common site for hydatid disease after the liver. The aim of this study is to present the clinical symptomatology, diagnostic evaluation, and surgical techniques for the treatment of lung hydatid disease. During the last 25 years, 42 patients with lung hydatid cysts were treated surgically in our department. In four patients there were cysts in the liver and in one case in the spleen. The cysts were located in the right lung in 16 patients (38%), in the left lung in 23 patients (54.8%), and in both lungs in 3 patients (7.14%). Eighteen patients (42.9%) presented with complications: suppuration in one patient (2.4%), rupture to the bronchial tree in 16 patients (38%), and pneumothorax in one patient (2.4%). Diagnosis was established preoperatively in all cases; chest radiography and computed tomography were most helpful for diagnosis. Forty-six operations were performed in 42 patients; three patients with bilateral cysts underwent staged thoracotomies, and one patient was reoperated for recurrent disease. All cases were managed surgically, with several types of radical (34 cases) or conservative (12 cases) procedures. Radical procedures were lobectomy and rarely pneumonectomy, which were used more often during the first half of the study period. Cystectomy with capitonnage, the most commonly performed conservative procedure, was mainly used during the second half of the study period. Postoperative morbidity was 15.2% and the 30-day mortality rate was 0%. In one case there was postoperative hemorrhage that required reexploration. The median hospital stay for uncomplicated cases was 12 days and for complicated cases 21 days. In conclusion, pulmonary hydatidosis often presents with complications requiring emergency surgery. A lung-conserving operation is the treatment of choice for lung hydatid disease and offers a good surgical outcome with a minimal recurrence rate.

Transplenic and transtumoral in vivo immunostimulation: effect on cellular immunity parameters

BACKGROUND/AIMS

It has been shown that IL-2 and gamma-IFN own an additive immunostimulatory effect against tumors. Moreover, it has been suggested that the locoregional route of administration of immunopotentiating agents has substantial advantages compared to the systemic route. The aim of the present study was to evaluate the immune response of patients with advanced unresectable liver and pancreatic malignant disease who were submitted for transplenic and transtumoral IL-2 and gamma-IFN combination immunotherapy.

METHODOLOGY

In 32 patients, the following therapeutic regimen was applied for 10 consecutive days: a) 5 days transplenic administration of 5 mg IL-2 plus 50 micrograms gamma-IFN in a Lipiodol-Urografin emulsion, and b) 5 days transtumoral administration of the same drug cocktail. In the beginning (T1) and on day 15 (T2) after treatment, the following parameters were performed: CD3+, CD4+, CD8+, IL-2r+, HLA-DR+ lymphocytes in peripheral blood spontaneously, and after 48-hour T-lymphocyte cultures in the presence of PHA.

RESULTS

CD3+, CD4+ and CD8+ T-lymphocytes were significantly increased in peripheral blood after treatment (p < 0.05, p < 0.05, and p < 0.003, respectively), whereas IL-2r expression and HLA-DR expression on CD4+ T-cells were not influenced significantly (p > 0.05). After PHA 48-hour T-cell cultures, T-cell subpopulations showed the following alterations: CD3+, CD4+ and CD8+ T-cells were significantly increased (p < 0.001, p < 0.006 and p < 0.01, respectively). Moreover, IL-2r expression as well as HLA-DR expression on CD4+ T-cells were also significantly increased (p < 0.001).

CONCLUSIONS

Locoregional treatment exerted a beneficial immunopotentiating effect on T-cell populations, IL-2r expression and HLA-DR expression. This is a promising mode of action in the management of malignant metastatic disease.

Stop-flow thoracic perfusion for unresectable pulmonary carcinoma with or without inhalation IL-2 immunotherapy. A prospective randomized study

BACKGROUND/AIMS

Pulmonary carcinoma, metastatic or primary, remains a challenging disease with a poor and dismal prognosis. This prospective randomized study compares the results of stop-flow thoracic perfusion and systemic chemotherapy with or without the addition of Interleukin-2 (IL-2) inhalation immunotherapy with respect to overall survival and quality of life.

METHODOLOGY

From January 1996 to January 1999 stop-flow thoracic perfusion using two balloon-tipped catheters was carried out in combination with maintenance system chemotherapy, with (Group B) or without (Group A) inhalation IL-2 immunotherapy in 67 patients suffering from histologically diagnosed unresectable lung carcinoma.

RESULTS

The mean survival for Group A patients was 12 months (M +/- SD: 12 +/- 8.82) while in Group B patients it was 19 months (M +/- SD: 19 +/- 8.47).

CONCLUSIONS

Stop-flow thoracic perfusion in combination with systemic maintenance chemotherapy and IL-2 inhalation immunotherapy prolongs survival and ensures a good quality of life.