Surgical management of acute cholecystitis (experience of 249 cases).

BACKGROUND/AIMS: Although laparoscopic cholecystectomy is the most widely used technique in the surgical treatment of acute cholecystitis, some schools continue to perform the open approach in the treatment of that disease. Our objective is to make a comparative analysis of results obtained with laparoscopic cholecystectomy (LC) and gall bladder removal by open cholecystectomy (OC). METHODOLOGY: The study includes 249 acute cholecystitis cases operated on between January 2007 to December 2008. Mean age was 60.9 years (+/- 16.6) (21-94 years); 51.8% men and 48.2% women. The diagnosis was made considering clinical, laboratory and echographic findings. There were 217 acute calculous cholecystititis and 32 noncalculous. Surgery was performed as follows: 167 LCs, 64 by OC and 18 percutaneous cholecystostomies (PC). RESULTS: The comparative analysis of mortality and morbidity of LC with gall bladder removal by OC showed the following results: mortality (1.19% vs 4.6% p=n.s.), major morbidity (5.3% vs 31.25% p<0.001), lesions of the main bile duct (0.5% vs 3.1% p=n.s.) reoperation (3.6% vs 12.5% p<0.05) and hospital discharge up to 48 hours (69.5% vs 10.9% p<0.001). CONCLUSIONS: Laparoscopic cholecystectomy provides superior results to open cholecystectomy, and is therefore the first choice treatment in acute cholecystitis.

Low frequency of MAP kinase pathway alterations in KIT and PDGFRA wild-type GISTs.

AIMS: Gastrointestinal stromal tumours (GISTs) are commonly driven by oncogenic mutations in KIT and PDGFRA. However, 10-40% of these patients are wild-type for these genes. The prognostic significance of wild-type GISTs is controversial, and they rarely respond to imatinib. The aim of this study was to elucidate the molecular lesions underlying wild-type GISTs tumorigenesis. METHODS AND RESULTS: Twenty-nine KIT and PDGFRA wild-type GISTs were re-assessed for the presence of 'cryptic'KIT exon 11 duplications. Using a specific polymerase chain reaction assay, three previously undetected mutations were identified. In the remaining 26 wild-type GISTs, KIT, stem cell factor (SCF), phospho-KIT and phospho-ERK expression was evaluated by immunohistochemistry. Samples were screened for gain-of-function mutations in the mitogen-activated protein kinase (MAPK) cascade. KIT and SCF co-expression associated with KIT activation was observed in approximately 30% of cases. Furthermore, phospho-ERK expression showed that MAPK is activated in approximately 30% of cases. None of RAS family (H-, K- and N-RAS) oncogenes exhibited activating mutations, whereas BRAF mutations were found in approximately 4% of cases. CONCLUSIONS: In the absence of RAS mutations, MAPK could be activated through SCF/KIT autocrine/paracrine mechanisms and/or mutated BRAF in a subset of KIT/PDGFRA wild-type GISTs.

Mucins MUC1, MUC2, MUC5AC and MUC6 expression in the evaluation of differentiation and clinico-biological behaviour of gastric carcinoma.

Normal gastric mucosa expresses MUC1 and MUC5AC in foveolar epithelium and MUC6 in mucous neck cells of the body and deep glands of the antrum. Several studies have reported aberrant expression of an under-glycosylated form of MUC1, decreased expression of "gastric" mucins and aberrant expression of "non-gastric" mucins in gastric carcinoma. In this study, we analysed the expression profile of mucins MUC1, MUC2, MUC5AC and MUC6 in 94 gastric carcinomas using immunohistochemistry. Our results showed that: (1) mucin expression is associated with tumour type (MUC5AC with diffuse and infiltrative carcinomas and MUC2 with mucinous carcinomas) but not with the clinico-biological behaviour of the tumours; and (2) mucin expression is associated with tumour location (MUC5AC with antrum carcinomas and MUC2 with cardia carcinomas), indirectly reflecting differences in tumour differentiation according to tumour location.

c-erb B-2 expression is associated with tumor location and venous invasion and influences survival of patients with gastric carcinoma.

The HER-2/neu gene or c-erb B-2, localized on chromosome 17q, belongs to a family of tyrosine kinase receptors and shares extensive homology with the epidermal growth factor receptor. c-erb B-2 gene amplification and protein overexpression have been reported in several human cancers. The prognostic value of this genetic alteration in gastric carcinoma is far from being established. In the present study, formalin-fixed, paraffin-embedded gastric carcinoma tissues from 157 patients were evaluated for c-erb B-2 overexpression, by immunohistochemistry using a polyclonal antibody. c-erb B-2 expression was evaluated according to clinical and pathological parameters, and to the survival of the patients. Our results show that: (1). c-erb B-2 was overexpressed in 15.3% of gastric carcinoma cases; (2). c-erb B-2 overexpression was significantly more frequent in cardia (23.8%) and fundus/body (25.0%) carcinomas than in antrum (7.2%) carcinomas; (3). c-erb B-2 overexpression was significantly associated with venous invasion; (4). c-erb B-2 is a prognostic factor for gastric carcinoma.

Acute diverticulitis in younger patients: any rationale for a different approach?

AIM: To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently. METHODS: This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B > 50 years (n = 126). Mean patient follow-up was 15 mo. RESULTS: The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence. CONCLUSION: Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.

Primary gastric adenosquamous carcinoma in a Caucasian woman: a case report.

INTRODUCTION: Most gastric tumors are adenocarcinomas. Primary gastric adenosquamous carcinoma is a rare malignancy, mostly associated with Asian populations. It constitutes less than one percent of all gastric carcinomas and its clinical presentation is the same as adenocarcinoma. It occurs more frequently in the proximal stomach, usually presents with muscular layer invasion and tends to be found in advanced stages at diagnosis, with a worse prognosis than adenocarcinoma. CASE PRESENTATION: We report the case of an 84-year-old Caucasian woman with an adenosquamous carcinoma extending to her serosa with lymphatic and venous invasion (T3N1M1). Nodal and hepatic metastasis presented with both cellular types, with dominance of the squamous component. CONCLUSIONS: Adenosquamous gastric cancer is a rare diagnosis in western populations. We present the case of a woman with a very aggressive adenosquamous carcinoma with a preponderance of squamous cell component in the metastasis. Several origins have been proposed for this kind of carcinoma; either evolution from adenocarcinoma de-differentiation or stem cell origin might be possible. The hypothesis that a particular histological type of gastric cancer may arise from stem cells might be a field of research in oncological disease of the stomach.

Loss of RKIP expression is associated with poor survival in GISTs.

Gastrointestinal stromal tumours (GISTs) are rare mesenchymal tumours of the digestive tract and are commonly driven by oncogenic mutations in KIT and PDGFRA genes. Tumour size, location, mitotic index and KIT/PDGFRA mutations are the most important prognostic parameters in GISTs. However, additional studies screening for new molecular prognostic markers in GISTs are missing. Raf kinase inhibitor protein (RKIP) has been considered as a suppressor of metastasis and a prognostic marker in several neoplasms. In the present study we aimed to examine whether RKIP expression is associated with GIST clinical-pathological features. Using immunohistochemistry, we determined RKIP expression levels in a well-characterised series of 70 GISTs. We found that RKIP is expressed in the great majority of cases, and absent in approximately 9% of GISTs. Additionally, we found that loss of RKIP expression was not due to the promoter methylation as assessed by methylation-specific PCR. Loss of RKIP expression was associated with poor disease-specific survival and with tumour necrosis in GISTs. Furthermore, a statistical tendency was observed between the positive RKIP expression and absence of metastasis. So far, this is the first study assessing RKIP expression levels in GISTs. We conclude that loss of RKIP expression could have an important role as prognostic marker in GISTs.

Surgical margin status and prognosis of gastrointestinal stromal tumor.

BACKGROUND: Surgery is the best treatment for primary GIST and may be curative, but resection extension/completeness impact on the prognosis remains controversial. The authors aim was to evaluate the clinicopathological (CP) parameters and surgical margins status influence on GIST patients' outcome. MATERIALS AND METHODS: The study evaluated 113 consecutive patients with sporadic GIST; the influence of CP parameters on recurrence-free survival (RFS) and disease-specific survival (DSS) was determined by univariate analysis (UA) and multivariate analysis (MA). RESULTS: Of 104 cases, macroscopically complete resection was achieved in 96: R0 surgical margin status in 78 and R1 in 18. Recurrence rates (12.5%) were significantly lower in R0 (9.0%) than in R1 (27.8%). Tumor > 10 cm, mitotic count > 5/50 high power field (HPF), and high-risk GIST predicted poor RFS and DSS (UA). Disease-specific survival was significantly shorter after macroscopic incomplete (R2) resection, for mixed cellular morphology, and in tumors with necrosis (UA). High-risk GIST (p = 0.016) and R2 resection (p = 0.013) predicted poor DSS of patients (MA). CONCLUSIONS: High risk and positive macroscopic surgical margin status are parameters associated with poor disease-specific survival in GIST patients.

Carcinoma secretor da mama no adulto, existem parâmetros bem definidos para decisäo terapêutica? / Secretory carcinoma of the breast in adults. are there well defined parameters for decision making?

O carcinoma secretor (CS) da mama é uma neoplasia muito rara. O CS da mama foi inicialmente descrito em crianças e adolescentes, mas a maioria dos casos é descrito em doentes adultos. É muitas vezes associado a um prognóstico particularmente favorável, mas em doentes adultos com tumores de maiores dimensöes pode apresentar um comportamento mais agressivo. Apresenta-se um caso de uma doente com 62 anos de idade, que apresentava uma volumosa tumefacçäo da mama com 16 anos de evoluçäo. O exame objetivo revelou extensa fixaçäo da lesäo à pele, com sinais inflamatórios acentuados e áreas de necrose cutânea. O tratamento inicial consistiu numa mastectomia simples, com intençäo paliativa. O diagnóstico anatomopatológico de carcinoma secretor (3,5 cm), sem invasäo cutânea, motivou a posterior realizaçäo de esvaziamento ganglionar axilar, que revelou metástases em 2 dos 13 gânglios isolados. A doente faleceu 24 meses depois, por disseminaçäo da doença, comprovando a maior agressividade do CS em doentes adultos com tumores de maiores dimensöes (T2) e com metastizaçäo ganglionar (N1). Os autores revêem a literatura com particular ênfase nos factores de prognóstico importantes para decisäo terapêutica deste tipo raro de carcinoma da mama, em doentes adultos.

Esophageal carcinoma originating in a duplication cyst: case report

Apresenta-se um caso de homem com 61 anos de idade, portador de carcinoma do terço médio do esôfago. Foi submetido a ressecçäo gastro-esofágica radical através de laparotomia mediana e toracotomia direita. O exame histopatológico mostrou carcinoma de células escamosas nitidamente originado da camada epitelial de cisto esofágico duplicado. Mostrou-se mediante imunohistoquímica células tumorais coradas para p53. Em 11 meses de evoluçäo o paciente permanece asssintomático

Incidência de micobactérias anônimas no conjunto sanatorial Raphael de Paula Souza

No período de janeiro de 1971 a agosto de 1975 foram examinados,na seção de bacteriologia do conjunto Sanatorial Raphael de Paula Souza 6.786 espécimes de materiais patológicos compreendendo 5.087 escarros,1476 lavados traqueobrônquicos e 223 de natureza diversa,dos quais foram obtidos 2.612 culturas positivas.Destas,2.270 foram estudadas bioquimicamente,encontrando-se uma freqüência de zero,cinco porcento de estirpes micobacterianas atípicas,sendo uma (zero,zero quatro por cento)escotocromogênica,9(zero,zero nove porcento) de crescimento rápido(grupo IV da classificação de Runyon.Procurou-se estabelecer a significação clinico-bacteriologica das micobactérias são isoladas,utilizando-se dados clínicos radiológicos laboratoriais disponivéis

A case report of a rare disease: primary malignant melanoma of the esophagus

The case of 69 year-old caucasean woman with a primary malignant melanoma of the esophagus is described. She came to us with a 12-month history of digestive symptoms and was submitted to a near-total esophageal resection, followed by a cervical esophago-gastric anastomosis. The pathological study of the surgical specimen revealed an esophageal melanoma having foci of "junctional activity" involving the entire esophagus. The tumor invaded but did not extend beyond the muscularis propria. All lymph nodes were without metastases, but lymphatic invasion was present. Two courses of chemotherapy with DTIC, Cisplatinum, BCNU and Tamoxifen and later with Interferon and Carboplatin were tried. She died 2 years and 2 months after surgery.