Abstract: AIM: In this study, we analyze clinical parameters, survival and possible advantage of surgery in patients affected by symptomatic Dukes D colorectal cancer. METHODS: From July 2005 to December 2008 at our Oncological Surgery Unit we treated 69 symptomatic stage IV CRC, 46 of them resected at our Oncological Surgical Unit. Clinical variables were tested for their relationship to survival in a univariate prognostic analysis and revealed the interaction of the prognostic factors. RESULTS: In symptomatic stage IV CRC with noncurable resection, the most robust univariate predictor for poor prognosis was impossibility to cancer resection. It is associated with significative decrease of survival also in the short term. In our series we do not observe correlation between poor prognosis and age, gender, localisation of tumor, depth of invasion, 19.9 and surgeons. CEA more than 100 microg/L and impossibility to adiuvant therapy have a significative role and are associated with poor prognosis. CONCLUSION: Our results suggested that impossibility to perform cancer resection is associated with poor prognosis in symptomatic stage IV CRC and worse survival also in the short term.
Abstract: AIM: Colorectal cancer (CRC) harbors accumulated genetic alterations with cancer progression, which results in uncontrollable disease. To regulate the most malignant CRC, we have to know the most dismal phenotype of stage IV disease. METHODS: A retrospective review of our Oncological Surgical Unit was performed (from 2005 to 2008) to extract the 52 resected stage IV CRC. Clinical variables were tested for their relationship to survival in a univariate prognostic analysis and revealed the interaction of the prognostic factors. RESULTS: In stage IV CRC with noncurable resection, the most robust univariate predictors for poor prognosis were preoperative high value of CEA. In our series we did not observe correlation between poor prognosis and depth of invasion, age, gender, pathologic lymph node metastasis status, Ca 19.9 and postoperative therapy. The mean average survival rate was 10.9 months. CONCLUSIONS: Our results suggested that only preoperative value CEA is associated with poor prognosis in stage IV CRC.
Abstract: AIM: The aim of this study was to analyze the factors affecting the number of lymph nodes examined in colorectal cancer specimens after elective or urgent surgery on the current clinical practice in our surgical unit. METHODS: The authors considered 120 patients who had undergone surgery for colorectal carcinoma from July 2005 to December 2007 divided into two groups, 102 elective oncologic resections (group A) and 18 performed in emergency (group B). All patients underwent laparotomic colorectal resection. The groups were similar in age, weight and body mass index, different in gender e in cancer stage. The authors analyze prognostic differences in number of examined lymph nodes and factors involved in differences between groups. RESULTS: There were no statistically significative differences in number of nodes harvested in specimen (15.85+/-8.17, CI 95% 14.25-17.46 for group A and 13.83+/-6.56, CI 95% 10.57-17.09 for group B, P-value 0.36). Operating time was shorter in group B (P-value 0.012). We not observed differences between groups in survival rate (P-value 0.62). CONCLUSIONS: The results of the study suggest that a correct lymphadenectomy and an adequate lymph node harvest in colorectal cancer surgery is essential also in resections performed in urgency, to allow a correct staging and an accurate selection of patients for adjuvant chemotherapy, with improvement of results at follow-up.
Abstract: Small bowel metastases from a primary lung carcinoma are rare. We report a case of a 76-year-old male with a primary neuroendocrine small cell carcinoma of the lung, treated by chemotherapy, who developed fever and bowel symptoms (subocclusion and pain). On CT examination, he was found to have a tumour in the small bowel. The patient then underwent abdominal surgery. At operation we found small bowel occlusion by neoplasia and we therefore resected 15 cm of ileum with a side-to-side anastomosis. Early recognition of this rare condition is important due to the fact that complicated intestinal metastases from lung carcinoma can lead to high mortality rates and poor short-term outcomes. With advances in chemotherapy and palliative care, patients with metastatic lung carcinoma can sometimes survive more than a year with a reasonable quality of life.
Abstract: Here we report a case of a 60 years old woman who came to the Emergency Department of San Martino Hospital suffering from abdominal pain for about a week with high fever in the last 24 hours. The final histological examination led to the diagnosis of ileal diverticulosis associated with perforation and peritonitis with a fibrotic reaction involving the last ileal loop, the caecum and the appendix.
Abstract: Versione italiana Riassunto: Deiscenza di anastomosi colorettale dopo terapia neoadiuvante con bevacizumab. Case report. S. Scabini, D. Pertile, R. Boaretto, E. Rimini, E. Romairone, R. Scordamaglia, V. Ferrando Premessa. Nonostante i progressi ottenuti nelle ultime decadi nel trattamento del cancro del retto, la deiscenza anastomotica continua ad essere la principale complicanza chirurgica. Pazienti e metodi. Si riportano due casi di pazienti con quadro di piccola deiscenza, o forse di microperforazione, dopo resezione anteriore del retto, entrambi trattati con bevacizumab. I pazienti erano affetti da adenocarcinoma del retto inferiore e avevano ricevuto una terapia neoadiuvante secondo il protocollo sperimentale di fase II ROCHE ML 18522 (comprendente Xeloda(R), Avastin(R) e radioterapia). A distanza rispettivamente di uno e due mesi dall'intervento chirurgico di resezione anteriore del retto, con anastomosi ultrabassa e colostomia temporanea, i pazienti hanno presentato un quadro clinico-strumentale di ascesso pelvico presacrale, che ha reso necessari il ricovero e l'instaurazione di una terapia antibiotica, in un caso associata al posizionamento di un drenaggio sotto guida TC. Risultati. Ambedue i pazienti hanno avuto un decorso favorevole ed è stata soppressa la colostomia derivativa a distanza di sei mesi e un anno dall'intervento. Discussione. Sono state segnalate in corso di terapia con bevacizumab, anticorpo monoclonale contro il VEGF (Vascular Endothelial Growth Factor), perforazioni gastrointestinali "spontanee", anche in pazienti affetti da tumori non digestivi; verosimilmente esse sarebbero indotte dalla capacità del farmaco di inibire la neoangiogenesi. Conclusioni. Molta attenzione va rivolta agli "effetti indesiderati" del trattamento neoadiuvante combinato del cancro del retto, valutando, in presenza di determinati fattori di rischio, il confezionamento di una colostomia temporanea. English version Summary: Leakage of colorectal anastomosis after neoadjuvant therapy with bevacizumab. Case report. S. Scabini, D. Pertile, R. Boaretto, E. Rimini, E. Romairone, R. Scordamaglia, V. Ferrando Background. Despite progresses achieved in last decades in treatment of rectal cancer, anastomotic leakage remains the main complication. Patients and methods. We report two cases of patients affected by distal rectal cancer. Both patients received neoadjuvant therapy according to ROCHE ML 18522 experimental protocol (Xeloda(R), Avastin(R) and radiotherapy). After about respectively one and two months after anterior resection of the rectum, with transanal anastomosis and temporary colostomy, presacral abscess occurred. Patients were hospitalized and started antibiotic therapy. In one case it was necessary TC-guided drainage placement. Results. Both patients had a favourable course and, after respectively 6 months and 1 year, underwent closure of colostomy. Discussion. "Spontaneous" gastrointestinal microperforation (small leakage) is reported during treatment with bevacizumab, a monoclonal antibody against Vascular Endothelial Growth Factor (VEGF), also in patients with non gastrointestine tumours. Probably this results from inhibition of neoangiogenesis induced. Conclusions. Surgeons have to pay attention to adverse effects of combined neoadiuvant treatment of rectal cancer, considering temporary colostomy in presence of particular risk factors.
Abstract: BACKGROUND: Urachal carcinoma is an uncommon neoplasm associated with poor prognosis. CASE PRESENTATION: A 45-year-old man was admitted with complaints of abdominal pain and pollakisuria. A soft mass was palpable under his navel. TC-scan revealed a 11 x 6 cm tumor, which was composed of a cystic lesion arising from the urachus and a solid mass component at the urinary bladder dome. The tumor was removed surgically. Histological examination detected poor-differentiated adenocarcinoma, which had invaded the urinary bladder. The patient has been followed up without recurrence for 6 months. CONCLUSION: The urachus is the embryological remnant of urogenital sinus and allantois. Involution usually happens before birth and urachus is present as a median umbilical ligament. The pathogenesis of urachal tumours is not fully understood. Surgery is the treatment of choice and role of adjuvant treatment is not clearly understood.
Abstract: AIM: The aim of this study was to compare the safety, the efficacy and the oncologic results in rectal cancer with total mesorectal excision using Ligasure (LS), a modern bipolar vessel sealing system, with monopolar electrocoagulation or stitches (ME). METHODS: From July 2005 to December 2007 one hundred twenty-nine patients underwent colon resection for cancer at the San Martino Hospital of Genoa (Italy); 43 patients underwent rectal resection. All patients underwent laparotomy rectal resection with total mesorectal excision; 9 (21%, group LS) underwent total mesorectal excision with radiofrequency, 34 (79%, group ME) with monopolar electrocoagulations, vessels ligation or stitches. Patients of group LS were similar to patients of group ME in age, gender, weight and body mass index. Cancer stage was for group A 3 stage B, 5 stage C and 1 stage D, for group B 4 stage A, 15 stage B, 8 stage C, 6 stage D and 1 non-staged tumor. RESULTS: There were no differences in intraoperative or postoperative complications. Operating time was similar in both group. Oncological results was similar in both groups. The major cost in group LS were attributable to cost of service. CONCLUSION: The Ligasure device does not reduce operating time in laparotomy rectal cancer resection but permit correct oncological results in patients submitted to total mesorectal excision. The costs of device reserved its use to surgery of low-rectal cancer or laparoscopic approach.
Abstract: The case of a 27-year-old woman, admitted to our surgical ward with symptoms of epigastric-ache, postmeal vomiting and significant weight loss, is reported. Clinical and radiographic suspicion of mesenterium commune, with duodenal compression due to bands, requested an explorative laparatomy that confirmed the mesenterium commune presence with left caecum and colon adhesion and left Bochdaleck hernia, which is rare in adult age.
Abstract: Vascular leiomyosarcoma (LMS)is a rare malignant tumor arising from the muscle cells of the media of the vessels. Vascular LMS is often diagnosed as a result of the clinical manifestations of impaired venous flow such as edema and phlebothrombosis. The authors present a case of an LMS in a 72-year-old woman. Physical examination revealed a round mass deep in the left inguinal region close to the inguinal vessels, fixed and not pulsating. There was no sign of left lower-limb edema nor of articular impairment of the hip. Inguinal and distal pulses were normal. Results of laboratory analysis, including values for the oncologic markers, were normal. An ultrasound scan of the left inguinal fossa showed a 50-by-30 mm mass of mixed aspect that adhered to the left common iliac artery. An echo color Doppler showed conservative arterial flow. Thus, a thrombotic aneurysm of the left iliac artery was diagnosed. Chest x-ray showed no pathological findings. An abdominal computerized tomograph (CT) scan confirmed the location of the neoplasm and revealed a narrowing of the left iliac vein compressed behind the mass. The finding was interpreted as a colliquative lymph node. The patient underwent explorative laparotomy with midline incision. The finding was a neoplastic bilobed mass compressing and infiltrating the left iliac vein with no cleavage surface between the mass itself and the venous wall. An intraoperative frozen section revealed a necrotic mass with a cortex of ambiguous interpretation. Surgical procedure was then finished with no further venous resection. Histologic examination revealed the presence of leiomyosarcomatous tissue with nuclear pleomorphisms inside necrotic material limited by a thin fibrotic capsule. According to Coindre's classification the tumor was a G3. After six months the patient is fit and a CT scan showed no evidence of recurring disease.
