Parathyroid carcinoma in chronic renal disease - a case series of three patients and review of literature.

BACKGROUND: Apart from being a rare endocrine tumor, parathyroid carcinoma is also one of the rarest malignancies in human beings. Parathyroid carcinoma is even more uncommon in haemodialysis patients with end-stage renal disease. The pathogenesis of parathyroid hyperplasia in haemodialysis patients is well known, but the mechanism of development of parathyroid carcinoma in these patients remains unclear. METHODS: Three cases of parathyroid carcinoma in haemodialysis patients are presented in this study: a 69-year-old male patient and two female patients (67 and 61 years old). In all cases parathyroid carcinoma infiltrated the ipsilateral thyroid lobe and in one patient the right laryngeal nerve was involved as well. One patient underwent three surgical procedures. RESULTS: After surgical treatment, all patients were normocalcaemic and showed a significant reduction in PTH levels. CONCLUSION: In patients with secondary hyperparathyroidism, who develop parathyroid carcinoma, surgical resection is the only viable treatment option.

Sclerosing Mesenteritis Presenting as a Pseudotumor of the Greater Omentum.

OBJECTIVE: The aim was to demonstrate a diagnostic challenge of sclerosing mesenteritis initially considered as liposarcoma. CLINICAL PRESENTATION AND INTERVENTION: A 45-year-old man was admitted with a painful abdominal mass. Abdominal computed tomography demonstrated a well- demarcated tumor in his left hemiabdomen, with a large fat component and areas of soft tissue attenuation suggestive of liposarcoma. Intraoperative findings showed a tumor arising from the greater omentum. The tumor was completely removed, and histopathology confirmed a pseudotumorous type of sclerosing mesenteritis with dominant mesenteric lipodystrophy. CONCLUSION: This case showed that a pseudotumorous type of sclerosing mesenteritis should be considered in the differential diagnosis of the mesenteric tumors.

Does the computed tomography perfusion imaging improve the diagnostic accuracy in the response evaluation of esophageal carcinoma to the neoadjuvant chemoradiotherapy? Preliminary study.

PURPOSE: To estimate whether the computed tomography (CT) perfusion imaging could be useful to predict the pathological complete response (pCR) of esophageal cancer to the neoadjuvant chemoradiotherapy (NACRT). METHODS: Twenty-seven patients with the advanced squamous cell esophageal carcinoma, who were treated with concomitant CRT (CIS/5-FU/LV and 45-50 Gy total radiation dose), were re-evaluated using CT examination, which included the low-dose CT perfusion study. CT perfusion series were analysed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE), and color parametric maps of the blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface area product (PS) were displayed. All patients were operated and histopathological analysis of the resected esophagus considered the gold standard for pathologic complete response (pCR). RESULTS: BFpost-NACRT, BVpost-NACRT, and PSpost-NACRT were significantly lower, and MTTpost-NACRT significantly higher in the pCR group. Mean (±SD), or median perfusion parameter values in the pCRs (11 patients) vs non-pCRs (16 patients) were: BFpost-NACRT- 21.4±5.0 vs 86.0±29 ml/min/100 g (p<0.001), BVpost-NACRT- 1.3 vs 3.9 ml/100 g (p<0.001), MTTpost-NACRT- 5.5 vs 3.7 s (p=0.018), and PSpost-NACRT- 5.9 vs 9.8 ml/min/100 g (p=0.006). ROC analysis revealed that BFpost- NACRT (AUC=1.000), BVpost-NACRT (AUC=0.932), MTTpost-NACRT (AUC=0.801), and PSpost-NACRT (AUC=0.844) could predict the pCR (p<0.01), while maximal esophageal wall thickness could not (AUC=0.676, p=0.126). If we set a cut-off value of BFpost-NACRT<30.0 ml/min/100 g, pCR was predicted with sensitivity and specificity of 100%. CONCLUSION: CT perfusion imaging enables accurate prediction of pCR of esophageal carcinoma to neoadjuvant chemoradiotherapy.

Pharyngolaryngoesophagectomy in a patient with an aberrant right subclavian artery: report of a case.

We report a case of carcinoma of the hypopharynx and cervical esophagus in a patient with an aberrant right subclavian artery. Barium esophagography, endoscopy, and computed tomography showed a resectable tumor in the hypopharynx and cervical esophagus, coexistent with an aberrant right subclavian artery. We performed pharyngolaryngoesophagectomy with bilateral neck dissection and gastric pull-up through cervical, right thoracic, and abdominal incisions. We also partially resected the aberrant right subclavian artery with reimplantation in the right common carotid artery. To our knowledge, this is the first report of pharyngolaryngoesophagectomy with transposition of an aberrant right subclavian artery.

Colon interposition for pharyngoesophageal postcorrosive strictures.

BACKGROUND/AIM: Aim of this paper is to report a 40 years experience in performing colon interposition for pharyngoesophageal caustic injury. METHODOLOGY: In the period between 1965 and 2005, 83 colon interpositions were performed due to the pharyngeal and high esopahageal injuries. Patients were classified according to the uppermost level of stricture in 3 groups: supraglotic, hypopharyngeal and esophageal ostium. In most of the patients (89.1%) an extrapleural retrosternal by-pass colon interposition was performed, while in the remaining 10.9% a colon interposition with esophagectomy had to be done. Long-term follow-up results were obtained in the period between one and up to 30 years. RESULTS: Early postoperative complications occurred in 16.8% of patients, among which anastomotic leakage was the most common. Overall intrahospital mortality rate was 6%, while late postoperative complications were present in 14.4% of patients. Long-term follow-up was obtained in 84.2% of patients, with excellent functional results being present in 86.7% of them. CONCLUSION: Colon graft is an excellent esophageal substitute for patients with pharyngoesophageal corrosive strictures, and used by experienced surgical team it provides low postoperative morbidity as well as mortality rate, and a long time good and functional quality of life.

Intraoperative endoscopy in obstructive hypopharyngeal carcinoma.

AIM: To demonstrate the necessity of intraoperative endoscopy in the diagnosis of secondary primary tumors of the upper digestive tract in patients with obstructive hypopharyngeal carcinoma. METHODS: Thirty-one patients with hypopharyngeal squamous cell carcinoma had been operated, with radical intent, at our Institution in the period between 1978 and 2004. Due to obstructive tumor mass, in 7 (22.6%) patients, preoperative endoscopic evaluation of the esophagus and stomach could not be performed. In those patients, intraoperative endoscopy, made through an incision in the cervical esophagus, was standard diagnostic method for examination of the esophagus and stomach. RESULTS: We found synchronous foregut carcinomas in 3 patients (9.7%). In two patients, synchronous carcinomas had been detected during preoperative endoscopic evaluation, and in one (with obstructive carcinoma) using intraoperative endoscopy. In this case, preoperative barium swallow and CT scan did not reveal the existence of second primary tumor within esophagus, despite the fact that small, but T2 carcinoma, was present. CONCLUSION: It is reasonable to use intraoperative endoscopy as a selective screening test in patients with obstructive hypopharyngeal carcinoma.

[Well differentiated endocrine carcinomas of the pancreas].

INTRODUCTION: For the difference from poorly differentiated, well differentiated endocrine carcinomas of the pancreas are the tumours in whom with aggressive surgery and chemotherapy fair results can be achieved. OBJECTIVE: The aim of the study was to point out the importance of such treatment. METHODS: Over a 6-year period eight patients (seven female and one male) of average age 51 years (ranging from 23 to 71 years) were operated on for well differentiated endocrine carcinoma: six of the head and two of the tail of the pancreas. There were two functional and six nonfunctional tumours. Pain in the upper part of the abdomen in seven, mild loss in weight in two, strong heartburn in two, obstructive jaundice in three, diarrhoea in one, sudden massive bleeding from gastric varicosities due to prehepatic portal hypertension caused by pancreatic head tumour in one, and bruise in one patient were registered preoperatively. US and CT in all, angiography in one, octreoscan in two and PET scan in one patient were performed. Whipple's procedure was performed in six and distal pancreatectomy in two patients, as well as systemic lymphadenectomy in all and excision of liver secondary tumours in two patients. In the patient with massive gastric bleeding a total gastrectomy was performed first, followed by Whipple's procedure a month later. RESULTS: R0 resection was achieved in all patients. Lymph nodes metastases were found in six patients. Six patients were given chemotherapy. One patient died 3 years after surgery, seven are still alive, on average 2.5 years. A local recurrence after distal pancreatectomy that occurred 5 years after surgery was successfully reresected and the patient is on peptide-receptor radiotherapy. In other six patients there were no local recurence or distant metastases. CONCLUSION: With aggressive surgery and chemotherapy fair results can be achieved in well differentiated endocrine carcinomas of the pancreas.

Minimally invasive esophagectomy in the treatment of esophageal cancer.

In the Western countries, the incidence of esophaeal carcinoma is 3-6 cases per 100,000 persons. g Despite tremendous success of other therapeutic options, surgical treatment still represents the best therapeutic option whenever possible. For the long period, debate has centered on which of the a vailable surgical procedures is superior-transhiatal or transthoracic esophagectomy. Minimally invasive esophagectomy (MIE) could offer both minimally invasive approach and proper mediastinal lymph node dissection. Minimally invasive esophagectomy is safe and adequate, but time consuming and technically demanding procedure. It is procedure reserved for the surgeons experienced in open esophagectomy for cancer, and specially trained in advanced minimally invasive procedures. Even in that case, learning curve is steep.

Bloodless esophageal replacement in children with corrosive esophageal strictures--report of two cases.

BACKGROUND: Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children. METHODS: We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus. RESULTS: No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course. CONCLUSION: In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.

Acinetobacter spp. colonization and infection risk factors in surgical patients.

INTRODUCTION: The results of numerous studies carried out over the last two decades have increasingly important cause of intrahospital infections (IHI). The aim of the study was to determine potential differences in distribution of individual risk factors between the group of patients in whom multiresistant Acinetobacter spp. was isolated and the group of patients in whom it was not. MATERIAL AND METHODS: A prospective cohort study of 64 patients hospitalized with recorded IHI at the University Hospital for Digestive Surgery, Clinical Center of Serbia in the period between January and July 2011. The subjects were divided into two groups: patients with IHI in whom multiresistant Acinetobacter spp. was isolated from the biological material samples, and those with IHI without the presence of Acinetobacter spp. RESULTS: Univariate data analysis indicated presence of statistically significant difference in distribution of certain types of surgeries (esophageal, pancreatic and hepatobiliary) among the two groups of subjects, distribution of CVC placement, application of mechanical ventilation and nasogastric tube placement, length of stay in ICU, lethal outcomes and administration of third generation cephalosporins. The results of multivariate analysis indicated that length of hospitalization in ICU (> 7 days), CVC, mechanical ventilation, esophageal, pancreatic and hepatobiliary surgeries as well as administration of third generation cephalosporins are independent risk factors for colonization and infection of patients with Acinetobacter spp. CONCLUSION: Colonized or infected patients with Acinetobacter spp. play a major role in contamination of hands of the medical staff in the course of care and treatment, while inadequate hand hygiene of the staff leads to cross transmission of the causative organism to infection-free patients. Selective antibiotic pressure, particularly administration of quinolones and broad-spectrum cephalosporins, favor onset of multiresistant species of Acinetobacter spp., and therefore appropriate prophylaxis and treatment represent basic preventive measures against the onset and spreading of the causative organisms.

Gastric multicentric glomangioma: a case report of this rare cause of abdominal pain.

BACKGROUND: A glomus tumor is a rare neoplasm derived from glomus cells, specialized cells that surround small blood vessels which are important in regulating peripheral blood flow. Glomangiomas are a subset of glomus tumors. They are usually localized in the skin and subcutaneous tissue. They have also been reported in viscera, most notably in the gastrointestinal tract. CASE REPORT: A case of gastric multicentric glomangioma is described in an 18-year-old male who presented with chronic continuous abdominal pain over a 4-6 month period. Preoperative diagnosis, operative findings, histology, and immunohistochemistry of the tumor are discussed in detail. CONCLUSIONS: Case reports of this rare tumor are important because of the paucity of studies noted in the gastro-intestinal literature as a result of poor identification prior to the advent of modern immunohistochemistry. The significance of accurately diagnosing a gastrointestinal glomangioma is crucial for appropriate treatment.

[The use of recombinant activated factor VII in the treatment of gastrointestinal bleeding following acetylsalicylic acid therapy in a surgical patient].

INTRODUCTION: Gastrointestinal bleeding is the most important complication associated with acetylsalicylic acid therapy. Patients with preexisting haemostatic disorders are at the higher risk and may experience life-threatening hemorrhagic syndrome. Platelet transfusions and desmopressin administration commonly successfully arrest bleeding. However, in clinical situations with profound bleeding and haemorrhagic shock, these therapeutic approaches may fail. CASE OUTLINE: We report a 24-year old female patient with previously undetected acquired platelet dysfunction, who underwent reconstructive surgical intervention. On the 20th postoperative day, acetylsalicylic acid was introduced due to reactive thrombocytosis (platelet count 1480x10(9)/L) with daily dose of 100 mg tablets. On the 12th day of the acetylsalicylic acid treatment, massive gastrointestinal bleeding with haemorrhagic shock suddenly occurred. Attempts to control massive haemorrhage by resuscitation, blood products and haemostatics (desmopressin, tranexamic acid) failed. Two bolus doses of recombinant activated factor VII (rFVIIa) (100 microg/kg and 60 microg/kg respectively) in 90 minutes interval were given. Bleeding was successfully controlled with no requirements for further haemoproducts and haemostatic remedies treatment. CONCLUSION: This case demonstrates that the use of rFVIIa may be a specific treatment option in patients suffering from severe gastrointestinal bleeding associated with acetylsalicylic acid treatment.

Primary esophageal diffuse large B-cell lymphoma: report of a case.

Primary esophageal lymphoma is very rare, with fewer than 25 cases documented in the English-language literature. We report a case of primary diffuse large B-cell lymphoma of the esophagus in a 42-year-old woman. Barium esophagogram revealed almost complete esophageal obstruction at the level of the cervical esophagus, and flexible endoscopy showed a circumferential submucosal tumor covered with intact mucosa. Neck magnetic resonance imaging (MRI) showed a wide cervical mass circumferentially encompassing the lumen of the cervical esophagus. Biopsies taken with multiple forceps during flexible and rigid esophagoscopy were nondiagnostic. Finally, external esophageal wall biopsies taken during neck exploration provided information that helped us establish the diagnosis. Pathohistological findings confirmed non-Hodgkin's lymphoma of the diffuse large B-cell type. The patient was treated with combined immunochemotherapy, consisting of rituximab plus cyclophosphamide, vincristine, adriablastin, and prednisone (CHOP), followed by irradiation. A complete response was achieved, and 3 years after diagnosis and treatment the patient was disease-free.

[Prevalence and importance of nodal micrometastasis in patients with gastric adenocarcinoma]. / Ucestalost i znacaj nodusnih mikrometastaza kod bolesnika s adenokarcinomom zeluca.

Micrometastasis is a microscopic (less than 2 mm) deposit of malignant cells separated from the primary tumor. The incidence and importance of occult perigastric lymph node involvement were analyzed in 26 pN0 patients using the prospective method. The occult lymph node involvement was detected by immunohistochemical method using the anticytokeratin 8/18 antibody. Prevalence of clinically significant occult lymph node involvement (Mi+) was statistically significant, and found in 38.5% of pN0 patients. Out of tumor characteristics analyzed as possible predictors of occult lymph node involvement, the histological grade (GH) and the involvement of lymphatic vessels within gastric wall (pL1) had significant effect on the respective evaluation. The patients with histological grade 3 and 4 had occult lymph node involvement more often than those with grade 1 and 2 (p<0.05). More than 60% of pL1 patients had occult lymph node involvement LN (Mi+). Due to high prevalence of micrometastatic lymph node involvement, detection with specific immunohistochemical or molecular biology techniques should be a part of routine specimen examination in patients with pN0 gastric cancer.