Lambilliotte Jp

Pancreatic metastasis from renal cell carcinoma

Pancreatic metastasis from renal cell carcinoma is exceptional, but may appear many years after initial diagnosis and radical nephrectomy of an apparently limited tumour. We report one case of an asymptomatic isolated pancreatic metastasis discovered fortuitously, 21 years after right radical nephrectomy for a low-grade renal cancer. In 1969, a 47-year-old man underwent right nephrectomy for renal cell carcinoma of “low-grade malignancy”. At this time, no metastases were evident and he remained well on follow-up.

Computerized morphonuclear characteristics and DNA content of adenocarcinoma of the pancreas, chronic pancreatitis, and normal tissues: Relationship with histopathologic grading

We report the morphonuclear characteristics of normal (13 cases), benign (ie, chronic) pancreatitis (six cases), and neoplastic (ie, ductal) adenocarcinoma (22 cases) tissues of the pancreas. This description is based on computerized cell image analysis, which permits the determination of parameters related to the morphometric (nuclear area), densitometric (nuclear DNA content), and chromatin texture features of Feulgen-stained nuclei from paraffin-embedded archival material. We observed that nuclear area discriminates between normal and benign (ie, chronic pancreatitis) as opposed to neoplastic cell nuclei. Morphonuclear parameters describing chromatin pattern characteristics made it possible to discriminate between grade I pancreatic carcinoma and normal and benign cell nuclei on the one hand, and grades I and III carcinoma on the other hand. The nuclear DNA content increased in a continuous manner from normal and benign through low-grade to high-grade neoplastic tissues of the pancreas. Combining the morphometric, densitometric, and textural parameters into one equation, we were able to calculate a score (ie, the malignancy level index) that showed a close relationship to conventional histopathologic grading. Thus, the computer-aided diagnosis of cytologic specimens from pancreatic lesions offers information of the same significance as that obtained by conventional histopathologic grading.

Squamous cell carcinoma of the esophagus: multimodal therapy in locally advanced disease.

The aim of this prospective study is to report our experience in the multimodal management of locally advanced esophageal squamous cell carcinoma (LAESC; stage III cTNM), focusing on the results of chemoradiotherapy followed by surgery. These findings were compared to the results of a standard group of patients with locally advanced esophageal carcinoma (LAEC; stage III pTNM) treated in our center with surgery alone. Sixty-one patients with LAESC underwent preoperative chemoradiotherapy (5-fluorouracil cisplatin) with concomitant 45 Gray radiotherapy in a 5-week course. Transthoracic esophagectomy was performed 4 to 5 weeks after the end of the neoadjuvant therapy. Thirty-eight patients underwent surgery, and 37 of them had resections (resectability: 97% in the multimodal group; 84% in the standard surgical series; p 0.07). The R0 (complete) resection rate was 78% compared to 56% in the standard surgical group (p < 0.03). Eleven patients had no residual tumor in the resected specimen (pathologic complete response: pCR: 30%). The operative mortality rate was 19% compared with 8.8% in the standard series. The overall median survival of the resected patients was 21 months, with a 5-year survival rate of 11% (14% in the surgical group; NS). The 3-year and 5-year survival rates were 34% for the pCR group and respectively 5% and 0% for the group with pathologic incomplete response (pIR; p < 0.05). The median survival was 28 months for the pCR patients and 19 months for the pIR group. In this non-randomized trial, preoperative chemoradiotherapy in LAESC seems to increase the resectability and R0 resection rates, to allow a higher pCR rate and a longer survival only in the pCR group, at the expense of an inadequate increase in operative mortality. This multimodal treatment cannot be proposed as a standard procedure unless less toxic regimens are developed, increasing the benefits with better local and distant failure control and decreasing operative mortality. Despite many technical advances, esophageal cancer still represent a therapeutic challenge. Major improvements in the management of this disease include preoperative risk evaluation [1], preoperative staging with more accurate detection of local involvement and distal spread leading to a better adapted treatment [1]. Other important improvements are the standardization of the surgical techniques and the advances in perioperative care. The poor prognosis for esophageal cancer in the Occidental countries is related to the lower operability rate of patients in poor general condition with associated chronic heart, pulmonary, and/or liver diseases and associated tobacco and alcohol abuse. Another important factor is the lower resectability rate, related to the advanced stage of the disease at presentation, with regional lymph node involvement, adjacent structure infiltration, and especially distant spread in 20% to 30% of the patients [2]. A late diagnosis, with esophageal tumor penetrating through the esophageal wall and regional lymph node involvement, seen in more than 75% of the patients [3], compromises the resectability and decreases significantly the 5-year survival rate (15% to 20%) [4]. Therefore, efforts must be focused on the initial use of preoperative combined therapy to induce downstaging of the primary lesion, to eliminate the potential for metastases, and consequently to improve long-term survival. Although the multimodal approach is theoretically sound, its worth remains unproved and its use remains controversial because of the conflicting data emerging from phase II and phase III trials. The aim of this study is to report our experience in the multimodal management of esophageal squamous cell carcinoma in locally advanced disease, focusing on the results of chemoradiotherapy followed by surgery. These findings were compared to those emerging from a historical group of patients with locally advanced esophageal cancer treated in our center with surgery alone. Patients and Methods Between 1990 and 1995, 198 patients with esophageal cancer were assessed in our department. Sixty-one patients presented with locally advanced squamous cell carcinoma. Operability was evaluated by risk analysis, including performance status and respiratory, cardiac, and liver function evaluation. Patients with high surgical risk were considered inoperable. Loco-regional resectability was assessed with laryngoscopy, Correspondence to: I. El Nakadi, M.D., e-mail: ielnakad@ulb.ac.be bronchofibroscopy, esophagogastroscopy, barium swallow, mediastinal and esophageal computed tomography (CT), and endoscopic ultrasonography (US). The carcinoma was considered “locally advanced” when preoperative staging by mediastinal CT and endoscopic US revealed a T3/T4 with any N tumor [5]. Distant metastases were assessed with lung and abdominal CT with or without liver US. This assessment led to preoperative cTNM staging including 3 T3N0, 41 T3N1, 1 T3Nx, 4 T4N0, 11 T4N1 and 1 T4Nx. Resected tumors were classified according to pTNM staging [5]. The following nonrandomized multimodal strategy was applied prospectively. All operable patients (n 48) underwent a preoperative chemoradiotherapy including a chemotherapy regimen of cisplatin (CDDP) 15 mg/m with 5-fluorouracil (5-FU) 750 mg/m from day 1 to day 5. Concomitantly a 45 GY radiotherapy was delivered in 25 fractions over 5 weeks with a linear accelerator (Fig. 1). The chemotherapy regimen was repeated during the fifth week. Following this treatment, patients were questioned about dysphagia relief or improvement. The objective reassessment of the preoperative treatment for operability and resectability was carried out 2 to 3 weeks after chemoradiotherapy. The resectability was reevaluated with endoscopy, barium swallow, CT scan, and endoscopic US. The clinical response to treatment was classified as complete response, incomplete response (partial and minimal), no change, or progression according to the World Health Organization (WHO) criteria [6]. Patients with disease progression underwent an additional course of radiotherapy; those with partial or complete response underwent surgery (Fig. 2). Patients evaluated as inoperable or those who rejected the protocol were treated with chemoradiotherapy with or without esophageal endoprosthesis. This protocol included the same chemotherapy regimen associated with a dose of 60 GY radiotherapy.

Laparoscopic treatment of a sigmoid perforation after colonoscopy

The authors report a case of sigmoid colon perforation post colonoscopic polypectomy. Such perforation is rare and has been estimated to occur between 0.1 and 3% of the time. Surgical treatment is necessary when there is deterioration of the clinical state. In this reported case, surgical closure of the perforation was achieved by laparoscopy. We believe that this approach is effective for colonic suture, peritoneal lavage, and drainage.

Spontaneous spleen rupture after bacterial endocarditis

A 50-year-old man presenting with high fever, dysarthria and partial unconsciousness was admitted to the emergency department. The diagnosis was bacterial endocarditis. A week after his admission, he suddenly had a hypovolemic shock. Operation revealed splenic rupture. Histological examination of the spleen revealed sites of infarct colonized by Streptococcus mitis and a large fissure. Spontaneous spleen rupture following bacterial endocarditis is a rare complication. Copyright

Intussusceptions in Adults: Clinical Course and Associated Lesions

Intussusception in adults is rare. The authors report 18 cases and illustrate the pathological and clinical findings. Intussusception is usually secondary to a benign small bowel lesion or to a malign