Large somatostatin-producing endocrine carcinoma of the ampulla of vater in association with GIST in a patient with von Recklinghausen's disease. Case report and review of the literature.

CONTEXT: Somatostatin-producing endocrine tumors of the duodenum are very rare neoplasms of the gastrointestinal tract. These tumors may be associated with von Recklinghausen's disease. CASE REPORT: We present the case of a 49-year-old female patient with von Recklinghausen's disease and an incidentally diagnosed ampullary neoplasm. The patient was treated with a classical pancreaticoduodenectomy. At surgery, a mass was found in the greater curve of the stomach which was resected using the classic Whipple procedure. Histology and immunohistochemistry showed that the duodenal tumor was an ampullary somatostatin-producing endocrine carcinoma while the gastric tumor was a gastrointestinal stromal tumor (GIST). The postoperative course was uneventful and the patient is alive, without tumor recurrence, six years after surgery. CONCLUSION: Somatostatin-producing endocrine tumors of the duodenum are rare tumors, often associated with von Recklinghausen's disease; these neoplasms should be treated aggressively using radical surgical resection. Although local resection may be appropriate for small duodenal somatostatin-producing tumors, a pancreaticoduodenectomy is usually required for larger tumors.

Patients with pelvic fractures due to falls: A paradigm that contributed to autopsy-based audit of trauma in Greece.

BACKGROUND: Evaluation of the pelvic fractures (PFx) population in auditing effective components of trauma care is the subject of this study. METHODS: A retrospective, case-control, autopsy-based study compared a population with PFx to a control-group using a template with trauma outcome variables, which included demographics, ICD-9, intention, mechanisms, toxicology, Abbreviated Injury Scale (AIS-90), Injury Severity Score (ISS), causes of haemorrhage, comorbidity, survival time, pre-hospital response, in hospital data, location of death, and preventable deaths. RESULTS: Of 970 consecutive patients with fatal falls, 209 (21.5%) had PFx and constituted the PFx-group while 761 (78.5%) formed the control-group.Multivariate analysis showed that gender, age, intention, and height of fall were risk factors for PFx. A 300% higher odds of a psychiatric history was found in the PFx-group compared to the control-group (p < 0.001).The median ISS was 50 (17-75) for the PFx-group and 26 (1-75) for the control-group (p < 0.0001). There were no patients with an ISS less than 16 in the PFx group.Associated injuries were significantly more common in the PFx-group than in the control-group. Potentially preventable deaths (ISS < 75) constituted 78% (n = 163) of the PFx-group. The most common AIS3-5 injuries in the potentially preventable subset of patients were the lower extremities in 133 (81.6%), thorax in 130 (79.7%), abdomen/pelvic contents in 99 (60.7%), head in 95 (58.3%) and the spine in 26 (15.9%) patients.A subset of 126 (60.3%) potentially preventable deaths in the PFx-group had at least one AIS-90 code other than the PFx, denoting major haemorrhage. Deaths directly attributed to PFx were limited to 6 (2.9%).The median survival time was 30 minutes for the PFx-group and 20 hours for the control-group (p < 0.001). For a one-group increment in the ISS-groups, the survival rates over the post-traumatic time intervals were reduced by 57% (p < 0.0001).Pre-hospital mortality was significantly higher in the PFx-group i.e. 70.3% of the PFx-group versus 42.7% of the control-group (p < 0.001). CONCLUSIONS: The PFx-group shared common causative risk factors, high severity and multiplicity of injuries that define the PFx-group as a paradigm of injury for audit. This reduced sample of autopsies substantially contributed to the audit of functional, infrastructural, management and prevention issues requiring transformation to reduce mortality.

Survivin isoforms and clinicopathological characteristics in colorectal adenocarcinomas using real-time qPCR.

AIM: To investigate three isoforms of survivin in colorectal adenocarcinomas. METHODS: We used the LightCycler Technology (Roche), along with a common forward primer and reverse primers specific for the splice variants and two common hybridization probes labeled with fluorescein and LightCycler-Red fluorophore (LC-Red 640). Real time quantitative polymerase chain reaction (PCR) was performed on cDNAs from 52 tumor specimens from colorectal cancer patients and 10 unrelated normal colorectal tissues. In the patients group, carcinoembryonic antigen (CEA) and CA19-9 tumor markers were also measured immunochemically. RESULTS: Wild type survivin mRNA isoform was expressed in 48% of the 52 tumor samples, survivin-2b in 38% and survivin-ΔΕx3 in 29%, while no expression was found in normal tissues. The mRNA expression of wild type survivin presented a significant correlation with the expression of the ratio of survivin-2b, survivin-ΔΕx3, survivin-2b/wild type survivin and survivin-ΔΕx3/wild type survivin (P < 0.001). The mRNA expression of wild-survivin and survivin-ΔΕx3 was related with tumor size and invasion (P = 0.006 and P < 0.005, respectively). A significant difference was found between survivin-2b and morphologic cancer type. Also, the ratio of survivin-ΔEx3/wild-survivin was significantly associated with prognosis. No association was observed between the three isoforms and grade, metastasis, Dukes stage and gender. The three isoforms were not correlated with CEA and CA19-9. CONCLUSION: Survivin isoforms may play a role in cell apoptosis and their quantification could provide information about clinical management of patients suffering from colorectal cancer.

Kallikrein-related peptidase 13 (KLK13) gene expressional status contributes significantly in the prognosis of primary gastric carcinomas.

OBJECTIVES: Gastric cancer is a fatal human malignancy with poor prognosis. Modifications in gene expression, including those of the kallikrein-related peptidase family, have been portrayed in gastric carcinogenesis. Given KLK13 involvement in human malignancies, we aimed to uncover its prognostic strength in stomach cancer. DESIGN AND METHODS: Quantitative analysis of KLK13 profiles was accomplished in human gastric cancer cells and in a statistically significant sample size of stomach tissue specimens with the development of the highly sensitive real-time PCR methodology. RESULTS: Decreased KLK13 expression was demonstrated in cancerous compared with their matching non-malignant pairs (p=0.002) and in poorly differentiated gastric tumors (p=0.029). KLK13-positive patients were shown to live considerably longer (p=0.014) and with low risk of disease recurrences (p=0.043). CONCLUSIONS: This is the first study disclosing the possible clinical utility of KLK13 as a new tumor biomarker capable of predicting a favorable outcome for gastric cancer patients.

Motor vehicle collision fatalities involving alcohol and illicit drugs in Greece: the need for management protocols and a reassessment of surveillance.

AIMS: The frequency and the effect of alcohol and illicit drugs on injury type, severity and location of death in motor vehicle collision (MVC) fatalities were investigated. DESIGN: Retrospective case-control study based on autopsy and toxicology. SETTINGS: Single faculty accepting referrals from Greater Athens and prefectures. PARTICIPANTS: Consecutive pre-hospital and in hospital fatalities. MEASUREMENTS: Demographics, toxicology, abbreviated injury scale (AIS), injury severity score (ISS), and location of death. FINDINGS: Of the 1860 screened subjects, 612 (32.9%) constituted the positive toxicology group (PTG) for alcohol or illicit drugs or both and the 1248 (67.1%) the negative toxicology group (NTG). The median age was 34 (4-90) years for the PTG and 45 (3-97) years for the NTG. The PTG included significantly higher proportions of males and motorcyclists. The PTG had a 50% increased risk for a severe (AIS ≥3) cervical spine and 85% for a severe upper extremity injury, compared to the NTG. A total of 29.2% of the PTG and 22.4% of the NTG deaths were non-preventable (ISS=75). The frequency of severe trauma (ISS ≥16) was comparable between PTG and NTG (P=0.87). The PTG presented with a median ISS of 43 (6-75) versus 41 (2-75) of the NTG, hence without significant difference (P=0.11). The pre-hospital death rate was 77.8% for the PTG versus 58% of the NTG (P<0.001). The analysis confirmed that the odds of positive toxicology were considerably higher in the subjects who arrived dead at the hospital (OR 2.62, P <0.001). CONCLUSIONS: In the greater Athens region, almost a third of motor vehicle collision-related fatalities involved alcohol, illicit drugs or both. Individuals screened positive for alcohol or drugs were 2.6 times more likely to die before hospital admission than those with a negative toxicology screen, despite comparable injury severity. Specific evidence-based management protocols and reassessment of surveillance are required.

Good results after major pancreatic resections in a middle-volume center.

OBJECTIVES: Recently, hospital and surgeon volume is widely discussed as a prognostic factor after major pancreatic surgery. We present our experience regarding major pancreatectomy in a middle-volume center. METHODS: During the last 11 years, 66 patients underwent major pancreatectomy (pancreaticoduodenectomy [n = 52], distal pancreatectomy with splenectomy [n = 13], and central pancreatectomy [n = 1]). Postoperative course and long-term outcome were recorded and analyzed. RESULTS: One patient died after pancreaticoduodenectomy for ampullary cancer (total mortality of approximately 1.5% for the whole group of patients or 1.9% for the group of patients who underwent pancreatoduodenectomy). None of our patients was reoperated on. Transient pancreatic fistula was observed in 46 patients (36 patients after pancreatoduodenectomy [69%] and 10 patients after distal pancreatectomy [77%]). Two patients required percutaneous computed tomography-guided drainage of fluid collections, whereas in another one, a tube thoracostomy was performed to drain a pleuritic fluid collection. Delayed gastric emptying was observed in 6 patients after pancreatoduodenectomy. Median survival for the whole group of patients was 17 months. CONCLUSIONS: Major pancreatic resections can be performed safely, with acceptable morbidity and mortality and good long-term results, even in middle-volume centers. However, experience is required from the part of the operating surgeon. ABBREVIATIONS: PD - pancreatoduodenectomy, DP - distal pancreatectomy, PPPD - pylorus-preserving pancreatoduodenectomy.

Ultrasound-guided catheterization of the internal jugular vein in oncologic patients; comparison with the classical anatomic landmark technique: a prospective study.

AIM: To compare the traditional anatomic landmark technique with the ultrasound-guided method for central venous catheterization. MATERIAL AND METHODS: During three years, 551 patients underwent internal jugular vein catheterization; in 347 patients, the ultrasound-guided technique was used, while in the other 204 patients the catheter was introduced by using the classical anatomic landmark method. Operating time, complications (pneumothorax, puncture of carotid artery with or without hematoma formation), and number of attempts to achieve central venous catheterization were recorded. RESULTS: The ultrasound-guided technique was associated with significantly shorter operating time (9.83+/-3.1 vs. 20+/-4.4 min, p<0.001) and less morbidity (pneumothorax, 0 vs. 2 patients [p<0.05], carotid artery puncture with or without hematoma formation, 1 vs. 16 patients [p<0.05]). Moreover, the ultrasound-guided technique was highly successful in achieving central venous catheterization (failure, 0 vs. 18 patients [p<0.05]), with significantly fewer attempts (1-3 attempts in 204 vs. 283 [p<0.01]), compared to the classical anatomic landmark technique. CONCLUSION: The ultrasound-guided method is faster, more efficient, and less morbid procedure compared with the classical anatomic landmark technique. Therefore, it should be preferred over the classical landmark method, especially in high-risk patients for the development of complications.