[CA19-9 Producing Gastric Cancer with Early Recurrence of Multiple Colon Metastases Following Gastrectomy-A Case Report]

A 90-year-old male underwent total gastrectomy for gastric cancer 10 months earlier. The cancer was pathologically diagnosed as Stage ⅢA. Preoperative serum CA19-9 level was as high as 1,326 U/mL, but quickly decreased after surgery. Although the serum CA19-9 level gradually re-increased, CT did not reveal recurrence of the disease. Ten months following surgery, the patient visited our hospital due to vomiting, and ileus was suspected because of finding of sigmoid colon tumors in the abdominalCT. Colonoscopy showed a circumferentialtumor with severe stenosis in the sigmoid colon, which was diagnosed as tubular adenocarcinoma by biopsy. After preoperative diagnosis of multiple colon cancers, sigmoidectomy was performed. A total of 4 tumors were revealed in the resected specimen. Pathological findings showed cancer cells with nuclear atypia in all tumors, which was very similar to findings in the previous gastric cancer. Immunohistochemical staining confirmed high expression of CA19-9 in both gastric and colon tumors. We concluded that the tumors were metastases of the CA19-9 producing gastric cancer.

Sigmoid Colon Metastasis from Sarcomatoid Renal Cell Carcinoma

The sarcomatoid histological type of renal cell carcinoma is a clinically aggressive variant of parenchymal tumor, typically resistant to systemic treatment. We report the case of a 65-year-old female patient who had undergone a left radical nephrectomy for a sarcomatoid renal cell carcinoma together with enucleation of a mass of the right kidney and a contralateral nodule diagnosed as clear cell carcinoma. One year later lung, adrenal and sigmoid colon metastases from sarcomatoid renal cell carcinoma were detected and the patient was started on systemic immunotherapy with interleukin-2 and interferon-α. Computed tomography showed marked disease progression and the patient died 3 weeks later. Sigmoid colon metastasis from a primary sarcomatoid renal cell carcinoma has never been described in the literature.

Accuracy of ultrasound in prediction of rectosigmoid infiltration in epithelial ovarian cancer

OBJECTIVE

To examine prospectively the accuracy of ultrasound in predicting rectosigmoid tumor infiltration in patients with epithelial ovarian cancer.

METHODS

Patients referred for a suspicious pelvic mass between 2012 and 2014 were examined by ultrasound following the standard protocol for assessment of tumor infiltration. Of the 245 patients examined, 191 had proven ovarian cancer and underwent primary surgery and were included in the analysis. Patients with apparently benign or inoperable disease were excluded. Rectosigmoid infiltration was evaluated by histopathology or according to perioperative findings. Clinical, pathological and laboratory parameters were analyzed as factors potentially affecting the sensitivity and specificity of sonography.

RESULTS

The sensitivity of ultrasound in detecting rectosigmoid infiltration in patients with ovarian cancer was 86.3%, with specificity of 95.8%, positive predictive value of 92.6%, negative predictive value of 91.9% and overall accuracy of 92.1%.

CONCLUSION

Ultrasound is a highly accurate method for detecting rectosigmoid tumor infiltration in ovarian cancer patients, and thus, can be used for planning adequate management, including patient consultation, surgical team planning, suitable operating time and postoperative care. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

[A Case of Colon Metastasis from Breast Cancer with Resection by Laparoscopic Surgery]

A 50-year-old woman underwent breast-conserving surgery and axillary lymph node dissection for left breast cancer in May 2003. She received chemotherapy and radiation for lymph node, lung, and brain metastases. In October 2015, because of abdominal pain and melena, she underwent colonoscopy for suspected sigmoid colon metastasis from breast cancer. We performed laparoscopic sigmoidectomy and diagnosed sigmoid colon metastasis from breast cancer after histopathological examination. Colon metastasis from breast cancer can occur, although it is very rare.

[Significance of surgical resection of local recurrence after gastrectomy for gastric carcinoma - report of two cases]

We report on 2 patients with gastric carcinoma who underwent surgical resection for local recurrence after gastrectomy. Patient 1 was admitted to our hospital because of left-upper abdominal pain caused by local recurrence with abdominal wall invasion. He had undergone distal gastrectomy for gastric cancer 2 years and 4 months previously. Surgical resection of the tumor involving the stomach-jejunum anastomosis region with partial hepatectomy and colectomy was performed. The patient was subsequently discharged without symptoms. A re-recurrence requiring ileocolic bypass then occurred. In spite of chemotherapy and radiotherapy, he died 6 months after the re-recurrence. Patient 2 was admitted to our hospital because of ileus by transverse colon obstruction. He had undergone total gastrectomy for gastric cancer 6 years and 7 months previously and received chemotherapy for local recurrence 4 years after the first surgery. Resection of the local recurrence involving the right transverse colon and the gallbladder was performed at that time. He was discharged without symptoms. He exhibited re-recurrence in the right-upper abdomen 2 months after the second operation. Surgical resection for local recurrence is useful for the improvement of quality of life (QOL) in appropriate cases, but the re-recurrence risk is high because of low curability in these cases.

The increasing incidence of remote metastasis: a case report of metastatic hepatocellular carcinoma to the rectosigmoid

As the fifth most common malignancy worldwide, survival rates of hepatocellular carcinoma (HCC) have only slightly improved over the years due to early-stage detection. HCC is well known to metastasize to the lung, lymph nodes, and musculoskeletal regions; however, only 0.5% to 6% of HCCs metastasize to the gastrointestinal tract. In the case described here, a CT scan and subsequent colonoscopy of a 51-year-old Asian male with a history of hepatitis B and HCC revealed a mass lesion of metastatic HCC 12 cm from the anal verge. Because metastatic HCC to the lower gastrointestinal tract has only recently been reported, it is speculated that the prolonged survival of patients is also increasing the incidence of extrahepatic metastasis, giving the disease greater opportunity to spread to more distant regions of the body. This case may be the farthest metastasis within the gastrointestinal tract to date.

Virchow lymph node metastatic recurrence of sigmoid colon cancer with severe lymph node metastases successfully treated using systemic chemotherapy combined with radiotherapy

Metastatic recurrence of colon cancer in the left supraclavicular lymph node (Virchow lymph node) is rare, and to date there are no reports on radiotherapy as treatment. We report on a case of metastatic recurrence of sigmoid colon cancer in the Virchow lymph node with severe lymph node metastases successfully treated with a combined modality therapy of systemic chemotherapy and radiotherapy. The case is of a 58-year-old man, who underwent sigmoid excision and lymph node excision, and subsequently received systemic chemotherapy. After left supraclavicular lymph node recurrence appeared he later received radiotherapy. Complete response was achieved, and there has been no further recurrence, to date, 10 months after the radiotherapy. Radiotherapy was effective as a local treatment, and local control of distant metastasis of colonic cancer may lead to a good prognosis.

[Primary clear cell adenocarcinoma of the colon]

Clear cell adenocarcinoma generally develops in the kidney and the female genital organs. In 1964 the first case of primary clear cell adenocarcinoma of the colon was described. Since then less than 20 cases have been reported in the literature. We report a case of a 69-year-old man with a primary clear cell adenocarcinoma of the colon sigmoideum associated with adenoma and metastasis to two of 12 lymph nodes. Immunhistochemistry supported the diagnosis. The patient received adjuvant chemotherapy and 19 months following operation he was alive and had no signs of recurrences.

Uncommon metastatic site from breast cancer

INTRODUCTION

Breast cancer is one of the most common malignancies in women and the main leading cause of cancer death. The most frequent sites of metastases from breast cancer are bones, lungs, the central nervous system, the liver and soft tissue. Colonic metastases from breast cancer are rare.

CASE REPORT

We presented a 70-year-old woman with bulky obstructing lesion of sigmoid colon. A physician in charge on our department examined the patient and past history of breast cancer was found up. Surgery was performed with removal of sigmoid colon and three of six lymph nodes were positive. Pathological examination, including immunohistochemical stains, confirmed the diagnosis of metastatic breast cancer to sigmoid colon. The multidisciplinary oncology team suggested postoperative chemotherapy. The patient received four cycles of chemotherapy with paclitaxel followed by anastrozole. On the first control visit no disease activity was detected.

CONCLUSION

In patients with the past history of breast cancer the symptoms of hematochezia or anemia may indicate colonic metastases.

Isolated sigmoid colon metastasis from a primary fallopian tube carcinoma: a case report

Isolated metastasis of primary fallopian tube carcinoma (PFTC) is extremely rare. We describe a case of a 41-year-old asymptomatic woman who was referred three years after the initial treatment for PFTC due to elevated sertum CA-125 levels. The abdominal and pelvic CT scans revealed a pelvic mass near the top of the vaginal vault. On surgery, a sigmoid colon tumour was found and a sigmoidectomy was performed. On histopathology the tumour involved the bowel wall from serosa to submucosa, without involvement of the underlying mucosa. Immunohistochemical staining was positive for cytokeratin 7 and negative for cytokeratin 20, and the tumour was determined to be a metastatic müllerian neoplasm, consistent with the initial PFTC. Although this is the first reported case of colon metastasis of PFTC, the possibility of such an unusual site of metastasis should be kept in mind, as PFTC may recur as isolated bowel lesions even in the absence of peritoneal disease.

[Results of surgical treatment of locally-spread colorectal cancer]

During the period from 2001 to 2005 operations were performed on 186 patients with locally-spread colorectal cancer. In 132 cases (the 1st group) radical combined resections were performed, 54 patients (the 2nd group) underwent palliative operations. The morbidity rate was 18.2% (24 cases) in the first group and 7.4% (4 cases) in the second group. The mortality rate in the first group was 2.3% (3 cases), no mortality was observed in the second group. Overall 3-year survival in the first group was 69.9%, and no one patient of the second group survived longer than 3 years. Overall 5-year survival in the first group was 54.7%, and the relapse-free 5-year survival was 52.8%. The data obtained have shown the effectiveness of combined resections in treatment of locally-spread colorectal cancer. We suggest that further improvement of long-term results can be achieved using chemoradiation.

[Pleomorphic carcinoma of the lung with uncommon initial manifestation of intestinal perforation]

A 47-year-old woman suddenly developed abdominal pain and visited the emergency room of our hospital. Chest and abdominal CT scan revealed free air in the abdominal cavity and a bulky pulmonary tumor in the right middle lobe. The perforated sigmoid colon was removed in an emergency operation. Histological examination of the resected tissue revealed undifferentiated carcinoma, but the histological differentiation could not be determined. We used immunohistochemical staining to distinguish primary non-small cell lung cancer from colon cancer; the resected tumor was positive for TTF-1 and CK7, but negative for CK20. Therefore, by using immunohistochemical staining we could diagnose the tumor of the large intestine as metastasis from non-small cell lung cancer. After the operation, systemic chemotherapy with carboplatin and docetaxel was repeated, but the lung tumor did not regress and the patient died. Autopsy examination confirmed the histology of the lung tumor as pleomorphic carcinoma. Morphological characteristics and the immunohistochemical staining pattern of the pulmonary tumor were consistent with that of the colon tumor. In Japan, this is the first report in which the initial manifestation of lung cancer was perforation of the large intestine due to metastasis.

Squamous cell carcinoma arising in an ovarian mature cystic teratoma: a case report

Malignant transformation in a mature cystic teratoma of the ovary is rare. The most common malignancy is squamous cell carcinoma, which consists of about 75% of malignant transformations. In the present report, we describe a case of advanced-stage squamous cell carcinoma arising in a mature cystic teratoma. A postmenopausal 63-year-old woman with squamous cell carcinoma arising in a mature cystic teratoma is presented. The initial investigation by ultrasound showed a left adnexal mass with mixed echo pattern, which arose the suspension of malignancy. She underwent a laparotomy and left oophorectomy. Histopatholog was compatible with squamous cell carcinoma arising in a mature cystic teratoma. After a few episodes of intestinal obstruction and colostomy, she underwent partial resection of the ileum and sigmoid colon four months after the initial oophorectomy. Histopathologic study showed metastatic poorly-differentiated squamous cell carcinoma. Subsequently, she underwent two courses of combination chemotherapy with cisplatin, leucovorin, and 5-fluorouracil with no response. She died from progression of the disease nine months after the initial operation.

CT colonography to detect rectosigmoid involvement in patients with primary ovarian cancer

INTRODUCTION

We retrospectively evaluated the performance of preoperative computed tomographic (CT) colonography to detect tumor involvement of the rectosigmoid wall and predict the need for rectosigmoid resection in patients with primary ovarian cancer.

METHODS

Thirty-three patients with primary ovarian cancer who underwent preoperative CT colonographic examination were evaluated. The images of the examination were analyzed and compared with the subsequent surgical findings.

RESULTS

All abnormal findings (malignant infiltration of the rectosigmoid mucosa and extrinsic compression) revealed by conventional colonoscopy were correctly observed as extrinsic compression using CT colonography. The sensitivity, specificity, positive predictive value and negative predictive value of CT colonography for the prediction of rectosigmoid resection were 100%, 64.7%, 72.7%, and 100%, respectively. Though conventional colonoscopic examinations could not be completed in five patients because of the presence of extrinsic stenosis and occlusion at the sigmoid colon, CT colonography enabled the entire large bowel to be examined in these patients.

CONCLUSIONS

This preliminary study showed that the CT colonographic examination is feasible and safe. CT colonography seems to have several advantages over conventional colonoscopy for the detection of rectosigmoid involvement in patients with advanced ovarian cancer. For confirmation of the efficacy of CT colonography, further large prospective studies are needed.

A diagnostic dilemma following risk-reducing surgery for BRCA1 mutation - a case report of primary papillary serous carcinoma presenting as sigmoid cancer

Background

Women that carry germ-line mutations for BRCA1 or BRCA2 genes are at an increased risk of developing breast, ovarian and peritoneal cancer. Primary peritoneal carcinoma is a rare tumour histologically identical to papillary serous ovarian carcinoma. Risk-reducing surgery in the form of mastectomy and oophorectomy in premenopausal women has been recommended to prevent breast and ovarian cancer occurrence and decrease the risk of developing primary peritoneal cancer.

Case presentation

We present a case report of a woman with a strong family history of breast cancer who underwent risk-reducing surgery in the form of bilateral salpingo-oophorectomy following a mastectomy for a right-sided breast tumour. Following the finding of a BRCA1 mutation, a prophylactic left-sided mastectomy was performed. After remaining well for twenty-seven years, she presented with rectal bleeding and altered bowel habit, and was found to have a secondary cancer of the sigmoid colon. She was finally diagnosed with primary papillary serous carcinoma of the peritoneum (PSCP).

Conclusion

PSCP can present many years after risk-reducing surgery and be difficult to detect. Surveillance remains the best course of management for patients with known BRCA mutations.

Evaluating patients with mildly elevated transaminase levels

CASE STUDY

S.B. is a 52-year-old woman with recurrent stage IV ovarian cancer. She initially presented three and a half years ago with complaints of abdominal pain, increased abdominal girth, and abdominal bloating. A CA-125 blood test was elevated, and a computed tomography scan of the abdomen and pelvis revealed bilateral ovarian masses highly suspicious for malignancy. She was taken to surgery for a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and suboptimal tumor reduction. Pathology revealed poorly differentiated papillary serous ovarian cancer. Metastatic disease was noted in the rectosigmoid area and vaginal apex. Postoperatively, she received six cycles of paclitaxel and carboplatin. At completion, her CA-125 normalized and imaging studies showed no evidence of disease. However, within three months, her CA-125 was elevated and a palpable mass at the vaginal apex was proven by biopsy to be recurrent disease.

Oxaliplatin-related acute myelogenous leukemia

A 56-year-old woman diagnosed with a poorly differentiated cecal adenocarcinoma with metastases to ovaries, omentum, and sigmoid colon went into remission after 12 cycles of infusional 5-fluorouracil, luecovorin, and oxaliplatin (FOLFOX-4 regimen). Thirteen months later, a pelvic recurrence was diagnosed, and the patient received nine cycles of FOLFOX-6 plus bevacizumab, resulting in a clinical complete response but the development of pancytopenia. Bone marrow biopsy was consistent with therapy-related acute myelogenous leukemia. Chromosome analysis showed structural rearrangements with partial deletions of the long arms of chromosomes 5, 7, 20, and 21, as well as trisomy of chromosome 8 and losses of chromosomes 3 and 11. Induction chemotherapy led to remission, but the patient died two months later from complications of colon cancer progression. It is likely that the leukemia was related to the oxaliplatin administration.

Metastasis to sigmoid colon mucosa and submucosa from serous borderline ovarian tumor: response to hormone therapy

Distant metastasis to sites other than lymph nodes of borderline ovarian tumor is rare. We describe a case metastasized to sigmoid colon mucosa and submucosa. The metastatic lesion was detected incidentally by screening colonoscopy 7 years after the patient was treated for the primary tumor. The metastatic lesion responded well to treatment with oral Arimidex 1 mg/day. A follow-up colonoscopy with biopsy and imaging studies after 3 months of treatment revealed no evidence of disease in the sigmoid colon. This case showed that the sigmoid colon mucosa and submucosa should be considered as one of distant metastatic sites of a serous borderline ovarian tumor and the favorable response to Arimidex provides support the use of hormone therapy in women with serous borderline ovarian tumor.

Metastatic colon cancer from intrahepatic cholangiocarcinoma

A 62-year-old man had been followed because of an elevated serum level of carcinoembryonic antigen without the detection of any cancer lesions. However, there was a sudden increase in the serum level of carcinoembryonic antigen, and abdominal imagings showed a hepatic tumor with peripheral intrahepatic bile duct dilatation, and a submucosal tumor at the sigmoid colon with intact mucosa. Histopathological findings showed that the hepatic tumor had perineural invasion, suggesting an intrahepatic cholangiocarcinoma, and that the colon tumor infiltrated the submucosa, while its mucosa was intact. Both tumors showed similar pathological features and were positive for cytokeratin 20 and 7. These findings suggested intrahepatic cholangiocarcinoma with metastatic sigmoid colon cancer.

Subcutaneous Pneumocele Associated With Ventriculoperitoneal Shunt Migration Into the Mechanically Occluded Colon-Case Report-

A 62-year-old man presented with shunt failure manifesting as consciousness disturbance 4 years after placement of a ventriculoperitoneal shunt for subarachnoid hemorrhage. Physical examination found subcutaneous pneumocele around the peritoneal catheter extending from the abdomen to the neck. He had undergone pelvic radiation therapy for bladder cancer 2 years before. The peritoneal catheter was removed from the cervical region, and external ventricular drainage and a descending colon stoma for ileus release were positioned. The cerebrospinal fluid was clear and yielded no cultures. No inflammatory changes were seen. He developed carcinomatous peritonitis and died 4 months later. Retrograde colon gas reflux due to catheter perforation into the colon occluded by metastatic sigmoid cancer was probably the cause. Fragility of the wall of colon associated with the prior abdominal radiation therapy might have been a contributing factor. Subcutaneous pneumocele around the peritoneal catheter, i.e. pneumocele within the fibrous sheath surrounding the catheter, is a differential diagnosis to cerebrospinal fluid collection in patients with subcutaneous swelling around the catheter.

Metastatic Bednar tumor (pigmented dermatofibrosarcoma protuberans) with fibrosarcomatous change: a case report

Bednar tumor (pigmented dermatofibrosarcoma protuberans) is a variant of dermatofibrosarcoma protuberans (DFSP) that constitutes 5% of all DFSP and has a very low rate of distant metastases. We encountered a rare case of Bednar tumor with multiple different distant metastases. A 51-year-old man, who had had a history of mass resection in his left shoulder 4 years previously, was referred to our institution, complaining of a recurrence of the shoulder mass. The histological diagnosis of primary tumor was Bednar tumor, and he underwent resectional surgery for the recurrent lesion. A second local relapse, lung metastasis, retroperitoneal metastasis, and metastasis to the sigmoid colon have occurred. The recurrence lesion and all metastatic lesions were resected surgically. The histological features of all specimens showed fibrosarcomatous change. Seven months after the last surgical resection, the tumor recurred and the patient died of multiple abdominal metastases 10 years after the first surgical treatment.

Trophoblastic tissue spread to the sigmoid colon after uterine perforation

BACKGROUND

Trophoblastic tissue spread following uterine perforation during dilation and curettage is rare. We present a case of trophoblastic spread to the sigmoid colon following uterine perforation, which was treated by surgical removal of the implants and intramuscular administration of methotrexate.

CASE

A woman presented 3 weeks after curettage for a blighted ovum. Laparotomy performed for suspected intra-abdominal bleeding revealed bleeding trophoblastic implants in a perforation tract and the anterior uterine wall and on the appendix epiploica of the sigmoid colon. The implants were surgically removed and methotrexate was administered for persistently high beta-hCG levels. The patient fully recovered.

CONCLUSION

Extrauterine trophoblastic implants should be considered in women evaluated for abdominal pain whose pregnancy test is positive after uterine perforation. Conservative treatment with methotrexate in nonacute patients may be considered.

Atypical sigmoid metastasis from a high-grade mixed adenocarcinoma of the ovary

BACKGROUND

Intraperitoneal seeding is the most common form of dissemination of epithelial ovarian cancer. Metastasis to the bowel mucosa can occur by invasion from the serosal surface or infiltration of the submucosal capillary network. Hematogenous dissemination usually occurs in the presence of advanced peritoneal disease.

CASE

A 39-year-old gravida 3 para 2 woman was diagnosed in October 2000 with a large pelvic mass. She underwent an exploratory laparotomy and a left salpingo-oophorectomy with multiple abdominal and pelvic biopsies. She was diagnosed with an ovarian tumor of low malignant potential, and no further treatment was recommended. Six months later, she developed abdominal discomfort and constipation. A colonoscopy was performed, and a biopsy showed metastatic carcinoma of ovarian origin. The patient presented to The University of Texas M.D. Anderson Cancer Center in September 2001 for consultation. The surgical pathology evaluation from her previous surgery indicated high-grade ovarian carcinoma. The patient underwent a total abdominal hysterectomy, right salpingo-oophorectomy, infracolic omentectomy, right pelvic lymph node sampling, and segmental resection with primary end-to-end sigmoid colon anastomosis. The tumor within the colon was a polypoid mass arising from the mucosa with no involvement of the colonic wall. Microscopically, the tumor was a high-grade ovarian papillary serous carcinoma with areas of endometrioid adenocarcinoma. The colonic tumor was immunohistochemically positive for cytokeratin-7 and negative for cytokeratin-20. The patient was treated with six cycles of carboplatin and paclitaxel. The patient then incidentally developed disseminated sarcoidosis. At the time of this report, the patient had no evidence of recurrent or metastatic disease for 2 years.

CONCLUSIONS

Epithelial ovarian carcinomas may recur as intraluminal bowel lesions with serosal sparing even in the absence of peritoneal disease. Immunohistochemical staining using cytokeratins-7 and -20 may prove useful in differentiating such lesions from primary colonic malignancies.

[Atypical presentation of angiomiolypoma in a patient with peritoneal metastases from ovarian cancer: a case report]

A renal mass with not typical instrumental characteristic in patient in follow-up for ovarian neoplasia sets to the surgeon serious doubts about proper surgical strategy. Achieve of the conservative renal surgery assisted by the intraoperative use of the radiofrequency energy has allowed to preserve the renal function and the diagnosis of unknown angiomyolipoma.

[Secondary primary, bilocal sigmoid colon adenocarcinoma in a patient previously treated for testicular cancer]

Frequency of neoplastic diseases among patients cured successfully from testicular cancer is higher than in normal population. Synchronous occurrence of neoplasms in those patients is a rarity. The case of simultaneous adenocarcinoma of ascending and sigmoid colon in a man effectively treated before for testicular cancer is presented. The patient underwent nearly total colectomy and resection of the rectal polyp. Six months after operation patient did not present any features of neoplastic disease. This case is an illustration of the problem of cancerogenesis within polyps of the large bowel in patients treated before by chemotherapy because of testicular cancer.

Solitary papillary breast carcinoma metastasis to the large bowel presenting as primary colon carcinoma: case report and review of the literature

Breast carcinoma has the potential for widespread dissemination. Spread to the lower gastrointestinal tract is infrequent, often multifocal, occurs in association with spread to other sites, and most commonly develops from lobular carcinoma. Solitary colorectal metastasis as the first and sole manifestation of spread is a rare occurrence and can be confused with primary intestinal malignancy. We present a case of metastatic papillary breast carcinoma presenting as a perforated primary colon cancer. Identity of the lesion was confirmed by direct histologic comparison of the resected tumor with prior breast specimen, cytokeratin expression, and the presence of estrogen receptors.

Carcinoma in situ spread to mucosa of sigmoid colon neobladder

This is the first case of carcinoma in situ (CIS) of a transitional cell carcinoma that had spread into a neobladder constructed using a bowel segment associated with local recurrence at the ureteral-neobladder anastomosis. Considering that the CIS lesion was found in macroscopically intact epithelium remote from the main tumor, this strongly suggests that CIS could arise from solid tumor by implantation. Although some studies have reported secondary malignancy occurring in the neobladder, most have been adenocarcinoma that arose from the replaced bowel segment. To our knowledge, the present case is the first of widespread CIS of transitional cell carcinoma in an orthotopic neobladder.

Massive intestinal hemorrhage resulting from a polypoid tumor in the sigmoid colon: an unusual complication of a giant cell tumor of the fifth lumbar vertebra

STUDY DESIGN

Clinicopathologic study of a case of giant cell tumor of the spine.

SUMMARY OF BACKGROUND DATA

Giant cell tumors of the spine are uncommon, accounting for 1.3-6.5% of all cases in various series. Because of their location, they may cause neurologic deficits. The treatment consists of excision or curettage and has been claimed to give good results.

METHODS

A 33-year-old woman presented with low back pain in 1995; radiologic investigation and biopsy showed features of giant cell tumor involving the fifth lumbar and first sacral vertebrae. Wide excision was performed, but the tumor recurred in 1996 and was curetted. She developed massive intestinal bleeding in 1997 resulting from infiltration of the sigmoid colon by giant cell tumor in the form of a polypoid intraluminal mass. The involved segment of colon was resected, and the patient remained alive, although debilitated, 7 years after initial presentation.

RESULTS

Examination of the tumor in the spine and the colon showed typical histology of giant cell tumor with no evidence of malignant transformation. The involved colon was freely mobile and away from the tumor of the spine.

CONCLUSION

Giant cell tumor of the spine can result in unusual complication, massive intestinal hemorrhage in our case, which causes considerable morbidity.

Inhibin is more specific than calretinin as an immunohistochemical marker for differentiating sarcomatoid granulosa cell tumour of the ovary from other spindle cell neoplasms

AIMS

To describe a case of recurrent sarcomatoid adult granulosa cell tumour (AGCT) of the ovary and to evaluate the usefulness of two ovarian sex cord stromal markers (inhibin and calretinin) in separating sarcomatoid AGCT from true sarcomas.

METHODS

A 72 year old woman presented with a recurrent sarcomatoid AGCT in the sigmoid colon mesentery, which histologically mimicked a malignant gastrointestinal stromal tumour (GIST). This index case and 79 sarcomas (32 GISTs, 28 leiomyosarcomas, 15 endometrial stromal sarcomas (ESSs), including one with sex cord-like areas, and four undifferentiated uterine sarcomas) were immunostained using antibodies to inhibin and calretinin.

RESULTS

The recurrent sarcomatoid AGCT expressed diffuse, strong cytoplasmic immunoreactivity with inhibin and focal but strong nuclear and cytoplasmic positivity with calretinin. Focal, weak cytoplasmic inhibin expression limited to sex cord-like areas was present in one ESS. None of the other sarcomas expressed inhibin. Focal, strong calretinin immunoreactivity was identified in 11 leiomyosarcomas and one GIST. The case of ESS with sex cord-like areas showed strong immunoreactivity for calretinin limited to the sex cord-like areas.

CONCLUSIONS

Inhibin is a useful immunomarker to distinguish sarcomatoid AGCT from other spindle cell neoplasms that may enter into the differential diagnosis. Calretinin appears to be less specific than inhibin.

Metastasis to the Breast from Nonmammarian Solid Neoplasms: A Report of Five Cases

Primary breast carcinoma is the commonest neoplasm in women. Although rare, metastases of solid tumors from elsewhere to the breast may occur. Apart from cross-lymphatic metastasis from contralateral primary breast carcinoma, hematopoietic neoplasms occasionally involve the breast. As far as we know, less than 500 patients with secondary extramammary solid neoplasms involving the breasts have been reported in the English literature, of which malignant melanoma and lung tumors constitute the leading cause. Herein, five additional adult cases are reported and literature is reviewed. Two of the patients had primary rhabdomyosarcomas, two ovarian carcinomas, and one colon carcinoma. In one case with ovarian carcinoma, breast mass was the only manifestations of the disease relapse. All, except one with disseminated disease, had pathological diagnosis. Two of the patients died soon after the detection of breast metastasis. As a result, breast mass can be the first manifestation of relapse or part of a disseminated disease, and usually predicts poor survival.

Stenting the sigmoid colon in a terminally ill patient with prostate cancer

Large bowel obstruction in the terminally ill patient can be difficult to manage. We describe a patient with sigmoid colon obstruction caused by metastatic prostate cancer in the pelvis who required hospitalization because of severe pain and obstructive symptoms. Treatment with an endoscopically placed self-expandable metal stent allowed the patient to have immediate resolution of symptoms and to receive hospice care at home.

Overcoming Wallstent malposition in the treatment of rectosigmoid obstruction

In recent years, the use of transanal stenting of malignant colonic strictures for the palliation of obstructive symptoms has increased. Due to the rectosigmoid angle, stenting sigmoid tumors is more troublesome than rectal lesions, but the difficulty may be overcome by using a two-team approach. The radiologist assists the endoscopist with the use of fluoroscopy to ensure proper positioning of both the colonoscope and the stent. The most common complication is stent migration, but stent obstruction and colonic perforation may also occur. We treated a woman suffering from metastatic gastric cancer with peritoneal metastases by creating a 12-cm stricture in the sigmoid colon. Two adjoining Wallstents were required to bridge the obstruction. Following migration of the proximal stent, a third stent was introduced to bridge the previous two stents with satisfactory outcome.

Hormone replacement therapy after uterine leiomyosarcoma treatment. Case reports

Uterine sarcomas are extremely rare uterine malignancies; with a review of the literature we could not find any data dealing with exogenous oestrogens or combined hormone replacement therapy (HRT) after leiomyosarcoma treatment. We report two cases of patients with leiomyosarcoma of the uterine corpus. Both patients were without pelvic irradiation or exogenous oestrogen treatment before the diagnosis. Leiomyoma of the uterus was found during surgery in both cases. Both patients were receiving HRT with non-conjugated oestrogens, after an intensive non-hormonal treatment had failed. No recurrence was established after surgical treatment in the patient with 12 mitoses per 10 high power fields (HPF). The patient is still on HRT (61 months). The other patient with a leiomyosarcoma with very high mitotic activity (40 mitoses per 10 HPF) received cytostatic and irradiation therapy after surgery because of locally widespread disease. Ten months after the diagnosis and 3 months after beginning HRT, recurrence was observed. The patient thereupon stopped HRT. After two additional operations, the patient is alive and without evidence of disease. We presume that the present case reports observations might suggest that HRT did not appear to have a pronounced adverse effect on the leiomyosarcoma outcome in our patients. Nevertheless, until more collected data determine that HRT is safe, caution is needed.

[Positron-emission tomography with gamma camera in patients with colorectal and anal cancer. Preliminary results]

Metastasectomy after the primary surgical treatment of colorectal cancer may prolong survival in patients with resectable recurrences. Dedicated 18F-FDG-PET is of growing interest as a diagnostic tool in the staging and diagnosis of recurrent disease. We wanted in our departments to investigate whether a dual-head gamma camera with coincidence detection could serve as a substitute for the dedicated PET scanner. Twenty consecutive PET scans of 18F-FDG were performed by means of an Adac VertexPLUS gamma camera in 14 patients with colorectal cancer and four patients with anal cancer with known or suspected recurrences. Evaluation of the patients were, however, according to the routine in the department. In fourteen patients one or more abnormal foci were detected by PET, nine of these were verified by biopsy and one by renewed CT scan. In the four patients with negative PET the findings were in agreement with later biopsies. In one patient PET was "falsely" negative with regards to other processes than a solitary metastasis to be removed, as he six months later revealed dissemination confirmed by biopsy. Four patients with positive PET findings and elevated CEA remain to be evaluated. We conclude that PET with a coincidence detection gamma camera in this preliminary study seems to have the same possibilities to stage and diagnose recurrent anal- and colorectal cancer as the dedicated PET scanner.

Metabolic complications of urinary diversions: an overview

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

Indications for laparoscopic formation of intestinal stomas

A laparoscopic technique for formation of intestinal stomas is described and reported in four cases. The procedure has a role where difficulties with trephine stoma formation are anticipated, where simultaneous laparoscopic procedures are performed, and where accurate assessment of the extent of intra-abdominal malignancy is indicated.

[Pseudomyxoma peritonei associated with appendiceal mucinous cystadenoma. Report of a case and review of the literature]

Mucinous cystadenoma of the appendix is a rare entity. Its incidence is low, between 0.1 and 0.3%. Constitutes are found incidentally al surgery and is generally asymptomatic. We present a case of a 60 years old woman which was complicated by a pseudomyxoma peritonei, idiopathic ulcerative rectocolitis and infiltration of the muscular layer of the colon sigmoid wall with poorly differentiated adenocarcinoma. We reviewed the literature, emphasize modern concepts about its terminology and its possible pathogenesis.