Gastrointestinal bleeding as initial presentation of extramedullary plasma cell neoplasms: A case report and review of the literature.

BACKGROUND: Plasma-cell neoplasms rarely involve the gastrointestinal tract and manifest as gastrointestinal bleeding. Plasmablastic myeloma is an aggressive plasma cell neoplasm associated with poor outcomes. A small number of cases with gastrointestinal involvement is reported in the literature and therefore high index of suspicion is essential for avoiding delays in diagnosis and treatment. CASE SUMMARY: Our aim is to present our experience of a 70-year-old patient with a secondary presentation of plasmablastic myeloma manifesting as unstable upper gastrointestinal bleeding and to review the literature with the view to consolidate and discuss information about diagnosis and management of this rare entity. In addition to our case, a literature search (PubMed database) of case reports of extramedullary plasma cell neoplasms manifesting as upper gastrointestinal bleeding was performed. Twenty-seven cases of extramedullary plasmacytoma (EMP) involving the stomach and small bowel presenting with upper gastrointestinal bleeding were retrieved. The majority of patients were males (67%). The average age on diagnosis was 62.7 years. The most common site of presentation was the stomach (41%), followed by the duodenum (15%). The most common presenting complaint was melena (44%). In the majority of cases, the EMPs were a secondary manifestation (63%) at the background of multiple myeloma (26%), plasmablastic myeloma (7%) or high-grade plasma cell myeloma (4%). Oesophagogastroscopy was the main diagnostic modality and chemotherapy the preferred treatment option for secondary EMPs. CONCLUSION: Despite their rare presentation, upper gastrointestinal EMPs should be considered in the differential diagnosis of patients with gastrointestinal bleeding especially in the presence of systemic haematological malignancy.

Surgery remains the best option for the management of pain in patients with chronic pancreatitis: A systematic review and meta-analysis.

Controversy related to endoscopic or surgical management of pain in patients with chronic pancreatitis remains. Despite improvement in endoscopic treatments, surgery remains the best option for pain management in these patients.

Lymphoepithelial Cyst of the Pancreas.

Lymphoepithelial cyst (LEC) of the pancreas is an extremely rare, benign pancreatic cystic lesion that is difficult to differentiate preoperatively from other cystic pancreatic lesions. LEC may have malignant potential. Here, we describe a case of LEC of the pancreas - initially suspected to be a mucinous cyst neoplasm - in an elderly man presenting with abdominal pain, who went on to have a distal pancreatectomy and splenectomy. We also review the relevant literature and discuss implications for the diagnosis and management of this rare lesion.

Reduced dissemination of circulating tumor cells with no-touch isolation surgical technique in patients with pancreatic cancer.

Circulating tumor cells (CTCs) disseminate from the primary tumor and travel through the bloodstream and lymphatic system. The detection of and/or increase in the number of CTCs during a patient's clinical course may be a harbinger of forthcoming overt metastasis. We aimed to examine the impact of 2 different surgical techniques, standard (ST) pancreaticoduodenectomy (PD) and no-touch isolation (NT) PD, on tumor behavior and outcome in patients with pancreatic cancer by using CTCs as biomarkers. In this pilot study, patients were randomized to either ST-PD (n = 6) or NT-PD (n = 6). Intraoperatively, blood samples were taken from the portal vein for measurement of CTCs before and immediately after removal of the tumor. An increase in CTCs was seen in 5 of 6 patients (83%) with ST-PD but no patients with NT-PD (P = .003). In the ST-PD and NT-PD groups, median overall survival was 13.0 and 16.7 months, respectively (P = .33); there was no difference in disease-free survival (P = .42). The use of NT-PD significantly reduced the number of CTCs in the portal vein with no benefit in survival outcomes compared with ST-PD, although more extensive studies are required.

Preoperative superselective mesenteric angiography and methylene blue injection for localization of obscure gastrointestinal bleeding.

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Percutaneous intraductal radiofrequency ablation is a safe treatment for malignant biliary obstruction: feasibility and early results.

PURPOSE: Previous clinical studies have shown the safety and efficacy of this novel radiofrequency ablation catheter when used for endoscopic palliative procedures. We report a retrospective study with the results of first in man percutaneous intraductal radiofrequency ablation in patients with malignant biliary obstruction. METHODS: Thirty-nine patients with inoperable malignant biliary obstruction were included. These patients underwent intraductal biliary radiofrequency ablation of their malignant biliary strictures following external biliary decompression with an internal-external biliary drainage. Following ablation, they had a metal stent inserted. RESULTS: Following this intervention, there were no 30-day mortality, hemorrhage, bile duct perforation, bile leak, or pancreatitis. Of the 39 patients, 28 are alive and 10 patients are dead with a median survival of 89.5 (range 14-260) days and median stent patency of 84.5 (range 14-260) days. One patient was lost to follow-up. All but one patient had their stent patent at the time of last follow-up or death. One patient with stent blockage at 42 days postprocedure underwent percutaneous transhepatic drain insertion and restenting. Among the patients who are alive (n = 28) the median stent patency was 92 (range 14-260) days, whereas the patients who died (n = 10) had a median stent patency of 62.5 (range 38-210) days. CONCLUSIONS: In this group of patients, it appears that this new approach is feasible and safe. Efficacy remains to be proven in future, randomized, prospective studies.

Tumor infiltration in the medial resection margin predicts survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

BACKGROUND: Microscopic tumor involvement (R1) in different surgical resection margins after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been debated. METHODS: Clinico-pathological data for 258 patients who underwent PD between 2001 and 2010 were retrieved from a prospective database. The rates of R1 resection in the circumferential resection margin (pancreatic transection, medial, posterior, and anterior surfaces) and their prognostic influence on survival were assessed. RESULTS: For PDAC, the R1 rate was 57.1% (48/84) for any margin, 31.0% (26/84) for anterior surface, 42.9% (36/84) for posterior surface, 29.8% (25/84) for medial margin, and 7.1% (3/84) for pancreatic transection margin. Overall and disease-free survival for R1 resections were significantly worse than those for R0 resection (17.2 vs. 28.7 months, P = 0.007 and 12.3 vs. 21.0 months, P = 0.019, respectively). For individual margins, only medial positivity had a significant impact on survival (13.8 vs. 28.0 months, P < 0.001), as opposed to involvement in the anterior (19.7 vs. 23.3 months, P = 0.187) or posterior margin (17.5 vs. 24.2 months, P = 0.104). Multivariate analysis demonstrated R0 medial margin was an independent prognostic factor (P = 0.002, HR = 0.381; 95% CI 0.207-0.701). CONCLUSION: The medial surgical resection margin is the most important after PD for PDAC, and an R1 resection here predicts poor survival.

Isolated laparoscopic caudate lobe resection.

The local anatomy of the caudate lobe of the liver, between the hepatic hilum and the inferior vena cava, presents a surgical challenge when an isolated resection is attempted. The video of the laparoscopic technique is presented in a 20-year-old woman with a 60 × 40 mm lesion.

18F-fluorodeoxyglucose positron emission tomography in management of pancreatic cystic tumors.

OBJECTIVES: To evaluate the effectiveness of PET in differentiating malignant from benign pancreatic cystic tumors. METHODS: Between 2009 and 2010, all patients with pancreatic cystic tumors who had PET, triple phase contrast computed tomography (CT) and endoscopic ultrasound (EUS) were reviewed. Clinicopathological characteristics and final histology were correlated with preoperative PET, CT and EUS to assess the value of each modality in detecting malignant from benign lesions for clinical decision-making. RESULTS: Twenty of a total of 116 patients with pancreatic cystic tumors had 18F-FDG PET because of diagnostic difficulties after evaluation with conventional modalities. Sensitivity and specificity of PET in differentiating malignant from benign pancreatic cystic tumors were 100% and 93.75%, with an accuracy of 95%. PET had the best sensitivity, specificity and accuracy for detecting malignant cystic tumors compared with CT and EUS. In 5 cases, the PET results altered the treatment options completely to follow-up instead of surgery (n=2), limited resection instead of Whipple's resection (n=1), and surgery instead of follow-up (n=2). CONCLUSIONS: PET is an accurate, non-invasive method to distinguish malignant from benign pancreatic cystic tumors and can be used as an adjunct to facilitate clinical decision making.

Loco-recurrence after resection for ductal adenocarcinoma of the pancreas: predictors and implications for adjuvant chemoradiotherapy.

PURPOSE: Loco (regional)-recurrence rate after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) remains high, and the efficiency of adjuvant chemoradiotherapy is still debated. We aimed to assess predictors of loco-recurrence in order to tailor the indications for adjuvant chemoradiotherapy. METHODS: Patients who underwent PD for PDAC between January 2001 and December 2010 were retrieved from a prospective database. Tumor recurrence was categorized as either loco-recurrence or distant recurrence. Clinicopathological characteristics and survivals were compared between patients with different recurrence patterns. The predictors for loco-recurrence were assessed. RESULTS: Seventy-nine patients were included. Loco-recurrence alone was identified in 22 patients (27.8%), distant recurrence alone in 33 (41.8%), both loco- and distant recurrences in 17 (21.5%) and no recurrence in 7 (8.9%). Median survival after recurrence (SAR) was significantly better in patients with loco-recurrence alone than in those with distant recurrence alone (10.4 vs. 5.0 months, P = 0.002) or in those with both loco- and distant recurrences (10.4 vs. 5.8 months, P = 0.044); the survival for patients with distant recurrence alone and those with both patterns was identical. Patients with early recurrence had a significantly poorer SAR than those with late recurrence (median, 5.5 vs. 9.0 months, P = 0.001). Logistic regression analysis revealed that positive resection margin (P = 0.001, HR = 14.532; 95% CI 7.399-38.466), early T stage (P = 0.018, HR = 0.014; 95% CI 0.000-0.475) and large tumor size (P = 0.030, HR = 4.345; 95% CI 1.152-16.391) were the determinant factors directly related to loco-recurrence alone. CONCLUSIONS: Patients with PDAC loco-recurrence alone had a significantly better SAR than those with distant recurrence. Adjuvant chemoradiotherapy should be considered to reduce loco-recurrence further and improve long-term survival.

Laparoscopic resection of a giant exophytic liver haemangioma with the laparoscopic Habib 4× radiofrequency device.

Haemangiomas are the most common solitary benign neoplasm of the liver with an incidence ranging from 5% to 20%. Although usually small and asymptomatic, they may reach considerable proportions and rarely give rise to life-threatening complications. Surgical intervention is required for incapacitating symptoms, established complications, and diagnostic uncertainty. The resection of haemangiomas demands meticulous surgical technique, owing to their high vascularity and the concomitant risk of intra-operative haemorrhage. Laparoscopic resection of giant haemangiomas is even more challenging, and has only been reported twice. We here report the case of a giant 10 cm liver haemangioma which was successfully resected laparoscopically using the laparoscopic HabibTM 4×, a bipolar radiofrequency device, without clamping major vessels and with minimal blood loss. Transfusion of blood or blood products was not required. The patient had an uneventful recovery and was asymptomatic at 7-mo follow-up.

Radiofrequency-assisted hepatic resection.

BACKGROUND: The only curative procedure to date for liver tumors is surgical resection, which remains a major procedure with marked morbidity and mortality. Radiofrequency (RF) has increasingly been used for both ablation and resection. On the basis of this technique, a new bipolar RF device, Habib 4X, has been developed and used clinically. We present our technique of liver resection with this device in a patient with colorectal liver metastases. METHODS: A patient with situs inversus who had colorectal liver metastases in her left lobe underwent left lateral segmentectomy with the new device, a four-electrode bipolar resection device that uses RF energy for tissue necrosis. After laparotomy and intraoperative ultrasound, the plane resection was marked 1 cm away from the edge of the lesion. Coagulative desiccation was performed along this plane using this sealer connected to a RF generator. The necrosed band of parenchyma was then divided with a scalpel and resection completed. RESULTS: The length of the procedure was 105 minutes; resection time was 35 minutes. Total blood loss was 100 ml. No blood transfusions were required, and the patient was not admitted to the intensive care unit after surgery. The patient was discharged 10 days after surgery without any surgical complications. CONCLUSIONS: We think that RF-assisted liver resection with this new device is safe and effective. It is quicker than conventional RF and may reduce overall hospital stay in liver resection patients.

En bloc resection of the pancreatic head and second part of duodenum for a duodenal gastrointestinal stromal tumor: a multi-media report.

Duodenal gastrointestinal stromal tumors are rare tumors. When these tumors arise from the second part of the duodenum they can easily be misdiagnosed as a pancreatic head cancer. A case of a 37-year-old female presenting with a one-year history of right upper quadrant pain is described here, who was subsequently found to have a mass in the head of the pancreas. Computed tomography scans showed a 2 cm hypervascular lesion lying between the head of pancreas and the second part of the duodenum, suggestive of a neuroendocrine tumor, and confirmed by endoscopic ultrasound scan. She underwent a pancreatic head resection with duodenal segmentectomy. Histopathological and immunohistochemical analysis revealed the tumor to be peri-ampullary duodenal gastrointestinal stromal tumor not invading the pancreas. Duodenal gastrointestinal stromal tumor can have a wide spectrum of clinical presentation. The accurate diagnosis of duodenal gastrointestinal stromal tumor is essential for determining the appropriate surgical intervention. In our case, a conservative surgical approach was utilised therefore avoiding a formal pancreaticoduodenectomy.