Large bowel obstruction in women with pelvic malignancies. What is the primary?

BACKGROUND: Large bowel obstruction is occasionally the mode of presentation of advanced colorectal or pelvic malignancies, and a prognostic of poor survival. The choices of treatment range from palliative tube decompression to curative or palliative surgery. METHODS: Twelve out of 500 women with various malignancies and symptomatology of large bowel obstruction were studied. All patients required urgent exploratory laparotomies. RESULTS: The primary site was established intra-operatively to be the colon (2 cases), stomach (2 cases) and ovaries (2 cases). In the remaining 6 cases there was uncertainty about the origin of primary disease. Routine histology and immuno-histochemistry of the specimens revealed the origin of primary malignancy in all cases. CONCLUSIONS: Meticulous histological examination is essential for the establishment of correct diagnosis and selection of the best available treatment in women with pelvic malignancies, presenting with acute bowel obstruction.

Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature.

BACKGROUND: Perforation of a solitary caecal diverticulum is a rare cause of acute abdomen and an uncommon differential diagnosis for acute appendicitis. Nine hundred cases have been described since Potiers' first description of perforated caecal diverticulum in 1912. METHODS: We describe 2 cases of perforated diverticulum of the caecum. The first patient was a 50-year-old man diagnosed by subsequent histology, and the second a 77-year-old woman diagnosed intra-operatively. Radiography, ultrasound and CT scan of the abdomen pointed at the diagnosis in the second case. A right hemicolectomy was performed. RESULTS: There were no complications, apart from a transient faecal fistula in the first patient managed conservatively. In both patients histology revealed a perforated caecal diverticulum. CONCLUSIONS: The surgeon must be familiar with the diagnosis and management of this rare, inflammatory benign caecal entity.

Spontaneous rupture of the rectosigmoid with small bowel evisceration through the anus.

Spontaneous rupture of the rectosigmoid with small bowel evisceration through the anus is a rare and acute condition of the gastrointestinal tract. After Brodie's first description, only 52 such cases have been reported in the literature. An 83-year-old woman experienced a sudden, spontaneous rectosigmoid rupture and protrusion of small bowel loops, through the ruptured colon and out of the anus. After an immediate management, an emergency operation was performed, and a small bowel resection and suturing of the ruptured rectosigmoid were carried out for restoration of bowel continuity. On the 41st postoperative day, a massive cerebro-vascular accident (CVA) was the cause of the patient's death. Discussion of the aetiology and treatment of this rare condition.

Metachronous breast carcinoma (second malignancy), following "cure" from colorectal carcinoma.

Metachronous or synchronous breast carcinoma following or co-existing with colorectal carcinoma are well recognised clinicopathological entities, and the risk of developing both possibly underlines the similarities in carcinogenesis pathways for these carcinomas. We present a 60-year-old housewife with a history of a treated primary colon carcinoma (Duke's C) 15 years previously. Six months ago, during the follow-up care a small sub-areolar lesion was determined in a mammogram. A lumpectomy was performed under local anaesthesia, which revealed an infiltrating ductal carcinoma (6 mm in greatest diameter). Immuno-histochemical assays for oestrogen and progesterone receptors and c-erb B2 ongoprotein were performed. Axillary lymphadenectomy showed 1/11 positive node. She received adjuvant radiotherapy and hormone manipulation. To date, seven months later she is disease free. The aim of this report is to emphasise the risk of metachronous second malignancy of breast or colorectal carcinoma following colorectal carcinomas. A second primary colonic malignancy following breast primary carcinoma is more frequent than inverse clinical form.

A case of mucinous adenocarcinoma arising in long-standing multiple perianal and presacral fistulas.

Chronic anal fistulas are not rare; however, the development of a carcinoma in long-standing, perianal fistulas is rare. We describe a case of an 85-year-old man with multiple, recurring, perianal fistulas, extending to the natal cleft. The patient underwent en bloc resection of the fistulas which were in direct continuity with the middle rectum. Histological examination revealed a mucinous colonic adenocarcinoma. Abdominal CT and colonoscopy revealed an extramural residual rectal mass. The patient refused a radical colorectal operation. Three years later, because of fistula recurrence, he underwent loop sigmoidostomy and radical en bloc excision of the perianal fistula and rectum, with immediate reconstruction by bilateral gluteal flaps. The patient was discharged on the 12th postoperative day, refusing adjuvant radiotherapy. We present this rare malignant entity, successfully treated by staged operations and without any adjuvant therapy.

Serum concentrations of soluble ICAM-1 and VCAM-1 in patients with colorectal cancer. Clinical implications.

BACKGROUND: In colorectal cancer (CRC), serum levels of adhesion molecules ICAM-1 and VCAM-1 increase with progressing disease. Our aim was to investigate the effect of treatment in serum ICAM-1 and VCAM-1. METHODS: Serum levels of ICAM-1 and VCAM-1 were determined in 154 patients with CRC. Patients with non-metastatic disease had been treated with "curative" resections, and those with advanced disease were receiving chemotherapy. A group of 48 healthy blood donors served as control. Serum concentrations ranging 2SD above and below the controls median were accepted as "normal". RESULTS: Significantly more patients with advanced disease demonstrated high serum ICAM-1 and VCAM-1 (p<0.001, p=0.043 respectively). However, in some of them serum ICAM-1 and VCAM-1 were below "normal". CONCLUSIONS: Serum ICAM-1 and VCAM-1 may be valuable markers of residual or biologically aggressive disease after curative resections. In advanced disease, they could be useful predictors of response to chemotherapy.

Environmental and other risk factors for colorectal carcinogenesis.

Diet plays a role in the risk of colon cancer, but exactly how it affects risk is unknown. In western countries diet is low in fibre and high in animal protein, fats and refined carbohydrates such as sugar. Risk seems to be reduced by a diet high in calcium, vitamin D and vegetables such as Brussels sprouts, cabbage and broccoli. Familial polyposis has been studied sufficiently and increases the risk of colon cancer. Moreover, in relatives there is frequently a familial history of an increased incidence of colorectal cancer. There is no conclusive evidence to support any of the hypotheses proposed to explain the role of dietary factors in colorectal carcinogenesis. Prospective trials should generate the information required to develop strategies for diet modification to reduce the incidence of colorectal carcinoma. There is hope that this understanding will lead to a variety of dietary, medical, hormonal and molecular interventions to reduce disease incidence and improve the prognosis of patients with cancers of the colon and rectum.

[Noninvasive mucinous cystic pancreas carcinoma with a 16-year course]. / Nicht invasives mucinös-cystisches Pankreascarcinom mit 16jähriger Verlaufszeit.

A 26-year-old woman was operated on because of a suspected infectious pseudocyst of the pancreas. A large cyst was found on the body of the pancreas. During laparotomy a biopsy specimen was taken from the cystic wall, but no evidence of a tumor was obtained. On the basis of these intraoperative findings, a cystogastrostomy was performed and the patient had an uneventful postoperative course. The patient presented 8 years later with a recurrent cyst and was operated. As there was a suspicion of a cystic neoplasm, total resection of the cyst was performed. Based on the histological findings a noninvasive mucinous cystadenocarcinoma of the pancreas was diagnosed. We believe that from the beginning this cyst was a noninvasive mucinous cystadenocarcinoma. Following the complete resection the clinical course was favorable for 8 more years without evidence of recurrence or metastases.