Upper Gastrointestinal Bleeding - Initial Manifestation of Pancreatic Head Carcinoma

Pancreatic head carcinomas are a rare cause of upper digestive bleeding and the diagnosis and the treatment of these pose particular problems. We selected 6 cases from a number of 283 patients who were hospitalized for surgery between January 2014 and December 2016 with signs of upper digestive bleeding with no varicose origin who were subsequently diagnosed with pancreatic head carcinomas. The diagnosis was established by endoscopic and surgical methods. The evolution of these patients was influenced by whether there was active digestive bleeding or history of digestive bleeding and the possibility of tumor resection. Four patients needed emergency surgery due to continuous bleeding or rebleeding. The resectability of the cephalo-pancreatic tumor was determined and then subsequently performed in two patients who had a favorable postoperative outcome, while in two patients the tumor resection was impossible. The other two patients with upper digestive haemorrhage responded favorable to drug therapy, and digestive endoscopy and CT explorations were negative. After a 5-month interval they presented with clinical signs of a pancreatic neoplasm with invasion into the common bile duct, unwanted weight loss, abdominal pain, and icterus of the sclera and skin. The surgical intervention resulted in the confirmation of locally advanced pancreatic head carcinomas and the performing of bilio-digestive derivations. Pancreatic head carcinomas may be associated with upper digestive tract haemorrhage due to duodenal or bile duct invasion. The clinical picture of these patients can vary from occult haemorrhage to severe upper digestive tract haemorrhage accompanied by hypovolemic shock.

Local surgical treatment with curative intent in rectal cancer

The surgical treatment of rectal cancer includes radical resection techniques and local excision procedures. Radical resection techniques are still the golden standard in the management of rectal cancer, but the increased postoperative morbidity and mortality led to the idea that less traumatizing procedures of local excision may have the same oncologic results, in selected cases. Yet, the significantly higher local recurrence rate after local excision in comparison to radical resection has been certified by most studies; that points out the need of clearly defined guidelines for local excision. In the present review the following aspects were taken into consideration, when considering local surgical excision as a radical procedure for rectal cancer: the clinico-pathological features of the tumours, the various types of surgical techniques used in local excision, the need for an adjuvant or neoadjuvant oncological treatment, the variety of results obtained in a large number of studies, making this particular issue a topic that is currently subject to debate.

Intestinal perforated malignant melanoma: diagnostic and therapeutic difficulties

The intestinal malignant melanoma is a rare occurrence in the daily surgical practice, with difficult diagnosis (even on usual pathologic examination) and therapeutic attitude. Most of the lesions are secondary to a cutaneous primary melanoma, but there are cases in which the original site may not be discovered, and are considered as primitive intestinal melanomas. This paper presents the case of a 50 year old male patient, diagnosed and operated as emergency with acute abdomen caused by a tumoral perforation of the small bowel; several tumors, in different stages of local evolution, were discovered during laparotomy. A triple enterectomy with end-to-end entero-enteral anastomosis was performed, with uneventful postoperative recovery. The later postoperative evolution was marked by the occurrence of multiple subcutaneous recurrences and a bulky metastasis in the mediastinum; 18 month after the initial surgery, the patient died due to the melanoma recurrence. Diagnostic and therapeutic difficulties are discussed in this paper, related especially to the differential diagnosis of the origin of the intestinal lesion (a metastatic melanoma with unknown primary site or a primary malignant melanoma of the small bowel), since no other sites of origin were discovered after a thorough examination.

The prognostic value of the immunohistochemical aspects of tumor suppressor genes p53, bcl-2, PTEN and nuclear proliferative antigen Ki-67 in resected colorectal carcinoma

This study aim was to identify the relations between tumor suppressor genes (p53, bcl-2, PTEN), nuclear proliferative antigen Ki-67 and epidemiologic, morphologic and histologic patient related factors, in colorectal cancer.

MATERIALS AND METHODS

Twenty-two prospectively collected colorectal cancer resection specimens were histologically prepared, using standard paraffin-embedded and Hematoxylin-Eosin staining method; for immunohistochemical study, the Streptavidin-Biotin (sABC)/Horseradish Peroxidase (HRP) method was used.

RESULTS

P53 was positive in 86.36% of cases, more intense (>50%) in rectal cancer and in women 59.16 ± 9.49-year-old; the G1/2 adenocarcinoma was dominant. Bcl-2 was positive in 18.18% of the cases, in distal colorectal cancer, only in men, 63.5 ± 13.2-year-old. PTEN was positive in 95.45% of the cases; intense positivity was recorded in 12 men and six women, 61.47 ± 11.67-year-old, in rectal topography. Ki-67 was positive in 86.36% of the cases, more intense in four men and four women, 63.45 ± 12.22-year-old, in proximal and advanced colorectal cancers (pT3N1/2 - 62.5%).

CONCLUSIONS

Tumor suppressor genes mutations are often present in colorectal cancer; the intensity of the expression of these mutations varies, which could explain the different prognosis for these patients.

Sentinel lymph node study in colorectal cancer using serial sectioning and Hematoxylin-Eosin staining: importance and limitations

The lymph node involvement represents an important predictor for survival in colorectal cancer; consequently, the best pathologic evaluation is necessary in order to adequately assess the lymph node status. This study aims to evaluate the impact of sentinel lymph node technique in colorectal cancer in lymphatic basin staging. The study included 43 consecutive operated cases, in which the identification of sentinel lymph node was performed during surgery (in vivo procedure - colon cancer) or immediately after the removal of the resection specimen (ex vivo procedure - rectal cancer). These cases were matched with 45 control cases. The identified sentinel lymph node was separately examined using multiple sections and Hematoxylin-Eosin staining method. The detection rate, accuracy, sensitivity and false negative rate were better for colon cancer (86.36%; 84.21%; 66.66%; 23.07%) vs. rectal cancer (61.9%; 84.61%; 50%; 18.18%), but there are no arguments for the feasibility of the technique in every day practice. Further studies and methods are mandatory in order to improve the staging of the pN status in colon and rectal cancer.