Helen Bolanaki

Serum vascular endothelial growth factor levels in pancreatic cancer patients correlate with advanced and metastatic disease and poor prognosis

The serum concentrations of vascular endothelial growth factor (VEGF) were measured by an enzyme linked immunosorbent assay in 51 healthy controls and in 58 patients with pancreatic cancer before and 30 days after surgery. Pancreatic cancer patients had significantly higher serum VEGF levels compared with healthy controls with a significant association between serum VEGF levels, disease stage and the presence of both lymph node and distant metastases. Serum levels of VEGF decreased significantly after radical resection of the tumor. Elevated preoperative serum VEGF level was a significant prognostic factor, although not independent of stage, for patient survival. These findings suggest that serum VEGF concentrations may reflect pancreatic cancer progression and that their determination may be clinically useful.

Prognostic role of APC and RASSF1A promoter methylation status in cell free circulating DNA of operable gastric cancer patients

Gastric carcinogenesis is a multistep process including not only genetic mutations but also epigenetic alterations. The best known and more frequent epigenetic alteration is DNA methylation affecting tumor suppressor genes that may be involved in various carcinogenetic pathways. The aim of the present study was to investigate the methylation status of APC promoter 1A and RASSF1A promoter in cell free DNA of operable gastric cancer patients. Using methylation specific PCR, we examined the methylation status of APC promoter 1A and RASSF1A promoter in 73 blood samples obtained from patients with gastric cancer. APC and RASSF1A promoters were found to be methylated in 61 (83.6%) and 50 (68.5%) of the 73 gastric cancer samples examined, but in none of the healthy control samples (p < 0.001). A significant association between methylated RASSF1A promoter status and lymph node positivity was observed (p = 0.005). Additionally, a significant correlation between a methylated APC promoter and elevated CEA (p = 0.033) as well as CA-19.9 (p = 0.032) levels, was noticed. The Kaplan-Meier estimates of survival, significantly favored patients with a non-methylated APC promoter status (p = 0.008). No other significant correlations between APC and RASSF1A methylation status and different tumor variables examined was observed. Serum RASSF1A and APC promoter hypermethylation is a frequent epigenetic event in patients with early operable gastric cancer. The observed correlations between APC promoter methylation status and survival as well as between a hypermethylated RASSF1A promoter and nodal positivity may be indicative of a prognostic role for those genes in early operable gastric cancer. Additional studies, in a larger cohort of patients are required to further explore whether these findings could serve as potential molecular biomarkers of survival and/or response to specific treatments.

Hepatoid Adenocarcinoma of the Gallbladder Case Report and Literature Review

Hepatoid adenocarcinoma (HAC) is a rare tumor consisting of three distinct patters, solid, tubular and trabecular, with morphological and functional features resembling hepatocellular carcinoma (HCC). The tumor is found most frequently in the stomach [1, 2], where it was originally described by Ishikura et al. [3] as a specific subtype of primary gastric carcinoma, with occasional reports describing locations in other organs such as the lung [4, 5], kidney [6], female reproductive tract [7–11], pancreas [12–14], and gallbladder [15, 16]. In this report, we present a case of HAC of the gallbladder. Case Report

Primary Squamous Cell Carcinoma of the Ampulla of Vater

CONTEXT Squamous carcinoma of the ampulla of Vater is a very rare tumor with only three cases been reported so far. CASE REPORT Here, we report the case of a 68-year-old man who presented with painless obstructive jaundice, general fatigue, loss of appetite and weight loss. Laboratory tests revealed hypochromic anemia. Total and direct bilirubin, alkaline phosphatase, liver enzymes, carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) were all elevated. Abdominal ultrasonography and computed tomography showed a distended gallbladder, dilatation of the intra- and extra-hepatic bile ducts and enlargement of the pancreatic head. Endoscopic retrograde cholangiopancreatography revealed a bulging papilla with infiltrative growth at the ampulla of Vater but endoscopic biopsies were inconclusive. The patient was treated with classical Whipples pancreaticoduodenectomy. Histopathological examination showed a moderately differentiated squamous cell carcinoma. Multiple serial sectioning of the tumor specimen failed to detect an adenomatous component. Regional lymph nodes and resection margins were free of tumor and the disease was classified as stage IIA (T3N0M0) according to the TNM system. Adjuvant treatment was not given. Despite curative resection, multiple liver metastases developed after four months and the patient succumbed to progressive hepatic failure 5 months after the operation. CONCLUSION Primary pure squamous cell carcinoma of the ampulla of Vater is a very rare histological type of carcinoma. Clinical characteristics and optimal treatment are obscure. Primary surgical treatment with curative intent should be performed although this type of carcinoma associates with dismal prognosis.

Primary Malignant Gastrointestinal Stromal Tumor (GIST) of the Gallbladder: Report of a Case

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract. They are believed to originate from the interstitial cells of Cajal which are located in the mesenteric plexus and are considered as the pacemaker cells of the GI tract [1]. The majority of GISTs (90%) have mutations in the transmembrane tyrosine kinase receptor CD117 (c-kit) and/ or mutations in another tyrosine kinase, namely, plateletderived growth factor receptor-α (PDGFRA), resulting in constitutive activation of the kit signaling pathway [2]. In fact, CD117 protein expression is a key feature to characterize a mesenchymal neoplasm as GIST and a large number of gastrointestinal smooth muscle tumors which had been previously diagnosed as leiomyomas, leiomyoblastomas, and leiomyosarcomas were actually GISTs. GISTs may occur throughout the GI tract from the esophagus to the rectum. Most commonly, they are located in the stomach (60%) and the small intestine (35%) and at less than 5% in the rectum, esophagus, and duodenum [3]. Localization of GISTs outside the GI tract has been only sporadically reported. Herein, we report a case of primary malignant GIST of the gallbladder.

Cutaneous metastasis at a surgical drain site after gastric cancer resection.

Cutaneous metastasis from intra-abdominal malignant solid tumours such as gastric adenocarcinoma is very rare. Here, we report the case of a 76-year-old male patient with a T4N2M0, poorly differentiated, signet-ring cell gastric carcinoma, who underwent potentially curative resection of the tumour and developed cutaneous metastasis at the site of the surgical drain 4 months after the operation while he was on chemotherapy. The lesion involved the skin and the subcutaneous fat only. A CT scan revealed local recurrence at the resection bed but no distant metastases. The patient died 1 month later. It is concluded that the development of cutaneous metastasis after gastric carcinoma resection indicates tumour recurrence or disseminated disease and is associated with poor prognosis.

Common Bile Duct Obstruction Secondary to a Periampullary Diverticulum

Periampullary duodenal diverticula are not uncommon and are usually asymptomatic although complications may occasionally occur. Here, we report the case of a 72-year-old woman who presented with painless obstructive jaundice. Laboratory tests showed abnormally elevated serum concentrations of total and direct bilirubin, of alkaline phosphatase, of γ-glutamyl transpeptidase, and of aspartate and alanine aminotransferases. Serum concentrations of the tumor markers carbohydrate antigen 19-9 and carcinoembryonic antigen were normal. Abdominal ultrasonography showed dilatation of the common bile duct (CBD), but no gallstones were found either in the gallbladder or in the CBD. The gallbladder wall was normal. Computed tomography failed to detect the cause of CBD obstruction. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed a periampullary diverticulum measuring 2 cm in diameter and compressing the CBD. The pancreatic duct was normal. Hypotonic duodenography demonstrated a periampullary diverticulum with a filling defect corresponding to the papilla. CBD compression by the diverticulum was considered as the cause of jaundice. The patient was successfully treated by surgical excision of the diverticulum. In conclusion, the presence of a periampullary diverticulum should be considered in elderly patients presenting with obstructive jaundice in the absence of CBD gallstones or of a tumor mass. Non-interventional imaging studies should be preferred for diagnosis of this condition, and surgical or endoscopic interventions should be used judiciously for the effective and safe treatment of these patients.

Synchronous Breast and Rectal Cancers in a Man

Breast cancer in men is relatively rare and its coexistence with other primary non-breast cancers exceptional. Here, we report the case of a 50-year-old man who presented with symptoms of rectal adenocarcinoma and in whom a synchronous, asymptomatic cancer of the left breast was found incidentally at physical examination.

Ischemic colitis of the left colon in a diabetic patient.

Diabetes mellitus may affect the gastrointestinal tract possibly as a result of autonomic neuropathy. Here we present a 68-year-old male with non-insulin-dependent diabetes mellitus who presented with prolonged watery diarrhea and in whom imaging studies demonstrated ischemic colitis of the left colon. Resection of the affected colon resulted in sustained disappearance of symptoms.

Early esophageal perforation caused by food bolus impaction

Summary � Background:� Impactedfoodbolusisthemostcommonesophagealforeignbodyinadults,�occurringmainlyin� patientswithanunderlyingpathologyandusuallyresolvingspontaneously. � Case Report:� A�71-year-oldmanpresentedwithacutedysphagiaduetocompleteesophagealobstructionbya� firmlyimpactedfoodbolusthatcouldnotberemovedendoscopicallyandresultinginearlyper- forationnecessitatingsurgicalintervention. � Conclusions:� Tightimpactionofafoodbolusmayresultinearlyperforationoftheesophagusandshouldbe� treatedwithoutdelay.