Paolo Bocus

Gastrointestinal stromal tumors: Report of an audit and review of the literature

Gastrointestinal stromal tumors (GISTs), tumors characterized by c-KIT mutations, are the most frequent mesenchymal tumors of the digestive tract. The stomach is the most commonly involved site. Localization, size and mitotic rate are reliable predictors of survival and the two milestones of GISTs treatment are surgery and imatinib. This article is aimed to report the data of an audit, carried out on the morphological and clinical aspects of the disease and to review the present knowledge on GISTs. A total of 172 patients with GISTs (M : F=1 : 1; mean age 65 years) were recruited. The stomach was the most frequently involved site. In 50% of the cases the tumor was smaller than 5 cm, whereas major symptoms were observed in 43% of the cases. Predictors of progressive disease were present only in a small percentage of cases but the disease was in the metastatic phase in over 25% of the cases at diagnosis. Familial aggregation was rare but a consistent share of the patients (21%) had other synchronous or metachronous cancers. The most frequent mutations were in-frame deletions and point mutations of c-KIT exon 11. This report confirms in part the available data on GIST in a consecutive series of patients recruited in Italy and shows that only large collaborative multicenter studies provide data sound enough to enable making reasonable clinical and therapeutic choices, and suggests that, as a measure of secondary prevention, a diagnostic definition should be obtained in all submucosal lesions of the GI tract and that GIST patients should be screened for second tumors.

Quality of life in patients with esophageal stenting for the palliation of malignant dysphagia

Incidence of esophageal cancer (EC) is rising more rapidly in the Western world than that of any other cancer. Despite advances in therapy, more than 50% of patients have incurable disease at the time of presentation. This precludes curative treatment and makes palliative treatment a more realistic option for most of these patients. Dysphagia is the predominant symptom in more than 70% of patients with EC and although several management options have been developed in recent years to palliate this symptom, the optimum management is not established. Self-expanding metal stents (SEMS) are a well-established palliation modality for dysphagia in such patients. Health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic or palliative intervention. To date, only a few published studies can be found on Medline examining HRQoL in patients with advanced EC treated with SEMS implantation. The aim of this study was to review the impact on HRQoL of SEMS implantation as palliative treatment in patients with EC. All Medline articles regarding HRQoL in patients with advanced EC, particularly those related to SEMS, were reviewed. In most studies, relief of dysphagia was the only aspect of HRQoL being measured and SEMS implantation was compared with other palliative treatments such as brachytherapy and laser therapy. SEMS insertion provides a swift palliation of dysphagia compared to brachytherapy and no evidence was found to suggest that stent implantation is different to laser treatment in terms of improving dysphagia, recurrent dysphagia and better HRQoL, although SEMS insertion has a better technical success rate and also reduces the number of repeat interventions.

Esophageal GIST: case report of surgical enucleation and update on current diagnostic and therapeutic options.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, but they have been rarely reported in the esophagus. The authors present the case of an esophageal GIST and discuss the diagnostic course and therapeutic options, as currently reported in the literature.

High-frequency miniprobes and 3-dimensional EUS for preoperative evaluation of the etiology of congenital esophageal stenosis in children (with video)

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A new endoscopic technique for suspension of esophageal prosthesis for refractory caustic esophageal strictures.

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patients hypopharynx. Using transillumination from the optical device, the patients neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Role of Confocal Laser Endomicroscopy in Detection of Residual Barrett's Esophagus after Radiofrequency Ablation

Endoscopic endoluminal radiofrequency ablation (RFA) is a novel and promising modality for Barretts esophagus (BE) treatment. Actually the only surveillance method after the ablation treatment is random biopsies throughout the whole treated area. Confocal laser endomicroscopy (CLE) is a new endoscopic imaging tool that permits high-resolution microscopic examination of the gastrointestinal tract. The technology has garnered increasing attention because of its ability to provide real-time “optical” biopsy specimens, with a very high sensitivity and specificity. This paper summarize the potential application of CLE in the surveillance of the reepithelialization of BE, after endoscopic RFA.

Cytology and CEA from Cystic Fluid Have Marginal Utility in the Management of Pancreatic Cystic Neoplasms

Context The management of patients with cystic lesion of the pancreas still remains controversial, mainly because traditional cross-sectional imaging have a limited ability to differentiate benign from premalignant or malignant pancreatic cysts. Endoscopic ultrasound (EUS) has been increasingly used in clinical practice, and the value of sample cyst fluid with fine-needle aspiration for cytology (FNAC) or fluid CEA concentration has been reported to be useful for risk assessment of malignancy in pancreatic mucinous cysts [1]. Objective The aim of this study was to determine whether EUS and cyst fluid analysis for cytology and CEA determination may be predictive of malignancy in a series of patients investigated for cystic neoplasms of the pancreas. Methods From January 2009 to June 2011, 51 patients underwent EUS in the preoperative work-up for suspected cystic tumor of the pancreas. Whenever possible, aspiration of cyst fluid for cytology and cyst fluid analysis for CEA, CA 19-9, amylase and lipase determination were performed. All patients underwent also abdominal MRI and whole-body PET/CT. Patients with symptoms or radiological or cytological suspicion of premalignant or frankly malignant lesion underwent surgical treatment. In the remaining patients validation of diagnosis was obtained by follow-up. Median follow-up was 23 months, range 12-41 months. Results There were 24 males and 27 females (mean age 52.7 years, range 34-81 years). The mean cyst size was 3.4 cm (range 2.0-12 cm). In all, 10 patients were symptomatic and 24 underwent surgery (47%). Diagnosis included: 29 IPMNs, 7 malignant mucinous cysts, 2 solid-pseudopapillary tumors, 2 mucinous cystadenomas, 8 serous cystadenomas, 1 endocrine tumor, and 2 pseudocysts. Ctytology and cyst fluid analysis were performed in 49 patients. Cytology was positive in 3/7 malignancies, 1/2 solid pseudopapillary tumors, doubtful in 1 IPMN, negative in 28 benign cysts, inconclusive in the remaining 11 patients. CEA was >200 ng/mL in 8 patients (>1,000 ng/mL in 5): only 2 patients proved to have malignant tumor. PET/CT was positive in 6/7 malignant tumors and false positive in 1 IPMN with low-grade dysplasia. Conclusion The correct evaluation of pancreatic cystsic neoplasms remains challenging. The decision to proceed with operative or non operative management should not be based on cytology or CEA levels in the cyst fluid aspirate.