Angelo Benevento

Result of liver resection as treatment for metastases from noncolorectal cancer.

While liver resection for metastatic disease from colorectal cancer extends survival in selected patients, the efficacy of hepatectomy for metastases from other malignancies has not been defined.

Primary pancreatic lymphoma

Primary pancreatic lymphoma (PPL) is a rare form of extranodal lymphoma (less than 0.5% of pancreatic tumors) originating from the pancreatic parenchyma. Histopathological examination is usually mandatory to obtain a definitive diagnosis since symptoms and radiological features are quite similar to those of other pancreatic masses. Percutaneous fine-needle aspiration (FNA) of the pancreas requires experienced cytopathologists as well as advanced immunohistochemical assays to obtain a final diagnosis on a small amount of tissue. A 46-year-old man complaining of watery diarrhea and severe weight loss (more than 20 kg) for more than 1 year was admitted to our hospital due to severe diabetic crisis. Enlarged lymph nodes (2.5 × 1 cm) were found at the right axillary stations. Abdominal ultrasound revealed the presence of a large hyperechogenic mass, mainly located at the pancreatic head. Abdominal computed tomography scan confirmed a diffuse enlargement of the head and body of the pancreas associated with lymphadenopathy along the lesser gastric curvature. Percutaneous ultrasound-guided FNA of the pancreas as well as gross biopsy of the axillary lymph nodes were unable to identify the nature of the mass. Diagnostic laparoscopy was performed: several enlarged lymph nodes along the lesser gastric curvature were revealed. Multiple biopsies of the pancreatic head were taken and lymphadenectomy along the lesser curvature and the hepatic hilus was also performed. The definitive histopathological examination of the pancreatic specimen revealed a primary low-grade non-Hodgkin B cell pancreatic lymphoma. The postoperative course was unremarkable; the patient underwent systemic chemotherapy regime for low-grade B cell Hodgkin lymphoma and he was symptom free at 9-month follow-up.

Injection of colorectal cancer cells in mesenteric and antimesenteric sides of the colon results in different patterns of metastatic diffusion: An experimental study in rats

BackgroundThis experimental study was designed to investigate the differences in pattern of local growth and diffusion of colorectal cancer cells injected into either mesenteric (M) or antimesenteric (AM) sides of the colon.MethodsA total of 1 × 106 colonic adenocarcinoma cells (line DHD/K12-TRb) were injected into the cecal wall of BDIX syngeneic male rats at an M or AM site of the colon. At six weeks after injection, all animals were sacrificed and the presence or absence of tumor in the cecum as well as regional metastasis and peritoneal carcinomatosis were determined.ResultsSix weeks after injection, macroscopic tumor growth was observed in 27/37 (72%) animals in group M and 21/32 (65%) in group AM (P = 0.98). In group AM, diffuse peritoneal carcinomatosis was present in 19/21 rats (90.4%) versus 3/27 rats (11%) in group M; this difference was statistically significant (P = 0.025). Regional mesenteric lymph nodes were the only location in which tumor was detected in 23/27 rats (85%) in group M versus 2/21 (9.5%) in group AM; this difference too was statistically significant (P = 0.031)ConclusionThe patterns of diffusion of tumors implanted in mesenteric and antimesenteric sites of the colon appear to be different, although the reason for this is not clear.

Multiple hemangiomas of the appendix and liver

A 34-year-old, nonsmoking, nonalcoholic woman had increasing diffuse abdominal pain for 3 months, with a large, painless mass (12 8 cm) in the lower quadrants. Past medical history was unremarkable. Routine blood tests, tumor markers, chest and abdominal x-rays were normal. Abdominal ultrasound (US) revealed a nonechogenic, hypervascularized lesion on the V hepatic segment with a thin, regular wall. A second hyperechogenic, vascularized hepatic lesion was present on segment VII. CT scan confirmed the presence of the two hepatic lesions located at segment V (A1) and VII (A2) with diameters of 13 8 and 7 8 cm, respectively. These lesions were enhanced by contrast and hypervascularized during the portal phase, as for metastatic lesions. Abdominal US, transvaginal US, and CT (A3) confirmed a 4-cm nonechogenic, cystic lesion that seemed to originate from the right ovary. Exploratory xifopubic laparotomy was performed. A large hepatic mass at segments IV and V (B) was revealed, and a second, smaller, cystic lesion arose from the appendicular mesentery (B, yellow arrow). Both ovaries were normal. After complete mobilization of the right liver, the presence of a second lesion at segment VIII was confirmed. Resection of the appendix and the paraappendicular lesion was performed. The two hepatic lesions were resected (C) using Pringle’s maneuver; total ischemia time was 34 minutes. The histopathologist described all three specimens as cavernous/capillary hemangiomas with epithelioid pattern (D); the appendix was normal. The patient was discharged on postoperative day 9 with no complications. Mixed cavernous and capillary hemangiomas are well-circumscribed tumors of variably dilated thinwalled vascular spaces and areas with a prominent proliferation of small, capillary-sized vessels, lined by a single layer of endothelial cells, partially with endothelioid and immature appearance. These cells have amphophilic or eosinophilic cytoplasm, sometimes vacuolated, and a single nucleus with scattered chromatin and central nucleolus. Cells that lined vascular spaces were strongly

Technological advances in minimally invasive surgery

Advances in technology continue at a rapid pace affecting several aspects of life; medicine is no exception. Minimally invasive surgery is, by its nature, a highly technological specialty of surgical practice. The development of new instruments and new technologies during the last few years have allowed complex procedures that were previously considered unsuitable for minimally invasive surgery. The aim of this article is to review some of these advances and the impact they are having on the managements of different surgical problems.

The mesenteric and antimesenteric location of colorectal cancer: The relationship with lymph nodes metastases

AIM Purpose of the study was to evaluate if the circumferential location of colorectal cancer may be identified as a possible prognostic factor. The hypothesis is that tumours located on the antimesenteric (AM) side could have a better prognosis than tumours located on the mesenteric (M) side. METHODS All patients undergoing curative resection for colorectal cancer were enrolled in the study. The specimens were sent to the pathologist to define the exact location of the tumour, the histological type, grading, T, N status as well as lymphatic, vascular and neural invasion, peritumoural lymphoid reaction, desmoplasia and microsatellite instability. Statistical analyses were performed using the test for proportions (with continuity correction), the Pearson Chi-square test and generalised linear models; p<0.05 were considered statistically significant. RESULTS From August 2000 to August 2002, 255 patients were enrolled in the study. There was a significantly higher incidence of tumours located on the M (101) compared with the AM (37) site (p<0.0001). M located tumours were associated with higher numbers of metastatic lymph nodes (N1 and N2; p-value=0.014), whereas AM tumours were associated with involved lymph nodes in only 5/37 (13.5%) of tumours. There was no statistically significant relation between AM versus M location and T status: the Pearson Chi-Square test showed that the lymph node involvement and the location (M versus AM) are not statistically independent variables (p-value=0.014). CONCLUSIONS Our preliminary results show that when M or AM tumour identification is possible, tumour location can be regarded as a prognostic factor. Further longer studies on recurrence rate and survival are required to validate these findings and the clinical usefulness of this putative prognostic factor.

A new device for minor bleeding control and blunt dissection in minimally invasive surgery

Background: Minor bleeding from small vessels could be a major complication in minimally invasive surgery (MIS). All the devices and techniques commonly used in open surgery to control bleeding or perform blunt dissection may be disappointing in endoscopic surgery. Materials and methods: Hydroxylated polyvinyl acetal tampons (HPA) are made by a synthetic, open cell foam structure able to absorb fluids up to 25 times the initial weight. We tested their efficacy for small bleeding control and tissue dissection during several minimally invasive procedures. Results: HPA tampons have been found extremely useful to absorb blood coming from minor and diffuse loss, helping to control bleeding by a combined action of fluid absorption and local compression. The porous design of the tampon allows the use of the suction device right through the tampon itself. Thanks to the initial mildly hard consistency, we also used HPA tampons as dissecting instruments. Conclusions: In our experience the use of HPA tampons resulted extremely efficient for minor bleeding control, fluids removal and tissue dissection during MIS.

Analyses of the Prognostic Factors in Colorectal Cancer. Preliminary Results of a Possible New Prognostic Factor: Mesenteric and Antimesenteric Tumor Location

Factors that are definitively proven to be of prognostic value, on the evidence of well-designated robust multi-centric trial are routinely used in clinical practice.

Hepatic Metastases from Non Colorectal Cancer: Which Ones Should be Resected?

Background and objectives While liver resection for metastatic disease from colorectal cancer is likely to extend survival in selected patients, the efficacy of hepatic resection as treatment for metastases from other malignancies has not yet been defined.