Atraumatic Splenic Rupture: A Notable Complication of Rivaroxaban Use

Direct oral anticoagulants (DOACs) are well known to be associated with bleeding complications. However, little is known about their association with atraumatic splenic rupture, a potentially fatal condition. We present the case of a 73-year-old female with paroxysmal atrial fibrillation managed with rivaroxaban who developed a spontaneous atraumatic splenic rupture. This highlights the importance of recognizing this complication in patients without previous risk factors, such as abdominal trauma or infiltrative splenic disease, who are under anticoagulation with DOACs. There is a strong need for further research on this complication's underlying mechanism and management.

Functional Quadriplegia as an Initial Presentation of Severe Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory condition with many manifestations primarily presenting in older female patients with joint stiffness. Quadriplegia associated with rheumatoid arthritis is common and can occur secondary to spinal cord compression from atlantoaxial dislocation. In contrast, functional quadriplegia is rare and has not been previously reported as an initial manifestation of rheumatoid arthritis. We report the case of a 56-year-old male with a past medical history of carotid artery stenosis, hypertension, and tobacco and alcohol misuse who presented to the emergency department with a five-month history of progressive bilateral shoulder pain and weakness resulting in functional quadriplegia. The patient required inpatient hospital admission for further evaluation of his functional quadriplegia and associated symptoms. His workup was significant for rheumatoid arthritis, and he was successfully treated with high-dose steroids and received physical and occupational therapy during admission. Prior to discharge, the patient was initiated on methotrexate therapy and appointed a follow-up with primary care and rheumatology. The purpose of this study is to facilitate early clinical recognition of a common disease with unique and underreported symptomatology.

Rare extension of pancreatic pseudocyst with Mycobacterium abscessus into the iliopsoas muscle

Pancreatic pseudocyst is a well-known complication of both acute and chronic pancreatitis. Although extension into other anatomical sites is common, extension into the retrofascial space causing an iliopsoas abscess is exceedingly rare. Although its low incidence creates a diagnostic challenge for clinicians, early diagnosis is essential to prevent significant complications and poor patient outcomes. We present a case of iliopsoas abscess with unusual culture fluid growth in the setting of acute on chronic pancreatitis secondary to extension of a pancreatic pseudocyst. We also offer a brief review of the literature and pathophysiology of the condition.

Management Challenge: An Atypical Variant of Takotsubo Presenting With Multiple Complications

An 84-year-old woman with depression, who witnessed the suicide of a close friend, presented with symptoms of chest pain, palpitations, and cold and clammy extremities. An electrocardiogram showed alternating tachycardia and bradycardia. Urgent transthoracic echocardiogram demonstrated left greater than right ventricular dysfunction, moderate mitral regurgitation, global hypokinesis, and an estimated ejection fraction of 20%. Cardiac catheterization demonstrated non-obstructive coronary artery disease and decreased cardiac output. Findings were consistent with Takotsubo cardiomyopathy complicated with cardiogenic shock, acute mitral regurgitation, and sinus node dysfunction. Management of this patient required the use of a mechanical device intra-aortic balloon pump, and pacemaker insertion for persistent symptomatic arrhythmia. This case highlights the challenging management of potentially fatal acute complications of Takotsubo cardiomyopathy and inadequate data on how to approach them.

An Unusual Case of Giant Abdominal Aortic Aneurysm Due to Type II Endoleak Persistent Failure

Abdominal aortic aneurysms (AAA) are considered giant when they exceed >10cm, and they are rare, with only a few cases described as >14cm. AAAs can be repaired through endovascular aneurysm repair (EVAR) or open surgery. EVAR involves the placement of a graft that contacts the aortic wall and the iliac vessels to prevent the aneurysm sac to have blood flow and pressure. One of the complications of EVAR is endoleak, the most common being type II. We describe an uncommon case of a progressively giant AAA with type II endoleak with poor evolution despite multiple repair attempts.

Intestinal Conventional Ultrasonography, Contrast-Enhanced Ultrasonography and Magnetic Resonance Enterography in Assessment of Crohn's Disease Activity: A Comparison with Surgical Histopathology Analysis

BACKGROUND AND AIMS

Contrast-enhanced ultrasonography (CEUS) is a potential interesting method for assessing accurately Crohn's disease (CD) activity. We compared the value of intestinal ultrasonography (US) coupled with contrast agent injection with that of magnetic resonance enterography (MRE) in the assessment of small bowel CD activity using surgical histopathology analysis as reference.

METHODS

Seventeen clinically active CD patients (14 women, mean age 33 years) requiring an ileal or ileocolonic resection were prospectively enrolled. All performed a MRE and a US coupled with contrast agent injection (CEUS) less than 8 weeks prior to surgery. Various imaging qualitative and quantitative parameters were recorded and their respective performance to detect disease activity, disease extension and presence of complications was compared to surgical histopathological analysis.

RESULTS

The median wall thickness measured by US differed significantly between patients with non-severely active CD (n = 5) and those with severely active CD (n = 12) [7.0 mm, IQR (6.5-9.5) vs 10.0 mm, IQR (8.0-12.0), respectively; p = 0.03]. A non-significant trend was found with MRE with a median wall thickness in severe active CD of 10.0 mm, IQR (8.0-13.7) compared with 8.0 mm, IQR (7.5-10.5) in non-severely active CD (p = 0.07). The area under the ROC curve (AUROC) of the wall thickness assessed by US and MRE to identify patients with or without severely active CD on surgical specimens were 0.85, 95% CI (0.64-1.04), p = 0.03 and 0.80, 95% CI (0.56-1.01), p = 0.07, respectively. Among the parameters derived from the time-intensity curve during CEUS, time to peak and rise time were the two most accurate markers [AUROC = 0.88, 95% CI (0.70-1.04), p = 0.02 and 0.86, 95% CI (0.68-1.04), p = 0.03] to detect patients with severely active CD assessed on surgical specimens.

CONCLUSION

The accuracy of intestinal CEUS is close to that of conventional US to detect disease activity. A thickened bowel and shortened time to peak and rise time were the most accurate to identify CD patients with severe histological disease activity.

Immunohistochemical evaluation of two antibodies against PD-L1 and prognostic significance of PD-L1 expression in epithelioid peritoneal malignant mesothelioma: A RENAPE study

BACKGROUND

Epithelioid peritoneal malignant mesothelioma (EPMM) is the most common subtype of this aggressive tumor. We compared two antibodies against PD-L1, a recent theranostic biomarker, and evaluated the prognostic value of PD-L1 expression by mesothelial and immune cells in EPMM.

METHODS

Immunohistochemistry was performed on 45 EPMM. Clinical and pathological data were extracted from the RENAPE database. Using E1L3N and SP142 clones, inter-observer agreement, PD-L1 expression by mesothelial and immune cells and inter-antibody agreement were evaluated. The prognostic relevance of PD-L1 expression was evaluated in 39 EPMM by univariate and multivariate analysis of overall survival (OS) and progression-free survival (PFS).

RESULTS

Inter-observer agreement on E1L3N immunostaining was moderate for mesothelial and immune cells, and fair for mesothelial and poor for immune cells using SP142. Using E1L3N, 31.1% of mesothelial and 15.6% of immune cells expressed PD-L1, and 22.2% of mesothelial and 26.7% of immune cells using SP142. Inter-antibody agreement was moderate. In most positive cases, 1-5% of tumor cells were positive. Using E1L3N, PD-L1 expression by lymphocytes was associated with better OS and PFS by both univariate and multivariate analysis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy predicted better prognosis than other treatments. Solid subtype was an independent prognostic factor for worse OS.

CONCLUSION

E1L3N appeared easier to use than SP142 to evaluate PD-L1 expression. A minority of EPMM expressed PD-L1, and only a few cells were positive. PD-L1 expression by immune cells evaluated with E1L3N was an independent prognostic factor in EPMM.

The RENAPE observational registry: rationale and framework of the rare peritoneal tumors French patient registry

Background

Rare peritoneal cancers represent complex clinical situations requiring a specific and multidisciplinary management. Because of their rarity, lack of awareness and knowledge often leads to diagnostic delays and misdiagnosis. And patients are not systematically referred to expert centers as they should be. Clinicians and researchers also face unique challenges with these rare cancers, because it is hard to conduct adequately powered, controlled trials in such small patient population. This is how an observational patient registry constitutes a key instrument for the development of epidemiological and clinical research in the field of these rare cancers. It is the appropriate tool to pool scarce data for epidemiological research and to assess the impact of diagnostic and therapeutic strategies. We aimed to provide the outlines and the framework of the RENAPE observational registry and share our experience in the establishment of a national patient registry.

Results

The RENAPE observational registry has been launched in 2010 thanks to institutional supports. It concerns only patients with a histological diagnosis confirming a peritoneal surface malignancy. A web secured clinical database has been implemented based on data management procedures according to the principles of international recommendations and regulatory statements. A virtual tumor bank is linked in order to the conduct translational studies. Specialized working groups have been established to continuously upgrade and evolve the common clinical and histological data elements following the last classifications and clinical practices. They contribute also to standardize clinical assessment and homogenize practices.

Conclusions

The RENAPE Registry may improve awareness and understanding of the rare peritoneal tumors into the incidence, prevalence, recurrence, survival and mortality rates, as well as treatment practices thereby enabling therapeutic intervention to be evaluated and ultimately optimized.

Trial registration

ClinicalTrials.gov Identifier: NCT02834169

Diffuse malignant peritoneal mesothelioma: Evaluation of systemic chemotherapy with comprehensive treatment through the RENAPE Database: Multi-Institutional Retrospective Study

PURPOSE

Diffuse malignant peritoneal mesothelioma (DMPM) is a severe disease with mainly locoregional evolution. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the reported treatment with the longest survival. The aim of this study was to evaluate the impact of perioperative systemic chemotherapy strategies on survival and postoperative outcomes in patients with DMPM treated with curative intent with CRS-HIPEC, using a multi-institutional database: the French RENAPE network.

PATIENTS AND METHODS

From 1991 to 2014, 126 DMPM patients underwent CRS-HIPEC at 20 tertiary centres. The population was divided into four groups according to perioperative treatment: only neoadjuvant chemotherapy (NA), only adjuvant chemotherapy (ADJ), perioperative chemotherapy (PO) and no chemotherapy before or after CRS-HIPEC (NoC).

RESULTS

All groups (NA: n = 42; ADJ: n = 16; PO: n = 16; NoC: n = 48) were comparable regarding clinicopathological data and main DMPM prognostic factors. After a median follow-up of 61 months, the 5-year overall survival (OS) was 40%, 67%, 62% and 56% in NA, ADJ, PO and NoC groups, respectively (P = 0.049). Major complications occurred for 41%, 45%, 35% and 41% of patients from NA, ADJ, PO and NoC groups, respectively (P = 0.299). In multivariate analysis, NA was independently associated with worse OS (hazard ratio, 2.30; 95% confidence interval, 1.07-4.94; P = 0.033).

CONCLUSION

This retrospective study suggests that adjuvant chemotherapy may delay recurrence and improve survival and that NA may impact negatively the survival for patients with DMPM who underwent CRS-HIPEC with curative intent. Upfront CRS and HIPEC should be considered when achievable, waiting for stronger level of scientific evidence.

Pathogenesis of spring viremia of carp virus in emerald shiner Notropis atherinoides Rafinesque, fathead minnow Pimephales promelas Rafinesque and white sucker Catostomus commersonii (Lacepede)

Spring viremia of carp (SVC) is a reportable disease to the World Organization of Animal Health (OIE) as it is known to cause significant international economic impact. In Canada, the first and only isolation of SVC virus (SVCV) was in 2006, from common carp Cyprinus carpio L., at Hamilton Harbour, Lake Ontario. The susceptibility of fathead minnow Pimephales promelas Rafinesque, emerald shiner Notropis atherinoides Rafinesque and white sucker Catostomus commersonii (Lacepede) to intraperitoneal injection of the Canadian isolate (HHOcarp06) was evaluated using experimental infection, virus isolation, quantitative reverse transcription polymerase chain reaction (qRT-PCR), histopathology and immunohistochemistry (IHC). Emerald shiner and fathead minnow were most susceptible with 43 and 53% cumulative mortality, respectively, compared with koi at 33%. Quantitative RT-PCR demonstrated that koi had high viral loads throughout the experiment. At 34 days post-infection, SVCV was detected from sampled emerald shiner and white sucker in very low titre and was not detected from fathead minnow. Koi, fathead minnow and emerald shiner had gross lesions typical of SVC disease. The histopathological picture was mostly dominated by necrotic changes in kidney, spleen, liver, pancreas and intestine. IHC further confirmed SVCV infection, and staining was largely correlated with histological lesions.

Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the only curative treatment for many peritoneal surface malignancies. The purpose of this study was to evaluate feasibility and safety of CRS combined with HIPEC by laparoscopy for patients with limited peritoneal disease and to compare postoperative outcomes with those for an open procedure.

METHODS

Between January 2011 and November 2012, all patients with low-grade pseudomyxoma peritonei (PMP) or multicystic mesothelioma (MM) and limited peritoneal disease (Peritoneal Cancer Index [PCI] less than 10) underwent CRS and HIPEC by a laparoscopic approach. The study cohort was matched with a historical cohort of patients with the same characteristics (completeness of cytoreduction, HIPEC agent, PCI ± 11 and age ± 20 years) treated with CRS and HIPEC by laparotomy.

RESULTS

Eight patients (five low-grade PMP and three MM) treated by a laparoscopic approach were compared to eight patients treated by laparotomy. All patients underwent complete cytoreductive surgery with HIPEC, and no conversion to laparotomy was needed. The median surgical length was 210 min (150-300) vs 240 (210-360), with a median hospital stay of 12 days (9-18) vs 19 (13-33). One patient had a postoperative complication (intraperitoneal haematoma treated by radiological drainage) vs four in the laparotomy group.

CONCLUSION

Laparoscopic CRS combined with HIPEC is feasible and safe for curative treatment of strictly selected patients with peritoneal surface malignancy and might reduce postoperative complications and length of hospital stay.

Loss of IGFBP7 expression and persistent AKT activation contribute to SMARCB1/Snf5-mediated tumorigenesis

SMARCB1 (Snf5/Ini1/Baf47) is a potent tumor suppressor, the loss of which serves as the diagnostic feature in malignant rhabdoid tumors (MRT) and atypical teratoid/rhabdoid tumors (AT/RT), two highly aggressive forms of pediatric neoplasms. SMARCB1 is a core subunit of Swi/Snf chromatin remodeling complexes, and loss of SMARCB1 or other subunits of these complexes has been observed in a variety of tumor types. Here, we restore Smarcb1 expression in cells derived from Smarcb1-deficient tumors, which developed in Smarcb1 heterozygous p53(-/-) mice. We find that while re-introduction of Smarcb1 does not induce growth arrest, it restores sensitivity to programmed cell death and completely abolishes the ability of the tumor cells to grow as xenografts. We describe persistent activation of AKT signaling in Smarcb1-deficient cells, which stems from PI3K (phosphatidylinositol 3'-kinase)-mediated signaling and which contributes to the survival and proliferation of the tumor cells. We further demonstrate that inhibition of AKT is effective in preventing proliferation of Smarcb1-deficient cells in vitro and inhibits the development of xenografted tumors in vivo. Profiling Smarcb1-dependent gene expression, we find genes that require Smarcb1 and Swi/Snf for their expression to be enriched for extracellular matrix and cell adhesion functions. We find that Smarcb1 is required for transcriptional activation of Igfbp7, a member of the insulin-like growth factor-binding proteins family and a tumor suppressor in itself, and show that re-introduction of Igfbp7 alone can hinder tumor development. Our results define a novel mechanism for Smarcb1-mediated tumorigenesis and highlight potential therapeutic targets.

[Giant ameloblastoma of the mandible]

INTRODUCTION

Giant ameloblastomas are more common in developing countries. They raise a serious problem of management. We present the case of one of the largest ameloblastoma ever reported.

CASE REPORT

A 48-year-old Congolese female patient was referred for mandibular swelling having begun 23 years before and now inducing severe functional disorders. A cephalic CT scan revealed a multicystic mass, 30×18×10cm in size, with a typical "soap bubble" presentation, and with thinned and inflated cortical bone. The treatment was sub-total segmental mandibulectomy with immediate reconstruction using a fibular free flap, modeled on the sampling site by four ostectomies. The pathological examination confirmed the diagnosis of a benign follicular and plexiform ameloblastoma. The excess of soft tissue was treated with a right commissuroplasty on the 15th postoperative day. There was no complication.

DISCUSSION

Radical treatment followed by immediate reconstruction using a free flap is the treatment of choice for giant mandibular ameloblastomas, when considering immediate functional and esthetic benefits. This is a prime concern for patients with a difficult access to health care and for whom long-term follow-up is not feasible.

Malignant peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: is GLUT1 expression a major prognostic factor? A preliminary study

PURPOSE

Diffuse malignant peritoneal mesothelioma (DMPM) is a rare primary peritoneal malignancy. Its prognosis has been improved by an aggressive locoregional treatment combining extensive cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Prognostic factors are currently poorly defined for this disease but are essential if treatment is to be standardized.

METHODS

Twenty-eight patients with DMPM, who were considered preoperatively to be candidates for CRS and HIPEC between June 1998 and August 2010 at our institution, were selected for this study. Medical records and histopathological features were retrospectively reviewed and 24 clinical, histological, and immunohistochemical parameters were assessed for their association with overall survival by univariate and multivariate analyses.

RESULTS

The following factors were significantly associated with overall survival by univariate analysis: predominant histological growth pattern in the epithelioid areas, nuclear grooves in the epithelioid areas, atypical mitoses, and calretinin and GLUT1 expression by immunohistochemistry in the epithelioid areas. Expression of the facilitative glucose transporter protein GLUT1 in the epithelioid areas was the only factor independently associated with overall survival by multivariate analysis.

CONCLUSIONS

GLUT1 expression appears to be an indicator of poor prognosis in DMPM. Standard histological classification of DMPM may not be adequate to select patients for aggressive locoregional treatments, such as CRS and HIPEC. Multicenter validation of the prognostic factors identified in this preliminary study is needed to refine patient selection for potential cure.

Pseudomyxoma peritonei: role of 18F-FDG PET in preoperative evaluation of pathological grade and potential for complete cytoreduction

INTRODUCTION

For pseudomyxoma peritonei (PMP), survival depends on pathological grade and completeness of cytoreductive surgery. The aim of the study was to assess the ability of preoperative 18F-FDG PET to determine these 2 prognosis indicators.

MATERIAL AND METHODS

In this prospective single centre study, all patients presenting with PMP were included. They underwent a preoperative 18F-FDG PET with a double radiological evaluation and an explorative laparotomy with the objective of optimal cytoreduction followed by a hyperthermic intra-operative intraperitoneal chemotherapy (HIPEC). Patients with non resectable disease underwent debulking surgery without HIPEC. The Completeness of Cytoreduction was assessed by CC score.

RESULTS

Thirty-four patients were included. PET scanning was positive for 19 patients with grade II (hybrid form) or III (Peritoneal Mucinous Carcinomatosis) and for 2 patients with grade I (disseminated peritoneal adenomucinosis), and negative for 3 patients with grade II - III and for 10 patients with grade I. PET scanning was positive for 6 patients with CC score 2 - 3 and for 16 patients with CC score 0, and negative for 2 patients with CC score 2 - 3 and for 10 patients with CC score 0. The 18F-FDG PET interpretation distinguished 2 patients groups (grade I and grade II - III) with a sensitivity of 90% and a specificity of 77%. Moreover, probability of complete cytoreduction when PET was negative was over 80%.

CONCLUSION

Preoperative 18F-FDG PET may predict pathological grade and completeness of cytoreduction which are the two main prognostic factors in patients with PMP.

[Sweet's syndrome associated with squamous cell bronchial carcinoma. Neutrophilic dermatosis and non-small cell lung cancer]

INTRODUCTION

Sweet's syndrome, one of the neutrophilic dermatoses, is idiopathic in most cases. In 10-20% of cases it is paraneoplastic, associated with a solid tumour or haematological malignancy. An association with carcinoma of the bronchus has been only rarely described.

CASE REPORT

We report the case of a 56 year old man who presented with Sweet's syndrome two months before the diagnosis of a squamous cell carcinoma of the bronchus. The dermatosis responded well to corticosteroids. The progress of the tumour was favourable, with stabilisation following 3 courses of chemotherapy and local radiotherapy.

DISCUSSION

This case report updates this rare association and underlines the importance of undertaking appropriate thoracic investigations in the presence of this dermatosis. A paraneoplastic secretion of interleukin-8, GM-CSF and/or G-CSF by the bronchial tumour cells facilitating the recruitment of neutrophils, particularly in the skin, may account for the pathophysiology of this condition.

[Gastropleural fistula presenting with a pyopneumothorax in pregnancy]

INTRODUCTION

Gastropleural fistula has only rarely been described in the literature, typically presenting with evidence of left-sided pleural infection.

CASE REPORT

The diagnosis may be suggested by the occurrence of chest pain and repeated vomiting with the diagnosis confirmed by microbiological examination of the pleural fluid and appropriate radiological investigations. The fistula occurs most frequently after abdominal or anterior thoracic surgery. Generally, surgical repair should be performed urgently but in the case that we describe occurring during pregnancy, surgery was delayed for 10 weeks until a caesarean section could be performed.

CONCLUSION

In the presence of left-sided basal pleuritic chest pain in the context of a possible gap in the diaphragm the diagnosis of gastropleural fistula should be considered. Treatment is usually a medico-surgical emergency.

Clinical implications of axillary sentinel lymph node ‘micrometastases’ in breast cancer

AIMS

The aim of this study was to determine, from a series of cases, the frequency and prognostic factors of invasion of non-sentinel lymph nodes when the axillary sentinel lymph node contains a metastasis < or =2 mm, and thereby select a population in which completion axillary dissection could be omitted.

METHODS

Between July 1996 and July 2003, 62 patients, which axillary sentinel lymph node contained a metastasis < or =2 mm had an evaluation of the axillary non-sentinel lymph nodes. Eleven patients had also an evaluation of internal mammary lymph nodes.

RESULTS

Eleven patients had axillary non-sentinel lymph node invasion: six by metastases < or =2 mm and five by macrometastases. When internal mammary lymph nodes were also concerned, nodal invasion apart from the axillary sentinel lymph node was seen in 14 patients. Vascular lymphatic invasion was the only factor, statistically significant, linked to non-sentinel lymph node invasion (p = 0.02).

CONCLUSION

Whatever the size or method of histological detection (pN1mi or pN0(i+)), the presence of a metastasis < or =2 mm in the axillary sentinel lymph node leads us to carry out completion axillary dissection to optimize staging and loco-regional control of the disease.

Peritoneal mesothelioma treated by cytoreductive surgery and intraperitoneal hyperthermic chemotherapy: results of a prospective study

BACKGROUND

Peritoneal mesothelioma is a rare disease with few therapeutic options. Recently, the combination of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy (HIPEC) has shown promising results.

METHODS

Fifteen patients with peritoneal mesothelioma who were treated by cytoreductive surgery and HIPEC between 1989 and 2004 were identified from a prospective database. HIPEC was performed with cisplatin and mitomycin C for 90 minutes by using the closed-abdomen technique.

RESULTS

All patients but one (multicystic) had malignant disease of the following pathologic types: 12 epithelial and 2 biphasic. After surgical resection, 11 patients were considered to have a CC-0 or CC-1 resection (macroscopic complete resection or diameter of residual nodules <2.5 mm). No postoperative death occurred, and six postoperative complications were recorded. All but one patient had resolution of ascites. The overall median survival for the 14 patients with malignant mesothelioma was 35.6 months. The median survival was 37.8 months for patients treated with a CC-0 or CC-1 resection, whereas it was 6.5 months for those treated with a CC-2 or CC-3 resection (diameter of residual nodules >2.5 mm; P < .001). In a univariate analysis, the only other significant prognostic factor was the carcinomatosis extent (P = .02).

CONCLUSIONS

A therapeutic strategy combining cytoreductive surgery with HIPEC seems to provide an adequate and efficient locoregional treatment for peritoneal mesothelioma. It is associated with acceptable morbidity when performed by an experienced surgical team. The completeness of cytoreduction is the major determinant of survival.

Intraperitoneal chemohyperthermia using a closed abdominal procedure and cytoreductive surgery for the treatment of peritoneal carcinomatosis: morbidity and mortality analysis of 216 consecutive procedures

BACKGROUND

Peritoneal carcinomatosis has been regarded as a lethal clinical entity. Recently, aggressive treatments combining intraperitoneal chemohyperthermia (IPCH) with cytoreductive surgery have resulted in long-term survival in selected patients. The aim of this trial was to analyze the mortality and morbidity of 216 consecutive treatments of peritoneal carcinomatosis by IPCH by using a closed abdominal procedure combined with cytoreductive surgery.

METHODS

Between February 1989 and August 2001, 207 patients who underwent 216 IPCH procedures using a closed abdominal procedure with mitomycin C, cisplatin, or both were prospectively studied.

RESULTS

The postoperative mortality and morbidity rates were 3.2% and 24.5%, respectively. The most frequent complications were digestive fistula (6.5%) and hematological toxicity (4.6%). Morbidity was statistically linked with the carcinomatosis stage (P =.016), the duration of surgery (P =.005), and the number of resections and peritonectomy procedures (P =.042). Duration of surgery and carcinomatosis stage were the most common predictors of morbidity.

CONCLUSIONS

The frequency of complications after IPCH and cytoreductive surgery was mainly associated with the carcinomatosis stage and the extent of the surgical procedure. The IPCH closed abdominal procedure has shown an acceptable frequency of adverse events.

[Lymphatic mapping and inguinal sentinel lymph node biopsy in anal canal cancers to avoid prophylactic inguinal irradiation]

Thirty-five patients with clinically N0 cancers of the canal anal, 33 epidermoid carcinomas et 2 melanomas were histologically staged with inguinal sentinel lymph node biopsy (ISN). With the combined technique, blue dye and radiocolloid the ISN was identified in 100% of the cases. The ISN was invaded in 7 cases/33 for epidermoid tumors and 2/2 for melanomas. After 18 months of follow-up, no inguinal recurrence could be seen in ISN pN0 cases. In conclusion, ISN biopsy is a reliable procedure to stage anal canal cancers. It should prevent unnecessary prophylactic inguinal irradiation for pN0 ISN. Inguinal irradiation is only indicated in pN1 ISN.

[Granulomatous arteritis through sarcoidosis]

INTRODUCTION

Digestive localisation of sarcoidosis is rare.

OBSERVATION

A 35 year-old man presented with sarcoidosis revealed by a mediastinal hilum lymphadenopathy 13 years earlier. Epigastric pain led to oeso-gastroduodenal fibroscopy and biopsies, showing inflammatory mucosa and numerous giant-cell epithelioid granulomas, without concomitant necrosis or fibrosis.

COMMENTS

The clinical manifestations and endoscopic profile of gastric localisations of sarcoidosis are not specific. Diagnosis relies on several elements: presence of epithelioid granulomas without necrosis, history of sarcoidosis or the simultaneous existence of other localisations, evocative biological signs and the absence of elements evoking any other diagnosis. Treatment relies on corticosteroid therapy and sometimes requires endoscopic or surgical management.

[Primary osseous leiomyosarcoma of the jaw. Apropos of a case]

Primary leiomyosarcoma of bone is a malignant smooth muscle tumour uncommonly found in the jaws. We report a case of primary leiomyosarcoma of the mandible in a 31-year-old man treated with wide resection and radiotherapy then secondary reconstruction with a fibula free flap. No recurrence or distant metastasis has developed four years after the initial surgery. We review the literature on primary leiomyosarcoma of the jaws.

Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature

BACKGROUND

The authors performed a specific analysis of the clinical significance of inguinal lymph nodes metastases in patients with anal canal carcinoma (ACC).

METHODS

A retrospective analysis was conducted of 270 patients who were treated in Lyon between 1980 and 1996 with radiotherapy with curative intent for ACC: No elective irradiation of clinically normal inguinal areas was performed. Patients with metastatic inguinal lymph nodes were treated with inguinal dissection and postoperative irradiation with a dose of 50 grays over 5 weeks. Concomitant chemoradiation, usually with a regimen of fluorouracil and cisplatinum, was given to 159 patients.

RESULTS

The median follow-up for the whole series was 72 months. Synchronous inguinal metastases were observed in 10% of patients (n = 27; the rate was 16% for patients with T3--T4 lesions), and the 5-year overall survival rate was 54.4%. Metachronous inguinal metastases were seen in 19 patients (7.8%), and the 5-year overall survival rate of these patients was 41.4%. An original finding was that, when the primary tumor clearly was located on a single lateral side of the anal canal, the inguinal lymphatic metastases was always homolateral to it (36 of 36 synchronous plus metachronous tumors).

CONCLUSIONS

The data from this series of patients and a review of the literature are in favor of a selective approach in the management of inguinal lymph node involvement for patients with ACC, depending on the disease stage and the location of the primary tumors.

Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature

BACKGROUND

The authors performed a specific analysis of the clinical significance of inguinal lymph nodes metastases in patients with anal canal carcinoma (ACC).

METHODS

A retrospective analysis was conducted of 270 patients who were treated in Lyon between 1980 and 1996 with radiotherapy with curative intent for ACC: No elective irradiation of clinically normal inguinal areas was performed. Patients with metastatic inguinal lymph nodes were treated with inguinal dissection and postoperative irradiation with a dose of 50 grays over 5 weeks. Concomitant chemoradiation, usually with a regimen of fluorouracil and cisplatinum, was given to 159 patients.

RESULTS

The median follow-up for the whole series was 72 months. Synchronous inguinal metastases were observed in 10% of patients (n = 27; the rate was 16% for patients with T3--T4 lesions), and the 5-year overall survival rate was 54.4%. Metachronous inguinal metastases were seen in 19 patients (7.8%), and the 5-year overall survival rate of these patients was 41.4%. An original finding was that, when the primary tumor clearly was located on a single lateral side of the anal canal, the inguinal lymphatic metastases was always homolateral to it (36 of 36 synchronous plus metachronous tumors).

CONCLUSIONS

The data from this series of patients and a review of the literature are in favor of a selective approach in the management of inguinal lymph node involvement for patients with ACC, depending on the disease stage and the location of the primary tumors.

Angiosarcoma after conservative treatment and radiation therapy for adenocarcinoma of the breast

Radio-induced angiosarcoma of the breast after conservative therapy for invasive adenocarcinoma is a very rare tumour. Between 1996 and 2000, four cases were operated in our Department of Surgical Oncology. After a review of the literature over the same period of time, natural history and treatment of radio-induced angiosarcomas of the breast were analysed.

Liver cystadenocarcinoma originating in cystadenoma without mesenchymal stroma. Therapeutic strategy in case of atypical radiological criteria. A case report

Optimal treatment of cystadenoma if diagnosed consists of complete resection of the tumor. In case of atypical radiological criteria, therapeutic strategy is not well defined. The attitude we adopt is to regularly monitor the lesion. Surgical removal of the tumor is of course indicated facing any significant change on sonography or tomodensiometry.

Pulmonary mucormycosis in a diabetic patient

We present the case of a 54 year-old male from Moldavia with diabetes mellitus (type II diabetic), admitted to hospital in January 1999, with ketoacidosis and consolidation of the lower left lobe. The diagnosis of mucormycosis was confirmed by identification of large, nonseptate hyphae of the order Mucorales. A strain of Rhizopus oryzae (Rhizopus arrhizus) was isolated from culture on sabouraud medium. The patient was treated by systemic amphotericin B, associated with surgical debridement (lobectomy). The treatment with amphotericin B was stopped after ten days and the patient was completely asymptomatic and returned to Moldavia. Mucormycoses are rare, and tend to be encountered in individuals with predisposing factors such as malignant blood disorders (immunocompromised patients) or diabetes mellitus. Prognosis is poor, resembling infection with Aspergillus, despite aggressive treatment as in the present case. The gravity of the condition can be accounted for by the thrombotic and necrosing nature of the fungal invasion of lung vessels.

[Lymph node mapping and axillary sentinel lymph node biopsy in 243 invasive breast cancers with no palpable nodes. The south Lyon hospital center experience]

STUDY AIM

To evaluate the effect of intraoperative lymph node mapping and sentinel lymph node dissection (SLND) on the axillary staging of patients with N0 breast carcinoma. Two techniques were used: blue dye alone (Evans Blue and Patent Blue) and combined technique (blue dye and isotope).

METHODS

The incidence of axillary node metastasis in axillary lymph node dissection (ALND) and SLND was compared prospectively. Multiple sections of each SLN were examined by HPS staining and immunohistochemical techniques. Two sections of each non sentinel node in ALND specimens were examined by routine HPS staining.

RESULTS

243 patients underwent ALND after SLN biopsy. The SLN detection rate was 225/243 cases (92.59%): 89.94% with blue dye alone and 100% with the combined technique. The false-negative rate was less than 2%.

CONCLUSION

SN biopsy is an accurate staging technique for N0 breast cancer. SLN biopsy with multiple sections and immunohistochemical staining of the SLN can identify significantly more patients with lymph node metastases than ALND with routine HPS staining.

A new case of congenital cyst of the pancreas

A new case of congenital cyst of the pancreas is reported. A 34-year-old woman was admitted with a painless, large, epigastric mass. Ultrasonography revealed an anechogenic retrogastric tumor. Computed tomography scan described a liquid cyst of the pancreas which was 15 cm in diameter. During surgery, a well-delimited translucent cyst was found and no local malignancy was observed. Extensive distal pancreatic resection with preservation of the spleen was performed and a thin part of cephalic pancreas was preserved. The liquid of the cyst did not contain any mucus. Microscopic study of the cyst wall described normal cuboidal cells and congenital cyst of the pancreas was diagnosed. Several diagnoses including hydatid cyst, pseudocyst and cystic tumors of the pancreas are discussed. Before surgery, lack of acute pancreatitis in recent medical history rules out pseudocyst and hydatid cyst. During the operation, if cystadenocarcinoma is easily ruled out, macrocystic serous cystadenoma is more difficult to exclude. Only histological examination of the cystic wall confirms the difference between cystadenoma and congenital cyst which remains an exceptional entity.

[Gallbladder cancers discovered fortuitously]

STUDY AIM

The aim of this retrospective study was to report a series of 12 carcinomas of the gallbladder diagnosed on the histological examination of specimens after cholecystectomy.

PATIENTS AND METHODS

From 1986 to 1996, 784 cholecystectomies were performed in the same center and 12 unexpected carcinomas of the gallbladder were histologically diagnosed (11 adenocarcinomas and one epidermoid carcinoma; one pT1, five pT2 and six pT3). There were nine women and three men (mean age: 72 years) with symptoms in relation with lithiasis. Complementary treatments were: intraoperative radiation therapy (IRT) plus external beam radiation therapy (ERT) in two cases (one pT1 and one pT2), surgery for a 2 cm deep excision of the liver bed plus lymph node dissection plus IRT and ERT in three cases (three pT3), ERT plus chemotherapy in one case (one pT3), no complementary treatment in six cases (four pT2 and two pT3).

RESULTS

One patient died on day 30 from acute respiratory failure. There was no morbidity. One patient died at 7 months from intercurrent disease. The mean survival rate for patients with pT1 and pT2 tumors was 45 months (with two recurrences at 1 year and 3 years) and for patients with pT3 tumors, 6.7 months.

CONCLUSION

Unexpected carcinomas of the gallbladder were recognized in 1.5% of specimens after cholecystectomy for lithiasis. In pT1 tumors, a simple cholecystectomy is sufficient. In pT2 and pT3, a liver resection with lymph node dissection is required, eventually associated with radiation therapy. Laparoscopic cholecystectomy is contraindicated in case of pre- or peroperative suspicion of a gallbladder carcinoma because of the risk of port site recurrences.