Aggressive gist with gastric location – case report

Spital Sf Spiridon Iași, Clinica III Chirurgie, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Rezumat: Tumorile stromale gastrointestinale (GIST) sunt definite printr-un ansamblu de argumente clinice, morfologice și imunohistologice. Prezentăm cazul unei paciente în varstă de 39 ani cu GIST localizată la nivelul fornixului gastric cu metastază hepatică, cu simptomatologie clinică nespecifică. Investigatiile paraclinice - ecografia abdominală și examenul computer tomografic (CT) - au evidențiat masele tumorale intraperitoneale fără a putea sugera diagnosticul. Examenul anatomo- patologic extemporaneu stabilește diagnosticul de tumora stromală gastrică și impune conduita chirurgicală corespunzatoare.Abstract: Gastrointestinal stromal tumors (GIST) are defined by a set of clinical, morphological and imunohistological elements. We present a patient, 39 years old, female, with GIST located in the upper part of the stomach with liver metastase, with nonspecific clinical symptoms. Paraclinical - abdominal ultrasound examination and computer tomography (CT) - have shown intraperitoneal tumor masses without suggested the diagnosis of GIST. Anatomic-pathological examination, made during the operation, diagnosed stromal tumors and gastric surgery requires proper conduct

Approach in treatement of primary intrahepatic lithiasis

Clinica III Chirurgie, Sp. ‘Sf. Spiridon’, Iaşi, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Litiaza căilor biliare intrahepatice (CBIH) reprezintă în statele vestice o entitate clinica rară, cu incidenţa în creştere în ultimele decade în seriile de cazuri raportate, odată cu creşterea sensibilităţii metodelor diagnostice.Etiologia este neclară, dar asocierea dintre staza biliară şi infecţie sunt factori determinanţi .Tratamentul este complex, scopul tratamentului este obţinerea statusului “stone-free”, decomprimarea arborelui biliar şi controlul infecţiei. Ca prima opţiune se propune derivaţia biliară asociată sau nu cu rezecţia hepatică, ca şi alternativă non-invazivă se enumeră abordul endoscopic retrograd sau litotritia percutană. Prezentam cazul unei paciente diagnosticate în urma unui puseu de angiocolită cu litiază de CBIH cantonată la nivelul segmentelor VII, VIII hepatice.Tratamentul chirurgical a presupus abordul bipolar al căilor biliare intrahepatice prin segmentectomie hepatică şi coledocotomie şi extracţia bipolară a calculilor, urmată apoi de sfincterotomie endoscopică. Primary intrahepatic lithiasis represents in western countries a rare clinical feature with an increas in incidence. The etiology is unclear but the association of biliary stasis and infection are determinant factors for stone formation. The treatment is complex, and the goal is to promote completestone clearance, decompression of the biliary tree, and control of bile infection. Most groups propose surgical treatment with bilioenteric anastomosis and/or liver resection as the first approach and nonsurgical procedures such as percutaneous cholangioscopic lithotripsy or endoscopic therapy.We present the case of a patient diagnosed with intrahepatic lithiasis after an episode of cholangitis.The surgical approachs consisted in a hepatic resection combined with bipolar exploration of bile ducts and extraction of bile stones

Triple primary malignancies in a patient with breast cancer: a rare occurrence

Scop. Stadializarea loco-regională și la distanță a tumorilor maligne poate evidenția prezența neoplaziilor sincrone în același organ sau la distanță. Neoplasmele primare sincrone prezente în trei sisteme de organ diferite sunt raportate în literatură cu o incidență de 2.4% -17%. Mirajul primei leziuni poate conduce frecvent spre erori de management terapeutic. Materiale și metode. O pacientă în vârstă de 66 ani, cunoscută cu importantă patologie cardiovasculară și tiroidiană, se prezintă în IRO Iași în urma decelării la palpare a unei formațiuni tumorale mamare stângi în cadranul infero-extern. La examenul clinic, se observă la nivel cutanat în zona sânului stâng o suprafață cu contur neregulat, alcătuită din zone de hipopigmentare și hiperpigmentare. Pacienta este stadializată imagistic pentru afecțiunea mamară – neoplasm ductal invaziv cT2N1 (triplu negativ) și un nodul solid neregulat în segmentul anterior al lobului stâng pulmonar. Decizia Comisiei Multidisciplinare Oncologice este de evaluare PET-CT a nodulului pulmonar, ocazie cu care se infirmă supoziția de metastază pulmonară, dar se evidențiază hipercaptare la nivelul glandei tiroide. Se decide inițierea chimioterapiei neoadjuvante pentru afecțiunea mamară, urmată de intervenție chirurgicală, secvențială, a sânului în bloc cu afecțiunea cutanată și a glandei tiroide. Rezultate. Buletinul histopatologic final a constat în răspuns complet anatomo-patologic al neoplaziei mamare și diagnosticul de microcarcinom tiroidian papilar, respectiv melanom malign cutanat tip Clark II. Pacienta a primit radioterapie adjuvantă pentru cancerul mamar, fiind supravegheată imagistic pentru cancerul tiroidian și cel cutanat. Concluzii. Tumorile maligne sunt definite ca neoplazii primare multiple dacă apar în locuri diferite și/sau aparțin unui grup histologic diferit. Astfel, este evitată clasificarea eronată a tumorilor multiple ca determinări secundare. Cazul prezentat subliniază importanța investigațiilor paraclinice efectuate meticulos pentru stadializarea preterapeutică, detecția cancerelor sincrone având un rol semnificativ în prevenția, diagnosticul și stabilirea tratamentului pacientului, în vederea obținerii celor mai bune rezultate terapeutice.Aim of study. Loco-regional and distant staging of malignant tumors can highlight the presence of synchronous neoplasias in the same organ or at distance. Synchronous primary neoplasms present in three different organ systems are reported in the literature with an incidence of 2.4%-17%. The mirage of the first lesion can often lead to therapeutic management errors. Materials and methods. A 66-year-old female patient, known to have important cardiovascular and thyroid pathology, presented to the IRO Iasi Hospital following palpation of a left mammary tumor in the infero-external quadrant. During the clinical examination, a surface with an irregular outline, made up of an area in which both hypopigmentation and hyperpigmentation are present, is observed at the skin level in the area of the left breast. The patient is staged by imaging for the breast condition – invasive ductal neoplasia cT2N1 (triple negative) and an irregular solid nodule in the anterior segment of the left lung lobe. The decision of the Multidisciplinary Oncological Team is to evaluate the PET-CT of the lung nodule, which refutes the position of lung metastasis, but shows hyper-uptake at the level of the thyroid gland. It is decided to initiate neoadjuvant chemotherapy for the breast disease, followed by sequential surgery of the breast en bloc with the skin disease and, after 3 weeks, total thyroidectomy. Results. The final histopathological report consisted of the complete pathological response of the breast cancer and the diagnosis of papillary thyroid microcarcinoma, respectively Clark II type malignant cutaneous melanoma. The patient received adjuvant radiotherapy for breast cancer, being monitored by imaging for thyroid and skin cancer. Conclusions. Malignant tumors are defined as multiple primary neoplasms if they occur in different sites and/or belong to a different histological group. Thus, the wrong classification of multiple tumors as secondary determinations is avoided. The presented case emphasizes the importance of meticulously performed paraclinical investigations for pre-therapeutic staging, the detection of synchronous cancers having a significant role in the prevention, diagnosis and stability of the patient's treatment, in order to obtain the best therapeutic results

Towards the introduction of the ‘Immunoscore’ in the classification of malignant tumours

The American Joint Committee on Cancer/Union Internationale Contre le Cancer (AJCC/UICC) TNM staging system provides the most reliable guidelines for the routine prognostication and treatment of colorectal carcinoma. This traditional tumour staging summarizes data on tumour burden (T), the presence of cancer cells in draining and regional lymph nodes (N) and evidence for distant metastases (M). However, it is now recognized that the clinical outcome can vary significantly among patients within the same stage. The current classification provides limited prognostic information and does not predict response to therapy. Multiple ways to classify cancer and to distinguish different subtypes of colorectal cancer have been proposed, including morphology, cell origin, molecular pathways, mutation status and gene expression-based stratification. These parameters rely on tumour-cell characteristics. Extensive literature has investigated the host immune response against cancer and demonstrated the prognostic impact of the in situ immune cell infiltrate in tumours. A methodology named ‘Immunoscore’ has been defined to quantify the in situ immune infiltrate. In colorectal cancer, the Immunoscore may add to the significance of the current AJCC/UICC TNM classification, since it has been demonstrated to be a prognostic factor superior to the AJCC/UICC TNM classification. An international consortium has been initiated to validate and promote the Immunoscore in routine clinical settings. The results of this international consortium may result in the implementation of the Immunoscore as a new component for the classification of cancer, designated TNM-I (TNM-Immune). © 2013 The Authors. Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland

Parametric POMDPs for planning in continuous state spaces

This thesis is concerned with planning and acting under uncertainty in partially-observable continuous domains. In particular, it focusses on the problem of mobile robot navigation given a known map. The dominant paradigm for robot localisation is to use Bayesian estimation to maintain a probability distribution over possible robot poses. In contrast, control algorithms often base their decisions on the assumption that a single state, such as the mode of this distribution, is correct. In scenarios involving significant uncertainty, this can lead to serious control errors. It is generally agreed that the reliability of navigation in uncertain environments would be greatly improved by the ability to consider the entire distribution when acting, rather than the single most likely state. The framework adopted in this thesis for modelling navigation problems mathematically is the Partially Observable Markov Decision Process (POMDP). An exact solution to a POMDP problem provides the optimal balance between reward-seeking behaviour and information-seeking behaviour, in the presence of sensor and actuation noise. Unfortunately, previous exact and approximate solution methods have had difficulty scaling to real applications. The contribution of this thesis is the formulation of an approach to planning in the space of continuous parameterised approximations to probability distributions. Theoretical and practical results are presented which show that, when compared with similar methods from the literature, this approach is capable of scaling to larger and more realistic problems. In order to apply the solution algorithm to real-world problems, a number of novel improvements are proposed. Specifically, Monte Carlo methods are employed to estimate distributions over future parameterised beliefs, improving planning accuracy without a loss of efficiency. Conditional independence assumptions are exploited to simplify the problem, reducing computational requirements. Scalability is further increased by focussing computation on likely beliefs, using metric indexing structures for efficient function approximation. Local online planning is incorporated to assist global offline planning, allowing the precision of the latter to be decreased without adversely affecting solution quality. Finally, the algorithm is implemented and demonstrated during real-time control of a mobile robot in a challenging navigation task. We argue that this task is substantially more challenging and realistic than previous problems to which POMDP solution methods have been applied. Results show that POMDP planning, which considers the evolution of the entire probability distribution over robot poses, produces significantly more robust behaviour when compared with a heuristic planner which considers only the most likely states and outcomes

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multi-disciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments

Changing outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer

Background Pelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is technically challenging but increasingly performed in specialist centres. The aim of this study was to compare outcomes of exenteration over time. Methods This was a multicentre retrospective study of patients who underwent exenteration for LARC and LRRC between 2004 and 2015. Surgical outcomes, including rate of bone resection, flap reconstruction, margin status and transfusion rates, were examined. Outcomes between higher- and lower-volume centres were also evaluated. Results Some 2472 patients underwent pelvic exenteration for LARC and LRRC across 26 institutions. For LARC, rates of bone resection or flap reconstruction increased from 2004 to 2015, from 3.5 to 12.8 per cent, and from 12.0 to 29.4 per cent respectively. Fewer units of intraoperative blood were transfused over this interval (median 4 to 2 units; P = 0.040). Subgroup analysis showed that bone resection and flap reconstruction rates increased in lower- and higher-volume centres. R0 resection rates significantly increased in low-volume centres but not in high-volume centres over time (low-volume: from 62.5 to 80.0 per cent, P = 0.001; high-volume: from 83.5 to 88.4 per cent, P = 0.660). For LRRC, no significant trends over time were observed for bone resection or flap reconstruction rates. The median number of units of intraoperative blood transfused decreased from 5 to 2.5 units (P < 0.001). R0 resection rates did not increase in either low-volume (from 51.7 to 60.4 per cent; P = 0.610) or higher-volume (from 48.6 to 65.5 per cent; P = 0.100) centres. No significant differences in length of hospital stay, 30-day complication, reintervention or mortality rates were observed over time. Conclusion Radical resection, bone resection and flap reconstruction rates were performed more frequently over time, while transfusion requirements decreased

Induction chemotherapy followed by chemoradiotherapy versus chemoradiotherapy alone as neoadjuvant treatment for locally recurrent rectal cancer: study protocol of a multicentre, open-label, parallel-arms, randomized controlled study (PelvEx II)

Background A resection with clear margins (R0 resection) is the most important prognostic factor in patients with locally recurrent rectal cancer (LRRC). However, this is achieved in only 60 per cent of patients. The aim of this study is to investigate whether the addition of induction chemotherapy to neoadjuvant chemo(re)irradiation improves the R0 resection rate in LRRC. Methods This multicentre, international, open-label, phase III, parallel-arms study will enrol 364 patients with resectable LRRC after previous partial or total mesorectal resection without synchronous distant metastases or recent chemo- and/or radiotherapy treatment. Patients will be randomized to receive either induction chemotherapy (three 3-week cycles of CAPOX (capecitabine, oxaliplatin), four 2-week cycles of FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) or FOLFORI (5-fluorouracil, leucovorin, irinotecan)) followed by neoadjuvant chemoradiotherapy and surgery (experimental arm) or neoadjuvant chemoradiotherapy and surgery alone (control arm). Tumours will be restaged using MRI and, in the experimental arm, a further cycle of CAPOX or two cycles of FOLFOX/FOLFIRI will be administered before chemoradiotherapy in case of stable or responsive disease. The radiotherapy dose will be 25 × 2.0 Gy or 28 × 1.8 Gy in radiotherapy-naive patients, and 15 × 2.0 Gy in previously irradiated patients. The concomitant chemotherapy agent will be capecitabine administered twice daily at a dose of 825 mg/m2 on radiotherapy days. The primary endpoint of the study is the R0 resection rate. Secondary endpoints are long-term oncological outcomes, radiological and pathological response, toxicity, postoperative complications, costs, and quality of life. Discussion This trial protocol describes the PelvEx II study. PelvEx II, designed as a multicentre, open-label, phase III, parallel-arms study, is the first randomized study to compare induction chemotherapy followed by neoadjuvant chemo(re)irradiation and surgery with neoadjuvant chemo(re)irradiation and surgery alone in patients with locally recurrent rectal cancer, with the aim of improving the number of R0 resections

The particular problems of low rectal cancer

Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Abstract: Introducere Neoplasmul rectal beneficiază de tratament multimodal ce trebuie adaptat fiecărui caz în parte. Material şi metode: Este prezentată experiența unei singure echipe pe un număr de 167 cazuri de neoplasm rectal tratate în perioada 2005-2011. Cazurile au fost supuse unui protocol de stadializare preterapeutică si s-au evidentiat 106 pacienți cu tumori situate în jurul distanței de 6 cm de marginea anală. Tratamentul neoadjuvant a fost reprezentat de radioterapie în regim de lungă durată pentru 89 de cazuri (T3, T4), iar chimioterapia a fost asociată în 56 cazuri. S-au practicat 19 rezecții anterioare de rect foarte joase cu excizie totală de mezorect, cu 11 anastomoze manuale si 8 anastomoze mecanice, 65 excizii abdomino-perineale de rect (18 asistate laparoscopic), 6 cazuri excizii locale transanale pentru tumori T0 si T1 şi 16 operații Hartmann cu excizie totală de mezorect. Ileostomia de protecție s-a practicat în 14 cazuri de rezecții foarte joase de rect și a fost închiăa la 6-8 saptămani. Rezultate Complicațiile imediate postoperatorii au fost: fistule anastomotice 1, fistulă recto-vaginală 3, disfuncții urinare 4. Recidivele locale după rezecțiile anterioare foarte joase de rect au fost întâlnite la 3 cazuri iar după excizie abdomino-perineală la 2 cazuri. Concluzii: Rezultatele postoperatorii sunt dependente de o corectă stadializare. Pacienții cu tumori jos situate tratate prin excizie abdomino-perineală de rect au avut tumori mai mari și mai agresive decat pacienții tratați prin rezecții anterioare foarte joase de rect.Introduction: The gold standard in rectal cancer today is a multimodal approach, tailored for each patient Material and methods: It is presented the one team experience with 167 cases of rectal cancer treated between 2005-2011. All patients have undergone a pretherapeutic staging protocol and there were 106 patients with tumours within 6 cm of anal verge. The neoadjuvant treatment was radiotherapy for 89 cases (T3, T4) and chemotherapy was associated in 56 cases. The procedures performed for low rectal cancer were 19 resections considered very low, with total mezorectal excision with 11 manual anastomosis and 8 mechanical anastomosis; 65 abdomino- perineal excision of the rectum (18 assisted laparoscopic), 6 transanal excision for T0 and T1 tumors and 16 extended Hartmann’s procedure, with total mesorectal excision. Protective ileostomy has been practiced for 14 cases of very low resection of the rectum and was closed 6-8 weeks later. Results: Postoperative complications were: anastomotique leakage-1, recto-vaginal fistula-3, urinary dysfunction-4. Local recurrence after very low anterior resection of the rectum were diagnosed in 3 cases and after abdomino-perineal excision in 2 cases. Conclusion: It is extremely important to perform a preoperative staging of all the diagnosed cancer patient in order to get the best results. Patients with low rectal cancer treated by abdomino-perineal excision have worse tumours and higher involved margin rates compared with those treated by anterior resection