Extreme Leukocytosis and Gangrenous Cholecystitis Associated with Cytoreductive Surgery and HIPEC-Treated Mucinos Ovary Cancer: Case Report and Literature Review.

Mucinous ovarian cancer occurs sporadically, with a frequency of approximately 3-5% among all subtypes of ovarian cancer. Extreme leukocytosis >40,000 and 50,000 has been described in most solid tumors and is associated with a poor prognosis, although there is a lack of literal data of its occurrence after cytoreductive surgery and HIPEC in the treatment of advanced mucinous ovarian cancer. There is higher risk of the occurrence of cholecystitis in oncology patients compared to the general population, although there is no formal evidence for this, and the association with ovarian cancer is accompanied by a relative risk of 1.38. Hypercalcemia-hyperleukocytosis is a syndrome associated with head and neck cancers, although, to our knowledge, it has not been described in mucinous ovarian cancer, especially after cytoreductive surgery and HIPEC.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for the treatment of advanced epithelial and recurrent ovarian carcinoma: a single center experience.

BACKGROUND: With standard treatment of epithelial ovarian cancer (EOC), prognosis is very poor. The aim of this study is to show early and late results in patients who underwent cytoreductive surgery and intraperitoneal chemotherapy. PATIENTS AND METHODS: This was a retrospective single centre study. All patients with advanced and recurrent ovarian cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) or modified early postoperative intraperitoneal chemotherapy (EPIC) were included in the study. RESULTS: In the period 1995-2014, 116 patients were treated, 55 with primary EOC and 61 with recurrent EOC. The mean age was 59 years (26-74). Statistically, median survival time was significantly longer in the group with primary advanced cancer of the ovary (41.3 months) compared to relapsed ovarian cancer (27.3 months). Survival for the primary EOC was 65 and 24% at 3 and 5 years, respectively. Survival for recurrent EOC was 33 and 16% at 3 and 5 years, respectively. Mortality was 1/116 (0.8%). Morbidity was 11/116 (9.5%). Peritoneal cancer index (PCI) was ≤20 in 59 (51%) patients and statistically, their average survival was significantly longer than in the group of 57 (49%) patients with PCI >20 (p = 0.014). CONCLUSIONS: In advanced or recurrent EOC, a curative therapeutic approach was pursued that combined optimal cytoreductive surgery and intraperitoneal chemotherapy. PCI and timing of the intervention (primary or recurrent) were the strongest independent prognostic factors.

Preoperative radiotherapy with capecitabine and mitomycin C in locally advanced rectal carcinoma.

PURPOSE: To evaluate the efficacy and safety of preoperative radiotherapy with capecitabine and mitomycin C in patients with locally advanced rectal cancer. METHODS: A prospective, open-label, non-randomized, phase II study was performed on 49 patients with locally advanced rectal cancer. Preoperative radiotherapy was conducted on linear accelerators (15 or 18 MV) with a tumor dose of 45 Gy in 25 fractions over 5 weeks, combined with mitomycin C 7 mg/m(2) on days 1 and 29 and oral capecitabine 825 mg/m(2) twice daily on days 1-35. Surgery was performed 5-6 weeks after the end of chemoradiation. The primary study endpoint was histopathological complete regression rate (pCR; Dworak grade 4). RESULTS: Disease stage at diagnosis was T3 in 34 patients (69%) and T4 in 15 patients (31%). Positive lymph nodes were diagnosed in 28 patients (57%). Toxicity (all grades) was documented in 35 patients (71%). Grade 3 toxicities were radiation dermatitis (25%), diarrhea (2%), neutropenia (2%), and granulocytopenia (2%). No patient experienced grade 4 toxicity. A pCR was seen in 8 (16%, 95% CI 9-29%) patients, a major response was noted in 24 (49%) patients and a minor response in 14 (29%) patients. R0 resection was performed in 46 patients (93.9%) and R1 in 3 patients (6.1%). Histopathological tumor downstaging was documented in 26 patients (53%). One-year disease-free survival was 93.3% and 1-year survival was 97.7%. CONCLUSION: Preoperative chemoradiation with capecitabine and mitomycin C appeared to be effective with low toxicity in patients with locally advanced rectal cancer.

Validation and feasibility of ex vivo sentinel lymph node "mapping" by methylene blue in colorectal cancer.

BACKGROUND/AIMS: There are currently divided opinions about the usefulness of sentinel lymph node mapping in colorectal carcinoma. This technique can potentially be useful in determining the volume of resection, reducing the number of analyzed lymph nodes limited to sentinel lymph nodes, and re-staging when metastases are detected in the sentinel lymph node. The aim of this study was to examine the feasibility of postoperative sentinel lymphatic node detection (hereinafter referred to as ex vivo sentinel lymph node mapping) in patients with colorectal carcinoma. METHODOLOGY: The clinical study included a total of 58 patients. Thirteen patients were intraoperatively excluded. Ex vivo sentinel lymph node mapping by methylene blue was used in this study to detect the lymphatic micrometastases. Lymph node preparations were also stained with hematoxylin eosin, followed by immunohistochemical staining of serial sections. RESULTS: Ex vivo sentinel lymph node technique was performed in 45 patients, successfully in 41/45 (91.1%). 22.9 lymph nodes (range: 11 to 43) and 1.7 sentinel lymph node (range: 0 to 4) were resected and stained. Sentinel lymph node staining was negative in 15/45 patients (33, 3% false negative results). CONCLUSIONS: Limited histopathology analysis by ex vivo sentinel lymph node mapping can not replace a complete histological analysis of all resected lymph nodes.

Double-barreled wet colostomy: urinary and fecal diversion.

PURPOSE: Double-barreled wet colostomy represents simultaneous urinary and fecal surgical diversion performed most commonly after pelvic exenteration as a palliative procedure or after actinic damage. We report the structural and functional results of double-barreled wet colostomy with special attention to surgical technique, morbidity and functional results compared to those described in the available literature. MATERIALS AND METHODS: We retrospectively followed 38 patients who underwent double-barreled wet colostomy at our institution from April 2003 to November 2007. The parameters were patient age and gender, the indication for double-barreled wet colostomy, postoperative morbidity and mortality, length of hospital stay and functional assessment by excreting excretory urography. RESULTS: A total of 38 double-barreled wet colostomies were performed at our institution, including 24 following total pelvic exenteration, 14 without resection, 9 in inoperable tumor cases and 5 in actinic damage cases. The postoperative morbidity rate was 15.7% with no treatment related mortality. Two patients had late postoperative complications, including stenosis of the ureterocolonic anastomosis and conduit necrosis, respectively. CONCLUSIONS: In our experience double-barreled wet colostomy has an acceptable morbidity and mortality rate, is performed without technical difficulties and does not require prolonged operative time. Double-barreled wet colostomy represents the procedure of choice in patients who require concurrent urinary and fecal diversion.

[The use of recombinant activated factor VII to control haemorrhage following exenteration and massive transfusion in coagulopathic patients].

INTRODUCTION: Exentheresis pelvis totalis due to locally advanced pelvic malignancies is an extensive surgical procedure. The operation is commonly associated with anticipated perioperative haemorrhage requiring a large volume of haemoproducts. Sometimes, the intervention can result in unexpected massive and uncontrolled haemorrhage that is frequently a combination of surgical and coagulopathic bleeding. Attempts to arrest massive bleeding by conventional means may fail. CASES OUTLINE: We describe our experience in the use of recombinant activated factor VII (rFVIIa) in three previously hemostatically competent patients who underwent exentheresis in order to control massive bleeding resulting from dilution coagulopathy in the operating theatre, as well as in the treatment of postoperative bleeding associated with consumptive coagulopathy. Of these, two massively transfused patients developed dilution coagulopathy in the operative theatre, which was poorly responsive to conventional management. In both cases, a single dose of rFVIIa (70 microg/kg and 60 microg/kg respectively) was given. Prompt clinical response was achieved and operations were successfully finished. In the third case, the patient developed consumptive coagulopathy on the first day after surgical procedure that was treated with conventional therapy. On the second postoperative day the patient became anuric and experienced severe intraabdominal bleeding. The bleeding was successfully controlled with rFVIIa in a single dose of 70 microg/kg. CONCLUSION: RFVIIa can be a treatment option in patients suffering from intractable coagulopathic bleeding when standard therapy has failed.

Hemodynamic and cardiovascular problems during modified hyperthermic intraperitoneal perioperative chemotherapy.

BACKGROUND/AIMS: Cytoreductive surgery and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) significantly improves patients survival with peritoneal carcinomatosis especially in low-grade tumor e.g. ovarian and appendiceal adenocarcinoma, peritoneal pseudomyxoma and grade I gastric and colorectal cancer. METHODOLOGY: During a period of nine years, hemodynamic and cardiac functions combined with urinary output during hyperthermic intraoperative intraperitoneal chemotherapy were prospectively measured in 60 patients. RESULTS: Statistically significant hemodynamic and cardiac parameters were characterized by an increased heart rate and cardiac output as well as decreased systemic vascular resistance associated with an increased body temperature and decreased effective circulating volume. The tendency of urinary output was to decrease as the therapy progressed. CONCLUSIONS: HIPEC induces a hyperdynamic circulatory state requiring increased intravenous fluid administration, which avoids changes because of increased intra-abdominal pressure. Documented by normal blood pressure and adequate urinary output hemodynamic and intravenous fluids, titrated to frequent urinary output determination, can achieve cardiac stability.

Mucinous cystadenoma of the appendix associated with adenocarcinoma of the sigmoid colon and hepatocellular carcinoma of the liver: report of a case.

Mucinous cystadenoma of the appendix is a rare condition and represents one of the three entities with the common name mucocele of the appendix. It is characterized by a cystic dilatation of the lumen with stasis of mucus inside it. Histopathologically mucocele is divided into three groups: focal or diffuse mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma. This condition is often associated with other neoplasia, especially adenocarcinoma of the colon and ovaries. We here describe a 57 year old male patient who presented with abdominal discomfort, constipation, fresh blood in stool and frequent urination. He had a big cystadenoma of the appendix associated with adenocarcinoma of the colon and hepatocellular carcinoma of the liver. The patient underwent right haemicolectomy, sigmoid colon resection and segmental resection of the liver. Now 3 years later he has no evidence of disease relapse. According to this, we stress the need of accurate preoperative diagnosis and intraoperative exploration of the whole abdomen in these patients.