Pathological Complete Response After Neoadjuvant Imatinib in a Recurrent Duodenal Gastrointestinal Stromal Tumor (GIST).

Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal neoplasms of the gastrointestinal (GI) tract. Although surgery is the treatment of choice in resectable disease, neoadjuvant therapy is indicated in advanced, metastatic, and recurrent tumors. Decreasing tumor burden may facilitate resection and reduce surgical morbidity. We describe a case of a 66-year-old male with a recurrent duodenal GIST, after surgery and adjuvant imatinib five years before. Following neoadjuvant therapy with imatinib for 12 months, the patient underwent a cephalic pancreaticoduodenectomy, without complications. The final histopathology showed a pathological complete response (pCR) with no residual neoplasm. A pathological complete response to imatinib in a recurrent disease is extremely rare. Molecular testing should be performed before neoadjuvant therapy to identify response-predictive mutations. In recurrent/metastatic disease, systemic therapy is the standard treatment for all patients. Surgery should be considered in a tailored approach in patients with good responses to systemic therapy before developing therapeutic resistance.

Invasive Lobular Carcinoma Arising in Ectopic Breast Tissue: A Case Report.

Incomplete regression of the embryonic mammary line occurs in 0.3-6% of the population. Ectopic breast tissue is mostly asymptomatic and can undergo malignant transformation. Ectopic breast cancer accounts for 0.2-0.6% of all breast cancers. Screening breast examinations can miss these lesions due to their location making the diagnosis more challenging. We describe a case of a primary invasive lobular carcinoma in an ectopic breast on the left axilla detected in a 49-year-old woman. Firstly diagnosed as a sebaceous cyst, the lesion was excised under local anesthesia. Histopathology showed breast tissue widely infiltrated by an invasive carcinoma. Excision of the remnant tissue with axillary lymph node dissection was performed. Ectopic breast carcinoma is a rare diagnosis and there is a general lack of awareness. The presence of an abnormal mass along the mammary ridge should raise clinicians' attention. Management of primary ectopic breast carcinoma should be based on a multidisciplinary approach under the same principles as breast cancer. Furthermore, it does not appear to bring a worse prognosis when diagnosed at similar disease stages.

Quality of Reporting in Upper Gastrointestinal Endoscopy: Effect of a Simple Audit Intervention.

BACKGROUND AND AIM: In contrast to colonoscopy, there are few studies regarding upper gastrointestinal (UGI) endoscopy reporting its quality and ways of improving it. Quality audits are recommended, but their influence on the abovementioned quality is not well studied. Our aim was to evaluate the quality of UGI endoscopy reports and assess the effect of a simple audit intervention on UGI endoscopy reporting quality. METHODS: This was a prospective study in a tertiary referral center, including the evaluation of 1,000 consecutive reports of UGI endoscopies before an audit intervention and 250 after. The reports were analyzed according to performance measures defined by three experienced gastroenterologists. RESULTS: Before the intervention, 51.8% of the incomplete endoscopies did not present any justification for its incompleteness and 88.1% of lesions were correctly described. Overall, 64.1% of the reports were considered as being of high quality. After the audit intervention, follow-up recommendation (53.4 vs. 80.8%, p = 0.001), correct lesion description (88.1 vs. 95.8%, p = 0.001), and correct segment description (92.2 vs. 96.4%, p = 0.020) improved significantly. The rate of unjustified incomplete endoscopies decreased significantly (51.8 vs. 28.9%, p = 0.010). The high-quality endoscopy rate improved 13.9% after the intervention (p < 0.001). Both specialists and residents improved with the audit intervention with a similar percentage of improvement in the high-quality endoscopy rate (13.9 vs. 13.4%). CONCLUSIONS: A simple audit intervention is a good way to improve the quality of reporting of UGI endoscopy, independently of degree and experience. Some of the performance measure accomplishments may depend on the software used by the endoscopy centers and it should be a priority to optimize it.

INTRODUÇÃO: Em contraste com a colonoscopia, há poucos estudos relativos à qualidade dos relatórios da endoscopia digestiva alta (EDA) e métodos para a sua melhoria. Auditorias de qualidade são recomendadas, mas a sua influência na qualidade da EDA não está suficientemente estudada. O objetivo foi avaliar a qualidade dos relatórios de EDA, bem como do efeito de uma intervenção com auditoria. MÉTODOS: Estudo prospetivo realizado num centro terciário de referência. O estudo incluiu a análise de 1,000 relatórios de EDA consecutivas realizadas antes de uma intervenção e de 250 após. Os relatórios foram analisados de acordo com parâmetros de qualidade definidos por três gastrenterologistas com experiência. RESULTADOS: Antes da intervenção, 51.8% das endoscopias incompletas não continham qualquer justificação para o facto e 88.1% das lesões foram corretamente descritas. No total, 64.1% dos relatórios foram considerados de alta qualidade. Após a intervenção, a recomendação de follow-up (53.4% vs. 80.8%, p = 0.001), descrição correta das lesões (88.1% vs. 95.8%, p = 0.001) e descrição correta de todos os segmentos (92.2% vs. 96.4%, p = 0.020) aumentaram significativamente. A percentagem de endoscopias incompletas não justificadas diminuiu significativamente (51.8% vs. 28.9%, p = 0.010). A percentagem de EDA de alta qualidade aumentou 13.9% após a intervenção (p < 0.001). Tanto especialistas como internos melhoraram com a intervenção, verificando-se um aumento similar na percentagem de EDA de alta qualidade (13.9% vs. 13.4%). CONCLUSÕES: Uma intervenção baseada numa auditoria é uma boa forma de melhorar a qualidade da documentação de EDA independentemente do grau ou experiência. O cumprimento de parâmetros de qualidade pode depender do software utilizado e como tal o seu melhoramento deve ser uma prioridade.

Incidence and predictors of adenoma after surgery for colorectal cancer.

OBJECTIVE: Patients with colorectal cancer (CRC) are at increased risk for developing metachronous premalignant and malignant lesions. However, its real incidence and underlying risk factors are still unclear, and therefore quality measures for colonoscopy under this indication have not been completely established. The aim of this study was to assess the incidence of and risk factors for the development of adenomas after surgery for CRC. PATIENTS AND METHODS: A total of 535 patients submitted to curative surgery for CRC between January 2008 and December 2011 were selected and their clinical records and surveillance colonoscopies were reviewed. RESULTS: During a median follow-up of 62 months, 39.4% of the patients developed adenomas, 17.6% advanced adenomas and 3.4% developed metachronous cancers. Male sex [adjusted odds ratio (AOR)=1.99; 95% confidence interval (CI): 1.29-3.07] was an independent risk factor for adenomas during follow-up and absence of a high-quality baseline colonoscopy was the only independent risk factor for advanced adenomas (AOR=1.78; 95% CI: 1.03-3.07) and metachronous cancer (AOR=7.05; 95% CI: 1.52-32.66). In patients who had undergone a high-quality colonoscopy at baseline and at the first follow-up, the presence of adenomas (odds ratio=12.30; 95% CI: 2.30-66.25) and advanced adenomas (odds ratio=10.50; 95% CI: 2.20-50.18) in the first follow-up colonoscopy was a risk factor for the development of metachronous advanced adenomas during the subsequent surveillance. CONCLUSION: Undergoing a high-quality baseline colonoscopy is the most important factor for reducing the incidence of advanced lesions after CRC surgery. All patients remain at high-risk for adenomas and advanced adenomas, but standardized follow-up should be adjusted after the first year of follow-up.