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1/30. Molecular evidence of field cancerization in a patient with 7 tumors of the aerodigestive tract.

    Exposure of the mucosa of the upper aerodigestive tract to carcinogens can induce genetic changes resulting in various independent clones of neoplastic growth, a concept defined as "field cancerization." The risk of developing multiple tumors in this compartment of the body is well established. We studied 6 distinct tumors of the upper aerodigestive tract of a single patient for loss of heterozygosity (LOH), microsatellite instability (MSI), p53 mutations, and K-ras codon 12 point mutations. We detected a unique pattern of LOH and p53 mutations in all 6 tumors. No tumor showed a K-ras mutation or MSI. The results support the mechanism of "field cancerization" and illustrate the potential power of molecular techniques to elucidate pathogenesis. ( info)

2/30. Arterial and vena caval resections combined with pancreaticoduodenectomy in highly selected patients with periampullary malignancies.

    BACKGROUND/AIMS: To obtain a margin-negative resection and increase the indication for resection of periampullary malignancies, pancreaticoduodenectomy with a SM-PVR (superior mesenterico-portal vein resection) has been performed. However, an arterial resection, other vascular resections except SM-PVR (e.g., an inferior vena caval resection), or a metastatic tumor resection combined with pancreaticoduodenectomy has yet to be fully elucidated because of the high risk of postoperative complications and extremely poor long-term survival in patients undergoing these exceptional procedures. The present report focused on highly selected patients undergoing an arterial resection or a vena caval resection associated with pancreaticoduodenectomy. METHODOLOGY: Besides 31 patients with periampullary tumors undergoing pancreaticoduodenectomy associated with SM-PVR in our department, a group of 4 patients underwent arterial resections and another patient underwent pancreaticoduodenectomy combined with a resection of liver metastasis together with an inferior vena caval resection. These five patients were reported in the present study. RESULTS: A 27 year-old-woman presented pancreatic ductal adenocarcinoma of the pancreatic head and a liver metastasis in which involvements of the superior mesenterico-portal vein and the inferior vena cava were shown. pancreaticoduodenectomy was performed with SM-PVR associated with a left hemihepatectomy combined with a segment 1 resection and an inferior vena caval resection. The patient did not present severe postoperative complications and experienced a good quality of life during 16 months after surgery. Four other patients underwent arterial resections. These arterial resections were performed only when a margin-negative resection was feasible. The superior mesenteric artery was resected and reconstructed with a Goretex graft in one patient. The right hepatic artery was resected and reconstructed with a saphenous graft in two patients. The other patient underwent a resection of the common hepatic artery and reconstruction was performed with the splenic artery. Three of the four patients presented postoperative complications but were conservatively treated. Two patients are still alive 25 months and 8 months after surgery. One patient died of sepsis 5 months after surgery, and the other died of cancer progression 19 months after surgery. CONCLUSIONS: The indication for retropancreatic arterial resection associated with pancreaticoduodenectomy should be carefully evaluated only when a margin-negative resection can be achieved. An appropriate bypass method of arterial reconstruction should be selected because a direct end-to-end anastomosis is not always feasible. hepatectomy for metastases of pancreatic ductal carcinoma should be also regarded as an exceptional procedure. ( info)

3/30. Transcatheter microcoil embolotherapy for ruptured pseudoaneurysm following pancreatic and biliary surgery.

    PURPOSE: To evaluate the outcome of transcatheter microcoil embolotherapy for bleeding pseudoaneurysms complicating major pancreatic and biliary surgery. MATERIALS AND methods: Over an 8-year period, 8 patients were encountered who developed massive bleeding from pseudoaneurysms 15-64 days (mean 31 days) following major pancreatic and biliary surgery. Urgent transcatheter microcoil embolotherapy was performed in all 8 patients. RESULTS: Transcatheter embolotherapy was successful in 7 of 8 patients (88%) but failed in one due to development of disseminated intravascular coagulation. One patient developed recurrent bleeding 36 days after the first embolotherapy from a newly developed pseudoaneurysm, which was again treated successfully with embolization. Two patients subsequently underwent additional surgery for residual pathology. Three of the 7 patients with successful embolotherapy were alive at 10-96 months, 4 patients died of associated malignancies 4-20 months after embolotherapy. CONCLUSION: Transcatheter microcoil embolotherapy is effective for bleeding pseudoaneurysms complicating pancreatic and biliary surgery, and should be considered the first treatment of choice. ( info)

4/30. Mucinous digestive tumors. case reports and review of the literature.

    We present three rare entities of mucinous tumors: appendiceal mucinous adenomas, enteroid mucinous cyst and pseudomyxoma peritonei, the latter as a developmental course or separate idiopathic etiology of mucinous tumors. We attempted to clarify the term of pseudomyxoma peritonei, a poorly understood condition, characterized by a diffuse intraperitoneal collection of gelatinous fluid with mucinous tumoral implants on the peritoneal surfaces. With this rare condition it is often difficult to establish the histological and developmental malignant or benign characteristics. We analyzed 4 patients admitted during the period of February 2000 - February 2002 in the First Surgical Clinic of St. Spiridon Hospital and in addition we referred to the current approach in the recent literature. In three of the four patients the diagnosis was possible preoperatively by imaging techniques and consequently they were operated by laparoscopic procedure for the complete removal of tumor cells at macroscopic level. We preferred to administrate chemotherapy accordingly to the malignant/ benign aspect, choosing the long term follow up of the patients to ward off the eventual relapse. We considered the future state of these cases to be uneventful, with a real chance of long term survival. In conclusion, the symptoms are not always specific, allowing errors in diagnosis. Imaging techniques offer real elements of diagnosis. Laparoscopic techniques could offer an oncologic approach with no less benefit compared to open surgery. This methodology also allows different surgery for a different pathology at the same time. The origin of these tumors is more frequently digestive and less ovarian. ( info)

5/30. Surgical management of distant melanoma metastases.

    Disseminated melanoma remains a tumour that is poorly responsive to chemotherapy and radiotherapy. However, this review demonstrates that surgical removal of visceral metastases such as at the, lung or digestive sites, as well as the brain, yields consistent median survivals, often longer than 12 months, and long-term survivors. Such surgery is followed by little complication cost and low perioperative mortality. Our experience tends to confirm that complete debulking offers longer survivors as compared to partial. Also, one site of metastases, whatever its anatomical location, when operated on, gives a better chance for survival than when there are multiple sites. ( info)

6/30. First reported case of esophageal paraganglioma. A review of the literature of gastrointestinal tract paraganglioma including gangliocytic paraganglioma.

    paraganglioma and the variant gangliocytic paraganglioma are rare gastrointestinal tumors. We present the first reported case of an esophageal paraganglioma and a review of the literature. From this review it seems that these tumors can occur at any age and usually present with acute or chronic bleeding with or without abdominal pain. The majority of reported cases originated in the foregut, most commonly the second part of the duodenum. Macroscopically the tumor may be pedunculated, sessile or ulcerated and have been described up to 10 cm in size. There are no reported cases of gut paragangliomas shown to be producing clinically significant amounts of catecholamines. The majority of reported tumors have been benign, only 7% malignant at presentation and all with lymph node metastases. One case developed bone metastases 3 years after excision and another recurred locally. There has been no benefit seen from radiotherapy or chemotherapy to date and it is recommended that all of these tumors are widely excised together with a lymph node resection if possible. ( info)

7/30. Metastatic cancer to the renal pelvis: a novel approach to management.

    We describe a novel application of percutaneous renal surgery for the management of an unusual and challenging urologic problem. Two patients with symptomatic, metastatic adenocarcinoma in the renal pelvis were treated with percutaneous resection. The lesion was in a solitary kidney in 1 patient, and was bilateral in the second. Percutaneous resection resulted in complete relief of symptoms and obstruction. Although both patients ultimately died of their primary disease, their quality of life was significantly improved in the interim. Percutaneous resection of renal pelvic tumors is accepted management for select patients with upper tract transitional cell carcinoma. These 2 cases demonstrated both an unusual presentation for metastatic adenocarcinoma and an expanded application for percutaneous renal surgery. ( info)

8/30. Laparoscopic surgery for the management of obstruction of the gastric outlet and small bowel following previous laparotomy for major upper gastrointestinal resection or cancer palliation: a new concept.

    BACKGROUND: Surgical relief of gastric outlet obstruction (GOO) or small bowel obstruction in patients who had undergone major resection or palliative bypass surgery for malignancy is conventionally achieved at a laparotomy. The potential role of minimally invasive surgery in the management of these complications has not been previously explored. methods: Between 2003 and 2004, 4 consecutive patients, age range 37 to 72 years, where admitted with gastric outlet or proximal small bowel obstruction following previous open surgery for suspected intra-abdominal malignancy, under the care of one surgeon. The respective past histories of these patients were recurrent GOO and concomitant distal biliary obstruction following a previous open gastric bypass elsewhere for metastatic pancreatic head cancer; persistent adhesive small bowel obstruction following radical gastrectomy for gastric cancer; GOO secondary to intra-abdominal recurrence 6 months after hepatobiliary resection for hilar cholangiocarcinoma; and GOO following previous pancreatico-duodenectomy for suspected pancreatic head cancer. Their respective surgical management consisted of a laparoscopic re-do gastric bypass and concomitant cholecystojejunostomy; adhesiolysis and revision of the Roux-en-Y enteric anastomosis; a Devine exclusion gastroenterostomy; and resection and refashioning of the gastroenterostomy. RESULTS: There were no conversions to open surgery and no postoperative complications. The median operating time was 240 minutes (range, 145 to 300 minutes). Oral free fluid intake was resumed on postoperative day (POD) 1, while diet was resumed between POD 2 and 4. The median postoperative hospital stay was 15.5 days (range, 14 to 25 days). CONCLUSION: Previous laparotomy and major resection or palliation of malignancy do not preclude the application of the laparoscopic approach for the management of upper gastrointestinal obstruction. Laparoscopic adhesiolysis and revision of enteroenteric and gastroenteric anastomoses are feasible management options in the hands of those experienced with complex laparoscopic surgery. ( info)

9/30. Multiple effects of somatostatin analogs verified in three cases of metastasized neuroendocrine tumors of the gastroenteropancreatic system.

    AIMS AND BACKGROUND: In neuroendocrine tumors of the gastroenteropancreatic (GEP) system, radiolabeled analogs of somatostatin (SST) are useful to the surgeon in different phases of treatment: preoperatively, to identify the lesion with somato-statin receptor scintigraphy (SRS), intraoperatively for localization using a hand-held gamma probe, and postoperatively acting directly to eliminate any residual tumor cells. Additional features of these analogs that are of value in treating such GEP tumors include their antiproliferative potential, which is in the process of being verified, and, above all, their anti-secretory action, so effective in symptom control. In this study the authors, based on their own experience, evaluate the effectiveness of SST analogs in treating GEP endocrine tumors. methods: Three patients with malignant GEP apudomas were studied. In case 1, an insulinoma, the patient underwent four surgical procedures for ablation of the pancreatic tumor and of hepatic and lymph node metastases in addition to local radiofrequency treatment and radiometabolic therapy. Case 2 was a carcinoid tumor of the small intestine with hepatic metastases, managed by ileal resection, local radiofrequency treatment and receptor-mediated radionuclide therapy. In case 3, a non-functioning pancreatic carcinoma with liver and lymph node metastases, the patient underwent four surgical procedures, hepatic chemoembolization, antiproliferative treatment using octreotide (OCT) and metabolic radionuclide therapy. RESULTS: In all three cases SRS proved highly sensitive in the early detection of even the smallest recurrences. There was uncertainty, however, regarding the effectiveness of therapy with radiolabeled SST analogs. Hepatic metastases from the carcinoid were completely unresponsive, but in the case of the insulinoma, the hepatic metastases showed necrosis following treatment, while lymph node metastases were unaffected. In the case of the non-functioning carcinoma, there was a correlation between treatment and a marked improvement in the patient's clinical condition, although the appearance of the lesions themselves remained unchanged. The antiproliferative effect of OCT in this case was nil. CONCLUSIONS: SRS proved highly accurate in detecting recurrences during follow-up. The merits of radiometabolic therapy, on the other hand, were unclear, a finding reported elsewhere in the literature, and in the only case treated by prolonged OCT treatment, no antiproliferative action was observed. The diagnostic usefulness of SRS was thus confirmed and it appears likely that radiolabeled analogs used intraoperatively for tumor localization will prove equally of value. The effectiveness of receptor-mediated radionuclide therapy is still in the process of being verified. Based on the expectation of analogs with an universal affinity for SST receptors (sst), it is reasonable to look forward to a significant increase in the efficacy of this type of therapy. ( info)

10/30. Familial multiple upper gastrointestinal leiomyoma.

    This report describes three adult members of a family who developed leiomyomas in the muscularis propria of their upper gastrointestinal tract. When in their thirties, numerous leiomyomas were present in ileum and jejunum. In their sixties, multiple and confluent esophageal leiomyomas formed the clinical picture of esophageal leiomyomatosis. Presenting symptoms were esophageal obstruction and hemorrhage. This is the first case in the published literature describing an association of familial multiple upper gastrointestinal leiomyomas with esophageal leiomyomatosis. ( info)
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