[The sentinel lymph node mapping in colon cancer]

BACKGROUND

malignant tumors of the colon can metastases along the lymphatic system in a sequential way, which means that there will be a first node to be involved and then from this disease will pass to another node and so gradually. The sentinel lymph node is the first lymph node or group of nodes reached by metastasizing cancer cells from a tumor.

OBJECTIVES

the present work aims to determine the predictive value of the sentinel lymph node procedure in the staging of non-metastatic colon cancer.

PATIENTS AND METHODS

in this prospective study joined up only 26 patients with adenocarcinoma of the colon T2-T3, without systemic metastases, and with these criteria for inclusion: a) minimum age: 18 years old; b) staging by total colonoscopy, chest X-ray and CT scan; c) patients classified as ASA 1-3; d) informed consent. Within 20 minutes from the colic resection, the bowel was cut completely along the antimesenteric margin and is performed submucosal injection of vital dye within 5 mm from the lesion at the level of the four cardinal points; then the lymph nodes are placed in formalin and sent to the pathologist. The lymph nodes were subjected to histological examination with haematoxylin-eosin and with the immunohistochemistry technique.

RESULTS

from January to December 2008 only 26 patients joined up in this prospective study. From the study were excluded the 4 patients with T4 and M1 tumour. Also 7 patients with stenotic lesions were excluded. Patients considered eligible for our study were only 14. The histopathological examination of haematoxylin-eosin revealed: a) in 4 cases were detected mesocolic lymph node metastases; b) in 10 cases were not detected mesocolic lymph node metastases. In cases there were no metastases, the mesocolic sentinel lymph nodes lymph nodes were examined with immunohistochemical technique; in 2 cases were revealed the presence of micrometastases. In one case was identified aberrant lymphatic drainage patterns (skip metastasis); the sentinel lymph node (negative examination wit eaematoxylin-eosin) was studied with immunohistochemical technique that has not revealed the presence of micrometastases.

CONCLUSIONS

the examination of the sentinel node is feasible with the ex vivo method. Using the immunohistochemical technique we detect micrometastasis in 20% of the cases, not revealed with the classical haematoxylin-eosin examination. The study of sentinel lymph node with multilevel microsections and immunohistochemical techniques allow a better histopathological staging.

[Presacral myelolipoma: a case report]

BACKGROUND

Presacral tumors are more frequently benign, and only occasionally malignant, showing a slow growth and an incidence of 1:40.000. They are asymptomatic in the 26-50% of the cases. When symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection.

CASE REPORT

We report the case of a 69-year old woman with a lower abdominal pain associated with paresthesia and ipostenia of the right inferior limb. Digital rectal examination showed a fixed, mild tender and hard tumor of the posterior rectal wall. CT, MR and CT-guided biopsy sequently performed revealed a solid, dishomogeneous mass, located in the presacral region, with a connective likely origin, without pelvic lymphoadenopathy. The operation allowed to esteem a mass which was tenaciously adherent to the sacrum. We performed a total excision. Final histological diagnosis was myelolipoma.

CONCLUSIONS

The Authors' opinion is that the en-bloc resection of these tumors with an anterior surgical approach allows a histological diagnosis of the nature, representing the best treatment for potentially malignant lesions, which are frequently radio and chemo-resistant.

[Abdominal compartimental syndrome as a complica-tion of Fournier's gangrene]

Analyzing a complex case and referring to the literature, the authors describe abdominal compartmental syndrome as a complication of Fournier's gangrene, stressing out the importance of an early diagnosis to perform prompt and effective treatment. The characteristic of this case is not represented only by the Fournier's gangrene rarity, but also by the appearance of an abdominal compartmental syndrome due to the gangrene extension from the scrotum to the abdominal wall and cavity through the spermatic funiculus. The treatment of the abdominal compartmental syndrome was the surgical toilette of the necrotic regions (scrotum, abdominal wall and cavity) together with an orchiectomy.

An unusual case of rectal carcinoid removed by transanal endoscopic microsurgery

The name ''carcinoid'' was invented by Oberndorfer in 1907, when the nature of those histological entities was little understood. Usually, they were found in various locations in the gastrointestinal (GI) apparatus (67%), most of them in the small intestine (25%), appendix (12%), and rectum (14%).The techniques used for their removal are various. The authors present here a case of rectal carcinoid removed using the transanal endoscopic microsurgery technique, and referred to the diagnosis and treatment of this uncommon tumor. A 37-year-old male was admitted to the Santa Maria Hospital of Terni (Italy) with a chief complaint of intermittent pain in the lower right quadrant, that began three years ago. Complete blood count (CBC) and laboratory data as tumor markers and urinary 5-hydroxyindoleacetic acid (5-HIAA) showed no abnormalities, while urinary vanilmandelic acid level was elevate (18 mg/24 h). The patient was submitted to a colonoscopy with magnifying endoscopy and biopsy. The histological finding demonstrated a nodule characterized by cellular proliferation, with few microscopical abnormalities, arranged in small cords with a glandular pattern, separated by dense connective tissue. Histochemically the tumor cells were cytocheratins +/-, chromogranin positive, synaptophysine positive, CD56 positive and Growth Index MIB1-Ki67 which was almost zero. The patient also underwent an endoscopic ultrasonography and an Octreoscan. He was operated using a transanal endoscopic microsurgery technique. The use of Transanal Endoscopic Microsurgery (TEM) as a safe and feasible technique for exciding rectal tumors can be easily understood, for the excellent view and precise dissection. The use of new surgical devices as Harmonic Scalpel has improved the precision of this kind of approach, increasing the appropriateness of this approach compared to other kind of resection. A full diagnostic course and an immunohistochemistry are mandatory for precise diagnosis of rectal carcinoid. Careful attention must be paid to these tumors because of their unexpected behaviour.

[Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report]

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).

[Locoregional complications of stomas. Therapeutic approach]

Principal local complications of ostomies are examined. Etiologic factors and possibilities of treatment are analyzed. These pathologies are often extremely troublesome and their resolution very difficult, unless appropriate therapy is established and, when possible, causal factors removed. However, because of the particular problems of these patients it would be better for them to be assisted by a specialized staff, in qualified centers.