Francesco Scintu

Primary hydatid cysts of psoas muscle

Background:  Hydatid cysts may occur in any area of the body, but they usually localize to the liver and the lungs. Primary localization in muscle is not common, accounting for 2−3% of all sites; even rarer is the development of multiple cysts.

Aspirin as a neoadjuvant agent during preoperative chemoradiation for rectal cancer.

Background:Recently, many studies have suggested a possible adjuvant role of aspirin in colorectal cancer, reporting a positive prognostic effect with its use in patients with established disease. The aim of this study was to investigate the anticancer effect of aspirin use during preoperative chemoradiation for rectal cancer.Methods:Two hundred and forty-one patients with stage II–III rectal cancer and candidates for chemoradiation (CRT) were selected and assigned to two groups: group 1, patients taking aspirin at the time of diagnosis, and group 2, all others. Treatment and oncological outcomes were explored.Results:Aspirin use was associated with a higher rate of tumour downstaging (67.6% vs 43.6%, P=0.01), good pathological response (46% vs 19%; P<0.001), and a slightly, although not significant, higher rate of complete pathological response (22% vs 13%; P=0.196). Aspirin use was also associated with a better 5-year progression-free survival (86.6% vs 67.1%; hazard rate (HR)=0.20; 95% CI=0.07–0.60) and overall survival (90.6% vs 73.2%; HR=0.21; 95% CI=0.05–0.89). Although chance of local relapse was similar (HR=0.6; 95% CI=0.06–4.5), aspirin use was associated with a lower risk of developing metastasis (HR=0.30; 95% CI=0.10–0.86).Conclusions:Aspirin might have anticancer activity against rectal cancer during preoperative CRT. This finding could be clinically relevant and should be further investigated with randomised trials.

Neuromuscular and Vascular Hamartoma of the Small Intestine

Neuromuscular and vascular hamartoma is an extremely rare stricturing condition of the small bowel. It consists of abnormal mixtures of intestinal tissues: disorganized fascicles of smooth muscle derived from the submucosa, bundles of nonmyelinated nerve fibers with scattered abnormal ganglion cells and hemangiomatous vessels, occurring focally and causing recurrent obstructive symptoms or occult chronic gastrointestinal bleeding. In this paper we report our experience with this tumor.

Giant sigmoid lipoma covered by a villous adenoma

Dear Editor: We would like to report an interesting case of a giant sigmoid lipoma covered by adenomatous mucosa. A 39-year-old male, with a family history of colon cancer (one brother dead), presented to our Clinic after an episode of rectal bleeding. A colonoscopy demonstrated 35 cm from the anal verge a sessile, fungoid mass (5×5 cm), almost completely occupying the lumen. The covering mucosa appeared normal at the base, while it was eroded at the head of the tumour. Biopsies were taken, but they revealed only a markedly inflamed mucosa. Subsequently, he was admitted in a good general condition and clinical examination was unremarkable. Haematological exams, liver and renal function tests, haemocoagulation and tumoral markers (CEA, Ca 19.9, αFP) were within normal ranges. A US scan of the abdomen did not show any other abnormalities. Considering the dimensions of the lesion and the impossibility of excluding its malignant nature, it was decided to perform an anterior resection with colorectal stapled anastomosis. The patient’s subsequent recovery was uneventful. The macroscopic examination of the specimen confirmed the presence of an ovoid, sessile, intraluminal tumour, about 5 cm in diameter. The mucosa at the base of the tumour was smooth, whilst it was largely eroded in the apical portion. At the cut surface the tumour showed a lipomatous aspect. Histology confirmed a submucosal proliferation of typical fatty cells with a lining mucosa that was almost completely ulcerated, except for the base, which was circumferentially involved by hyperplastic epithelium with villous adenomatous morphology (flat villous adenoma). This case is of particular interest because of its rarity and its pathogenetic implications. Colonic lipomas are benign tumours with low tendency to malignancy. They generally occur in the right colon, the sigmoid being involved in less than 5% of all cases. Although they are the commonest mesenchymal colonic tumours, their incidence in clinical and autoptic series is 0.2–4.4% [1, 2]. Patients, usually asymptomatic, may present with diarrhea, constipation, haemorrhage and abdominal pain, especially when the lipoma reaches 2–3 cm in diameter. Different authors have described alterations in the mucosa covering a lipoma, such as hyperplasia [3, 4], atrophy [5], ulceration [6–8] and necrosis [9]. To the best of our knowledge the association of lipoma and adenoma has been reported only once, but it concerned a very small adenomatous polyp on the top of a colonic lipoma in the distal transverse colon [10]. It is not clear whether this is due to a coincidence or whether there is a correlation between these entities. F. Capra (*) . L. Zorcolo . F. Scintu . G. Casula Chirurgia Generale II, Universita degli Studi di Cagliari, Ospedale Binaghi, Cagliari, Italy e-mail: facapra@tiscali.it Tel.: +39-070-6093011 Fax: +39-070-304462

The Role of Aspirin as Antitumoral Agent for Heavily Pretreated Patients With Metastatic Colorectal Cancer Receiving Capecitabine Monotherapy

Background The potential clinical impact of aspirin use beyond its canonical indications is a novel matter of scientific debate. In patients with metastatic colorectal cancer failing all available options, regorafenib and TAS 102 represent the only chance of treatment. Although effective, these therapeutic options bring along a not‐negligible burden in terms of economic costs and toxicity. In this setting, the indication to use aspirin in combination with chemotherapy would potentially represent a medical revolution under the economic and toxicity profile. Patients and Methods We assessed the role of aspirin in patients with metastatic colorectal cancer who failed all previous treatments and were receiving capecitabine as a salvage option before the introduction of regorafenib and TAS‐102. Results Sixty‐six patients were eligible. Twenty patients (30%) were on incidental treatment with aspirin for cardiovascular diseases. Twelve (60%) partial responses were seen in patients on treatment with aspirin, compared with 3 (6%) partial responses in the remaining patients (P = .00007). Sixteen patients on aspirin (80%) obtained disease control versus 14 (30%) patients who were not on aspirin (P = .000377). The median progression‐free survival for patients receiving treatment with aspirin was 6.5 months versus 3.3 months for patients who were not on aspirin (hazard ratio, 0.48; 95% confidence interval, 0.30‐0.79; P = .0042). A significantly improved overall survival was also evident in aspirin users (median overall survival, 14.7 vs. 8.7 months, respectively; hazard ratio, 0.43; 95% confidence interval, 0.26‐0.72; P = .0023). Conclusion Aspirin may improve the clinical outcome of heavily pre‐treated patients with metastatic colorectal cancer receiving chemotherapy. Further studies are necessary before application in the clinical practice. Micro‐Abstract The potential use of aspirin beyond recognized indications is becoming increasingly important in the oncology field of research. Besides accumulating data about aspirin in the prevention and postoperative setting for patients with colorectal cancer, we found that aspirin might have a relevant therapeutic role also in heavily pretreated patients with a potentially impressive efficacy profile, low toxicity, and negligible economic costs.

Limits of endorectal ultrasound in tailoring treatment of patients with rectal cancer.

Background: Endorectal ultrasound (ERUS) is considered reliable in staging rectal cancer, but recently some critics have questioned its accuracy. The aim of this study was to evaluate how often an ERUS-based decision leads to an appropriate treatment. Methods: Two hundred and twenty patients with rectal cancer staged with ERUS who underwent a surgical resection or a local excision without neoadjuvant therapy from 1997 to 2012 were included. According to ERUS, patients were divided into three groups of indication: (a) local excision (Tis-1 N0), (b) direct surgery (T2 N0), (c) preoperative chemoradiation (T3-4 or N+). Accuracy was explored by the correlation established with the final pathology. Results: Accuracy for T and N staging was 65 and 64%, respectively. Indication to local excision and to chemoradiation was correct in 97 and 88% of patients staged by ERUS. Accuracy of indication to direct surgery was poor (37%), and 21% of patients were overtreated in this group. Conclusions: ERUS seems not able to fulfill all the needs of ideal tailored therapeutic strategies. T2 diagnosis needs to be confirmed by an excisional biopsy before a final decision is made because overstaging of early tumors may occur in a not-so-negligible proportion of patients.

Metformin-associated lactic acidosis and temporary ileostomy: a case report

IntroductionLactic acidosis is a well-known complication of the anti-hyperglycemic biguanide agent metformin, especially in peculiar but not rare clinical conditions. Attempts to reduce the incidence of this adverse reaction have been enforced by national agencies over the years. The Italian Medicines Agency recently released a safety recommendation on prescribing the drug and with regard to the existence of several conditions that contraindicate drug continuation, such as dehydration, infection, hypotension, surgery or hyperosmolar contrast agent infusion, but the recommendation does not mention the increased risk related to stoma. The present case report is, to our knowledge, the first in the literature of metformin-associated lactic acidosis in a patient with a recently created ileostomy and low anterior resection for rectal cancer.Case presentationA 70-year-old Caucasian man who had undergone low anterior resection with total mesorectal excision and temporary loop ileostomy creation at our institution returned to our department 30 days later because of nausea, vomiting, diffuse abdominal pain and anuria of about 24 hours’ duration. During his physical examination, the patient appeared dehydrated and had tachypnea and a reduced level of consciousness. His laboratory tests showed that he had acute kidney injury and severe lactic acidosis.ConclusionAn ileostomy puts patients at high risk for output losses that can lead to dehydration and electrolyte abnormalities. The assessment of the losses through the stoma, especially the ileostomy, should be added to the recommendations issued by pharmacovigilance societies. The present clinical case illustrates the need for clinicians on surgical wards to carefully evaluate patients before resuming metformin therapy and to provide appropriate information at discharge to patients with type 2 diabetes mellitus who have undergone ileostomy. Furthermore, this case report highlights the increasing need for more training of general physicians regarding both surgical and internal medicine problems that may arise in the post-operative course after major surgery in patients with co-morbidities.