Jason S. Mizell

Response of metastatic mucosal melanoma to immunotherapy: It can get worse before it gets better

Immune therapy with checkpoint inhibitors has revolutionized the management of metastatic melanoma. Ipilimumab, nivolumab, and pembrolizumab are all FDA-approved immune checkpoint inhibitors to treat metastatic melanoma. Responses to immune checkpoint inhibitors are usually delayed. An interim progression on restaging computed tomography scans “pseudo-progression” may be observed before response to treatment occur. In this case, we report a significant interim progression of metastatic mucosal melanoma before meaningful responses to immunotherapy occurred. The patient developed significant immune therapy-related colitis and new onset vitiligo. Further restaging computed tomography scans showed sustained tumor response despite stopping the immune therapy.

Money matters: a resident curriculum for financial management.

BACKGROUND A 2005 survey reported 87% of surgery program directors believed practice management training should occur during residency. However, only 8% of program directors believed residents received adequate training in practice management [1]. In addition to the gap in practice financial management knowledge, we recognized the need for training in personal finance among residents. A literature review and needs assessment led to the development of a novel curriculum for surgery residents combining principles of practice management and personal finance. METHODS An 18-h curriculum was administered over the 2012 academic year to 28 post graduate year 1-5 surgery residents and faculty. A self-assessment survey was given at the onset and conclusion of the curriculum [2]. Pre-tests and post-tests were given to objectively evaluate each twice monthly sessions content. Self-perception of learning, interest, and acquired knowledge were analyzed using the Wilcoxon signed ranks test. RESULTS Initial self-assessment data revealed high interest in practice management and personal finance principles but a deficiency in knowledge of and exposure to these topics. Throughout the curriculum, interest increased. Residents believed their knowledge of these topics increased after completing the curriculum, and objective data revealed various impacts on knowledge. CONCLUSIONS Although surgery residents receive less exposure to these topics than residents in other specialties, their need to know is no less. We developed, implemented, and evaluated a curriculum that bridged this gap in surgery education. After the curriculum, residents reported an increase in interest, knowledge, and responsible behavior relating to personal and practice financial management.

Multidisciplinary surgical treatment of presacral meningocele and teratoma in an adult with Currarino triad

Background: Currarino syndrome (CS) is a rare genetic condition that presents with the defining triad of anorectal malformations, sacral bone deformations, and presacral masses, which may include teratoma. Neurosurgeons are involved in the surgical treatment of anterior meningoceles, which are often associated with this condition. The accepted surgical treatment is a staged anterior-posterior resection of the presacral mass and obliteration of the anterior meningocele. Case Description: This case involved a 36-year-old female who presented with late onset of symptoms attributed to CS (e.g., presacral mass, anterior sacral meningocele, and sacral agenesis). She successfully underwent multidisciplinary single-stage approach for treatment of the anterior sacral meningocele and resection of the presacral mass. This required obliteration of the meningocele and closure of the dural defect. One year later, her meningocele had fully resolved. Conclusion: While late presentations with CS are rare, early detection and multidisciplinary treatment including single-state anterior may be successful for managing these patients.

Quantitative analysis of ex vivo colorectal epithelium using an automated feature extraction algorithm for microendoscopy image data

Abstract. Qualitative screening for colorectal polyps via fiber bundle microendoscopy imaging has shown promising results, with studies reporting high rates of sensitivity and specificity, as well as low interobserver variability with trained clinicians. A quantitative image quality control and image feature extraction algorithm (QFEA) was designed to lessen the burden of training and provide objective data for improved clinical efficacy of this method. After a quantitative image quality control step, QFEA extracts field-of-view area, crypt area, crypt circularity, and crypt number per image. To develop and validate this QFEA, a training set of microendoscopy images was collected from freshly resected porcine colon epithelium. The algorithm was then further validated on ex vivo image data collected from eight human subjects, selected from clinically normal appearing regions distant from grossly visible tumor in surgically resected colorectal tissue. QFEA has proven flexible in application to both mosaics and individual images, and its automated crypt detection sensitivity ranges from 71 to 94% despite intensity and contrast variation within the field of view. It also demonstrates the ability to detect and quantify differences in grossly normal regions among different subjects, suggesting the potential efficacy of this approach in detecting occult regions of dysplasia.

Rectal gastrointestinal stromal tumor with metastasis to the penis: Case report and review of literature

Highlights • The first reported case of a rectal GIST with metastasis to the penis is documented by this report.• The primary cancer was treated with neoadjuvant chemotherapy and abdominoperineal resection.• Biopsies of lesions identified on follow-up imaging were consistent with metastatic GIST.• Metastasectomy and adjuvant chemotherapy have been utilized to help prolong survival.

Qualitative and quantitative comparison of colonic microendoscopy image features to histopathology

Colorectal cancer is the second leading cause of cancer deaths in the United States, affecting more than 130,000 Americans every year1. Determining tumor margins prior to surgical resection is essential to providing optimal treatment and reducing recurrence rates. Colorectal cancer recurrence can occur in up to 20% of cases, commonly within three years after curative treatment. Typically, when colorectal cancers are resected, a margin of normal tissue on both sides of the tumor is required. The minimum margin required for colon cancer is 5 cm and for the lower rectum 2 cm. However, usually more normal tissue is taken on both sides of the tumor because the blood supply to the entire segment is removed with the surgery and therefore the entire segment must be removed. Anastomotic recurrences may result from inadequate margins. Pathologists look at the margins to ensure that there is no residual tumor and this is usually documented in the pathology report. We have developed a portable, point-of-care fiber bundle microendoscopy imaging system for detection of abnormalities in colonic epithelial microstructure. The system comprises a laptop, a modified fiber bundle image guide with a 1mm active area diameter and custom LabVIEW interface, and is approved for imaging surgically resected colon tissue at the University of Arkansas for Medical Sciences. The microendoscopy probe provides high-resolution images of superficial epithelial histology in real-time to assist surgical guidance and to localize occult regions of dysplasia which may not be visible. Microendoscopy images of freshly resected human colonic epithelium were acquired using the microendoscopy device and subsequently mosaicked using custom post-processing software. Architectural changes in the glands were mapped to histopathology H&E slides taken from the precise location of the microendoscopy images. Qualitatively, glandular distortion and placement of image guide was used to map normal and dysplastic areas of the colonic tumor and surrounding region from microendoscopy images to H&E slides. Quantitative metrics for correlating images were also explored and were obtained by analyzing glandular diameter and spatial distribution as well as image texture.

Fiber Bundle Microendoscopy for Characterization of Dysplastic Lesions in Colonic Epithelium

Fiber bundle microendoscopy has shown promise as a point-of-care imaging system for epithelial dysplasia visualization. Here we present the use of this technology as a means to characterize lesions in colorectal cancer.

Dedifferentiated Liposarcoma Mimicking a Primary Colon Mass

Dedifferentiated liposarcoma is typically a nonlipogenic high-grade sarcoma that arises from well-differentiated liposarcoma. It most commonly presents as a large mass in the retroperitoneum. Significant involvement of the gastrointestinal tract by dedifferentiated liposarcoma is uncommon. We present a unique case of dedifferentiated liposarcoma radiographically mimicking a primary colon mass with resulting intussusception; stranding of the adjacent adipose tissue was presumed to be a secondary reactive change. On histopathologic analysis of the hemicolectomy specimen, a high-grade sarcoma was seen growing through the colonic wall, and the majority of the surrounding pericolonic adipose tissue was actually composed of well-differentiated liposarcoma with characteristic fibrous bands rather than benign fat with reactive fibrosis. This case raises awareness that well-differentiated liposarcoma and dedifferentiated liposarcoma can rarely present as a primary intestinal mass mimicking colon cancer or other more common entities. When radiographic examination shows a perigastrointestinal or retroperitoneal fatty mass and/or stranding of the fat adjacent to a solid gastrointestinal mass, this unusual scenario should be considered in the radiologic differential diagnosis. Pathologists should keep dedifferentiated liposarcoma in the initial histologic differential diagnosis for any high-grade spindle cell tumor of the retroperitoneum or intra-abdominal visceral organs.

Fluorescein as a topical fluorescent contrast agent for quantitative microendoscopic inspection of colorectal epithelium

Fiber bundle microendoscopic imaging of colorectal tissue has shown promising results, for both qualitative and quantitative analysis. A quantitative image quality control and image feature extraction algorithm was previously designed for quantitative image feature analysis of proflavine-stained ex vivo colorectal tissue. We investigated fluorescein as an alternative topical stain. Images of ex vivo porcine, caprine, and human colorectal tissue were used to compare microendoscopic images of tissue topically stained with fluorescein and proflavine solutions. Fluorescein was shown to be comparable for automated crypt detection, with an average crypt detection sensitivity exceeding 90% using a combination of three contrast limit pairs.

Approaches and Treatment of Intussusception, Volvulus, Rectal Prolapse, and Functional Disorders of the Colon, Rectum, and Anus

I would like to thankDr. Steele for invitingme to participate as a guest editor for this issue of Clinics in Colon and Rectal Surgery. This issue focuses on two broad categories of diseases that are complicated, frequentlymisdiagnosed, and commonly misunderstood—anatomic abnormalities of the small bowel and colon, and functional disorders of the colon, rectum, and anus. Not only are these diseases extremely debilitating for patients but they are also some of the most challenging and complex for the colorectal surgeon. Additionally, lack of a comprehensive understanding of their workup and treatment can lead to poor outcomes, patient harm, and surgeon frustration. This issue provides current data regarding etiologies, evaluation, workup, and medical and surgical management of these difficult and perplexing problems. Dr. Kapadia from the University of Iowa has provided an extensive review of volvulus in the small intestine and colon, and medical and surgical repair of each when appropriate. Drs. Ivatury and Holubar fromDartmouth-HitchcockMedical Center describe in depth the etiology, diagnosis, and treatment of intussusception in the pediatric and adult population, including a detailed description of open and laparoscopic treatments of this complex disease. Rectal prolapse is covered extensively by a team of colorectal surgeons. Dr. Cannon from the University of Alabama at Birmingham describes the etiology, methods of diagnosis, and medical therapy for rectal prolapse. Drs. Joubert and Laryea from the University of Arkansas for Medical Sciences (UAMS) describe abdominal approaches for surgical repair of rectal prolapse, giving a thorough review of emerging therapies and data regarding mesh repair of prolapse. Dr. Barfield from Our Lady of the Lake Physicians Group in Baton Rouge, Louisiana, completes the section with a description of perineal approaches for rectal prolapse. The remainder of the issue switches gears from anatomic abnormalities to functional disorders of the rectum, anus, and pelvicfloor. These topics canbequite perplexing, but the authors have done an outstanding job describing a clear method for evaluation and management of these difficult problems. Drs. Tillou and Poylin from Beth Israel Deaconess Medical Center begin this section with a detailed evaluation of the data that can be used to guide evaluation and treatment of colonic inertia. Drs. Fabrizio, Alimi, and Kumar from the Medstar Georgetown University Hospital and Virginia Mason Medical Center were challengedwith the difficult and tedious task of reviewing the data regarding methods of evaluation of the causes of obstructed defecation. Details regarding tools for physiologic testing and imaging are covered at length. The often poorly understood and somewhat controversial topic of rectoanal intussusception and its clinical implications is reviewed by Drs. Blaker and Anandam from the University of Texas Southwestern Medical Center. Dr. Mustain from UAMS gives a thorough review of the anatomy of the pelvic floor, along with etiologies for why rectoceles develop. The symptomatology of rectoceles, their role in obstructed defecation syndrome, their workup, and finally detailed treatment options are described for this often overtreated anatomic abnormality. Finally, Drs. Payne and Grimm from the University of South AlabamaMedical Center describe the frequently misunderstood and difficult problems of paradoxical puborectalis contraction and increased perineal descent (IPD). Details of dyssynergia are well describedalongwithnewermodalities for evaluationof IPD. I would like to sincerely thank all of the contributors for their hard work in contributing to this issue of the Clinics in Colon and Rectal Surgery. Editing this issue and working with these outstanding physicians has been a very rewarding experience. Their sacrifice, research, and efforts have provided an in-depth resource for physicians who aim to treat these complex and debilitating disorders. Jason S. Mizell, MD, FACS, FASCRS