Local excision with adjuvant imatinib therapy for anorectal gastrointestinal stromal tumors.

Rectal gastrointestinal stromal tumors (GISTs) are uncommon, and the role of local excision versus a more extensive resection after the advent of effective targeted chemotherapy with imatinib is not known. Our aim is to present two cases of large anorectal GIST treated with local excision through a new anterolateral trans-sphincteric approach followed by adjuvant therapy with imatinib. Two patients (both males, 68 and 63 years old) presented at our institution with anorectal GIST in the period October-November 2010. Their medical records, pathology results, and imaging studies were retrospectively reviewed. Both patients presented with an anterior perianal mass. Imaging studies were characteristic of GIST originating in the lower rectum, circumscribed by a pseudocapsule, and protruding into the ischiorectal fossa. Both patients underwent local excision via an anterolateral trans-sphincteric approach. Both tumors were removed intact, with microscopically negative margins. The maximum tumor diameter was 8 and 9 cm, and the diagnosis of GIST was confirmed by positive CD117 and CD34 staining in both cases. Both tumors had a high (>5/50HPF) mitotic index. The patients had an uneventful postoperative course and were discharged on days 5 and 6. Both patients were started on imatinib 400 mg bid postoperatively. Postoperative magnetic resonance imaging and positron emission tomography computed tomography were carried out at 12 months and did not reveal any signs of recurrence. The patients are currently disease-free at 24 and 23 months of follow-up. In selected cases, complete excision of rectal GIST with negative margins is feasible via a trans-sphincteric approach. With the use of adjuvant therapy, which is currently advocated in all high-risk cases, it is possible that local excision with its reduced morbidity may become a viable alternative, especially in patients who would otherwise require abdominoperineal excision such as the two presented here. Prospective studies with longer follow-up are needed to confirm adequate oncologic results.

[Low rectal cancer treatment in frail elderly patients. A personal series]. / Il trattamento del carcinoma del retto basso nel paziente anziano fragile. Contributo casistico.

Rectal cancer predominantly affects elderly people, who are however more likely to have concomitant medical diseases and, therefore, are at higer surgical risk. After a careful selection of the patients, some surgical procedures can be performed safely. We studied a series of 149 patients affected by low rectal cancer; of these, 46 were aged 75 or older and comprise the elderly group; 94 curative resections, 19 palliative surgical treatments, 31 local excisions were performed. This approach demonstrated to be safe and effective among older patients too; therefore we may conclude that it is associated with a good control of surgical risk and of cancer in selected patients.

Surgical resection for neuroendocrine tumors of the pancreas: a fourteen years single institutional observation.

OBJECTIVE: Pancreatic neuroendocrine tumors (PNETs) are a rare entity that can present with symptoms of hormone overproduction with surgical resection being the only chance for cure despite the poorly defined tumor behavior. Their management involves a variety of therapies which require a well coordinated multidisciplinary team with the effort to optimize outcomes. PATIENTS AND METHODS: A retrospective analysis of 25 consecutive patients was performed by means of our single institution prospectively maintained database. All patients' files from 1999 to 2013, with histologically proven neuroendocrine tumors of the pancreas, were reviewed for clinical presentation, functional status, treatment, postoperative morbidity and mortality. RESULTS: Of 25 patients a total of 22 patients (11 females, 11 males, average age 49.7 years) underwent surgery with curative intent. We had 3 female patients that underwent palliative surgery because of unresectable disease. Nineteen of the 25 were not functional tumor. For the resected patients the overall morbidity was 38.8%. The 30-day mortality rate was zero. The overall median length of hospital stay was 10.4 days (range 4-23 days). CONCLUSIONS: Surgical resection with regional lymph node dissection is the only potentially curative therapy for patients with localized PNETs with the exceptions of most insulinomas where simple enucleation may be the standard of treatment. The anatomic considerations for determining the resecability are the same as those for pancreatic adenocarcinomas. Careful follow-up after surgery is essential because up to 50% of patients who undergo complete resection develop metachronous liver metastasis. Distant metastatic disease should be resected if possible.

Serous cystadenocarcinoma of the pancreas with portal thrombosis.

Serous cystadenocarcinoma of the pancreas is a rare entity. We report on a primary tumor of the pancreas in a 74-year-old male. Computerized tomography showed an abdominal mass within pancreatic head, portal vein infiltration and absence of metastatic lesions. Patient underwent Whipple's procedure and portal vein thrombectomy. Pathologic examinations of the specimen showed it to be serous cystadenocarcinoma. To the knowledge of the authors, serous cystic neoplasms of the pancreas have been uniformly benign in biologic behaviour. However, serous cystadenocarcinoma of the pancreas has been reported as a new entity. The current report is the fi rst among 22 cases described to present portal vein thrombosis and might support the local malignant behaviour of this controversial class of tumours.

Portal vein thrombosis following laparoscopic total mesorectal excision: case report.

Data continue to grow regarding the safety and technical feasibility of laparoscopically assisted total mesorectal excision (TME). As this minimally invasive alternative to open colonic resection becomes more popular, it is inevitable that information on the benefits and complications associated with it will continue to expand. Portal vein thrombosis (PVT) has been reported after a variety of laparoscopic procedures. We report a case of superior mesenteric, splenic and portal vein thrombosis following laparoscopically assisted TME. To our knowledge, this complication of laparoscopic TME has not been previously reported in the literature. PVT should be ruled out in patients who present with vague abdominal symptoms. The course of this complication, while potentially devastating, is usually benign and responds well to lysis and/or anticoagulation.