Quadruple primary tumors in a lynch syndrome patient surviving more than 26 years with genetic analysis: a case report and literature review.

The incidence of multiple primary tumors(MPTs) is on the rise in recent years, but patients having four or more primary tumors is still rare. Lynch syndrome (LS) patients have a high risk of developing MPTs. NGS sequencing could identify the genetic alterations in different tumors to make a definite diagnosis of uncommon cases in clinical practice. Here, we report the case of a 66-year-old female patient who develops four MPTS between the ages of 41 and 66, that is sigmoid colon cancer, acute non-lymphocytic leukemia, urothelial carcinoma and ascending colon cancer. She has survived for more than 26 years since the first discovery of tumor. Targeted sequencing indicates that she has a pathogenic germline mutation in the exon 13 of MSH2, and her 2020 ureteral cancer sample and 2023 colon cancer sample have completely different mutation profiles. To the best of our knowledge, this is the first case of multiple primary tumors with an acute non-lymphocytic leukemia in LS patients.

Long-Term Outcomes of the Self-Expandable Metallic Stent as a Bridge to Surgery versus Elective Surgery without Stent Placement for Colorectal Cancer: A Retrospective Cohort Study.

BACKGROUND: The uncertainty surrounding whether delaying surgery after self-expandable metal stent (SEMS) placement for neoplastic stricture can yield similar oncologic outcomes as elective surgery remains. This study aims to investigate the impact of elective surgery following SEMS placement for obstructive colorectal cancer (OCC) on patients. METHODS: Patients diagnosed with stage I to III colorectal cancer (CRC) were recruited and randomly allocated into two groups: group A, receiving elective surgery after SEMS placement for obstructive colon cancer, and group B, undergoing elective surgery for non-obstructive colorectal cancer. Following a 1:2 matching process based on age, gender, tumor location, tumor depth, pathological stage, and adjuvant chemotherapy, group A comprised 95 patients, while group B consisted of 190 patients for comparative analysis. RESULTS: The 5-year disease-free survival (DFS) rate and overall survival (OS) rate were worse in group A (62.3% vs. 70.9%, p = 0.086) and (65.6% vs. 75.8%, p = 0.093) compared with group B, although these differences were not statistically significant. This discrepancy in long-term oncologic outcomes did not reach significance when the analysis was stratified by tumor perineural invasion (PNI) status. Univariate analysis revealed that SEMS placement was not a poor prognostic factor for DFS (p = 0.086). CONCLUSIONS: Elective surgery for obstructive colorectal cancer (OCC) following SEMS placement may exhibit poorer long-term oncologic outcomes compared to elective surgery for non-obstructive colorectal cancer, particularly due to the higher rate of PNI associated with OCC. Upon stratification of patients in each group by PNI status, the observed differences became marginal.

The value of ICG-guided left colon vascular variation and anatomical rules for the radical resection of proctosigmoid colon cancer.

Objective: During laparoscopic radical resection for proctosigmoid colon cancer (PCC), surgeons could inadvertently damage the arteries when following the operation path.This study investigated the variations in left colon blood vessels in order to guide the scientific protection of the marginal artery (MA) during laparoscopic surgery for PCC. Methods: Data from seven patients who underwent inferior mesenteric artery (IMA) angiography were included as imaging references to preliminarily explore the vascular structure and variation in the left colon. The clinical video data of 183 PCC patients were retrospectively analyzed to observe intraoperative MA injury. Meanwhile, a prospective cohort of 96 patients with the same disease underwent intraoperative indocyanine green (ICG) fluorescence imaging of the peripheral sigmoid artery network, the variation of marginal arteries was summarized, and the distance between vessels and the bowel was measured at different levels. Patients were divided into 'ICG group' and 'non-ICG group' according to whether ICG guidance was performed, and perioperative conditions were compared between the two groups. Taking the integrity of lymph node dissection into consideration, 18 patients underwent carbon nanonode tracing. This study was conducted under the standard consent and ethical approval of the Ethics Committee of our center. Results: 7 patients with IMA angiography shared some vascular structures, defined as 'Dangerous Triangle' and 'Secure Window'. Through intraoperative observation, the primary arch was typically located 4.2 (2.3-6.0) cm away from the intestinal canal, and 5.21% (5/96) patients had poor anastomosis at the primary arch. Moreover, secondary vascular arches (6.4 (4.6-10.0) cm from the intestinal wall) were observed in 38.54% of patients. MA injury was identified in 2 of 183 cases, and the ischemic bowel was timely dissected, whereas no such injury occurred during ICG fluorescenceguided surgery. Guided by carbon nanoparticles, the integrity of lymph node dissection can be maintained while preserving the secondary arch in all patients. Conclusions: This study demonstrated the benefits of ICG guidance in protecting the intestinal blood supply in laparoscopic PCC surgery. By enhancing the understanding of primary and secondary vascular arches, secure windows, and dangerous triangles, surgeons can safely optimize the surgical path during surgery.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis.

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

Primary extra-gastrointestinal stromal tumor of retroperitoneum: Clinicopathologic characteristics and prognosis of six cases.

Aim: This study investigates the clinicopathological features and prognostic genic biomarker factors of primary retroperitoneal extra-gastrointestinal stromal tumors (EGISTs). Methods: The clinicopathological data of six patients with primary retroperitoneal EGIST were analyzed, including cell type (epithelioid or spindle), mitoses, and the presence of intratumoral necrosis and hemorrhage. Mitoses were counted and summed from 50 high power fields (HPFs). Mutations of exons 9, 10, 11, 13, 14, and 17 of the C-kit genes and those of exons 12 and 18 of the PDGFRA gene were examined. Follow-up was performed via telephone, and all outpatient records were reviewed. The last follow-up date was February 2022, the median follow-up was 27.5m and the postoperative status, medication, and survival of the patients were recorded. Result: The patients were treated with radical intent. Four cases (patients 3, 4, 5, and 6) underwent multivisceral resection for encroachment on the adjacent viscera. The postoperative pathological results demonstrated that all biopsy specimens were negative for S-100 and desmin, and positive for DOG1 and CD117. Additionally, four patients (case 1, 2, 4, and 5) were positive for CD34, four (case 1, 3, 5, and 6) were positive for SMA, four (case 1, 4, 5, and 6) had >5/50 HPFs, and three (case 1, 4, and 5) had Ki67 >5%. According to the modified National Institutes of Health (NIH) guidelines, all patients were graded as high-risk cases. By exome sequencing, exon11 mutations were detected in the six patients, while exon10 mutations were detected in two cases (patients 4 and 5). The median follow-up time was 30.5 (11-109) months, with only one fatality at 11 months. Conclusion: Retroperitoneal EGIST is a rare mesenchymal tumor that is difficult to distinguish from other retroperitoneal tumors. To diagnose this highly malignant tumor, low-threshold suspicion is necessary, and Kit and PDGFRA gene mutations should be routinely tested to confirm the diagnosis and guide subsequent treatment.