Perforated small intestine in a patient with T-cell lymphoma; a rare cause of peritonitis

The nontraumatic perforations of the small intestine are pathological entities with particular aspects in respect to diagnosis and treatment. These peculiarities derive from the nonspecific clinical expression of the peritonitis syndrome, and from the multitude of causes that might be the primary sources of the perforation: foreign bodies, inflammatory diseases, tumors, infectious diseases, etc. Accordingly, in most cases intestinal perforation is discovered only by laparotomy and the definitive diagnosis is available only after histopathologic examination. Small bowel malignancies are rare; among them, lymphomas rank third in frequency, being mostly B-cell non Hodgkin lymphomas. Only 10% of non-Hodgkin lymphomas are with T-cell. We report the case of a 57 years’ old woman with intestinal T-cell lymphoma, whose first clinical symptomatology was related to a complication represented by perforation of the small intestine. Laparotomy performed in emergency identified an ulcerative lesion with perforation in the jejunum, which required segmental enterectomy with anastomosis. The nonspecific clinical manifestations of intestinal lymphomas make from diagnosis a difficult procedure. Due to the fact that surgery does not have a definite place in the treatment of the small intestinal lymphomas (for cases complicated with perforation), and beyond the morbidity associated with the surgery performed in emergency conditions, prognosis of these patients is finally given by the possibility to control the systemic disease through adjuvant therapy

Primary Transitional Cell Carcinoma of the Fallopian Tube

Primary carcinoma of the fallopian tube is a rare entity that accounts for 0.2-0.5% of all gynecologic malignancies, and most are discovered during or after surgery. Primary transitional cell carcinoma of the fallopian tube is an extremely rare tumor that is reported only occasionally in the worldwide literature. As primary transitional cell carcinoma (TCC) of the fallopian tube is so rare, the clinicopathologic characteristics are as yet unknown. The authors recently experienced a case of primary transitional cell carcinoma arising in the left fallopian tube and thus report the clinical features, management, and also a review of the past pertinent literature. A 52 years old woman presenting with lower abdominal pain was found to have a left adnexal mass. Exploratory laparotomy revealed a mass arising from the left fallopian tube with the histologic features of transitional cell carcinoma

Evaluation and treatment decision of pancreatic tumors by use of MRI with MRCP imaging

Background: Pancreatic cancer is one of the most malignant tumors. Symptoms are usually nonspecific and insidious such that the cancer is advanced by the time of diagnosis. The aim of our work was to investigate the use of MRI and MRCP in diagnosis of the patients suspected of pancreatic carcinoma and to determine the role of these methods in the evaluation of resectability of pancreatic cancer in comparison to surgical findings. Material/Methods: Forty-nine patients (33 men and 16 women) aged 44-82 had undergone to MRI and MRCP imagination of the upper abdomen on 1.5 T system with use of a standard flexible surface coil. The results of those radiological diagnostic tests were compare to the surgical findings and histopathological examination. The capacity of MR and MRCP to detect pathological mass, assess disease process nature and accuracy of assessment of the resectability of the malignant lesion were evaluated. In the statistical analysis test X2 and Fisher's precise test were performed. Results: A statistical analysis determined 88% sensitivity, 95% specifity and 94% exactness of MRI and MRCP in the evaluation of nature of tumors within the pancreas and 100% sensitivity, 91% specificity and 95% accuracy in determining the resectability of the lesion. The positive predictive value came to 83%, while the negative predictive value to 100%. The Kappa compatibility index in comparison with a surgical findings came to 0.85714. Conclusions: MR and MRCP appears an important stage in diagnosis and in assessment of pancreatic tumors. By the estimation of tumor respectability it aids clinical management

Gastric Cancer at a University Teaching Hospital in Northwestern Tanzania: A Retrospective Review of 232 Cases.

Despite marked decreases in its incidence, particularly in developed countries, gastric cancer is still the second most common tumor worldwide. There is a paucity of information regarding gastric cancer in northwestern Tanzania. This study was undertaken to describe our experience, in our local setting, on the management of gastric cancer, outlining the clinicopathological and treatment outcome of these patients and suggesting ways to improve the treatment outcome. This was a retrospective study of histologically confirmed cases of gastric cancer seen at Bugando Medical Centre between January 2007 and December 2011. Data were retrieved from patients' files and analyzed using SPSS computer software version 17.0. A total of 232 gastric cancer patients were enrolled in the study, representing 4.5% of all malignancies. The male to female ratio was 2.9:1. The median age of patients was 52 years. The majority of the patients (92.1%) presented late with advanced gastric cancer (Stages III and IV). Lymph node and distant metastasis at the time of diagnosis was recorded in 31.9% and 29.3% of cases, respectively. The antrum was the most frequent anatomical site (56.5%) involved and gastric adenocarcinoma (95.1%) was the most common histopathological type. Out of 232 patients, 223 (96.1%) patients underwent surgical procedures for gastric cancer of which gastro-jejunostomy was the most frequent performed surgical procedure, accounting for 53.8% of cases. The use of chemotherapy and radiotherapy was documented in 56 (24.1%) and 12 (5.1%) patients, respectively. Postoperative complication and mortality rates were 37.1% and 18.1%, respectively. According to multivariate logistic regression analysis, preoperative co-morbidity, histological grade and stage of the tumor, presence of metastases at the time of diagnosis was the main predictors of death (P <0.001). At the end of five years, only 76 (32.8%) patients were available for follow-up and the overall five-year survival rate was 6.9%. Evidence of cancer recurrence was reported in 45 (19.4%) patients. Positive resection margins, stage of the tumor and presence of metastasis at the time of diagnosis were the main predictors of local recurrence (P <0.001). Gastric cancer in this region shows a trend towards relative young age at diagnosis and the majority of patients present late with an advanced stage. Lack of awareness of the disease, poor accessibility to health care facilities and lack of screening programs in this region may contribute to advanced disease at the time of diagnosis. There is a need for early detection, adequate treatment and proper follow-up to improve treatment outcome

Recent advances in minimally invasive colorectal cancer surgery

Laparoscopy has improved surgical treatment of various diseases due to its limited surgical trauma and has developed as an interesting therapeutic alternative for the resection of colorectal cancer. Despite numerous clinical advantages (faster recovery, less pain, fewer wound and systemic complications, faster return to work) the laparoscopic approach to colorectal cancer therapy has also resulted in unusual complications, i.e. ureteral and bladder injury which are rarely observed with open laparotomy. Moreover, pneumothorax, cardiac arrhythmia, impaired venous return, venous thrombosis as well as peripheral nerve injury have been associated with the increased intraabdominal pressure as well as patient's positioning during surgery. Furthermore, undetected small bowel injury caused by the grasping or cauterizing instruments may occur with laparoscopic surgery. In contrast to procedures performed for nonmalignant conditions, the benefits of laparoscopic resection of colorectal cancer must be weighed against the potential for poorer long-term outcomes of cancer patients that still has not been completely ruled out. In laparoscopic colorectal cancer surgery, several important cancer control issues still are being evaluated, i.e. the extent of lymph node dissection, tumor implantation at port sites, adequacy of intraperitoneal staging as well as the distance between tumor site and resection margins. For the time being it can be assumed that there is no significant difference in lymph node harvest between laparoscopic and open colorectal cancer surgery if oncological principles of resection are followed. As far as the issue of port site recurrence is concerned, it appears to be less prevalent than first thought (range 0-2.5%), and the incidence apparently corresponds with wound recurrence rates observed after open procedures. Short-term (3-5 years) survival rates have been published by a number of investigators, and survival rates after laparoscopic surgery appears to compare well with data collected after conventional surgery for colorectal cancer. However, long-term results of prospective randomized trials are not available. The data published so far indicate that the oncological results of laparoscopic surgery compare well with the results of the conventional open approach. Nonetheless, the limited information available from prospective studies leads us to propose that minimally invasive surgery for colorectal cancer surgery should only be performed within prospective trials

The accurate staging of ovarian cancer using 3T magnetic resonance imaging - a realistic option

Objectives: The aim of the study was to determine whether staging primary ovarian cancer using 3.0 Tesla (3T) magnetic resonance imaging (MRI) is comparable to surgical staging of the disease. Design: A retrospective study consisting of a search of the pathology database to identify women with ovarian pathology from May 2004 to January 2007. Setting: All women treated for suspected ovarian cancer in our cancer centre region. Sample: All women suspected of ovarian pathology who underwent 3T MRI prior to primary surgical intervention between May 2004 and January 2007. Methods: All women found to have ovarian pathology, both benign and malignant, were then cross checked with the magnetic resonance (MR) database to identify those who had undergone 3T MRI prior to surgery. The resulting group of women underwent comparison of the MR, surgical and histopathological findings for each individual including diagnosis of benign or malignant disease and International Federation of Gynecology and Obstetrics (FIGO) staging where appropriate. Main outcome measures: Comparisons were made between the staging accuracy of 3T MRI and surgical staging compared with histopathological findings and FIGO stage using weighted kappa. Sensitivity, specificity and accuracy were calculated for diagnosing malignant ovarian disease with 3T MRI. Results: A total of 191 women identified as having ovarian pathology underwent imaging with 3T MR and primary surgical intervention. In 19 of these women, the ovarian disease was an incidental finding. The group for which staging methods were compared consisted of 77 women of primary ovarian malignancy (20 of whom had borderline tumours). 3T MRI was able to detect ovarian malignancy with a sensitivity of 92% and a specificity of 76%. The overall accuracy in detecting malignancy with 3T MRI was 84%, with a positive predictive value of 80% and negative predictive value of 90%. Statistical analysis of the two methods of staging using weighted kappa, gave a K value of 0.926 (SE ±0.121) for surgical staging and 0.866 (SE ±0.119) for MR staging. A further analysis of the staging data for ovarian cancers alone, excluding borderline tumours resulted in a K value of 0.931 (SE ±0.136) for histopathological staging versus MR staging and 0.958 (±0.140) for histopathological stage versus surgical staging. Conclusion: Our study has shown that MRI can achieve staging of ovarian cancer comparable with the accuracy seen with surgical staging. No previous studies comparing different modalities have used the higher field strength 3T MRI. In addition, all other studies comparing radiological assessment of ovarian cancer have grouped the stages into I, II, III and IV rather than the more clinically appropriate a, b and c subgroups. © 2008 The Authors

Practical guidance for applying the ADNEX model from the IOTA group to discriminate between different subtypes of adnexal tumors.

All gynecologists are faced with ovarian tumors on a regular basis, and the accurate preoperative diagnosis of these masses is important because appropriate management depends on the type of tumor. Recently, the International Ovarian Tumor Analysis (IOTA) consortium published the Assessment of Different NEoplasias in the adneXa (ADNEX) model, the first risk model that differentiates between benign and four types of malignant ovarian tumors: borderline, stage I cancer, stage II-IV cancer, and secondary metastatic cancer. This approach is novel compared to existing tools that only differentiate between benign and malignant tumors, and therefore questions may arise on how ADNEX can be used in clinical practice. In the present paper, we first provide an in-depth discussion about the predictors used in ADNEX and the ability for risk prediction with different tumor histologies. Furthermore, we formulate suggestions about the selection and interpretation of risk cut-offs for patient stratification and choice of appropriate clinical management. This is illustrated with a few example patients. We cannot propose a generally applicable algorithm with fixed cut-offs, because (as with any risk model) this depends on the specific clinical setting in which the model will be used. Nevertheless, this paper provides a guidance on how the ADNEX model may be adopted into clinical practice

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for patients with peritoneal metastases from endometrial cancer

Background: More information is needed for selection of patients with peritoneal metastases from endometrial cancer (EC) to undergo cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC). Methods: This study analyzed clinical, pathologic, and treatment data for patients with peritoneal metastases from EC who underwent CRS plus HIPEC at two tertiary centers. The outcome measures were morbidity, overall survival (OS), and progression-free survival (PFS) during a median 5 year follow-up period. Uni- and multivariate analyses were performed to identify significant factors related to outcome. Results: A total of 33 patients met the inclusion criteria and completed the follow-up period. At laparotomy, the median peritoneal cancer index (PCI) was 15 (range 3–35). The CRS procedure required a mean 8.3 surgical procedures per patient, and for 22 patients (66.6%), a complete cytoreduction was achieved. The mean hospital stay was 18 days, and major morbidity developed in 21% of the patients. The operative mortality was 3%. When surgery ended, HIPEC was administered with cisplatin 75 mg/m2for 60 min at 43 °C. During a median follow-up period of 73 months, Kaplan–Meier analysis indicated a 5 year OS of 30% (median 33.1 months) and a PFS of 15.5% (median 18 months). Multivariate analysis identified the completeness of cytoreduction (CC) score as the only significant factor independently influencing OS. Logistic regression for the clinicopathologic variables associated with complete cytoreduction (CC0) for patients with metachronous peritoneal spread from EC who underwent secondary CRS plus HIPEC identified the PCI as the only outcome predictor. Conclusions: For selected patients with peritoneal metastases from EC, when CRS leaves no residual disease, CRS plus HIPEC achieves outcomes approaching those for other indications such as colon and ovarian carcinoma

A Rare Case Of Fallopian Tube Cancer

Fallopian tube carcinoma is a very rare malignancy and we report a case of stage IIC primary fallopian tube cancer

Laparoscopy or laparotomy? A comparison of 240 patients with early-stage endometrial cancer

Background: This study aimed to compare the safety and efficacy of laparoscopy and laparotomy in the surgical treatment of early endometrial cancer, especially in obese women. Methods: The results obtained after laparoscopic surgical treatment of early endometrial cancer (International Federation of Gynecology and Obstetrics (FIGO) stage 1 or 2) in patients between 1996 and 2007 were compared with an age- and tumour-matched historical group of patients treated with laparotomy between 1988 and 1996. All the patients underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic ± paraaortic lymphadenectomy. Results: Both groups included 120 patients with a preoperative diagnosis of early endometrial cancer. The postoperative diagnosis was endometrial cancer stage 1 or 2 for 89% of the cases in both groups. The mean operating time was 170min for the laparotomy group compared with 178min for the laparoscopy group (nonsignificant difference). The estimated intraoperative blood loss was significantly greater in the laparotomy group, and the hospital stay was significantly shorter in the laparoscopy group. Conclusions: The results show that early endometrial cancer can be treated effectively by laparoscopy. Because of this study's retrospective design, the results should be interpreted with caution. However, the advantages of this method for obese patients are evident. The age and weight of these patients should not be used as a contraindication for laparoscop